Illustrated Manual of Injectable Fillers: A Technical Guide to the Volumetric Approach to Whole Body Rejuvenation (Series in Cosmetic and Laser Therapy)

Illustrated Manual of Injectable Fillers

SERIES IN COSMETIC AND LASER THERAPY Series Editors David J. Goldberg, Nicholas J. Lowe, and Gary P. Lask Published in association with the Journal of Cosmetic and Laser Therapy

David J. Goldberg, Fillers in Cosmetic Dermatology, ISBN 9781841845098 Philippe Deprez, Textbook of Chemical Peels, ISBN 9781841842954 C. William Hanke, Gerhard Sattler, Boris Sommer, Textbook of Liposuction, ISBN 9781841845326 Paul J. Carniol, Neil S. Sadick, Clinical Procedures in Laser Skin Rejuvenation, ISBN 9780415414135 David J. Goldberg, Laser Hair Removal, Second Edition, ISBN 9780415414128 Benjamin Ascher, Marina Landau, Bernard Rossi, Injection Treatments in Cosmetic Surgery, ISBN 9780415386517 Avi Shai, Robert Baran, Howard I. Maibach, Handbook of Cosmetic Skin Care, Second Edition, ISBN 9780415467186 Jenny Kim, Gary Lask, Comprehensive Aesthetic Rejuvenation: A Regional Approach, ISBN 9780415458948 Paul Carniol, Gary Monheit, Aesthetic Rejuvenation Challenges and Solutions: A Global Perspective, ISBN 9780415475600 Neil Sadick, Diane Berson, Mary P. Lupo, Zoe Diana Draelos, Cosmeceutical Science in Clinical Practice, ISBN 9780415471145 Anthony Benedetto, Botulinum Toxins in Clinical Aesthetic Practice, Second Edition, ISBN 9780415476362 Robert Baran, Howard I. Maibach, Textbook of Cosmetic Dermatology, Fourth Edition, ISBN 9781841847009 David J. Goldberg, Alexander L. Berlin, Disorders of Fat and Cellulite, ISBN 9780415477000 Kenneth Beer, Mary P. Lupo, Vic A. Narurkar, Cosmetic Bootcamp Primer : Comprehensive Aesthetic Management, ISBN 9781841846989 Neil S. Sadick, Paul J. Carniol, Deborshi Roy, Luitgard Wiest, Illustrated Manual of Injectable Fillers: A Technical Guide to the Volumetric Approach to Whole Body Rejuvenation, ISBN 9780415476447

Illustrated Manual of Injectable Fillers A Technical Guide to the Volumetric Approach to Whole Body Rejuvenation Edited by

Neil S. Sadick MD FAAD FAACS FACP FACPh Sadick Aesthetic Surgery and Dermatology New York, New York, USA

Paul J. Carniol MD FACS Cosmetic, Laser and Reconstructive Plastic Surgery and New Jersey Medical School Summit, New Jersey, USA

Deborshi Roy MD Facial Plastic & Reconstructive Surgery Private Practice, Los Angeles, California, USA and

Luitgard Wiest MD Dermatology Private Practice AB-Centrum, Munich, Germany

First published in 2011 by Informa Healthcare, Telephone House, 69–77 Paul Street, London EC2A 4LQ, UK. Simultaneously published in the USA by Informa Healthcare, 52 Vanderbilt Avenue, 7th Floor, New York, NY 10017, USA. Informa Healthcare is a trading division of Informa UK Ltd. Registered Office: 37–41 Mortimer Street, London W1T 3JH, UK. Registered in England and Wales number 1072954. © 2011 Informa Healthcare, except as otherwise indicated No claim to original U.S. Government works Reprinted material is quoted with permission. Although every effort has been made to ensure that all owners of copyright material have been acknowledged in this publication, we would be glad to acknowledge in subsequent reprints or editions any omissions brought to our attention. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, unless with the prior written permission of the publisher or in accordance with the provisions of the Copyright, Designs and Patents Act 1988 or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1P 0LP, UK, or the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, USA (http://www.copyright.com/ or telephone 978-750-8400). Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. This book contains information from reputable sources and although reasonable efforts have been made to publish accurate information, the publisher makes no warranties (either express or implied) as to the accuracy or fitness for a particular purpose of the information or advice contained herein. The publisher wishes to make it clear that any views or opinions expressed in this book by individual authors or contributors are their personal views and opinions and do not necessarily reflect the views/opinions of the publisher. Any information or guidance contained in this book is intended for use solely by medical professionals strictly as a supplement to the medical professional’s own judgement, knowledge of the patient’s medical history, relevant manufacturer’s instructions and the appropriate best practice guidelines. Because of the rapid advances in medical science, any information or advice on dosages, procedures, or diagnoses should be independently verified. This book does not indicate whether a particular treatment is appropriate or suitable for a particular individual. Ultimately it is the sole responsibility of the medical professional to make his or her own professional judgements, so as appropriately to advise and treat patients. Save for death or personal injury caused by the publisher’s negligence and to the fullest extent otherwise permitted by law, neither the publisher nor any person engaged or employed by the publisher shall be responsible or liable for any loss, injury or damage caused to any person or property arising in any way from the use of this book. A CIP record for this book is available from the British Library. ISBN-13: 9780415476447 ISSN: (Print) 2158-0286 ISSN: (online) 2158-026X Orders may be sent to: Informa Healthcare, Sheepen Place, Colchester, Essex CO3 3LP, UK Telephone: +44 (0)20 7017 5540 Email: [email protected] Website: http://informahealthcarebooks.com/

For corporate sales please contact: [email protected] For foreign rights please contact: [email protected] For reprint permissions please contact: [email protected]

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Library of Congress Cataloging-in-Publication Data Illustrated manual of injectable fillers : a technical guide to the volumetric approach to whole body rejuvenation / edited by Neil Sadick ... [et al.]. p. ; cm. — (Series in cosmetic and laser therapy) Includes bibliographical references and index. Summary: “For optimal results from the growing number of fillers available it is important to understand the use and the limitations of each; it is also important to have an understanding of potential complications, in order to be able to minimize their incidence, and of how to treat any complications if they occur. The growth in other volume replacement procedures has similarly brought new opportunities as well as new problems. This text offers a multidisciplinary and international perspective on volumetric procedures for the face and neck, as well as therapies for hand rejuvenation and for defects of the torso”--Provided by publisher. ISBN 978-0-415-47644-7 (hardback : alk. paper) 1. Tissue expansion. 2. Surgery, Plastic. 3. Fillers (Materials) I. Sadick, Neil S. II. Series: Series in cosmetic and laser therapy. [DNLM: 1. Cosmetic Techniques. 2. Biopolymers--therapeutic use. 3. Dermatologic Agents--therapeutic use. 4. Injections, Subcutaneous. 5. Tissue Expansion--methods. WO 600] RD119.5.T57I45 2011 617.9’54--dc22 2011001320

Contents

Contributors Preface Acknowledgments 1.

Introduction to volumetric enhancement Neil S. Sadick

2.1.

The approach to volumetric augmentation using injectable fillers: An overview of the U.S. experience Deborshi Roy

viii x xii 1

7

2.2.

The European experience Luitgard Wiest

12

3.1.

Choosing the ideal filler Cheryl Karcher

22

3.2.

European commentary Luitgard Wiest

33

4.

Anatomy of the forehead and periocular region Marcelo B. Antunes and Stephen A. Goldstein

36

5.1.

Volumetric approach to the upper face Deborshi Roy

44

5.2.

European commentary Luitgard Wiest

50

6.

Anatomy of the midface Stephen A. Goldstein and Evan Ransom

52

7.1.

Volumetric approach to midfacial rejuvenation Robert A. Glasgold, Mark J. Glasgold, and Jason D. Meier

59

7.2.

European commentary Luitgard Wiest

80

8.

Anatomy of the lower face and neck Evan Ransom and Stephen A. Goldstein

83

vi

CONTENTS

vii

9.1.

Volumetric approach to lower facial rejuvenation Robert A. Glasgold, Mark J. Glasgold, and Jason D. Meier

90

9.2.

European commentary Luitgard Wiest

105

10.1. Volumetric approach to the lips Mary P. Lupo

107

10.2. European commentary Luitgard Wiest

120

11.1. Volumetric approach to rejuvenation of the hands Anetta E. Reszko and Neil S. Sadick

122

11.2. European commentary Luitgard Wiest

136

12.

Complications and their management Jason Emer, Heidi Waldorf, and Joel L. Cohen

139

13.

Postliposuction defects Misbah H. Khan, Theodore Diktaban, and Neil S. Sadick

167

Appendix of product names Index

177 185

Contributors

Marcelo B. Antunes Department of Otolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA Joel L. Cohen USA

AboutSkin Dermatology and DermSurgery P.C., Englewood, Colorado,

Theodore Diktaban Sadick Aesthetic Surgery and Dermatology, New York, New York, USA Jason Emer Department of Dermatology, Mount Sinai Medical Center, New York, New York, USA Mark J. Glasgold Department of Surgery, UMDNJ – Robert Wood Johnson Medical School, Piscataway and Glasgold Group Plastic Surgery, Highland Park, New Jersey, USA Robert A. Glasgold Department of Surgery, UMDNJ – Robert Wood Johnson Medical School, Piscataway and Glasgold Group Plastic Surgery, Highland Park, New Jersey, USA Stephen A. Goldstein Department of Surgery, Division of Otolaryngology, The University of Arizona, Tucson, Arizona, USA Cheryl Karcher Sadick Aesthetic Surgery and Dermatology, New York, New York, USA Misbah H. Khan USA

Sadick Aesthetic Surgery and Dermatology, New York, New York,

Mary P. Lupo Lupo Center and Clinical Professor of Dermatology, Tulane Medical School, New Orleans, Louisiana, USA Jason D. Meier

Jacksonville, Florida, USA

Evan Ransom Department of Otolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA

viii

ix

CONTRIBUTORS

Anetta E. Reszko USA

Sadick Aesthetic Surgery and Dermatology, New York, New York,

Deborshi Roy Facial Plastic & Reconstructive Surgery, Private Practice, Los Angeles, California, USA Neil S. Sadick

Sadick Aesthetic Surgery and Dermatology, New York, New York, USA

Heidi Waldorf Department of Dermatology, Mount Sinai Medical Center, New York and Waldorf Dermatology and Laser Associates P.C., Nanuet, New York, USA Luitgard Wiest Dermatology, Private Practice AB-Centrum, Munich, Germany

Preface

There are a growing number of filler materials available, varying in their composition and optimal usage. In order to obtain the optimal results, it is important to understand each filler; this includes not only how to use it but also the limitations of each of these materials. It is also important to have an understanding of potential complications in order to be able to minimize their incidence and of how to treat any complications if they occur. With the rapid growth in information availability, our patients hear about new techniques and new products, sometimes even before their uses and limitations have been thoroughly evaluated. This rapid spread of “information” makes it more important for medical professionals to have a thorough understanding. Only through detailed analysis, patient education, and precise treatments can we achieve successful results and happy patients. In addition to facial fillers, this book includes a volumetric approach to rejuvenation of other parts of the body. Our unique multidisciplinary perspective offers insight into how to diagnose visible aging in the context of volume loss. Our approach to facial aging takes into account all layers of the face. This book includes detailed techniques for facial analysis and diagnosis of aging conditions. For rejuvenation of the upper face, we discuss advanced techniques involving the forehead, glabella, temple, and lateral brow complex. We introduce some of our new techniques for periorbital rejuvenation, especially for treatment of the nasojugal groove. The midface is one of the areas most affected by volumetric loss in aging. We illustrate some of our new techniques in this area for treatment of the malar and submalar complex as well as the nasolabial folds. Volume loss in the lower face occurs primarily around the perioral complex, but changes along the jawline affect the neck as well. Treatment of the lips, perioral rhytides, chin, and jawline are all demonstrated. This area is fraught with possible complications, and preventative techniques are stressed. One of our exciting new areas is volumetric enhancement of the face. Treatment of the aging hands also requires a multimodality approach, with replacement of lost volume as a key component, and we demonstrate new techniques with several fillers in the dorsum of the hand. Our treatment technique for post-liposuction and post-traumatic defects of the torso and lower extremities is also shown.

x

PREFACE

xi

This book both acts as an excellent introduction for the novice physician performing volume restoration procedures and also provides new techniques and advanced procedures for experienced physicians. In the past decade, the use of fillers and volume replacement procedures has been rapidly expanding and now offers many possibilities; we hope that this comprehensive coverage of all aspects from diagnosis to treatment will help practitioners to achieve the safe, reliable, and aesthetic results that patients desire. Neil S. Sadick Paul J. Carniol Deborshi Roy Luitgard Wiest

Acknowledgments

The anatomical drawings in Chapter 4 are the work of Philip Jones from Brian Leatherbarrow’s Oculoplastic Surgery, second edition, Informa Healthcare, London, 2010.

xii

1 Introduction to volumetric enhancement Neil S. Sadick

COSMETIC SURGERY TRENDS

The concept of cosmetic surgery and medicine is rapidly changing as it moves from infancy to adolescence. In the past, a youthful appearance was sought through invasive surgical face-lifting techniques. However, there has been a shift in the perception of what constitutes a youthful appearance. Physicians and their patients have moved away from the tight, “pulled-back” two-dimensional looks achieved via face-lifts and other surgical procedures. The new movement has been about conservative approaches that deal with the underlying loss of soft tissue to achieve a plumper, less wrinkled, more three-dimensional appearance. This shift in the perception of what constitutes a “youthful visage,” combined with patient demand for minimally invasive procedures, has led to a major expansion in the field of soft tissue augmentation. The “culture” of our civilization has changed dramatically and desires to avail itself of the new science and technology that allow us to look and feel younger as we live longer. The industry of aesthetic medicine and surgery has exploded and is soaring to even greater heights as the next generation becomes the new seniors and seeks to look as young as it feels. The facial aging process reflects an interplay of genetic, anatomic, chronologic, and environmental factors. It is characterized by thinning of the epidermis and subcutaneous fat layers and a degree of bone resorption. In addition, a progressive loss of elastic fibers and collagen and weakening of underlying muscles contribute to the wrinkling process. Ageassociated changes can create shadows and hollows where they did not exist before. The aged face has prominent rhytids in the glabella, forehead, nasolabial folds (NLFs), and perioral areas. Today cosmetic surgeons can approach these conditions of atrophic aging with alloplastic implants, autologous fat, or a variety of facial fillers. Volumetric filling offers an excellent option for the treatment of facial aging, wrinkling, and contour defects. There are viable alternatives to major surgery for patients seeking safe, minimally invasive, and affordable means of maintaining a youthful appearance. It is imperative for the plastic surgeon to have a thorough knowledge of all the available products and their properties. This knowledge will enable optimal pairing of facial filling techniques with specific concerns and consequent maximal efficacy and patient satisfaction. 1

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ILLUSTRATED MANUAL OF INJECTABLE FILLERS

EVOLUTION OF THE FIELD

Historically, significant volume enhancement has been available through the surgical use of alloplastic implants. The exact origin of maxillofacial prosthetics is difficult to identify but major work in the 1930s provided the initiative for maxillofacial, dental, and plastic surgeons to work together for the betterment of focally injured patients. Today, the techniques that have evolved from those early trials have become safe and applicable in situations where even minimal deformity is present. Transferring fat from one area of the body to another has revolutionized the trend of rejuvenation by volume restoration and it can be said that fat was the first available filler. There has been interest in fat transfer since the inception of whole fat grafts in the 1890s and injectable fat grafts in the 1920s. From then on, interest waned until the 1980s when interest once again boomed in the plastic surgery community. The rising popularity of this procedure has paralleled the development and popularity of liposuction for body contouring. Autologous fat is plentiful and readily accessible once the harvesting technique is mastered. The technique is intended to preserve the delicate structure of adipocytes and provide a robust blood supply on which fat cells are extremely dependent. Fat provides excellent volumetric filling and the possibility of long-term results exceeding that of resorbable fillers. Patients’ satisfaction with fat is high and many prefer using their own autologous fat rather than synthetic fillers. Autologous fat can also offer benefits to the skin quality, improving acne, scarring, and providing a healthy luster. Whether this phenomenon is due to nutrients in the fat cells or “stem cell” characteristics as has been proposed is purely theoretical. Some practitioners believe that fat transfers represent one of the most significant rejuvenation advances of the decade. Volumetric facial rejuvenation is excellent for the forehead, eyes, cheeks, chin, myelolabial lines, lips, marionette lines, and geniomandibular grooves. In the body, large volume fat transfers can be used in the buttocks, breasts, calves, and for posttraumatic or iatrogenic liposuction defects, as detailed in chapter 11.1 of this manual. Ongoing interest in fat transfer and constant reassessment of clinical results will lead to further improvements in the procedure of fat transfer for soft tissue volumization and augmentation. INJECTABLE FILLERS

The practice of using injectable fillers for soft tissue augmentation has a long and welldescribed history. Today it is a crucial tool in the armamentarium of facial volumization. Over the past decade, the use of injectable products in cosmetic dermatology has increased rapidly to become one of the top three cosmetic procedures performed in a physician’s office. Over the past few years, the search for an ideal filling agent has led to a plethora of available materials for facial rejuvenation. The ideal filler substance would be nonallergic, noncarcinogenic, nonteratogenic, durable, reproducible, stable, and affordable, and would cause a minimum of adverse events. Arguably, for some the ideal filler will be permanent and for others resorbable, depending on the patient’s prior experiences and the physician’s expertise. Although a filling material that satisfies all of the above criteria is yet to be found, there are numerous compounds that fall just short of doing so and are safely and easily administered in the office setting. The choice of filling substance depends on the

INTRODUCTION TO VOLUMETRIC ENHANCEMENT

3

depth of the target to be treated as well as various patient factors. It is important for the injector to be judicious, always informing patients of the risks and benefits of treatment and advocating appropriate test doses, if necessary, to avoid or minimize potential adverse events. In the 1980s, the use of bovine collagen for cosmetic purposes started a new era of soft tissue augmentation. Over the past five years alone, the number of approved facial fillers in the United States and abroad has grown rapidly. To date, the most widely used fillers fall into three major categories: collagens, hyaluronic acid, and biosynthetic fillers. In addition to the categorical differences described earlier, facial fillers can be grouped according to their degree of permanence after injection. Nonpermanent fillers produce short-lived results and eventually undergo resorption. Fillers of this type will require repeated injections for long-term results. Semipermanent fillers typically last longer than most nonpermanent fillers but can be expected to experience some resorptions as well. Only permanent fillers can be expected to produce long-term results with a single injection. Short-Term Fillers Collagens

Collagen is a major component of human connective tissues such as bone, cartilage, skin, and vasculature. The injectable forms consist of varying concentrations of purified bovine, porcine, or human collagen. Bovine collagen was the first Food and Drug Administration (FDA)-approved facial filler in 1981 and was harvested from an isolated U.S. herd. One major disadvantage of bovine collagens (Zyderm, Zyplast) is their potential for immunogenicity and mandatory skin testing. Improving on the issue of allergic reactions are human (CosmoDerm, CosmoPlast) and porcine (Evolence) collagens. At the time of this writing, Evolence has been removed by the manufacturer from the U.S. market; however, the potential remains for a porcine filler to be reintroduced. All collagen fillers are biodegradable and resorbable with results lasting under one year. Slowing of collagen resorption (prolonged filler effect) is accomplished by cross-linking the collagen with moieties such as glutaraldehyde or ribose. Rapid degradation is not necessarily a drawback to collagen products; indeed, it is an asset under some aesthetic requirements. Collagens are best suited for superficial correction and are injected into the dermal plane. Hyaluronic Acid

Hyaluronic acid (HA) fillers are particularly popular because they have a low potential for allergic reaction and require no skin testing. Although they are not permanent, most of these agents have a significant length of duration. As of the start of 2010, there are nine U.S. FDA-approved HA fillers: Restylane, Perlane, Juvederm Ultra, Juvederm Ultra Plus, Elevess, Prevelle Silk, Hylaform, Hylaform Plus, and Captique. A new HA product known as Puragen Plus in Europe is projected to be FDA-approved in spring 2010, and may be approved by the time of this publication. HA is a naturally occurring glycosaminoglycan that composes the extracellular matrix of connective tissues. In the skin, it provides structure and volume while also maintaining and attracting moisture. As the skin ages, the amount of HA decreases and correlates with the formation of rhytids. Clinically, the injection of HA into the skin replenishes

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ILLUSTRATED MANUAL OF INJECTABLE FILLERS

volume and revitalizes the skin’s appearance. Most of the HA on the market are nonanimalstabilized HAs and are manufactured by the fermentation of Streptococcus equi bacterium. The Hylaform family is animal derived from rooster combs. Most of the products differ in the total HA concentration and degree of cross-linked material. The total HA concentration refers to the measure of insoluble HA and soluble HA in a product. The soluble of liquid form of HA is absorbed very quickly and is added to some products to improve lubrication and flow through the needle. The insoluble gel portion that persists in the skin after injection contributes to the clinical effect. All of the currently available HA fillers are indicated by the FDA for injection into the mid to deep dermis for the correction of moderate to severe facial wrinkles and folds, specifically NLFs. However, HA products are routinely used for off-label indications. Intermediate to Long-Term Fillers Calcium Hydroxylapatite

Calcium hydroxylapatite (CaH), long used as a bone replacement, lends itself well to soft tissue augmentation. Its high density and low solubility provide a long-term effect with minimal immune sensitivity. Radiesse™ is the only FDA-approved CaH dermal filler. It is a viscous gel, composed of carboxymethylcellulose, glycerine, and purified water, within which 25 to 45 µm spherical particles of CaH are suspended. Radiesse is considered a medium- to long-term volumizer with duration of effect being reported to last over 12 months. Additionally this filler has been found suitable for diverse locations. In addition to volumizing the cheeks and NLFs, Radiesse is utilized for nose and chin augmentation as a panfacial volumizer and contouring agent. Currently several large prospective studies are underway examining Radiesse usage in the dorsum of the hands and this indication is reviewed in chapter 10 of this manual. In July 2009, Radiesse received FDA approval for lidocaine reconstitution prior to injection, a trend that is expected in other fillers as well. Poly-L-lactic Acid

Poly-L-lactic acid (PLLA) is a synthetic material used in resorbable sutures, plates, and screws. PLLA for injection is available as Sculptra, a powered form of PLLA in microspheres 40 to 63 µm in diameter, which must be reconstituted with sterile water prior to injection. PLLA is categorized as a bioactive filler due to its ability to stimulate neocollagenesis. PLLA was initially FDA-approved for HIV lipoatrophy correction but was frequently used off-label for other cosmetic concerns. In July 2009, Sculptra was approved for aesthetic indications by the FDA. It is primarily utilized for diffuse global correction rather than individual rhytids and often requires multiple sessions for desired results. Correction is not immediate and requires three to six months as fibroblasts are stimulated to produce new collagen and dermal remodeling occurs. Permanent Fillers

Currently only one filler, ArteFill, is FDA-approved for permanent correction. ArteFill is composed of polymethylmethacrylate microspheres in a bovine collagen carrier. The

INTRODUCTION TO VOLUMETRIC ENHANCEMENT

5

nondegradable microspheres serve to stimulate fibroblast activity and connective tissue ingrowth giving ArteFill a biostimulatory property. The end result is a biologically stable matrix that creates a durable, long-lasting cosmetic enhancement. An essential key to successful ArteFill use is a conservative approach with avoidance of overcorrection. In addition to ArteFill, off-label silicone usage is practiced for wrinkles, scars, and augmentation of the lips. Although aesthetic silicone usage is currently not widely practiced in the United States, the practitioner may encounter patients who have undergone previous volumization with this product. It is important to be aware of the complications that may develop in these patients and the risk profile of performing procedures on patients with implanted silicone.

OTHER CONSIDERATIONS

Although injectable fillers can offer an efficacious alternative to surgery, they also have their limitations. It is important for the plastic surgeon to recognize specific circumstances which may be best managed with an alternative to fillers, including superficial contour defects too shallow for fillers; areas with significant skin laxity in which filler injection may result in lumpiness; and deep defects or folds in areas of dynamic movement, which may result in filler dislodgement or visible filler implants. Appropriate and complete training is critical for success with all fillers. Indeed training is often a regulatory requirement associated with treatment. Choosing a dermal filler for a particular defect is perhaps more an art than science, with few hard and fast rules. Most products have only been studied in the NLFs, but are used in many other applications, thus experience remains the best teacher. Table 1.1 lists some general-use criteria for dermal filler products that are elaborated on in the later chapters. Short-term volumizers such as collagen and HA fillers are best used for superficial, smoothing applications. The longerlasting stimulatory fillers are beneficial for deeper contouring in areas where a more significant tissue response is instrumental in achieving the desired effect. Dermal fillers are labeled for injection at specific dermal depths. In general, the more viscous and thick the product, the deeper it is to be injected. Care must be taken in thinskinned areas, such as the glabellar lines, the lips (especially the vermillion border), which may be prone to vascular occlusion and necrosis, or may result in exaggerated protrusion. The literature is full of the trials and wisdom of the pioneers in this field of ever-expanding technology and increasing refinement of technique. It is imperative to refer to the medical annals and to remain updated on the evolving indications and recommendations of usage. Table 1.1 Typical Uses of Dermal Fillers Zyderm/CosmoDerm Zyplast/CosmoPlast Hyaluronic acids Radiesse Sculptra ArteFill Silicone

Superficial lines and creases Lips; short duration General use products Deeper folds; deep dermal/supraosteal placement Deep placement; panfacial volumizer Permanent in deep to mid dermis Deeper placement lessens beading and migration

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CONCLUSION

The field of aesthetic volumization has grown considerably from the humble beginnings of bovine collagen over 20 years ago. The ease and effectiveness of fillers has led to great patient acceptance and demand. Today there are many choices driven by powerful marketing campaigns that have patients clamoring to try the latest filler available. The race is on and the search will continue for better and more appropriate injectables that will allow cosmetic surgeons and dermatologists to offer a broad scope of therapeutic combinations. It has been said that a millimeter of improvement on the face is a kilometer in the soul. Although improvement may be transient, patients are very often gratified at turning back the clock, however temporarily. Volume filling in the face has moved on to other anatomic locations, such as the hands, décolleté, breasts, and buttocks. The combination approach with neurotoxins and anatomically tailored filler placement has allowed for the emergence of the “liquid facelift,” the epitome of noninvasive rejuvenation. Thanks to the success, safety, and ongoing research into dermal fillers, it is an exciting time for cosmetic surgeons, industry, and most importantly our patients.

2.1 The approach to volumetric augmentation using injectable fillers: An overview of the U.S. experience Deborshi Roy

INTRODUCTION

Our world is changing every day, but the desire to look younger remains the same. Technological advancements coupled with an explosion in the public’s interest in minimally invasive procedures have led to a major increase in the use of injectable fillers. In this chapter, we will be outlining our multidisciplinary approach for using injectable fillers for volumetric augmentation throughout the body. BACKGROUND

The quest for the ideal injectable filler continues to this day. The ideal injectable filler would be safe, easy to use, and give long-lasting, consistent results. Liquid silicone was the first filler available in the United States to treat contour defects, scars, and rhytides of the face. It was widely used for two decades until concerns about long-term safety caused it to fall out of favor (1,2). Several years ago, a new liquid silicone product was cleared by the Food and Drug Administration (FDA) and has been used in an “off-label” fashion for cosmetic enhancement of the face. Liquid silicone is an example of a permanent filler. Bovine collagen was the second available injectable filler and was widely used with a very low incidence of complications (3). Allergy testing of the skin was necessary with the original formulations—Zyderm and Zyplast. The results from these products lasted for a few months after injection, requiring frequent administration. Over the years, collagenbased products have evolved. CosmoDerm and CosmoPlast (recombinant human collagen) eliminated the need for skin testing. Evolence (porcine collagen) was cross-linked, giving it a longer-lasting quality, and did not require skin testing. Autologous fat transfer techniques were introduced around the same time as bovine collagen. The safety of using autologous material cannot be matched by any foreign body, 7

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ILLUSTRATED MANUAL OF INJECTABLE FILLERS

animal or synthetic. However, there is an increased morbidity associated with this more invasive type of procedure that requires a separate harvesting and administration. Consistent, reproducible results have also become an obstacle for some practitioners. Because it is a free graft of live tissue, autologous fat transfer has the potential for lasting over several decades, given the grafts remain viable. Hyaluronic acid fillers are among the pack of the latest, most widely used nonsurgical cosmetic treatments. Hyaluronic acid products can be derived from animal sources or from bacterial fermentation (Table 2.1.1). The various preparations currently available in the United States differ in cross-linking and concentration of hyaluronic acid in the carrier vehicle. Although the products are all similar, there are subtle differences that lead each injector to have his or her own preference. Results last from four to six months after injection. Calcium hydroxylapatite suspended in a matrix composed of water, glycerin, and sodium carboxymethylcellulose is known as Radiesse. This is a bulkier product than those previously mentioned and is injected into a deeper plane. The unique viscosity and elasticity of the material make it possible to mold the implant for several minutes after injection, minimizing irregularities in contour. Unlike the previous products, Radiesse has been shown to stimulate new collagen growth in the injected areas (4). Results last from 8 to 12 months after injection. Sculptra is a suspension of poly-L-lactic acid in water. Unlike the previously mentioned products, it is not used in a single-injection session. In order to obtain optimal results, multiple injection sessions several weeks apart must be utilized. This product can also induce new collagen growth, and has been clinically shown to increase dermal thickness over time, with results lasting for several years (5). Artefill is a combination of polymethylmethacrylate (PMMA) spheres and bovine collagen. This product requires skin testing, and can last for several years as the bovine collagen is replaced by autologous neocollagen over time, since the PMMA spheres provide a permanent platform. APPROACH TO INJECTABLE FILLERS

Ours is a multispecialty based approach that involves volumetric assessment and global improvement of all areas of concern. Since most problems are multifactorial, a comprehensive analysis is followed by a customized treatment plan that addresses each individual problem as well as overall aging. The most important facets of the aging process that we focus on are sun damage, loss of elasticity, and loss of volume. We will focus on volume loss and its relation to injectable fillers.

Table 2.1.1 Various Hyaluronic Acid Injectable Filler Preparations Juvederm Ultra Juvederm Ultraplus Restylane Perlane Elevess Hylaform

Nonanimal stabilized hyaluronic acid (NASHA) NASHA NASHA + lidocaine Animal hyaluronic acid

AN APPROACH TO VOLUMETRIC AUGMENTATION USING INJECTABLE FILLERS

9

EVALUATION

Careful evaluation and proper diagnosis is critical for a favorable outcome. We analyze the entire anatomic area including the skin, subcutaneous tissue, muscle, fat, and bone. A global appreciation for the proportion and geometry of the area as a whole and the harmony between aesthetic subunits helps to produce the finishing touches to volumetric rejuvenation. When evaluating the face, we break it up into three units: the upper face, from the hairline down to the horizontal axis that goes through the canthi; the midface, from the below the canthi to the upper lip; and the lower face, which starts from the upper lip and ends in the upper neck. Loss of volume can take place in any of the three areas and is usually not confined to one. The most common area treated for volume loss is the midface, followed by the lower face. Off the face, volume loss is most commonly treated in the dorsal part of the hands. Other areas such as the trunk and lower extremities are most commonly treated for scars or postsurgical deficits. INJECTION TECHNIQUES

Depending on which filler is being used and which area is being treated, there are three choices for the amount of material used. One can decide for a 1:1 correction, overfilling, or underfilling. In most cases, one would inject to the point of desired correction. In certain areas (such as the lips) and with certain fillers (such as collagen), a slight overcorrection is necessary. Undercorrection is most often used with Sculptra, since multiple treatment sessions are employed, with a gradual buildup of product. There are several injection techniques, and each injector has his or her favorites. There are some situations where one technique is preferred over the other due to anatomic considerations or the depth of injection required. The main techniques are serial puncture, linear threading, cross-hatching, fanning, and depot (Figs. 2.1.1–2.1.4). Although most injectors prefer using transcutaneous injection techniques, there are several transoral injection techniques for treatment of the mid and lower face.

Figure 2.1.1

Serial puncture.

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ILLUSTRATED MANUAL OF INJECTABLE FILLERS

Figure 2.1.2

Linear threading.

Figure 2.1.3

Figure 2.1.4

Fanning.

Depot.

AN APPROACH TO VOLUMETRIC AUGMENTATION USING INJECTABLE FILLERS

11

CONCLUSION

There are a myriad of choices when it comes to injectable fillers. The most important aspect of volumetric enhancement is the clinical evaluation of the patient. Our global approach, considering all aspects of the aging process and the overall picture is a comprehensive way of assessing the problem and tailoring the treatments accordingly. Fillers can also be combined with surgical and nonsurgical treatment modalities to achieve maximal treatment of multiple factors. Our approach, when combined with excellent injection technique, can produce wonderful results with a high degree of patient satisfaction. REFERENCES 1. 2. 3. 4. 5.

Aronsohn RB. A 22-year experience with the use of silicone injections. Am J Cosmet Surg 1984; 1: 21–8. Pearl RM, Laub DR, Kaplan EN. Complications following silicone injections for augmentation of the contours of the face. Plastic Reconstr Surg 1978; 61: 888–91. Cooperman LS, Mackinnon V, Bechler G, Pharriss B. Injectable collagen: a six-year clinical investigation. Aesthetic Plast Surg 1987; 79: 581–94. Carruthers J, Carruthers A. A prospective, randomized, parallel group study analyzing the effect of botulinum toxin A and non-animal sourced hyaluronic acid. Dermatol Surg 2003; 29(8): 802–9. Silvers SL, Eviatar JA, Echavez MI, Pappas AL. Prospective, open-label, 18-month trial of calcium hydroxylapatite (Radiesse) for facial soft-tissue augmentation in patients with human immunodeficiency virus-associated lipoatrophy: one-year durability. Plastic Reconstr Surg 2006; 118(3 Suppl): 34S–45S.

2.2 The European experience Luitgard Wiest

The marketing of bovine collagen preparations began in 1981 and reigned until the mid-1990s, heralding the beginning of the modern era of injectable fillers for facial rejuvenation. The introduction of the next generation of products, for example, hyaluronic acid (HA) products in the 1990s, started an increase in the number of newly available fillers (1), but today the number of available injectable products in Europe has dwindled to almost 200. Why is that? Until 1993 dermal fillers were considered drugs, but they are now included in the category of medical devices. Since 1998 injectable fillers are required to bear a CE (Conformité Européenne) marking. This marking does not offer any guarantee as to the efficacy of the product or its safety. The allocation of a CE marking is based on the product’s technical file, clinical data, and quality assurance. A CE marking exclusively controls the safety and performance claimed by the manufacturer. A product bearing a CE marking is registered automatically and can be sold in all European countries. These requirements are less stringent than those required for Food and Drug Administration (FDA) approval. The ease in obtaining a CE marking for injectable fillers has led to an explosion in the number of fillers especially HA products even resulting in the first CE certified Chinese HA product being marketed as a “Restylane alternative” from Hangzhou Gallop Biological Products, China. The current situation in Europe is such that the filler is produced and marketed and only after extensive use does it undergo random testing to see whether it works and is safe. More often, the new filler is introduced in Europe and thereafter FDA approval is adapted by U.S. practitioners. This allows for prior assessment of the newer filler products in Europe for their safety and use in cosmetic procedures. These injectable fillers available to practitioners in recent years have different properties, offering different modes of application with different durations of correction. Currently there are more than 120 different HA products on the market (Table 2.2.1), which are the most commonly used degradable fillers in Europe (2,3). They are very popular for dermal augmentation and, in the past few years, for soft tissue and facial volume restoration, which have recently become a focus in facial rejuvenation. The vast choice of fillers is a big challenge for the physician as well as the patient. Among the most 12

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popular HA products are various FDA-approved Q-Med products like Restylane® and Perlane® (see chaps. 2.1 and 3), and the FDA-approved HA fillers from Allergan Juvederm Ultra® and Juvederm Ultra Plus® (4).

Table 2.2.1

Hyaluronic Acid Fillers (June 2010)

Ac-Hyal® Amalian Balance, Amalian I, II, III, Amalian Lips Alayna Hydro, Light Regular, Repair, Lip Volume Beauty Gel, Beauty Sphere (HA+Dextranomers) Belotero Basic® Belotero Soft® Belotero Intense® Captique CRM-Dermal Filler, Soft, Dur, Gel, Dex, DX Cristal 1,2, Soft, Cristal Lips Dethail Coilingel, Dethail Lastingel (HA+Dextran.) Esthelis Basic, Esthelis Soft, Esthelis+Glycerol Esthelis Men® Fortélis Extra Glytone Hyacell Hyacorp S/Lips/S Face, L, H Hyal 2000 Injectio Hyal-System®, Hyalsystem HyalACP Hyaluderm® H. Revitalize Hydrafill Grade 1, 2, 3® Hydrafill Softline® Hydrafill Softline MAX® Hylaform Fine Lines® Hylaform® Hylaform Plus® IAL Sytem Isogel 1, 2, 3Juvederm® Ultra Smile Juvederm ™ Voluma ™ Juvederm ™ Hydrate ™ Juvederm Ultra 2,3,4, Juvélift Corneal® Juveni HA Volumizer, Juveni mesolift Juveni+Lidocaine 2% mixing Laresse™ M-HA18, X-HA, X-HA Volume NCTF 135, NCTF 135HA® Mac Dermol S and R® Mac dermol Bio® Macrolane® Matridur® (Continued )

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Table 2.2.1

ILLUSTRATED MANUAL OF INJECTABLE FILLERS

(Continued ) Hyaluronic Acid Fillers (June 2010)

Matridex® (HA+Dextran) Prevelle Silk™ Prevelle Plus Perlane Lidocaine ™ Princess Rich, Filler, Volume® Pluryal® Puragen™ Puragen Plus Restylane Perlane® Restylane Lidocaine Restylane® Restylane SubQ® Restylane Touch® Restylane Vital® Restylane Lipp® Revanesse, Pure Revanesse Ultra ReDexis, Redexis Ultra Reviderm Intra® (HA+Dextranomers) Revitacare Rofilan® SkinFill™ Silver, Gold, Diamond Succeev One, Two, Three® Surgiderm® 18, 30 Surgiderm® 24XP Surgiderm® 30XP Surgilips® Surgilift® Plus Stylage® S, M, L, XL, Hydro Teosyal Global action® Teosyal Deep Lines, Teosyal Ultra Deep Teosyal Kiss Varioderm ™ Varioderm Plus™ Varioderm Subdermal™ Varioderm FineLine™ Viscontour® Visagel® Voluma Corneal® Zetavisc L® Z Fill® Refresh, Deep, Z Fill Repair+Dextranomers

With the discovery of new technologies, the HA fillers have been developed into more sophisticated products (Tables 2.2.2 and 2.2.3) and address different aesthetic needs and clinical indications, some of them being combined with lidocaine to decrease the discomfort of the injection.

THE EUROPEAN EXPERIENCE

Table 2.2.2

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Products for Lip Augmentation

Amalian Lips Alayna Lip Volume Cristal Lips HYAcorp S/Lips Glytone Juvederm Ultra Smile Permalip Restylane Lipp Stylage Lip

Table 2.2.3

Increase in the Development of “Volumizers” During Recent Years

Volume enhancing injectables Fat grafts 2004: Restylane SubQ® (Q-Med), Redisesse 2005: Juvederm Volume® (Allergan) 2006: Atlean (TCP), Laresse (CMC + PEO) 2007: Fortélis Extra® (Anteis), Teosyal Ultradeep (Teoxane) 2008: Belotero Intense (Merz) Volume (Corneal) Glytone Redexis Ultra Revanesse Ultra Isogel (Filorga) CRM DX Stylage XL Amalian III 2009: Novabel (Merz) “Shaper” (?) Hyacorp L, HyaCorp H 2010: Succeev Three (Sanofi Aventis) Princess Volume

Flow properties and longevity vary among different HA preparations and are in general determined by • • • • • • •

Molecular weight Concentration of HA Degree and technique of cross-linking with different cross-linkers such as BDDE (butadiene diepoxide), DVS (divinyl sulfone), and 1,2,7,8-DEO (diepoxyoctane) More cross-linking—harder gel Sizing of the gel particles Relation cross-linked/noncross-linked HA Hydration level

Today the hyaluronans of the fourth generation are becoming more popular (Table 2.2.4). New technologies such as cohesive polydensified matrix (CPM®) have recently led to the introduction of a monophasic preparation. The CPM technology involves the creation of

16

Table 2.2.4 Generation G0 G0 G1 G2 G3 G4

ILLUSTRATED MANUAL OF INJECTABLE FILLERS

Development of Hyaluronic Acid Fillers: Fourth Generation of Hyaluronans Name

Source

Cross-linking

Technique

Form

Year

Healon Synvisc Hylaform Restylane Puragen Belotero

Avian Avian Avian Streptogen Streptogen Streptogen

DVS DVS BDDE 1,2,7,8-DEO BDDE

Simple Simple Simple Double CPM

Solution Particles Particles Particles Particles Polydense matrix

1966 1988 1990 1994 2001 2004 2006

Abbreviations: BDDE, butadiene diepoxide; CPM, cohesive polydensified matrix; DEO, diepoxyoctane; DVS, divinyl sulfone. Source: From Ref. 3.

a homogenous, totally cohesive, and elastic gel with different densities, thus yielding double cross-linking in areas with the highest density and simple cross-linking in areas with less density. The advantage of these cohesive gels is optimal biointegration of the product injected into the dermis (5,6) by minimizing the risk of nodule formation due to its elasticity. Lip augmentation has become very popular but demands a special injection technique (7,8). In this region, fillers tend to form nodules due to the multiple functions with constant movements of the lips while smiling, speaking, and eating. Special preparations (Table 2.2.2) for lip volume augmentation that penetrate homogenously with lower viscosity are available on the market. HA fillers prepared using the CPM technology rank among the most popular products in Europe along with those HA products which have already been approved by the FDA in the United States. They seem to provoke the least tissue response two to four weeks after injection in comparison with other HA fillers (4). Belotero® (Merz Aesthetics, Germany) and Esthélis® (Anteis SA, Switzerland) (5,9) both prepared using the CPM technology and representing the same product are marketed in different formulations: Belotero Soft® and Esthélis Soft®, with a HA content of 20 mg/mL, are designed for more superficial wrinkles and are to be injected into the upper dermis; Belotero Basic® and Esthélis Basic®, with a HA content of 22.5 mg/mL, are used for deeper wrinkles with a Wrinkle Severity Rating Scale score of 4 and for lip augmentation; Belotero Intense and Fortélis Extra, with double cross-linking and the highest HA content of 25.5 mg/mL, are used for very deep wrinkles, are injected deep into the dermis, and are used for volumizing and lip augmentation. Esthélis Men is the same as Esthélis Basic, but is marketed for male patients. To facilitate injection of their HA products especially for the novice Anteis has developed the Anteis Injection Pen, which is an automated injection system designed for local injections. The use of this injection pen will alleviate pain for the patient and decreases the amount of adverse effects compared with manual injections (hematomas, redness, bruising). It provides more comfort and ease of use for the practitioner with better control of depth, flow, and volume, thereby optimizing clinical results. All that remains is justifying the cost–benefit of this device. Since 2007 Macrolane (Q-MED) is the first HA injectable filler that has been injected in large volumes subcutaneously or subperiostally into the body; it is available in two forms

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Macrolane VFR 20 and Macrolane VFR 30. The injection should be performed under local anesthesia with a blunt 0.2 cannula mounted on a 10 mL syringe of Macrolane. With Macrolane, migration has been seen and in a breast pilot study, where amounts of 100 mL of gel were used, microcalcifications were observed on radiological examination (10). For longer-lasting results in some HA fillers such as Redexis® (Prollenium Medical Technologies Inc.), Matridex® (BioPolymer GmbH, Germany), Beauty Sphere® (Rofil Medical International Germany), Dethail Lastingel® (Phitogen, Italy), Reviderm Intra® (Rofil Medical International, The Netherlands), dextranomers (Sephadex)—cross-linked spherical dextran (sugar glucose) beads (size 40–60 µm)—are added, which are positively charged and considered to regenerate new collagen (11). It is believed that incorporation of glycerol into an HA filler (Esthélis+Glycerol, Anteis), will provide higher resistance to free-radical, enzymatic, and thermal degradation (tests in vitro) of the filler. Glycerol is an endogenous natural moisturizing factor which contributes to maintaining the hydration rate of the dermis and reinforces the stratum corneum in its role as a barrier to water loss. Autologous fat is considered the original filler, as it exhibits most of the properties that are expected of an ideal filler. It is fully biocompatible, readily available, easily transferred from one area to another, making the procedure for restoring volume in the aging face very cost-effective. All this contributes to its widespread use in Europe since the late 1970s when the procedure of fat grafting, first reported in 1893 by Neuber (12), was revived by Illouz (13) and Fournier (14). Since then the technique of harvesting, preparing, and delivering fat is being refined (15), with acceptable patient satisfaction (16,17). The degree of permanence of autologous fat grafts in the subcutaneous tissue varies. Techniques to add adipose derived stem cells to human autologous fat grafts are now being developed (18) to extend the longevity of the fat grafts. In Europe, collagen products no longer play a role since Johnson & Johnson announced in November 2009 their intention to discontinue the manufacturing and marketing of their Evolence® products, which initially had a very good start in Europe. Much to our regret, Zyderm® I and II and ZYplast® are no longer available in Germany. I consider Zyderm I to have the best flow capacity for correction of fine wrinkles when used in the upper dermis. Medical grade silicone is available in Europe in form of PMS 350 (Vikomed), which has a kinematic viscosity of 350 cSt. Its use is limited due to negative public opinion and the risk of foreign body granulomas. Among the biodegradable but slowly absorbable fillers, poly-L-lactic acid (PLLA) manufactured under the name Sculptra® (Sanofi-Aventis) has been used the longest in aesthetic medicine in Europe since 1999 (see chap. 3.1). PLLA is a biocompatible, slowly biodegradable synthetic polymer which results in a gradual increase in the facial volume via endogenous production of fibroblasts and subsequent generation of new collagen. Correct reconstitution and administration are considered very important parameters for the optimal use of this filler (19,20). The dermal thickening is achieved over the course of several months (21,22). PLLA is slowly degraded into lactic acid microspheres through nonenzymatic hydrolysis (23). The safety of injectable PLLA has been addressed in several HIV trials; adjustments undertaken in the dilution and injection technique of PLLA and correct placement of the product appear to have improved safety outcomes (24,25).

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ILLUSTRATED MANUAL OF INJECTABLE FILLERS

In earlier experiences with the PLLA product marketed under the name New Fill , side effects like nodules and foreign body granulomas were observed in 10% to 30% of subjects (26–28). This experience with a filler is an example of a product marketed before a wider series of clinical studies had proved that a greater amount of dilution of the agent and the tunneling technique without overcorrection subcutaneously would improve the safety parameters. Physicians used the product like a filler with injections that were too superficial. Since the reappearance of the PLLA product under the name Sculptra (Sanofi-Aventis Laboratories), which is reconstituted with a minimum of 5 mL of apyrogenic water, physicians have changed to a totally different injection technique and compared with the use of other “fillers” the safety records are excellent (29,30). Another degradable substance with a long-term effect is Radiesse® (Merz Pharmaceuticals) (see chap. 3.1), which was developed in the United States, made its way across the ocean, and was introduced into the European market in 2004. It provides immediate and long-term effects based on its twofold mechanism of action: immediate correction with the carrier gel containing carboxymethylcellulose and long-term correction with the development of new collagen surrounding the Ca HA microspheres (31). Only a few studies have been conducted in Europe (32). The popularity of this filler is growing, yet the U.S. experience outgrows by far the European clinical experience (33–35). The clinical use of Radiesse for hand rejuvenation shows encouraging results (36). Among the “permanent” fillers with the longest clinical experience is Artecoll® (Rofil Medical International, Breda, The Netherlands), containing polymethylmethacrylate (PMMA) spheres with a size of 30 to 42 µm suspended in a collagen gel matrix (37–39). At the time of injection, PMMA is effective for the correction of wrinkles and functions as a temporary spacer. When the carrier gel is degraded, the PMMA particles cause endogenous fibroblast activity which leads to a gradual increase of facial volume over time. PMMA Artecoll was introduced into the market in 1992 as a second-generation formulation following the PMMA product Arteplast®. A third-generation product ArteFill® (40,41) (see chap. 3.1) was manufactured in the United States (Artes Medical, San Diego) and was the first permanent dermal filler to be approved by the FDA in 2008 when the manufacturer went bankrupt. In this third generation, the collagen matrix is optimized with enhanced uniformity of the microspheres and a smaller size and near elimination of nanoparticles compared with the second-generation product Artecoll,, which is still in common use in Europe. It is indicated for glabella frown lines, nasolabial folds, upper lip lines, and marionette lines. It has to be injected very deep into the reticular dermis. My favorite technique with Artecoll is the microdroplet technique using only tiny amounts of the product. This helps to avoid late complications like foreign-body granulomas. Aquamid® (Ferrosan, Copenhagen, Denmark) has been marketed in Europe since 2001. It is a polyacrylamide 2.5% gel (PAAG) with a very high water content of 97.5 %; it is kept in place by means of a fibrous capsule (endoprothesis) (42). These capsules are surrounded by fibroblasts and macrophages (43). Larger amounts of injected PAAG remain in the tissue for about 20 years, while smaller amounts like 0.1 mL of Aquamid are absorbed in 9 months. PAAG gels are well tolerated (44), but if injected in larger amounts may cause late complications (45). Aquamid is indicated for lip augmentation, deep nasolabial folds, and marionette lines, to give volume to cheeks and chin. ®

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Dermalive® and Dermadeep® (Dermatech, Paris, France) have been on the European market since 1991 but were withdrawn from the market two years ago. They are composed of an acrylic polymer hydroxyethylmethacrylate and ethylmethacrylate with a water content of 26%. The filler is a combination of 40% polygonal hydrogel particles which are suspended in 60% cross-linked HA gel. The hydrogel particles in Dermalive had a diameter of 45 to 60 µm, whereas the hydrogel particles in Dermadeep had a diameter between 80 and 110 µm. The manufacturer claimed biocompatibility and inertness of these fillers; yet after the initial success (46) and after a few years of injecting these fillers, late adverse events increased (47), and electron microscopic studies demonstrated that these fillers undergo morphological changes in human dermal tissue (48) over the years. As a result, these two products were withdrawn from the European market and are no longer in clinical use, yet we do still see the late complications of these acrylic hydrogels in the form of disfiguring foreign body granulomas. Novabel® (Merz Aesthetics, Frankfurt, Germany) is a new injectable filler made up of biocompatible soft gel spheres of highly purified polysaccharides derived from natural brown algae, which undergo an intensive purification process to build a homogenous orbital matrix (HOM™). The matrix consists of a three-dimensional network of minerally linked polysaccharides, giving flexibility and stability simultaneously. One milliliter contains 12 mg of Ba cross-linked alginate. The low viscosity of Novabel requires very low injection force and can be injected through a 30 G1/2 needle. It is used primarily to treat deep nasolabial folds, mentolabial folds, and marionette lines. It can be used for volumization of the cheeks, chin, décolleté, and hands. Marketing of this filler began in January 2010 in several European countries. In a phase III study conducted with 154 patients at several locations in France and Germany, clinically relevant improvement after injections of Novabel for correction of nasolabial folds was still noticeable after 12 months in 47% of the patients, and after 18 months in 43% of patients. CONCLUSION

For the past 30 years, modern injectable fillers have become increasingly popular and represent a viable alternative to surgical intervention for correction of the aging face. With their different properties, and different modes of administration, they allow the physician to tailor the use these agents for facial rejuvenation as required. Some of these agents have disappeared from the market, but many more have just recently appeared. In Europe, the procedure to obtain the CE certification for the manufacture of such substances is relatively easy, and most of the injectable fillers for cosmetic use are brought into the market without sufficient clinical experience and relevant studies, thus provoking unnecessary complications. However, many adverse events are related to the procedure, experience, and skill of the injector, rather than to the product. These adverse events can be avoided with experience and training. Many injection techniques in approaching a specific problem have been changed or have been newly introduced. The techniques for facial rejuvenation have changed from simply correcting wrinkles to panfacial augmentation and to combining fillers with other modalities for rejuvenation. The use of Botulinum toxin for the treatment of expression areas has become gold standard before using fillers in these areas to optimize their rejuvenating effect (49,50).

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REFERENCES 1. Micheels P, et al. L’acide hayluronique en esthetique dix ans déjà.! J Med Esteth Chir Dermatol 2005; 32: 175–84. 2. Pavicic T. Filler-ein Überblick. J Ästhet Chir 2009; 2: 215–22. 3. Reinmüller J. Hyaluronsäure in der ästhetischen Medizin: Historie, Entwicklung und heutige Bedeutung. JDDG 2008; 6(Suppl.2): 4–9. 4. Rohrich RJ, Ghavami A, Crosby MA. The role of hyaluronic acid fillers (Restylane) in facial cosmetic surgery: review and mechanical considerations. Plast Reconstr Surg 2007; 120(Suppl): 41S–54S. 5. Reinmüller J, Wolters M, Steinkraus V, et al. Wirksamkeit und Verträglichkeit des Hyaluronsäurefillers (MD) Basic(Belotero Basic) bei Nasolabialfalten. October 2007 Symposium at the XVI Congress EADV Wien-Austria. 6. Taufig AZ, Szöke A, Kühnel W. Neue Strategie zur Erfassung intradermaler Reaktionen nach Implantation resorbierbarer Dermafiller. J Ästhet Chir 2009; 2: 29–36. 7. Braun M, Braun S, van Eijik T. Lip tenting: a simple technique for better lip enhancement. J Drugs Dermatol 2010; 9: 559–60. 8. Sanoff DS, Saini R, Gotkin RH. Comparison of filling agents for lip augmentation. Aesthet Surg J 2008; 28(5): 556–63. 9. Bezzola A, Micheels P. Esthelis, acide hyaluronique de conception Suisse. Première étude complète des caractéristiques physico-chimiques et essais clinique. J Med Esthet Chir Dermatol 2005; 125: 11–20. 10. Bauer Ute UI, Bom Trevor M. Shaping the future: new outcomes in Europe. In: Cohen SR, Born TM, eds. Facial Rejuvenation with Fillers. Saunders Elsevier Ltd, 2009: 121–34. 11. Laeschke K. Biocompatibility of microparticles into soft tissue fillers. Semin Cutan Med Surg 2004; 23: 214–17. 12. Neuber GA, Fett Transplantation.Verl Dtsch Ges Chir 1893; 22: 66. 13. Illouz YG. The fat cell “graft”: a new technique to fill depressions. Plast Reconstr Surg 1986; 78: 122–3. 14. Fournier PF. Microlipoextraction et microlipoinjection. Rev Chir esthet Lang Fr 1985;10: 40. 15. Coleman SR. Structural fat grafting: more than a permanent filler. Plast Reconstr Surg 2006; 118: 108S–20S. 16. Tzikas TI. Autologous fat grafting for mid-face rejuvenation. Facial Plast Surg Clin North Am 2006;118 (Suppl.1): 108–20. 17. Butterwick KJ, Nootheti PK, Hsu JW, Goldman MP. Autologous fat transfer: an in-depth look at varying concepts and techniques. Facial Plast Surg Clin North Am 2007; 15: 99–111. 18. Hedrick MH, Fraser JK, Hicok HC. The potential role of adipose derived stem calls as semi-permanent/permanent fillers in aesthetic surgery. In: Cohen SR, Born TM, eds. Facial Rejuvenation with Fillers. Saunders Elsevier Ltd, 2009: 107–19. 19. Hilinski JM, Cohen SR. Volumetric use of injectable fillers in the face. In: Cohen, SR, Born TM, eds. Facial Rejuvenation with Fillers. Saunders Elsevier Ltd, 2009: 80. 20. Lam SM, Azizzadeh B, Gravier M. Injectable poly-L-lactic acid (Sculptra): technical considerations in soft-tissue contouring. Plast Reconstr Surg 2006; 118(Suppl): 55–63. 21. Vleggar D. Facial volumetric correction with injectable poly-L-lactic acid. Dermatol Surg 2005; 31: 1511–18. 22. Vleggar D, Bauer U. Facial enhancement and the European experience with Sculptra (poly-Llactic acid). J Drugs Dermatol 2004; 3: 542–7. 23. Hartmann M. Biopolymers from Renewable Resources. Berlin: Springer Verlag, 1998. 24. Borelli C, Kunte C, Weisenseel P, et al. Deep subcutaneous application of poly-L-lactic acid as a filler for facial lipoatrophy in HIV-infected patients. Skin Pharmacol Physiol 2005; 18: 273–8. 25. Valentin MA, Aubron-Olivier C, Ghosn J, et al. Polylactic acid implants (New-Fill) to correct facial lipatrophy in HIV-infected patients: results of the open-label study VEGA. AIDS 2003; 17: 2471–7.

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26. André P, Lowe NJ, Parc A, Clerici TH, Zimmermann U. Adverse reactions to dermal fillers: a review of European experiences. J Cosmet Laser Ther 2005; 7: 171–6. 27. Woerle B, Haneke CW, Sattler G. Poly-L-lactic acid: a temporary filler for soft tissue augmentation. J Drugs Dermatol 2004; 3: 385–9. 28. Burgess CM, Lowe NJ. New-Fill for skin augmentation a new filler or failure? Dermatol Surg 2006; 32: 1530–2. 29. Guaraldi G, Orlando G, De Fazio D, et al. Comparison of three different interventions for the correction of HIV-associated facial lipatrophy: a prospective study. Antivir Ther 2005; 10: 753–9. 30. Burgess CM, Quiroga RM. Assessment of the safety and efficacy of poly-L-lactic acid injections for the treatment of HIV-related facial lipatrophy. J Am Acad Dermatol 2005; 52: 233–9. 31. Marmur ES, Phelps R, Goldberg DJ. Clinical, histologic and electron microscopic findings after injection of a calcium hydroxylapatite filler. J Cosm Laser Ther 2004; 6: 223–6. 32. Moers-Carpi MM, Vogt S, Martinez Santos B, et al. A multicenter, randomized trial comparing calcium hydroxylapatite to two hyaluronic acids for treatment of nasolabial folds. Dermatol Surg 2007; 33(Suppl 2): S144–S151. 33. Sadick NS, Katz BE, Roy D. A multicenter 47-month study of safety and efficacy of calcium hydroxylapatite for soft tissue augmentation of nasolabial folds and other areas of the face. Dermatol Surg 2007; 33(Suppl 2): S122–S127. 34. Busso M, Karlsberg PL. Cheek augmentation and rejuvenation using injectable hydroxylapatite (Radiesse®). Cosmetic Dermatol 2006; 19(9): 538–88. 35. Roy D, Sadick N, Mangat D. Clinical trial of a novel filler material for soft tissue augmentation of the face containing synthetic calcium hydroxylapatite microspheres. Dermatol Surg 2006; 32: 1134–9. 36. Busso M, Applebaum D. Hand augmentation with Radiesse® (calcium hydroxylapatite). Dermatol Ther 2007; 20: 315–17. 37. Lemperle G, Gauthier-Hazan N, Lemperle M. PMMA-microspheres (Artecoll) for long-lasting correction of wrinkles: refinements and statistical results. Aesthetic Plast Surg 1998; 22: 356–65. 38. Lemperle G, Ott H, Charrier U, et al. PMMA microspheres for intradermal implantation. Part I. Animal research. Ann Plast Surg 1991; 26: 57. 39. Lemperle G, Romano JJ, Busso M. Soft tissue augmentation with Artecoll: 10-year history, indications, techniques, and Complications. Dermatol Surg 2003; 29: 573–87. 40. Lemperle G, De Fazio S, Nicolau P. Artefill®: a third generation dermal filler and tissue stimulator. Clin Plast Surg 2006; 33; 4: 551–65. 41. Cohen SR, Berner CE, Busso M, et al. Five year safety and efficacy of a novel polymethylmethacrylate aesthetic soft tissue filler for the correction of nasolabial folds. Dermatol Surg 2007; 33(Suppl): S223–S230. 42. Gogolewski S, Jovanovic M, Perren SM, et al. Tissue response and vivo degradation of selected polyhydroxyacids (PLA, PHB, PHB/VA). J Biomed Mater Res 1993; 27: 1135–48. 43. Christensen L. Normal and pathologic tissue reactions to soft tissue gel fillers. Dermatol Surg 2007; 33(Suppl 2): S168–72. 44. von Buelow S, von Heimburg D, Pallua N. Efficacy and safety of polyacrylamide hydrogel for soft tissue augmentation. Plast Reconstr Surg 2005; 116: 1137–46. 45. Christensen L, Breiting V, Janssen M. Adverse reactions to injectable soft tissue permanent fillers. Aesthetic Plast Surg 2005; 25: 34–48. 46. Bergeret-Galley C. Comparison of resorbable soft fillers. Aesth Surg J 2004; 24: 33–46. 47. Zielke H, Wölber L, Wiest L, Rzany B. Risk profile of different injectable fillers: results from the injectable filler study (IFS study). Dermatol Surg 2007; 34: 1–10. 48. Wiest LG, Stolz W, Schroeder JA. Electron microscopic documentation of late changes in a filler and clinical management of granulomas in affected patients. Dermatol Surg 2009; 35(Suppl 2): 1688–99. 49. Sommer B, Sattler G. Cosmetic indications according to anatomic region (Chapter 3). In: Sommer B, Sattler G, eds. Botulinum Toxin in Aesthetic Medicine. Berlin: Blackwell Science, 2001. 50. Ascher B. Toxine botulique et rides: les associations médicales et chirurgicales. Real Ther Derm Venerol 2004; 138: 7–9.

3.1 Choosing the ideal filler Cheryl Karcher

HOW TO CHOOSE THE IDEAL FILLER

Over the past decade, the use of injectable products in cosmetic dermatology has increased rapidly to become one of the top three cosmetic procedures performed in a physician’s office. The youthful fullness and skin turgor are altered and reduced as we age with the loss and redistribution of facial fat, collagen, elastin, and bone resorption. These changes in combination with static and dynamic facial rhytids are largely responsible for the rise in soft-tissue augmentation procedures and the quest for the ideal dermal filler. The ideal filler substance would be nonallergic, noncarcinogenic, nonteratogenic, durable, reproducible, stable, and affordable and would cause a minimum of adverse events. Arguably for some, the ideal filler will be permanent and for others resorbable, depending on the patient’s prior experiences and the physician’s expertise. There is no filler yet that fulfills all these criteria, but a thorough understanding of the differences among the current array of cosmetic fillers at our disposal is essential for choosing the correct dermal filler for optimal cosmetic treatment. PATIENT SELECTION, FILLER SELECTION—WHERE DO THEY INTERSECT?

The choice of appropriate filler agent for each patient begins at the consultation visit. Notable points about the consultation include an in-depth medical history. Patients on aspirin, nonsteroidal antiinflammatory drugs, and some potentially blood thinning vitamins need to be warned of the risk of significant bruising and swelling and if possible to discontinue medication seven to ten days prior to treatment. Additional history points include pregnancy or lactation, history of anaphylactic reactions, beef allergy (for bovine collagens), lidocaine allergy (for fillers already reconstituted with lidocaine), and history of collagen vascular disease (for collagen fillers). Informed consent needs to be obtained prior to the procedure with all applicable risks outlined. Photographic documentation must be performed. This will allow the physician to effectively manage patient expectations, accurately see improvement post procedure, and document defects present prior to treatment. Only with the aid of photography can an objective evaluation of the patient be 22

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made. Therefore, it is a valuable tool to track progress, develop new techniques, and advance the field of volumetric filling. At the consultation, filler agents are discussed in relation to their best cosmetic uses, longevity, cost per volume, and potential adverse events. Key questions that must be proposed to the patient are the amount of downtime the patient is able to tolerate post procedure, the necessity of immediate versus delayed results, and the amount of treatments necessary to correct the concern. This enables the patient to decide which filler would best suit their cosmetic needs and budget. Some of the points that need to be addressed at the consultation visit include the following choices: •

•

Passive versus active: This distinction is very important for patients since some choose to globally rejuvenate their face, often opting for several treatments with active fillers, while others seek instant results in a local problem area and may choose a passive filler that will yield an immediate result. Passive fillers do not influence the patient’s production of collagen and volume replacement is provided by the filler agent alone, or by the recruitment of water to the area. In contrast, active fillers stimulate the infiltration of fibroblasts into the treatment area and the subsequent secretion of collagen. They provide the initial framework for the fibroblasts but the total final volume replacement results from the patient’s own collagen production. Two examples of Food and Drugs Administration (FDA)-approved active fillers are Sculptra and ArteFill. These fillers often require multiple visits to achieve the desired correction and ensure adequate scaffolding for fibroblast infiltration. To the patient this translates to delayed results. It must be stressed to the patient that active fillers are not immediate and that the body will take months to rebuild what has been lost over years. Resorbable versus permanent fillers: With the recent availability of ArteFill, the first FDA-approved permanent filler in the United States, it is now possible for patients to lastingly alter the contours of their face without the need for repeat visits or what is sometimes known as “wallet fatigue.” Prior to the availability of ArteFill, off-label use of silicone was the only permanent option available. Although there is a large body of data documenting silicone usage via the microdroplet technique for facial augmentation, this use was never sanctioned by the FDA due to large percentage of side effects and granulomas that are associated with this treatment. The option of permanent fillers should only be explored with patients familiar with the use of fillers who are seeking to recreate the impact of a resorbable filler they have already tried. Permanent fillers should not be explored with first time clients as results cannot be corrected and misplaced material is very difficult to remove. Permanent fillers are reserved for clinicians with expert technique and considerable experience in soft tissue augmentation. When choosing a resorbable filler, it is important to consider the duration of action versus cost to the patient. Many resorbable options are available with the range of action between six months and two years. Longer-lasting fillers tend to cost more per syringe used and cost to patient may be an important factor in filler selection. Additionally, it is important to consider whether a reversing agent is available for the filler in question. One huge advantage to using hyaluronic acid (HA) fillers is that the enzyme hyaluronidase may be used to break down filler placed incorrectly.

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Dermal versus subdermal placement: Placement of filler is an important consideration in the final aesthetic outcome. The choice of the filler will generally depend on the depth of the defect to be filled in. As a rule, subdermal placement is reserved for more viscous and larger filler agents such as Radiesse, Sculptra, and ArteFill. These bulkier fillers would produce an uneven appearance if placed too superficially. Dermal placement is better suited for finer particle size fillers such as collagens and HAs. When restoring volume to fine tissue zones, such as a periorbital and temporal areas, subdermal placement is recommended since the tissue is too thin to camouflage the addition of a foreign substance. Additionally, fine rhytids commonly found in the perioral area are treated with dermal placement of filler to restore volume in a more superficial plane.

BIODEGRADABLE—PASSIVE FILLERS Collagen

Collagen has been FDA-approved for cosmetic enhancement of the face since 1981. The mechanism of action of collagen fillers is primarily that of passive volume replacement (1,2). The results are immediate and these fillers are ideal for patients seeking instant local improvement. Collagen fillers are biodegradable and resorbable with various duration of action all under one year (3). Results with collagen are best suited for soft defects with distensible skin and treatment is most effective in fine superficial rhytids, including the vertical lines above and below the lip, nasolabial folds, glabellar frown lines (with caution due to underlying vasculature), lateral periorbital rhytids, and acne scars. Dermal placement of product is recommended (Fig. 3.1.1) (4). Highly purified bovine dermal collagens (Zyderm, Zyplast) were approved by the FDA in 1981 and 1985, respectively as injectable implants for facial aesthetics (5). The biggest factor related to the decreased use of these bovine collagen products is their risk of causing allergic reactions. To rule out hypersensitivity reactions at least two intradermal skin tests are necessary. Due to the inconvenience of skin testing, these products have been replaced by collagens from other sources (5). Improving on the issue of cross-species allergic reactions are human-derived collagen fillers, CosmoDerm and CosmoPlast. The FDA approved the use of these dermal fillers

(A)

(B)

Figure 3.1.1 (A) Before and (B) after rejuvenation with collagen (CosmoPlast) in the nasolabial folds and marionette lines. 1.0 cc syringe was split between the left and right sides.

CHOOSING THE IDEAL FILLER

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in 2003. Dermal fibroblasts are harvested from bioengineered human skin (6). This dermal tissue is identical to the human dermis but lacks immune cells and therefore pretreatment skin tests are unnecessary. The final product contains type I and type III triple helix collagen that is capable of binding with HA and other molecules to provide structure to the skin (6,7). CosmoDerm and CosmoPlast collagen is dispersed in a phosphate-buffered saline solution and lidocaine to decrease periprocedural pain. During administration, overcorrection of 1.5 to 2 times the initial defect is recommended. As the saline and lidocaine disperse, the correction becomes appropriate. Duration of action is between three and six months. Placement of filler is upper papillary dermis for CosmoDerm and deeper reticular dermis for CosmoPlast (8). Various injection techniques may be utilized, with the serial puncture technique being recommended. A porcine-derived collagen product, Evolence, attained FDA approval in June 2008. Porcine collagen is more similar to human than bovine collagen and has been used in heart valves, skin grafts, and dental membranes for many years with a minimum of hypersensitivity reactions (9). Clinical trials with Evolence demonstrate no evidence of adverse immunologic effects (10). The duration of action for Evolence is longer than for any other collagen product on the market with early clinical experience showing it to be six to nine months (11). Recommended placement is deep dermal and no overcorrection is necessary. Because of its longer duration of action, Evolence is in competition with HA products for convenience and ease of use. One drawback of this product is reports of nodule formation when injected into the lips; as such, this injection site is not recommended with this particular filler (12). Additionally, there are other collagen products on the market of cadaveric or autologous human origin. One such filler, Isolagen, is prepared from the patient’s own skin (13). It consists of cultured fibroblasts rather than a suspension of collagen fibrils and is currently in phase III clinical trials for facial rhytids and dermal depressions. As more collagen products gain FDA approval, achieving immediate popularity, natural feeling filler with forgiving results will continue to grow. Hyaluronic Acid

Hyaluronic acid (HA) is a type of glycosoaminoglycan macromolecule. These macromolecules are chains of repeating disaccharide units of D-glucoronic acid and N-acetylglucosamine and are found throughout the ground substance of the dermis (14). HAs are passive fillers acting via their extremely hydrophilic nature; attracting water up to 1000 times its volume and not requiring overcorrection (15). HAs fall into the class of fillers that are placed dermally due to their fine particle size and are best suited for lips, fine lines, nasolabial folds, and the nasojugal groove. HA is identical in all species and therefore has less antigenicity and does not require a skin test. Currently some HA products are derived from animals while others are nonanimal-derived stabilized hyaluronic acids (NASHAs) derived from bacteria via streptococcal fermentation. Commercially available HA agents have been cross-linked to increase their longevity in the body (15). Currently HA are the most used injectable fillers in the United States with the most requested being Restylane, Perlane, and Juvederm. The duration of action of these fillers is moderate with longevity reaching nine months (16). On average, HAs last two to four months longer than collagen fillers. If the HA is injected too superficially into the dermis, there may be an apparent “blue” mark caused by the Tyndall effect (Fig. 3.1.2).

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Restylane was the first HA to be approved by the FDA (in 2003) and is the most common filler in the United States today. It is derived from nonanimal sources and is partially cross-linked. The concentration of HA is 20 mg/mL and longevity is approximately six months (8,17). The Restylane line of products also includes Restylane Fine Lines and Perlane. Perlane was FDA-approved in 2007 for the correction of moderate to severe facial wrinkles and folds. The concentration of product is the same as Restylane at 20 mg/mL but the longevity of Perlane is longer than Restylane, clinically seen to be between six and nine months. Perlane has a higher degree of cross-linking than Restylane, resulting in a thicker consistency. Due to this the recommended placement is the reticular dermis (8,17). Juvederm was approved by the FDA in 2006 to treat deep facial lines and wrinkles and seems to offer greater longevity than any other HA on the market, touted to last up to one year. Juvederm is nonanimal derived and in contrast to other HA products the Juvederm HA formulation is composed of a homologous gel, while other products have particles of different sizes composing the mixture (18). In the United States, two different formulations of Juvederm are available: Juvederm Ultra and Juvederm Ultra Plus for deeper folds and rhytids. These products differ between each other in the concentration of HA available with 24 and 30 mg/mL, respectively. A new HA product, Prevelle Silk, recently attained FDA approval for the treatment of superficial to moderate facial lines. Prevelle is unique in that its HAs are double cross-linked to resist degradation in the skin and to further increase their clinical duration (19). Prevelle is a clear colorless gel that contains 5.5 mg/mL of HA as well as lidocaine for increased comfort upon injection. Prevelle is NASHA-derived product and is therefore contraindicated for anyone allergic to gram positive bacterial products or lidocaine. Prevelle is supplied in

(A)

(B)

Figure 3.1.2 (A) Before and (B) after two syringes of Restylane to the nasolabial folds (NLFs). 1.0 cc to each NLF.

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individual treatment 0.9 mL syringes with two 30 gauge needles and is packaged ready for patient use. Injection is into the dermis and duration of product is four to eight months. Over the past few years, HAs have become the gold standard of facial fillers for several reasons. HAs provide immediate volume replacement, and the heavy cross-linking of the HA molecules increases their duration within the dermis. Because HA molecules are very hydrophilic, they continue to attract water to sustain volume augmentation after they are injected. An additional advantage of HA fillers is the availability of a reversing agent. The enzyme hyaluronidase may be used to break down filler that is placed incorrectly, that moves, or in rare cases occludes a vessel. Calcium Hydroxylapatite

Radiesse is a facial filler composed of a suspension of calcium hydroxylapatite, an inert bioceramic that has mineral components similar to those in bones and teeth. As such, patients should be informed that the product may appear on facial x-ray. Radiesse was initially approved by the FDA for the treatment of vocal cord insufficiency, oral and maxillofacial defects before being approved for correction of deep to severe facial rhytids in 2006. The particle sizes of the synthetic calcium hydroxylapatite found in Radiesse range from 25 to 45 µm suspended in a 70% gel carrier composed of 1.3% carboxymethylcellulose, 6.4% glycerin, and 36.6% sterile water. The carboxymethylcellulose initially helps to maintain volume replacement; however, as the carboxymethylcellulose is degraded by the body, the left over calcium hydroxylapatite acts as a scaffold for fibroblast ingrowth (20). Whether this actively contributes to de novo collagen synthesis is still debated by the dermatologic community. Therefore, Radiesse is classified a passive filler (Figs. 3.1.3 and 3.1.4).

(A)

(B)

Figure 3.1.3 (A) Before and (B) after calcium hydroxylapatite (Radiesse) to the nasolabial folds (NLFs). 1.3 cc Radiesse was mixed with 0.2 cc lidocaine 1% and split between the left and right NLF.

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(A)

(B)

Figure 3.1.4 (A) Before and (B) after Radiesse for the malar creases. 1.5 mL syringe was split between the left and right sides.

Radiesse is used primarily to treat local rhytids such as the nasolabial folds and marionette lines (21). It can also be used in nose and chin augmentation, cheek augmentation, and diffuse facial contouring such as for HIV-associated lipoatrophy (22). Currently studies are underway to explore the use of Radiesse for global hand rejuvenation (23). Injection of Radiesse into the lips is controversial based on the high rate of nodule formation from the compression of the orbicularis muscle during chewing, and is not recommended. Placement is deep dermal/subdermal via a 27 gauge needle and after injection the product may be massaged and molded to fit the contours of the face. BIODEGRADABLE—ACTIVE FILLER Poly-L-Lactic Acid

Poly-L-lactic acid (PLLA) is a synthetic, biocompatible, biodegradable polymer derived from vegetable sources and has been used in synthetic suture material for over 40 years. PLLA is marketed in the United States as Sculptra and in 2004 received FDA approval specifically for treatment of HIV-associated lipoatrophy; any uses outside this indication are considered to be off-label (24). Sculptra is designed for the global correction of diffuse facial volume loss rather than the correction of a specific rhytid. The initial volume response to Sculptra is related to a mechanical volume effect of diluent and may last up to one week. The final correction may not be apparent for a few months. Thus it is ideal for patients seeking natural volume contouring who are comfortable with delayed results and often multiple treatments. Longterm tissue filling effects are caused by ingrowth of type I collagen into the areas previously

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CHOOSING THE IDEAL FILLER

(A)

Figure 3.1.5 each NLF.

(B)

(A) Before and (B) after Artefill rejuvenation of the nasolabial folds (NLFs). 0.8 cc to

occupied by PLLA particles. This type of neocollagenesis is thought to occur through a macrophage and fibroblast response and secretion of tumor necrosis factor-alpha (25). By contributing to soft tissue augmentation via new collagen synthesis, Sculptra is classified as an active filler. Sculptra is supplied as an anhydrous powder that must be reconstituted 2 to 72 hours prior to injection, therefore same-day procedures are not usually performed unless the product has already been mixed. Reconstitution with lidocaine immediately prior to injection will lessen the discomfort, reduce viscosity, and also potentially decreasing granuloma formation. Sculptra is injected into the subdermal space in a fan-shaped pattern while withdrawing the needle. A small depot or bolus injection can be used in the areas of the upper zygoma or temples. Overcorrection is not needed. Immediately after injection, massage should be done and repeated daily for several days. Repeat injections may be performed every four to six weeks and usually two to three treatments are planned. Effects may last two to four years. Recommended usage includes volumetric filling to correct facial fat and bone atrophy, the nasojugal grove, where the product is placed submuscularly, hand rejuvenation, and acne scars (25). SYNTHETIC—ACTIVE FILLERS Polymethylmethacrylate

Polymethylmethacrylate (PMMA) is marketed in the United States as ArteFill, and gained FDA approval in 2006. It is the only nonresorbable dermal filler for use in facial lines and rhytids. The effects are classified as permanent, with studies showing the persistence of PMMA spheres up to 10 years postinjection (26). As such this filler should not be the primary choice for first-time patients and is reserved for expert use (Fig. 3.1.5). ArteFill is a combination filler composed of 20% PMMA microspheres evenly suspended in an 80% solution of partly denatured bovine collagen and 0.03% lidocaine (27,28). The PMMA microspheres are permanent, while the bovine collagen is biodegradable. The collagen provides instantaneous correction while the PMMA spheres are, in theory, chemically inert and stable for many years. All microspheres have a diameter of 30 to 50 µm

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ILLUSTRATED MANUAL OF INJECTABLE FILLERS

and have a smooth, round surface. The size, smooth surface, and lack of electrical charge enables the microspheres to resist phagocytosis and dislocation as they are encapsulated by the patient’s own collagen (27,28). The bovine collagen in ArteFill is partially denatured and is thought to be less likely to cause an allergic reaction, however a skin test is still required and a 28-day waiting period is observed. ArteFill is indicated for glabellar frown lines, nasolabial folds, upper lip lines, and mouth corners. It is injected into the reticular dermis, just above the dermal-subcutaneous fat interface, by means of a tunneling technique. ArteFill should be deposited in layered fashion to provide a scaffold for tissue infiltration. Injection should be followed by gentle massage to evenly distribute the material. Complications can arise from inaccurate depth of injection. An injection that is too deep can lead to ineffective treatment and may require repeat injection. An injection that is too superficial can lead to erythema and itching, superficial bumps, and may require treatment with topical or intradermal steroids. Silicone

Medical grade silicone is available in the United States in two forms—Adatosil 5000 and Silikon 1000. Both products are highly purified, injectable, long-chain polydimethylsiloxane oils. The numbers 5000 and 1000 refer to centistokes (cs), which are a measure of viscosity (water has a viscosity of 100 cs). Medical grade silicone is FDA-approved for the treatment of retinal detachment and retinal tamponade. It is used off-label as a soft-tissue filler. The microdroplet technique is used. In this procedure 0.01 to 0.02 ml of silicone is injected subdermally with a tuberculin syringe through a 28 to 30 gauge needle by means of either linear fanning or multiple-stab technique (29). In time, the implant can harden through ingrowth of connective tissue, and it may form a granuloma or “late siliconoma.” These can generally be treated with steroid injections or antimitotic agents. Use of silicone in the United States has been limited by lack of FDA approval for aesthetic uses, small margin of error in its injection technique, and negative public opinion about the substance. Currently, high-purified 1000-cs silicone has attained investigative status for the treatment of facial lines and wrinkles and for lipoatrophy related to treatment for HIV infection (30). SUMMARY

The use of dermal fillers for soft tissue augmentation quickly has become the third most popular physician-administered cosmetic procedure in the United States. The development of rhytids, loss of subcutaneous fat, and gravitational changes that accompany the aging face ensure that the demand for soft tissue augmentation and fillers will only continue to grow. Currently used filling agents have different modes of action and different injection techniques, so the dermatologic surgeon must be knowledgeable about the product, its advantages and disadvantages, and its optimal uses. Presently, HA products are the most popular of the dermal fillers. However, longer-lasting or even permanent fillers are also available and may be more appealing to the patient and physician. Temporary fillers should be used as a trial or prelude to permanent or longer-lasting fillers. This will give the patient an idea of what can be accomplished and determine whether they would like a longerlasting filler, additionally it will give the surgeon a good idea of the amount of filler needed to accomplish the patient’s goal.

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As newer products are added to the marketplace dermatologists will have more tools to deliver results with fewer allergic events, greater duration, and lesser pain. The ideal facial rejuvenation treatment package will likely utilize combination approaches of dermal fillers and various lasers and light sources. Future research evaluating current products used alone or in combination will be helpful as treatment of the cosmetic patient is optimized.

REFERENCES 1. Sclafani AP, Romo III T. Collagen, human collagen, and fat: the search for a three-dimensional soft tissue filler. Facial Plast Surg 2001; 17: 79–85. 2. Klein AW. Skin filling. Collagen and other injectables of the skin. Dermatol Clin 2001; 19: 491–508. 3. Lemperle G, Morhenn V, Charrier U. Human histology and persistence of various injectable filler substances for soft-tissue augmentation. Aesthetic Plast Surg 2003; 5: 354–66. 4. Cirillo P, Benci M, Bartoletti E, Bertana C. Proposed guidelines for use of dermal and subdermal fillers. G Ital Dermatol Venereol 2008; 143: 187–93. 5. Klein AW, Elson ML. The history of substances for soft-tissue augmentation. Dermatol Surg 2000; 26: 1096–105. 6. Bauman L. Cosmoderm/Cosmoplast (human bioengineered collagen) for the aging face. Facial Plast Surg 2004; 20: 125–8. 7. Hotta T. Dermal fillers. The next generation. Plast Surg Nurs 2004; 24: 14–19. 8. Cohen J, Bar A. Fillers for facial rejuvenation. In: Hirsch R, Sadick N, Cohen J. eds. Aesthetic Rejuvenation: A Regional Approach. McGraw Hill Medical, 2009. 9. Fernandez EM, Mackley CL. Soft tissue augmentation: a review. J Drugs Dermatol 2006; 5: 630–41. 10. Shoshani D, Markovitz E, Cohen Y, Heremans A, Goldlust A. Skin test hypersensitivity study of a cross-linked, porcine collagen implant for aesthetic surgery. Dermatol Surg 2007; 33(Suppl 2): S152–8. 11. Narins RS, Brandt FS, Lorenc ZP, et al. Twelve-month persistency of a novel ribose-cross linked collagen dermal filler. Dermatol Surg 2008; 34(Suppl 1): S31–9. 12. Braun M, Braun S. Nodule formation following lip augmentation using porcine collagen-derived filler. J Drugs Dermatol 2008; 7: 579–81. 13. Boss Jr WK, Usal H, Fodor PB, Chernoff G. Autologous cultured fibroblasts: a protein repair system. Ann Plast Surg 2000; 44: 536–42. 14. Monheit GD. Hyaluronic acid filler. Facial Plast Surg Clin North Am 2007; 15: 77–84. 15. Falcone SJ, Berg RA. Cross-linked hyaluronic acid dermal fillers: a comparison of rheological properties. J Biomed Mater Res A 2008; 87: 264–71. 16. DeLorenzi C, Weinberg M, Solish N, Swift A. Multicenter study of the efficacy and safety of subcutaneous non-animal stabilized hyaluronic acid in aesthetic facial contouring: interim report. Dermatol Surg 2006; 32: 205–11. 17. Brandt FS, Cazzaniga A. Hyaluronic acid filler: Restylane and Perlane. Facial Plast Surg Clin North AM 2007; 15: 63–76. 18. Monheit GD, Prather CL. Juvederm: a hyaluronic acid dermal filler. J Drugs Dermatol 2007; 6: 1091–5. 19. Sagrillo D. Emerging trends with dermal fillers. Plastic Surg Nurs 2008; 28: 152–3. 20. Berlin A, Cohen J, Goldberg DJ. Calcium hydroxylapatite for facial rejuvenation. Semin Cutan Med Surg 2006; 25: 132–7. 21. Alam M, Yoo SS. Technique for calcium hydroxylapatite injection for correction of nasolabial fold depressions. JAAD 2007; 56: 285–9. 22. Tzikas TL. Evaluation of Radiance FN soft tissue filler for facial soft tissue augmentation. Arch Facial Plast Surg 2004; 6: 234–9.

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23. Busso M, Applebaum D. Hand augmentation with Radiesse. Dermatol Ther 2007; 20: 285–7. 24. Vleggaar D. Facial volumetric correction with injectable poly-l-lactic acid. Dermatol Surg 2005; 31: 1511–18. 25. Keni SP, Sidle DM. Sculptra (injectable poly-L-lactic acid). Facial Plast Surg Clin North Am 2007; 15: 91–7. 26. Lemperle G, Romano JJ, Busso M. Soft-tissue augmentation with Artecoll: 10 year history, indications, techniques, complications. Dermatol Surg 2003; 29: 573–87. 27. Lemperle G, de Fazio S, Nicolau P. Artefill: a third generation permanent dermal filler and tissue stimulator. Clin Plast Surg 2006; 33: 551–65. 28. Broder KW, Cohen SR. Artefill: a permanent skin filler. Expert Rev Med Devices 2006; 3: 281–9. 29. Orentreich DS. Liquid injectable silicone: techniques for soft-tissue augmentation. Clin Plast Surg 2000; 27: 595–612. 30. Jones DH, Carruthers A, Orentreich DS, et al. Highly purified 1000-cSt silicone oil for treatment of human immunodeficiency virus-associated facial lipoatrophy: an open pilot trial. Dermatol Surg 2004; 30: 1279–86.

3.2 European commentary Luitgard Wiest

For the most part over the last decade, a great number and a variety of injectable fillers have evolved in Europe, as shown in the Appendix. Physicians have to select the most appropriate filler for each specific use. Filler properties might differ significantly between the different classes, such as resorbable and permanent, so physicians must have a thorough understanding and knowledge of these properties, the safety considerations, the importance of patient factors, as well as knowledge of facial anatomy and the aging process. Physicians must also have received training in using the best techniques for each individual filler to provide the most satisfactory results as explained in chapter 2.2. So it is not only the choice of the filler per se that is the key to an optimal result, but also how it is used. In making the right choice of an injectable filler for individual use, these issues must be taken into account for a predictable aesthetic result, to optimize the outcome and patient satisfaction. Some of these fillers such as collagen fillers, Zyderm, Zyplast, and Evolence have been taken off the market in Europe, new fillers are being developed, and techniques continue to change and improve. Key properties of the different types of fillers have been described in the preceding chapters and the technical aspects of their use will be discussed in the following chapters. In choosing the best filler for the intended correction in a specific area, the following factors must be considered: • • • • •

Patient’s wishes Patient’s history ❍ Allergies, previous treatments with fillers Physician’s own experience with handling the specific filler agent Training of the physician Area of treatment ❍ Skin quality ❍ Elastosis ❍ Atrophy ❍ Skin type thick/thin ❍ Type of wrinkle superficial/deep 33

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Volume deficiency Area of expression Knowledge of the filling agent to be injected Resorbable/permanent Injection technique Injection level ❍ Dermis: Superficial/deep ❍ Subcutaenuos ❍ Epiperiostal Flow capacities of the filling agent Volume to be injected Size of needle Type of anesthesia Longevity of the filling agent Necessity of adjunctive treatment ❍ ❍

• • • •

• • • • • •

Besides autologous fat, filler products range from biologically derived substances to synthetic compounds as well as combinations of both. With regard to their properties, they show differences in terms of indications, application, handling, and durability. As previously discussed, choosing the best filling agent is sometimes difficult, especially when the choice is among the hyaluronic acid (HA) fillers that seem to fulfill many of the characteristics of a highly satisfactory filling agent, but differ considerably among themselves. With over 100 different formulations and multiple manufacturers, the physician has to be very familiar with the different properties (see chap. 2.2) of each of these agents to optimize his choice. Patients’ foremost interest is the longevity of the achieved correction. Longevity of a filling agent is one of the most decisive factors, besides safety issues, for a patient’s wish to be treated with a certain filler. Yet with regard to durability it must be remembered that results on longevity as reported in numerous studies do not take into account all the variables encountered in daily practice. The most important factors that might influence the permanence of a filling agent in the tissue are the technique used and the experience of the physician. A physician might be able to handle one product better than another with which he or she has not yet gained experience. Many side effects are more related to the experience and skill of the physician, rather than the product itself. Other interacting factors that influence the outcome of treatment and longevity may also be the volume of filler injected and the patient’s lifestyle, age, and quality of skin. The negative influence of UV radiation and smoking on the skin is well documented. When used properly, many fillers can provide satisfactory results. Some facial regions do better with one product than with another, and some facial areas are inappropriate for certain fillers. The thickness of the dermis of facial skin varies considerably and is the lowest in the periorbital region. This has to be taken into account when choosing a filler for this region or using a filler in older patients with atrophic skin where longer-lasting or permanent fillers are not recommended. The choice for this area and for fine wrinkles will be a less viscous material, with good flow capacities, like the monophasic HA gel fillers, which can be injected at an upper level and are more forgiving when used in excessive volumes. In general, fillers with a higher degree of viscosity, particulated fillers with a higher concentration of HA, the long-lasting fillers like Radiesse, or the permanent

EUROPEAN COMMENTARY

35

polymethylmethacrylate fillers like ArteFill have to be injected in deeper levels of the dermis, subcutaneuosly or epiperiostally. They are mostly used for the treatment of deep wrinkles or volume restoration and have to be applied using different techniques. Injectable poly-L-lactic acid remains in a distinct category, as aesthetic results are delayed and the principal goal is to restore volume and not to treat specific folds or wrinkles. When selecting a filler, the types of adverse effects have to be considered as any injectable filler can result in complications. Permanent fillers that are not reversible tend to be associated with more serious delayed-onset adverse events like foreign body granulomas. With an experienced physician and a correctly chosen patient and filling agent, the use of injectable fillers for aesthetic correction is a safe, minimally invasive procedure with an overall benefit to satisfy both the patient and the physician.

4 Anatomy of the forehead and periocular region Marcelo B. Antunes and Stephen A. Goldstein

For anyone undertaking even minimally invasive surgery of the face and neck it is vital to understand the vascular, nervous, and muscular anatomical structures (Figs. 4.1–4.3). INTRODUCTION

The upper third of the face is composed of the forehead and eyes. These structures can be said to comprise the first impression of someone’s face. The forehead and eyes together often convey a person’s emotional state or feelings. To this end, an accurate projection of a person’s true state of mind may be misrepresented secondary to the aging process. This is one of the primary reasons for which patients wish to address facial aging. Knowledge of the underlying anatomy of the upper third of the face is pertinent to accurately assess the stages of facial aging. This will allow the surgeon to determine which rejuvenation techniques are most beneficial for patients with aging of the upper third of the face. The upper third of the face is the segment between the anterior hairline (trichion) and the superior orbital rims and glabella on frontal view. The periocular area is technically included in the middle third of the face; but secondary to its importance for facial expression and aesthetics, it is usually described separately from the midface. The upper eyelids are most commonly described with the upper third of the face due to their close relationship with forehead and eyebrows. The eyes are arguably the most important aesthetic feature of the face. They are also often the first area to manifest age-related changes. In youth, the eyelids are taut and have a subtle and gentle fullness. The upper eyelid has a well-defined and sharp eyelid crease just above the tarsal plate. The lower eyelid comes down to the orbital rim and gradually blends into cheek creating a single convexity. The periorbital aging process starts with lateral canthal rhytids. Changes in skin texture with laxity and pseudo fat herniation follow. The upper eyelid may also develop excess skin and start to look skeletonized and hollow. The lower eyelid, malar fat, and suborbicularis oculi fat (SOOF) can descend. This can contribute to a tear trough deformity and a double convexity of the lower eyelid and cheek junction. 36

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ANATOMY OF THE FOREHEAD AND PERIOCULAR REGION

Supraorbital artery Supratrochlear artery Dorsal nasal artery Medial palpebral artery Infratrochlear artery

Orbital branch of superficial temporal artery Superficial temporal artery

Angular artery

Transverse artery Infraorbital artery

Facial artery

(A)

Frontal branch Orbital branch of superficial temporal artery Supraorbital artery Supratrochlear artery

Lacrimal artery Anterior ethmoidal artery Posterior ethmoidal artery Superficial temporal artery Internal carotid artery

Angular artery Zygomaticofacial artery Infraorbital artery Transverse artery

Ophthalmic artery Maxillary artery

Facial artery

(B)

Figure 4.1

(A,B) Vascular anatomy of the midface. Source: From Ref. 1, with permission.

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Temporal branch

Zygomatic branches

Buccal branches Marginal mandibular branch

Parotid gland

Carvical branches

(A)

Supraorbital nerve Supratrochlear nerve Infratrochlear nerve

Zygomaticotemporal nerve

Lacrimal nerve

Zygomaticofacial nerve Infraorbital nerve

(B)

Figure 4.2 (A) Branches of the facial nerve. (B) Nerves of the orbital region. Source: From Ref. 1, with permission.

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ANATOMY OF THE FOREHEAD AND PERIOCULAR REGION

Occipitofrontalis

Depressor supercilii Orbital orbicularis oculi Preseptal orbicularis oculi

Corrugator supercilii Procerus

Pretarsal orbicularis oculi Levator labii superioris alaeque nasi Levator labii superioris Zygomaticus minor Zygomaticus major Masseter Risorius Depressor anguli oris Platysma

Orbicularis oris

Depressor labii inferioris Mentalis

(A)

Orbital retaining ligament

Zygomatic retaining ligament (McGregor’s patch) Buccal-maxillary retaining ligament Masseteric ligament Platysma-auricular ligament Mandibular retaining ligament

(B)

Figure 4.3

(A) The muscles of facial expression. (B) The retaining ligaments. (Continued)

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ILLUSTRATED MANUAL OF INJECTABLE FILLERS The frontalis muscle

The orbital orbicularis muscle The preseptal orbicularis muscle The pretarsal orbicularis muscle

The corrugator supercilii muscle The depressor supercilii muscle The procerus muscle

Figure 4.3 (Continued ) (C) The forehead depressor muscles. Source: From Ref. 1, with permission.

Eyebrow aesthetics differ in female and male patients. A feminine eyebrow arches with the medial and lateral tails resting along the orbital rim. Aesthetically, the apex of the arch is a matter of personal preference. Most women desire the apex of the eyebrow arch at the level of their lateral limbus while others prefer the peak more laterally at the eyelid canthus. The male eyebrow, on the other hand, runs horizontally along the orbital rims and is relatively straight. The male eyebrow creates a T shape with the nasal dorsum. The hair quality and density are also different in men and women. The male eyebrow is thicker and bushier while the female brow is thinner and more refined. The remaining upper third of the face is ideally composed of a smooth skin to the level of the hairline. The anterior hairline is also aesthetically important. The ideal hairline creates a balanced face when it is divided into horizontal thirds. A naturally low hairline will shorten the upper third and is best addressed surgically. A receding and thinning hairline tends to lengthen the forehead and contribute to the perception of aging. An increasing distance between the hairline and eyebrows is a visual sign of aging. The earliest signs of an aging eyebrow include glabellar and horizontal rhytids typically starting in the early thirties. As people age, actinic skin changes in combination with weakening support of the soft tissue of the upper face continue to contribute to the visual signs of aging. Clinically this presents with dermatochalasis of the upper eyelids. The forehead rhytids become more defined as the frontalis muscle attempts to compensate for progressive descent of the eyebrows. The eyebrow descent adds to the excess skin and lateral hooding (2). The orbital fat then breaks through the orbital septum in the upper eyelid causing mechanical eyelid descent and fat pad herniation. The combination of these age-related changes projects a tired and angry appearance. BONY ANATOMY

The skeletal support for the upper third of the face is composed primarily of the frontal bone and a portion of the temporal bone laterally. The frontal bone has two components, the vertical squama portion and the horizontal orbital portion. The squama corresponds to the forehead and most commonly has a gentle convexity. This portion of the frontal bone is relatively thick, providing strength and protection for the cranial vault. Superiorly there are

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two elevated areas named the frontal eminence. These can be asymmetric disturbing the vertical balance of the face. Inferiorly, separated by a slight groove are two more prominent elevations called the superciliary arches. These are joined in the midline by the glabella. These arches are more prominent in males. On the inferior portion of the squama is the supraorbital margin. This is the boundary between the squama portion and the orbital portion of the frontal bone. At the junction of the middle and medial thirds of this arch, is the supraorbital foramen (or notch) that caries the supraorbital nerve. A small percentage of people have an accessory foramen 1 to 2 cm above the orbital rim (3). The orbit is composed of seven bones. For the purpose of facial aging and rejuvenation, only the bones creating the orbital rim have relevance. These are the frontal bone superiorly, maxillary bone inferiorly and medially, and the zygomatic bone laterally. MUSCULATURE AND INNERVATIONS

The muscle function of the upper third of the face enables a person to show surprise, pain, fear, anger, concern, and worry, among many other expressions. The eyebrow has several paired depressor muscles consisting of the corrugators, depressor supercilii, and the orbicularis oculi muscles. The frontal branch of the facial nerve innervates all of these muscles. The procerus muscle, also an eyebrow depressor, lies in the midline between the frontalis muscles. The zygomatic branch of the facial nerve innervates the procerus. The frontalis muscle serves as the sole brow elevator. It is a paired thin muscle and rhomboidal in form. There are no true bony attachments. It is enveloped by the galea aponeurotica. Inferiorly the frontalis muscle inserts into the forehead skin blending with fibers from the orbicularis oculi, procerus, and corrugator muscles. Superiorly it continues as the galea aponeurotica transitioning posteriorly into the occipitalis. The frontalis muscle raises the eyebrow and draws the scalp forward giving the expression of surprise. The vertical lift promotes the transverse rhytids in the forehead. These rhytids become well defined at rest as elongation of the forehead distance increases. The corrugator is a pyramidal muscle that originates from the medial end of the superciliary arch, travels superiorly and laterally becoming inserted into the subcutaneous tissue close to the pupillary line. The action of the corrugator is to draw the eyebrows medially and inferiorly, creating the oblique and vertical folds in the glabella. The procerus muscle lies medially to the corrugators in the midline of the forehead. Its origin is along the nasal bones. It inserts into the skin of the glabella. The contraction of the procerus muscle draws the eyebrows inferiorly and creates horizontal wrinkles in the glabella. The orbicularis oculi muscles arise medially from the frontal process of the maxilla, lacrimal bone, the medial palpebral ligament, and the nasal process of the frontal bone and extend laterally to insert in the subcutaneous tissue at the lateral part of the orbit. The orbicularis oculi is a sphincter of muscle responsible for eye closure. It is divided into three portions: orbital, palpebral, and tarsal. The orbital portion is the thickest most peripheral portion. The palpebral portion travels from the medial canthal tendon to the lateral canthal tendon immediately underneath the skin of the superior and inferior eyelids. The tarsal portion arises from the posterior lacrimal crest, behind the lacrimal sac and travels laterally, superficial to the tarsal plate, to insert into the lateral canthal tendon. The palpebral and tarsal portions act involuntarily. They are responsible for the involuntary closure of the eyelids during blinking or closing of the eyelids. They also form a significant part of the

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lacrimal pump system. The orbital portion of the orbicularis is a voluntary muscle. Its contraction causes tight closure of the eyelids, drawing the eyebrows inferiorly and creating rhytids over the lateral portion of the orbit, called crows’ feet. The action of the orbicularis oculi carries a significant importance in facial expression. The orbicularis oculi may be the most important source of nonverbal communication. As we all know “the eyes are the window to the soul.” Through movement of the eyelids, one can express many emotions, such as pain, anger, fear, and surprise. The tug of war between the eyebrow depressors and elevator muscles help create the signs of periorbital and brow aging. Understanding this interplay is a starting point for surgeons and physicians to apply minimally invasive modifications such as neuromodulators. Whether the goal is to decrease the action of brow depressors and promote eyebrow elevation, or suppress elevation and contribute to facial symmetry, neuromodulators can be used to provide a more youthful appearance. Most of the motor innervations of the upper third of the face come from the frontal branch of the facial nerve. The main trunk of the facial nerve divides, at the pes anserinus, typically into two divisions. The two divisions terminate with a total of five branches. The frontal branch originates from the superior division of the facial nerve. A cadaveric study tracing the topographic relationships of the frontal branch to the surrounding fascial layers revealed between one to four identifiable branches. More than one branch is encountered in about 85% of the cases, with two branches being most common at 57.1% (4). The trajectory of the frontal branches is roughly along a line that runs from the attachment of the ear lobe (about 5 mm below the tragus) to a point 1.5 cm above the lateral aspect of the ipsilateral brow, also known as Pitanguy’s line (5). Anatomically, this is a point half the distance between the root of the helix and the lateral canthus. The nerve is found between the superficial temporoparietal fascia and the superficial layer of the deep temporal fascia, until they penetrate the undersurface of the frontalis muscle. The ophthalmic branch of the trigeminal nerve provides the sensorial innervation to the upper third of the face. This nerve has two terminal branches, the supraorbital and the supratrochlear nerves. The supraorbital nerve passes through the supraorbital foramen, innervating the upper eyelid and then ascends on the forehead to innervate the lateral and superior parts of the forehead and the scalp. The supratrochlear nerve passes between the superior oblique muscle in the orbit and the supraorbital foramen and curves superiorly to innervate the skin of the inferior and central portion of the forehead. FAT PADS AND LIGAMENTS

Even though the upper third of the face does not contain much fat, the periocular region has an intricate anatomy with regard to fat pads. These are divided by the orbital septum into a preseptal and postseptal (orbital) compartment. The preseptal pads are located superficial to the orbital septum and deep to the orbicularis oculi muscle. The preseptal fat pads add contour and fullness, which help frame the eye. Superiorly, beneath the eyebrow rests the retro-orbicularis oculi fat (ROOF) pad, while just below the infraorbital rim is the SOOF pad. The ROOF pad is crescent-shaped and goes along the upper lid, laterally to the supraorbital nerve and extends superiorly over the supraorbital rim. The ROOF pad contributes to a youthful brow by providing fullness and support for the lateral third of the eyebrow. The SOOF pad is located inferiorly below the arcus marginalis and infraorbital

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rim (6). Descent and atrophy of the SOOF is related to the appearance of the nasojugal sulcus or tear trough deformity, which takes place with the aging process. This usually extends from the medial canthal area for about 2 cm inferolaterally most commonly with a slight curvature (7). The postseptal fat pads lie deep to the orbital septum. These are the fat pads that pseudoherniate into the eyelid with weakening of the orbital septum periorbital. There are five pockets within each orbit. The upper eyelid has two fat pockets, central and medial with the lacrimal gland sitting laterally. The lower eyelid has three pockets—central, medial, and lateral. These areas of adipose tissue have no relation to body weight. The medial fat pads are lighter in color and more fibrous than the central ones. The upper eyelid fat pads are positioned between the septum and the levator palpebrae aponeurosis. They are separated by the trochlea. The lacrimal gland occupies the lateral area in the superior postseptal space. The lower lid fat pads are also divided by anatomical structures. The inferior oblique muscle separates the medial and central pads, while the arcuate expansion divides the medial and lateral pads. REFERENCES 1. 2. 3. 4. 5. 6. 7.

Leatherbarrow B. Oculoplastic Surgery, 2nd edn. London and New York: Informa Healthcare, 2011. Codner MA, Kikkawa DO, Korn BS, Pacella SJ. Blepharoplasty and brow lift. Plast Reconstr Surg 2010; 126: 1e–17e. Gray H. Anatomy of the human body. II. Osteology, 5.a Cranial bones, 3. Frontal. Philadelphia: Lea & Febiger, 1918; New York: Bartleby, 2000. Babakurban ST, Cakmak O, Kendir S, et al. Temporal branch of the facial nerve and its relationship to fascial layers. Arch Facial Plast Surg 2010; 12(1): 16–23. Pitanguy I, Ramos AS. The frontal branch of the facial nerve: the importance of its variations in face lifting. Plast Reconstr Surg 1966; 38: 352–6. Ridgway JM, Larrabee WF. Anatomy for blepharoplasty and brow-lift. Facial Plast Surg 2010; 26: 177–85. Flowers RS, Flowers SS. Precision planning in blepharoplasty: the importance of preoperative mapping. Clin Plast Surg 1993; 20: 303–10.

5.1 Volumetric approach to the upper face Deborshi Roy

Volumetric rejuvenation of the upper face is often neglected, since most people tend to focus on the mid- and lower face when it comes to treatment of the aging face. However, ignoring the upper face can lead to a disharmony between the upper and lower face, leaving the patient with a suboptimal overall result. Aging of the upper face is multifactorial and involves the skin, soft tissue, and bone. Rhytides of the upper face are very common, followed by upper eyelid dermatochalasis and brow ptosis. Rejuvenation of the upper face is usually surgical, most often brought about by blepharoplasty and brow lift (also known as a forehead lift). The most common nonsurgical treatment of the upper face involves injections of botulinum toxin into the muscles that produce dynamic rhytides of the forehead, glabella, and crow’s feet. The two most common causes of volume depletion of the upper face are loss of fat, muscle, and bone due to the aging process and fat loss due to lipodystrophy. In general, the most commonly affected areas are the temples and the upper brow. Less commonly, the glabella is affected by volume loss. A subset of patients with HIV-associated lipoatrophy suffer from marked volume loss in the upper face, especially in the temporal area (1). Volume loss of the lower eyelid is very common, but this topic will be addressed in the chapter related to midfacial volumetric rejuvenation. The most important aspect of volumetric rejuvenation of the upper face is a proper facial analysis. After diagnosing volume loss in the upper face, the patient needs to be educated about it. Most patients can easily see volume loss in the mid- and lower face on their own, but often do not notice it in the upper face. After careful explanation, we can start the treatment process. To understand the temporal area, one must be familiar with the anatomy, as explained in detail in the preceding chapter. The most clinically pertinent points are resumed below. Superomedially, the temple is defined by the temporal line—the insertion of the temporalis muscle into the frontal bone. Inferiorly, the temple ends at the zygomatic arch. Within this area is the temporalis muscle, its investing fascia, and fat; volume loss in the temporal area will cause a prominent depression from two key fat pockets deep to the temporalis fascia. Adding volume to this area can have a dramatic effect on the appearance of the upper face, giving a youthful, healthy look. 44

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VOLUMETRIC APPROACH TO THE UPPER FACE

Volume loss in the brow area most commonly is a part of the aging process and takes place laterally. The key aspects that define normal brow anatomy are the supraorbital rim, the hair of the eyebrow, and the soft tissue in between. In the aging process, soft tissue and bone loss along the lateral aspect of the brow contribute to the loss of muscle tone causing brow ptosis. While most treatments try to reverse the ptosis, adding volume to this area can help with the rejuvenation process. The glabella is defined as the area between the eyebrows and is comprised of the corrugator supercilii and the procerus muscles and the underlying frontal bone. The most common sign of aging in the glabellar area is hyperkinetic rhytides caused by repeated frowning. Over time, these rhytides can turn into furrows requiring treatment with volume along with paralytic agents (2). TREATMENT OF THE TEMPORAL AREA

Almost all of the available fillers can be used in the treatment of the temporal and lateral brow areas. Prior to treatment, the patient’s photos should be taken in the standard fashion (Figs. 5.1.1 and 5.1.2). Additional photos in the Water’s view are important in order to adequately assess the temporal and brow area. After photos are taken, the patient should be marked in the upright position. The areas to be treated as well as the injection plan should be clearly defined with the marking (Fig. 5.1.3). Regardless of the material used, the usual technique is a depot injection followed by massage (Fig. 5.1.4A,B). The depth of the injection is the critical part of the treatment—care must be taken to stay in the supraperiostial plane. Postinjection massage is used to spread the product evenly. Superficial injections and inadequate massage can lead to palpable and/or visible nodules. Postinjection bruising can occur, but can be minimized by staying away from the

TL TL

ZA ZA

(A)

(B)

Figure 5.1.1 (A) The normal temporal area. Note the boundaries of the temporal line (TL) and the zygomatic arch (ZA). (B) A temporal area with severe volume loss. Note the prominent depression caused by volume loss in two key fat pockets deep to the temporalis fascia (arrow).

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SOR

SOR

(A)

(B)

Figure 5.1.2 (A) The normal brow area. Note the relationship to the supraorbital rim (SOR). (B) The aging brow with volume loss and ptosis. Note the change in relationship to the supra-orbital rim (SOR).

Figure 5.1.3

Preinjection facial markings.

superficial venous arcades. Edema is common after injections and can be easily managed with ice packs. Prolonged edema can occur rarely, usually correlating to the use of an excessive injection volume.

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VOLUMETRIC APPROACH TO THE UPPER FACE

(A)

(B)

Figure 5.1.4 (A) A demonstration of the depot injection technique in the temporal area. The product is placed in the subdermal plane. (B) A demonstration of the postinjection massage. Firm, circular motion is used to even out the product distribution.

Prior to any injections, the patient should be kept off any blood thinners, including vitamins, supplements, herbal therapy, and medications. We recommend the use of Arnica Montana pellets starting on the day of treatment and continuing for two weeks. This helps in minimizing any bruising and also decreasing the time it takes to resolve any bruising that does occur. The skin is prepped with alcohol swabs and then marked. Injections usually take place with the patient reclining in a chair. Postinjection massage and ice packs are important to ensure a smooth result and minimal swelling. Autologous fat transfer techniques have been well described (3,4). Core fat from the abdomen, buttocks, or thighs must be harvested, treated, and then injected into the desired location of the face. Specialized cannulas have been created for harvesting and injecting fat into the face. Typical volumes used for treatment of the temporal area range from 0.5 to 3 cc, depending on the amount of volumetric rejuvenation required. Fat transfer injections in this area are deep into the muscle. When using hyaluronic acid-based products in the temporal area, the injections must be in the deep dermis. Superficial injections can cause nodules to appear or can be visible in the skin due to the Tyndall effect. Approximately 0.8 to 1.6 cc of product is used per side in the average patient. Calcium hydroxylapatite can also be used in the temporal area. With this product, injections should be subdermal, using approximately 0.5 to 0.8 cc per side in the average patient. Thorough massage is needed to smooth out the distribution of the product after a depot injection. Repeated treatments with poly-L-lactic acid are necessary to build up an adequate tissue response and obtain proper results. For the temporal area, some injectors use the standard dilution of the product recommended by the manufacturer—that is, 4 cc of sterile water mixed with 2 cc of 1% lidocaine per vial. Others prefer to use a more dilute solution, mixing 6 cc of sterile water with 2 cc of 1% lidocaine. This dilute solution has less clumping and therefore a lower incidence of nodules. Injections should be in the supraperiostial plane when treating the temporal area with poly-L-lactic acid. Vigorous postinjection massage is crucial for an even result. With standard dilutions, 1 to 2 cc of product are needed per side. With the more dilute preparation, 2 to 4 cc may be needed per side.

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Figure 5.1.5 A demonstration of the injection technique in the lateral brow area. Note how the skin and soft tissue are pinched and tented up away from the supraorbital rim prior to injection.

TREATMENT OF THE BROW AREA

The lateral brow area is most often treated as an adjunct to treatment of the temporal area. All of the options available in the temporal area can be used in the brow as well. We prefer to use the “pinch” technique (Fig. 5.1.5). After marking and prepping the skin of the brow, the lateral brow tissue is pinched and tented off the orbital rim. The needle is passed into the skin and deep to the orbicularis oculi muscle. The product is injected into the supraperiostial plane and smoothed out with massage. In general, one would tend to use half the volume used to treat the temporal area. Adding too much volume to the lateral brow will give the appearance of worsening ptosis. TREATMENT OF THE GLABELLA

Due to the nature of the blood supply to the skin of the glabella, injections can cut off the blood supply causing necrosis. This happens due to embolic phenomena or increased pressure on local blood flow (5). It is best to keep injections very deep or to use lower density fillers with no particulate matter in the glabella to minimize the chances of these devastating complications. Deep (intra- and submuscular) injections of autologous fat using the smallest caliber cannula available can be very successful in the glabella. Small volumes (0.5–0.8 cc) are needed to treat this area. Hyaluronic acid fillers in the deep dermal plane can also be used to treat the glabella. Volumes of 0.3 to 0.8 cc are used in the typical patient. As mentioned before, these treatments work best when combined with treatment of the dynamic rhytides with botulinum toxin (Fig. 5.1.6).

VOLUMETRIC APPROACH TO THE UPPER FACE

49

Figure 5.1.6 A demonstration of the injection technique in the glabella in the deep dermal plane. The area just below the ryhtide is injected in order to replace the volume lost in the deep furrow.

CONCLUSION

Isolated upper facial rejuvenation is rare, except when we see patients who have had midand lower facial rejuvenation alone. Usually, upper facial volumetric rejuvenation is a facet of full-facial volumetric rejuvenation and should be seen as an integrated part of a thorough approach. Most volumetric treatments of the upper face are adjunctive in nature—usually complementing other treatments of the upper face such as upper eyelid blepharoplasty, brow lifting, or botulinum toxin therapy. Subtle additions of volume can create a more youthful, healthy look. Careful technique coupled with proper patient and product selection will yield very satisfying aesthetic results. The goal in volumetric rejuvenation is to restore the volume lost during the aging process and create an overall harmonious, natural aesthetic. REFERENCES 1. 2.

3. 4. 5.

Yang Y, Sitoh YY, Oo Tha N, Paton NI. Facial fat volume in HIV-infected patients with lipoatrophy. Antivir Ther 2005; 10(4): 575–81. Carruthers J, Carruthers A. A prospective, randomized, parallel group study analyzing the effect of BTX-A (Botox) and nonanimal sourced hyaluronic acid (NASHA, Restylane) in combination compared with NASHA (Restylane) alone in severe glabellar rhytides in adult female subjects: treatment of severe glabellar rhytides with a hyaluronic acid derivative compared with the derivative and BTX-A. Dermatol Surg 2003; 29(8): 802–9. Coleman SR. Facial contouring with lipostructure. Clin Plast Surg 1997; 24(2): 347–67. Shiffman MA, Kaminski MV. Fat transfer to the face: technique and new concepts. Facial Plast Surg Clin North Am 2001; 9(2): 229–37, viii. Review. Glaich AS, Cohen JL, Goldberg LH. Injection necrosis of the glabella: protocol for prevention and treatment after use of dermal fillers. Dermatol Surg 2006; 32(2): 276–81.

5.2 European commentary Luitgard Wiest

As the trend for surgical procedures is decreasing, the trend for nonsurgical, minimally invasive procedures is growing, especially in younger and middle-aged patients. Due to their early stages of aging, they are the best candidates for volumetric enhancement in the upper face. With more advanced signs of aging, surgical procedures like blepharoplasty in combination with more extensive volumetric enhancement lead to a more dramatic improvement. As the author of chapter 5.1 states, the key to success for volumetric enhancement is a thorough analysis of the changes of aging and the determination of volume-deficient areas, which are mostly the lateral brow and temple areas. After all the necessary preprocedure preparations described in chapter 5.1 are undertaken, we also take photographs of the patient with the marked areas to be treated for documentary reasons. One week prior to treatment patients cease use of any medications that would predispose excessive bleeding and swelling. For the treatment of the temporal area the autologous fat transfer techniques as described in chapter 5.1 are widely used in addition to the fat autograft muscle injection (FAMI) technique described by Amar in 1999 (1) preferably with blunt cannulas. Studies have been performed with variations in harvesting, storage techniques, and cell viability (2). Of the readily available fillers, the specially designed “volumizers” are among the preferred HA fillers for volumetric enhancement of the face. The treatment is accomplished by injecting small depots very slowly in the epiperiostal plane with the needle adjusted to the choice of filler, followed by a massage to avoid nodule formation. Best results using fillers in the periorbital and glabella areas are achieved in combination with botulinum toxin treatment 10 to 14 days prior to the filler treatment. After paralysis has taken effect, fillers are more evenly dispersed and usually less filler material is needed for the desired effect (3–5). To lift the lateral brow end the preferred fillers are HA fillers with a high viscosity (Volumizers) are injected with the pinch technique deep below the M. orbicularis oculi. Use of longer-lasting fillers in the glabella, which have to be placed into the deep dermis or subcutaneously, increases the risk, as an intravasal injection in this highly vascular region may result in skin necrosis and even blindness. In this region, it is recommended to use resorbable fillers in small amounts and injecting into the medial part of the glabella. 50

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REFERENCES 1. 2.

3. 4. 5.

Amar R. Microinfiltration adipocytaire (MIA) au niveau de la face, ou restructuration tissulaire par greffe de tissue adipeux. Ann Chir Plast Esthét 1999; 44(6): 593–608. Kaufman MR, Bradley JP, Dickinson B, et al. Autologous fat transfer national consensus survey: trends in techniques for harvest, preparation, and application, and perception of short- and longterm results. Plast Reconst Surg 2007; 119: 323–31. Ascher B. Toxine botulique et rides: les associations médicales et chirurgicales. Real Ther Derm Venerol 2004; 138: 7–9. Sommer B, Sattler G. Cosmetic indications according to anatomic region (Ch 3). In: Sommer B, Sattler G, eds. Botulinum Toxin in Aesthetic Medicine. Berlin: Blackwell Science, 2001. Carruthers J, Carruthers A. The adjunctive usage of botulinum toxin. Dermatol Surg 1998; 24: 1244–7.

6 Anatomy of the midface Stephen A. Goldstein and Evan Ransom

It is important to understand the underlying structures and the associated anatomy of the midface when planning aesthetic volume restoration procedures. The midface is defined as the central third of the face in the anterior projection. Its superior border is a horizontal line drawn through the infraorbital rims to the auricles at the root of the helix. The inferior border is more oblique, and is represented by a line drawn from the oral commissure to the lobule of each auricle. Laterally, the midface border is the masseter muscle. Medially, the nasolabial fold delineates the midface from the nasal and perioral subunit; this area represents the attenuation and fusion of the diverse midfacial layers. The majority of the fullness or bulk of the midface aesthetic unit is provided by the malar fat pad (1). Midfacial aging is among the first and most obvious indicators of the aging process as a whole. This follows a predictable course, with progressive exposure of the infraorbital rim and deepening of the nasolabial folds. In addition, rhytids form in typical locations, such as the “crow’s feet” or “smile lines” at the lateral border of the orbit. There is also visible flattening of the cheek regions. An understanding of the specific contributions of different anatomical components to the changes occurring in this complex area is integral to its rejuvenation. It is also important to understand the locations of the underlying muscular, osseous, and neurovascular structures to decrease the risk of complications associated with augmentation of this region. Midface anatomy will be described in layers, beginning with the skeletal foundation and moving superficially to encompass the pertinent cutaneous features. THE BONY MIDFACE

Midface aging transitions as the relationships between overlying soft tissues and underlying bony anatomy change. The skeletal foundation of the midface is composed of three bones: the zygomatic arch of the temporal bone, the zygomatic bone, and the maxilla. Only the zygomatic bone and maxilla are seen in the frontal view, while the zygomatic arch becomes

Illustrations of the midfacial anatomy can be found in Chapter 4.

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important in oblique and lateral views. The lateral projection of the zygoma should be the highest point and highlight of the cheek prominence. Strong cheekbones are associated with a certain sense of beauty and this area is often accentuated with makeup by many women. In youth, there is a smooth eyelid to cheek transition (single convexity). As aging occurs, changes in both adipose tissue position and volume loss expose the infraorbital rim. The infraorbital rim, normally hidden by the malar fat pad in the youthful face, is revealed over time. This bony edge is composed of the zygomatic bone laterally and the ascending process of the maxilla medially. Indeed, an important goal of surgical procedures for midface rejuvenation is largely the repositioning of adipose tissue at the infraorbital rim— either by elevation of the malar fat pad or by repositioning of lower lid or subseptal fat (2). In the early phases of aging, this goal can be achieved with the aid of volume replacement utilizing any number of filler-type agents. Care should be taken to avoid inadvertent injury to the extra ocular muscles or the globe. This will be discussed in separate chapters. The inferior and medial midface skeleton is formed by the maxilla. As with the orbital rim, aging and descent of soft tissue also result in exposure of the superomedial extent of the maxilla. This causes an apparent deepening of the nasojugal fold (tear trough deformity), which contributes to the appearance of aging in the periocular region and may change the perceived contour of the nasal pyramid in severe cases. Multiple modalities have recently been suggested for rejuvenation of this area, including fat repositioning, fillers, and free fat grafts (3–5). Even permanent implants have been described (6). The maxilla forms the superior alveolus and defines the inferior aspect of the midface. This bone holds the roots of the upper teeth providing a platform for the upper lip soft tissues. Over time, there can be a slow progressive volume loss in these regions. This often manifests as flattening of the upper lip. This is most noticeable in patients who are partially or totally edentulous. The loss of projection that results has implications for restoration especially in perioral rejuvenation. In addition, age-related volume loss within the soft tissue of the lips may be significant. This is amenable to FDA “off label” judicious filler placement. MIDFACE MUSCULATURE AND FACIAL NERVE

The midface musculature is essential to social interaction because of its mimetic function. These muscles are also involved in protecting the eye and contribute to oral competence. Unfortunately, years of repetitive contraction may result in significant lateral canthal and facial rhytids. The midface muscles include the orbicularis oculi, zygomaticus major and minor, levator labii superioris alaeque nasi (levator labii superioris and levator alae nasi), levator anguli oris, risorius, and buccinator. Some muscular anatomic variation is normal, and even the complement of facial muscles may differ between patients (7). Understanding their location and underlying actions in the face is essential for the use of neuromodulators such as Botulinum toxin. Muscular attachments to the overlying skin may weaken over time, though no age-related changes in muscle position or length have been demonstrated (8). This fact has been exploited in the fat autograft muscle injection (FAMI) technique, which involves free fat transfer into the mimetic muscles (9). The orbicularis oculi is divided functionally into the tarsal, palpebral, and orbital components. The first two allow for gentle unstrained closure of the eye as in blinking or during sleep. The remaining orbital portion surrounds the upper and lower palpebral parts

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with its origin at the medial canthal tendon and lacrimal bone and its insertion in the dermis underlying the periocular skin at the orbital margin. Contraction of the orbital part of the orbicularis oculi results in tight closure of the eye, as in a protective maneuver or expressions of pain and anguish. It is this portion where neuromodulators are injected to eradicate lateral canthal rhytids and provide lateral brow lifting. Contraction of the zygomaticus muscles provides the greatest contribution to the smile. The origin of the zygomaticus major muscle is on the inferolateral part of the zygoma. As the muscle reaches the mouth, it splits to insert on the orbicularis oris superior and inferior to the oral commissure. Contraction thus results in superolateral excursion of the oral commissure and an expression associated with happiness. Some variability exists at the distal end of the zygomaticus major, with microdissections showing different patterns insertion (10,11). Pessa et al. demonstrated a bifid zygomaticus major in 34% of specimens, with superior and inferior muscle bundles attaching at the upper corner and modiolus below the corner of the mouth, respectively (10). The authors suggest that this variation in muscle anatomy may explain differences in the presence and depth of cheek “dimples,” with implications for rejuvenation. In a similar study, Shim et al. delineate superficial and deep bands of the zygomaticus major in 60% of specimens (11). Superficial bands interlace with the levator anguli oris, while deeper bands blend with the fibers of the buccinators muscle. This highly varied anatomy attests to the challenge in correcting dimples with injectable fillers. The zygomaticus minor muscle may compliment the action of the zygomaticus major and levator labii. Interestingly, this muscle is frequently absent (12). In a dissection study, Pessa et al. describe seven patterns of midfacial musculature with the most common pattern being a single zygomaticus major with paired upper lip elevators (levator labii superioris and levator alae nasi) (10). When present, the zygomaticus minor originates medial to the zygomaticus major on the inferomedial aspect of the zygomatic bone and inserts at the lateral most upper lip. Contraction of this muscle raises the upper lip alone, as in a snarl or expression of contempt. The risorius muscle originates at the platysma and masseteric fascia and attaches to the complex of muscles at the angle of the mouth. Like the zygomaticus minor, this muscle is frequently absent (7). Contraction of the risorius results in lateral excursion of the oral commissure and produces a grinning expression or a toothless smile. The levator labii superioris alaeque nasi originates on the frontal process of the maxilla. Some texts consider these portions as two separate muscles (levator labii superioris and levator alae nasi). Muscle fibers are oriented slightly oblique to the vertical axis and divide into two slips distally to insert at the alar rim and in the dermis of the upper lip. Contraction of these divisions results in nostril flaring and lateral upper lip elevation, respectively. Dissection studies have shown this muscle complex to be present in 100% of specimens, highlighting its importance in mimetic function (7). Caution is urged with neurotoxin placement in this area, as overzealous injections here can result in nasal valve collapse. Motor supply to the midface muscles comes from the zygomatic and buccal branches of the facial nerve. The facial nerve emerges from the cranial base at the stylomastoid foramen before traveling anteromedially through the parotid gland. Here it divides into two trunks in about 87% of cases (13). Most commonly, this results in an upper division containing the frontotemporal and zygomatic contributions and a lower division which contains the buccal, marginal mandibular, and cervical contributions. The buccal branches

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form the most intricate and variable arcade, with 70% of specimens having extensive connections with zygomatic branches (13). The facial nerve lies deep to the superficial musculoaponeurotic system (SMAS) through most of its course, innervating most muscles of facial expression from their undersurface. This creates two safe dissection planes for open approaches: immediately superficial to the SMAS (beginning 2–3 cm anterior to the pretragal crease) and subperiosteal. Dissection deep to the SMAS is also possible but entails a higher risk of facial nerve injury. Facial nerve branches move more superficially as they approach the nasal pyramid and oral commissure. In addition, motor supply becomes unpredictable and redundant beginning approximately at a plumb line from the lateral canthus. Injuries to these distal branches typically do not necessitate aggressive repair efforts. ADIPOSE TISSUE, FAT PADS, AND THE SMAS

Perhaps the most important consideration in midface rejuvenation is the malar fat pad. This structure, which lies superficial to the SMAS and immediately below the lateral part of the infraorbital rim, provides the bulk of the convexity associated with a youthful midface. The malar fat pad is a thickening (about 6 mm) of the subcutaneous fat in the cheek area overlying the maxilla. Some authors have attempted to subdivide this adipose tissue, but the clinical relevance of this work is limited and beyond the scope of this review (14). Diffuse attachments to the overlying dermis, along with the lateral orbital thickening and orbicularis retaining ligament (discussed below) help to stabilize the malar fat pad in a superolateral position. No connections to the underlying SMAS, however, have been demonstrated. Thus, gravitational forces and age-related dermal and ligamentous laxity have profound effects on its position. With age, the dermal attachments of the malar fat pad loosen, resulting in gradual displacement inferiorly and medially. The effect of this movement may be pronounced, leading simultaneously to exposure of the infraorbital rim, a sunken appearance of the eyes, and a significant deepening of the nasolabial folds (15). In some cases where there is concomitant orbital fat herniation at the lower lids, this gives an unpleasant double convexity profile to the midface. Inferiorly, the weight of the malar fat pad settles at the cheek–lip junction, where the SMAS has an intimate connection to the dermis of the upper and lower lips. The result is an obvious enhancement of the nasolabial folds. This thesis that fat pad descent is the prime mechanism of midface contour changes has been challenged by a study demonstrating increased adipose tissue volume in the medial and lateral parts of the cheek in older subjects and a more even distribution of fat between the superior and middle thirds of the cheek (8). At the lateral aspect of the infraorbital rim, deep to the orbicularis oculi muscle but superficial to the preperiosteal fat lies a second important fat compartment—the suborbicularis oculi fat (SOOF). This adipose tissue is much smaller than the malar fat pad, but its elevation or increased volume can significantly improve results in midface rejuvenation. The ideal single convexity of youth changes to a double convexity over time, and this double convexity reveals an aged appearance with associated lengthening of the lower eyelid (2,16). A single convexity with a short eyelid may be accomplished with repositioning of the malar fat pad, SOOF, and possibly the lower lid fat pockets. Additionally, correction

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of the nasojugal fold with medial eyelid fat pad repositioning over the infraorbital rim or an implant can have a powerful effect (6). Lying in a plane superficial to the mimetic muscles and deep to the fat pads discussed is the SMAS. The SMAS is a difficult but critical concept in facial aesthetic surgery, and different descriptions have led to some confusion over time. The most straightforward definition of the SMAS is a fibrous connective tissue layer that extends over the cheek from the tragus to the nasolabial fold. It is contiguous with the parotidomasseteric fascia laterally, condenses with the temporoparietal fascia at the zygomatic arch superiorly, and invests the platysma inferiorly. The superficial surface of this layer is a starting point for a “traditional” facelift dissection. Dissection deep to the SMAS and subsequent plication or imbrication of this layer, however, is the hallmark of the modern “deep-plane” facelift. Advocates of this approach attest to a greater lift, longer-lasting results, and a less “operated” look. Currently this is controversial with proponents for each technique. In a recent presentation reporting on a five-year follow-up patient survey as well as comparative photos, Strahan (17) found that patients who had the SMAS lift reported greater satisfaction with the five-year results of their procedure. Regardless of the type of lift selected, facial plastic surgeons are increasingly aware of the concomitant need for volume replacement, which may be provided by fillers or structural fat grafting. LIGAMENTS AND CUTANEOUS ANATOMY

Ligamentous connections between the facial skeleton and the overlying skin, unlike other regions of the body, are a significant source of structural support and functionality. Any discussion of facial anatomy would be incomplete without a detailed description of these connections. In addition, alteration of the osseous, cartilaginous, or muscular components of the face and neck can produce striking results, but failure to address an irregular skin surface or pigmentary abnormalities may lead to an incomplete result and dissatisfied patient. McGregor first described the supporting ligaments of the face. A “patch of fibrous attachment” located anterior to the parotid and connecting to the overlying skin marks the area that bears his name. Furnas further elucidated the facial ligaments essential for midface support (18). There are two types of retaining ligaments anchoring the overlying skin to the osseous foundation: true osteocutaneous ligaments from the zygoma and mandible inserting into the dermis; and coalescence between the deep and superficial masseteric fascias (18,19). Release of these ligaments allows repositioning of the midface. Further anatomical refinements defining the periorbital retaining ligaments have been described in cadaver dissections, including the lateral orbicularis retaining ligament (ORL) and the lateral orbital thickening (LOT) (20–23). The release of the ORL to its junction with the LOT is essential in vertical mobilization of the malar fat pad. As described by Mendelson et al., the prezygomatic space and surrounding ligaments reveal the characteristic age-related changes in this region and explain much about shifts in the infraorbital and malar contours. Muzaffar et al. have demonstrated the orbitomalar ligament as the anatomic structure responsible for defining the palpebromalar groove (i.e., the visible junction between the preseptal part of the lower lid and the cheek). Downward displacement of the lid–cheek junction is associated with a lengthening and attenuation of the preseptal part of the lid as it extends into the area formerly occupied by the upper cheek. For bulging lower lid fat to

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extend beyond the orbital rim, the retaining ligament must also undergo distension along with the preseptal segment of the lid (22). Early in the aging process, support of these structures with the deep placement of a variety of fillers may recreate a youthful appearance, camouflaging the underlying orbital rim and protruding fat. Once bags and sags prevail, however, surgical intervention remains the gold standard. Lastly, an appreciation of age-related changes and differences in skin type is extremely important when considering rejuvenation procedures. It is well known that the dermis thins with age, and the relative elasticity of the skin as a whole increases. Recreating the thicker and healthier dermis of youth is the “Holy Grail” of skin rejuvenation. In addition, regardless of age, skin thickness and pigmentation differ between patients. This may have a profound effect on the results achieved with fillers. Certain areas where the dermis is particularly thin (such as the lower eyelid or dry vermillion border) deserve specific consideration when planning injectable-based treatments, in order to avoid palpable raised areas, inflammation, skin discoloration, and even ulceration. This topic will be explored in depth in later chapters. The epidermis is a continually renewing keratinizing squamous epithelium, composed of four layers or strata. Beginning at the deepest layer, just above the dermal–epidermal junction, is the stratum germinativum. This basal layer is composed of columnar-shaped keratinocytes which are attached to a basement membrane and which divide and give rise to more superficial layers. Interspersed at this level are the melanocytes, which are responsible for pigment production. Immediately above lies the stratum spinosum, which is several cells thick and contains keratinocytes that have detached from the basal layer. Next is the thinner stratum granulosum, typically one to four cells thick and darker in appearance. The most superficial is the stratum corneum, which consists of keratinocytes that have shed their nuclei and flattened to form keratin plates. As these cells are sloughed they are replaced from below. The dermis lies between the epidermis and subcutaneous fat, forming the greatest bulk of the skin in youth and progressively thinning with age. The papillary dermis is most superficial and interdigitates with the undulating epidermis. Below this lies the thicker reticular dermis, where the bulk of the sebaceous glands and apocrine sweat glands reside. Hair follicles sit at the deep margin of the dermis where it meets the subcutaneous fat and project through the dermis and epidermis to emerge at the skin surface. Along the way, the apocrine sweat glands and erector pili muscles attach to the follicles. Eccrine sweat glands also reside at the deep margin of the reticular dermis. The dermis provides the strength and distensibility of the skin, and is composed of an extracellular matrix of collagen, elastin, and ground substance. The cellular component of this layer is largely fibroblasts, which are more prevalent in the papillary dermis. These cells synthesize the extracellular connective tissue matrix and have a significant role in wound healing and scar formation. Dermal and subdermal fillers add volume and may promote collagen deposition within this layer. Together, these effects aid in creating a youthful appearance.

REFERENCES 1. Goldstein SA, Goldstein SM. Anatomic and aesthetic considerations in midface rejuvenation. Facial Plast Surg 2006; 22(2): 105–11. 2. Hamra ST. Arcus marginalis release and orbital fat preservation in midface rejuvenation. Plast Reconstr Surg 1995; 96(2): 354–62.

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3. Turk JB, Goldman A. SOOF lift and lateral retinacular canthoplasty. Facial Plast Surg 2001; 17(1): 37–48. 4. Kane MA. Treatment of tear trough deformity and lower lid bowing with injectable hyaluronic acid. Aesthetic Plast Surg 2005; 29(5): 363–7. 5. de la Cruz L, Berenguer B, Garcia T. Correction of nasojugal groove with tunneled fat graft. Aesthet Surg J 2009; 29(3): 194–8. 6. Flowers RS. Tear trough implants for correction of tear trough deformity. Clin Plast Surg 1993; 20(2): 403–15. 7. Pessa JE, Zadoo VP, Adrian EK Jr, et al. Variability of the midfacial muscles: analysis of 50 hemifacial cadaver specimens. Plast Reconstr Surg 1998; 102(6): 1888–93. 8. Gosain AK, Klein MH, Sudhakar PV, Prost RW. A volumetric analysis of soft-tissue changes in the aging midface using high-resolution MRI: implications for facial rejuvenation. Plast Reconstr Surg 2005; 115: 1143–52. 9. Butterwick KJ. Fat autograft muscle injection (FAMI): new technique for facial volume restoration. Dermatol Surg 2005; 31(11): 1487–95. 10. Pessa JE, Zadoo VP, Garza PA, et al. Double or bifid zygomaticus major muscle: anatomy, incidence, and clinical correlation. Clin Anat 1998; 11(5): 310–13. 11. Shim KS, Hu KS, Kwak HH, et al. An anatomical study of the insertion of the zygomaticus major muscle in humans focused on the muscle arrangement at the corner of the mouth. Plast Reconstr Surg 2008; 121(2): 466–73. 12. Greyling LM, Meiring JH. Morphological study on the convergence of the facial muscles at the angle of the mouth. Acta Anat 1992; 143: 127. 13. Kwak HH, Park HD, Youn KH, et al. Branching patterns of the facial nerve and its communication with the auriculotemporal nerve. Surg Radiol Anat 2004; 26: 494–500. 14. Rohrich RJ, Pessa JE, Ristow B. The youthful cheek and the deep medial fat compartment. Plast Reconstr Surg 2008; 121(6): 2107–12. 15. Gonzalez-Ulloa M. The aging face: elimination of wrinkles and other problems. In: GonzalezUlloa, ed. Aesthetic Plastic Surgery, Vol. 1. St Louis, MO: Mosby, 1988: 13–30. 16. Shorr N, Fallor MK. “Madame Butterfly” Procedure: combined cheek and lateral canthal tendon procedure for post blepharoplasty “round eye” and lower eyelid retraction. Ophthal Plast Reconstr Surg 1985; 1: 229–35. 17. Strahan R. Comparison of the five year results of deep plane and SMAS facelifts. Presentation, American Academy of Cosmetic Surgery, Annual Meeting. Scottsdale, Arizona, 2009. 18. Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg 1989; 83: 11–16. 19. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg 1992; 89: 441–9. 20. Lucarelli MJ, Khwarg SI, Lemke BN, et al. The anatomy of midfacial ptosis. Ophthalmic Plast & Recon Surg 2000; 16: 7–22. 21. Mendelson CB, Muzaffar AR, Adams WP. Surgical anatomy of the mid cheek and malar mounds. Plast Reconstr Surg 2002; 110: 885–96 22. Muzaffar AR, Mendelson CB, Adams WP. Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus. Plast Reconstr Surg 2002; 110: 873–84 23. Gamboa GM, de la Torre JI, Vasconez LO. Surgical anatomy of the midface as applied to facial rejuvenation. Ann Plast Surg 2004; 52(3): 240–5.

7.1 Volumetric approach to midfacial rejuvenation Robert A. Glasgold, Mark J. Glasgold, and Jason D. Meier

INTRODUCTION

For the purposes of this chapter, the midface is defined as extending from the lower eyelid superiorly to the oral commissure inferiorly. Midfacial aging is primarily a function of volume loss. A youthful midface has a single convexity spanning from the lower eyelid to nasolabial (NL) fold, without a demarcation between the lower eyelid and cheek. As one ages, a generalized deflation of the midface occurs, with more focal volume loss along the inferior orbital rim and anterior cheek (Fig. 7.1.1A and B). These changes transform the youthful highlights of the midface convexity to a shadow-filled double concavity. Midfacial rejuvenation requires restoration of volume to remove or minimize the shadows of senescence and restore the vibrant highlights of youth (Fig. 7.1.2A and B) (1). The potential options for adding midfacial volume has been greatly enhanced by the newest generation of injectable fillers. Traditional volume rejuvenation of the midface relied on preformed alloplastic implants. The benefits of alloplastic implants are in their ability to provide long-term predictable volume changes. The placement of implants is inherently limited by the facial anatomy, specifically the infraorbital nerve limiting the superior extent. Malar implants add cheek volume but do not address, and may even exaggerate, the volume deficit at the inferior orbital rim responsible for the shadowed demarcation between lower lid and cheek. Alloplastic implants are also limited in their ability to make very precise surface contour changes. Their subperiosteal placement leaves the retaining ligaments, and their effect on surface contour, intact. Autologous fat transfer has gained increasing popularity as an alternative for midface volume restoration. In our practice, it has become the primary means of surgical midface augmentation and provides a durable result. It has the advantage of creating a more tailored natural augmentation as it can be placed more diffusely, and is not limited by the underlying anatomy. Despite these advantages, fat transfer is a surgical procedure requiring more downtime and, due to variable resorption (average retention rate is 30%), may need multiple treatments to get the ultimate result (2). The advent of an increasing array of injectable fillers has opened the door to midface volume restoration with less downtime and performed as a quick office procedure. The presently available injectable fillers have only been Food and Drug Administration (FDA) approved for 59

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c a

b

(A)

(B)

Figure 7.1.1 (A) This woman in her mid-twenties displays the characteristics of a youthful midface. There is an absence of shadowing, with smooth transitions between facial zones. (B) Midface aging is characterized by inferior orbital rim, anterior and lateral cheek volume loss, all of which create a marked shadowing eliminating the once seamless transition from lower lid to cheek. As in this patient malar mounds (a), defined by the orbicularis retaining ligament superiorly (c) and the malar septum inferiorly (b), may become pronounced with age-related volume loss. Source: Adapted from Ref. 1.

(A)

(B)

Figure 7.1.2 (A, B) Midface rejuvenation is achieved with addition of volume to restore the single convexity, uniting the lower lid and cheek subunits. Lower lid transconjunctival blepharoplast was performed in addition to autologous fat transfer to the inferior orbital rim and cheeks. Source: From Carniol PJ, Sadick NS. Clinical Procedures in Laser Skin Rejuvenation. London: Informa Healthcare, 2007.

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aesthetic improvement of the NL folds. They have been used extensively in an off-label fashion for facial augmentation. In our experience, the newer generation of fillers provides a great minimally invasive alternative to surgery. There is less associated downtime, they have a relatively good durability, and offer patients the opportunity to see the results of added volume with the comfort that it can be reversed. In any patient who will be undergoing midfacial volume augmentation with injectable fillers appropriate informed consent should be obtained with an understanding of it being an off-label use. Pretreatment photographs are especially important for comparison with post-treatment results. Patients often forget their preinjection appearance; both in terms of their baseline volume loss and skin pigmentation, these photographs serve as an integral component of their medical record. In this chapter, we outline our approach to midface volume rejuvenation with injectable fillers. We present the techniques and materials that have given us the greatest success rate. REGION 1: INFRAORBITAL RIM

Patients seeking rejuvenation of the lower eyelid are usually focused on the appearance of lower lid “bags,” “dark circles” under their eyes, or lower lid skin texture (i.e., rhytids). The earliest signs of aging in the lower lid relate primarily to volume loss with development of shadowing under the eyes. This is usually first noted in the tear trough, at the medial aspect of the orbital rim, before progressing to involve the entire inferior orbital rim. Filling the concavity along the inferior orbital rim will eliminate shadowing and reestablish the smooth contour at the lid–cheek junction (Fig. 7.1.3A and B). Restoring volume does not improve skin pigment or texture. Patients must understand what will and will not be addressed by the procedure in order to optimize their satisfaction. At the pretreatment consultation, patient evaluation includes assessing the degree of pseudoherniated lower eyelid fat, volume loss in the orbital rim, skin pigmentation, and presence (and degree) of redundant lower-lid skin/rhytids.

(A)

(B)

Figure 7.1.3 (A) This patient demonstrates early midface aging with volume loss and shadowing along the inferior orbital rim. (B) One month following treatment with Restylane. The entire inferior orbital rim was injected to create an improved contour.

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Patients commonly exhibit a darker pigmentation on the medial lower lid skin. Filling the tear trough eliminates the darkened appearance secondary to shadowing; however, it will not improve the overlying hyperpigmentation. Patients are sometimes not aware of the degree of pigmentation in this location, as it is usually at the depth of the concavity and masked by shadowing. Once the shadow is eliminated they may become more aware of their underlying pigment. This should be reviewed with the patient prior to treatment when counseling them about the benefits of filling the tear trough (Fig. 7.1.4A–D). Volume added to the inferior orbital rim may expand the skin draped over the concavity between the lower lid and cheek. This may improve minor degrees of skin redundancy but in the presence of more significant redundancy will fail to unfold the excess skin (festoon) (Fig. 7.1.5). In these circumstances, surgical intervention to address the redundant skin is needed to obtain an optimal result. Assessment of the degree of pseudoherniated lower lid fat is also necessary for selecting potential candidates for a volume filling approach. In the presence of very significant pseudoherniated lower lid fat, filling the concavity inferior to this at the orbital rim may reduce shadowing but fall short of creating the ideal smooth contour from lid to cheek. In these select patients, the optimal result may require lower lid blepharoplasty to reduce the convexity secondary to pseudoherniated fat, in combination with volume augmentation along the inferior orbital rim. If these patients want to proceed with only a volume filling approach, they need to be counseled on the potential for an incomplete result. Since a primary goal of midface rejuvenation is to reestablish the continuity of the lower lid and cheek, this dictates that evaluation of the lower lid includes assessment of malar volume loss. Any patient who is a candidate for filling of the inferior orbital rim should be evaluated to determine the need for additional cheek volume. In patients with more global midface volume deficiency, filling of just the inferior orbital rim may eliminate the original convexity but lead to an exaggeration of anterior cheek volume loss (Fig. 7.1.6A and B). If not addressed at initial treatment these patients may return feeling that the orbital rim is overfilled. In some cases, it may truly be overfilled yet in others this is a pseudoelevation due to inadequate anterior cheek volume, which can be easily corrected. The preferred injectable materials for the periorbital region are the nonanimalstabilized hyaluronic acid (NASHA) fillers. The hyaluronic acid (HA) products are less viscous and can be injected with a smaller gauge needle, minimizing patient discomfort. HA fillers are more malleable than other available products and can be manually contoured after injection. In addition, the reversibility of HA products with hyaluronidase injections provides a great degree of reassurance to both the physician and the patient. Among the available NASHA fillers, Restylane is our preferred material for periorbital filling. Restylane allows for very precise correction and has the lowest potential for problems. In contrast, following periorbital injection with Juvederm, we have observed a significant incidence of a persistent edematous appearance, which had to be corrected with hyaluronidase injections (Fig. 7.1.7A and B). This has not been a problem with Restylane injection and may be due to an increased hydrophilic property of Juvederm compared with Restylane. This characteristic of Juvederm is beneficial in certain facial areas, such as the lips, but is undesirable where very precise volume correction is required. If Juvederm is to be used around the eyes, then maintaining a consistently deeper injection plane with significant undercorrection is highly recommended to minimize complications.

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Figure 7.1.4 In the presence of significant hyperpigmentation, correction of volume deficits will improve shadowing under the eyes but will not improve the pigment. Patients may even become more aware of the pigment now that the skin is elevated from the depth of the fold and the shadowing eliminated. Pre (A) and post (B) injection photographs of this patient do not demonstrate any significant improvement in the appearance of “dark circles” due to the degree of hyperpigmentation. The Vectra 3D contour (Canfield Scientific, Fairfield, NJ) pre (C) and post (D) images of the same patient demonstrate significant improvement in contour with a smooth transition from the lower lid to the cheek.

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Figure 7.1.5 In the presence of significant skin redundancy, whereupon the fold of skin (festoon) is draping across the tear trough, the mere addition of volume will not be adequate to create the optimal result. This patient demonstrates a situation where the demarcation at the lid–cheek junction is primarily a function of the skin fold, and not volume loss.

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Figure 7.1.6 (A) Vectra 3-D contour image prior to treatment demonstrates shadowing primarily in the tear trough (arrow). This patient subsequently underwent Restylane injection of the tear trough without augmentation of the cheek. (B) One month following treatment, the original tear trough is eliminated but the previously mild shadow (arrow) inferior to this from anterior cheek hollowing is now exaggerated. This creates the illusion of the tear trough being overfilled, when in actuality the anterior cheek volume needs to be restored to recreate the desired convexity spanning from lower lid to nasolabial fold.

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Figure 7.1.7 (A) Pretreatment Vectra 3-D contour image of a patient requesting treatment for shadowing under her eyes. (B) Post-treatment image of this patient two months after Juvederm ultrainjections along the inferior orbital rim. The image demonstrates the appearance of persistent edema (arrow). These patients more commonly have a boggy edema in the region with a greater incidence of a bluish hue in the tear trough.

Before proceeding with injections the planned area for filling is marked out. Topical anesthetic ointment alone provides almost complete anesthesia in the periorbital region. As bruising and swelling tend to be more extensive in this region, efforts are aimed at minimizing these sequelae, both to facilitate the injector’s assessment during treatment and to hasten the recovery period. All patients are instructed to be off aspirin containing products for 10 days, and nonsteroidal anti-inflammatory drugs (NSAIDs) for 2 days, prior to periorbital injection. Ice packs are applied for several minutes prior to injection for vasoconstriction to minimize bruising. Good lighting will aid in visualization and avoidance of superficial vessels while injecting, potentially reducing ecchymosis. The order of injections in the lower lid are planned to minimize the impact of bruising and swelling on intraprocedure judgment. The injector’s judgment is also aided by completing injections in an area before moving on to the next area. Proceeding from areas least likely to most likely to bruise, injections are begun medially, continuing across the tear trough in an inferolateral direction. Injections are stopped at the central infraorbital rim. Vessel injury in the central infraorbital rim, medial to the malar mound, is more likely and leads to more significant bruising and swelling. Therefore, upon completing the tear trough, injections are then initiated at the lateral orbital rim and progress medially. The remaining central deficit is filled last to complete the infraorbital rim correction (Fig. 7.1.8). Injections are performed using a serial puncture technique, with placement of material deep to the orbicularis oculi muscle. Although injection can be done at any level, deeper injection will reduce the chance of contour irregularities. In the tear trough and lateral inferior orbital rim, where there is a thin plane between muscle and bone, the needle can be advanced till the bony orbital rim is hit and injection done just superficial to the periosteum. In the central inferior orbital rim, which is addressed last, injection should be

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Figure 7.1.8 Injection technique for the inferior orbital rim. Recommended order for injections: fill tear trough from medial to lateral (yellow), fill lateral inferior orbital rim from lateral to medial (red), and fill central rim deficit (blue) last. Recommended depth of injection: suborbicularis oculi muscle and supraperiosteal in the tear trough (yellow) and lateral rim (red); immediately deep to the orbicularis oculi muscle (not down to bone) at the central rim (blue).

just below the orbicularis oculi muscle (Fig. 7.1.8). Advancing the needle down to the bone, which is deeper in this area, is associated with a much greater incidence of piercing blood vessels and exacerbating bruising and swelling. Additionally injection on bone in this location places material far from the surface which is to be treated, thus reducing precision of correction. Restylane is injected until full or slight undercorrection is obtained. Less experienced injectors should err on the side of undercorrection as more product can be easily injected at the follow-up visit. Approximately 0.2 to 0.3 mL of Restylane is generally needed to correct each tear-trough and another 0.3 to 0.4 mL is used to correct the remaining infraorbital rim concavity. After completing the orbital rim injections, the area is gently massaged to ensure an even contour using a gauze and petrolatum-based ointment. Broad, even pressure, not vigorous massage, is recommended. Patients are instructed to use ice intermittently on the day of injections. In contrast to recovery times in other areas of the face, patients undergoing periorbital injections are advised that ecchymosis may last up to a week. Patients with thicker skin types and more isolated medial hollowing tend to have less bruising. All patients are instructed to follow up at four weeks after injections to assess the result and possible need for touch up. The duration of effect of HA fillers in the inferior orbital rim is routinely about 18 months, and not uncommonly patients still have some residual benefit at 2 years following treatment (3). Initially this was noted anecdotally in patients, but since the availability of 3-D photography, we have been able to demonstrate the actual degree of volume augmentation persisting over this time frame (Fig. 7.1.9A–C).

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(B)

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Figure 7.1.9 Long-term results of Restylane injections in the tear trough demonstrated using the Vectra 3-D camera. (A) Vectra 3-D contour photo prior to filling the tear trough. (B) Result at 10 months after injections. (C) Persistence of result in the tear trough at 26 months following treatment.

Other injectable products are available and have been used in the periorbital region. Radiesse was used in our practice for infraorbital rim volume augmentation initially, with relatively good results. However, persistent erythema in the skin at the medial inferior orbital rim, lasting three to four months, occurred in approximately 5% of the patients. In the periorbital region, Radiesse is usually palpable and patients would require counseling prior to treatment to ignore this. Periorbital injections with Radiesse were generally associated with a greater degree of bruising and swelling, which was at least in part due to the need for a larger gauge needle. These issues, in combination with the fact that there is no quick reversibility of the effect, have made Radiesse a less than ideal choice for the periorbital region.

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REGION 2: CHEEK

Aging in the cheek manifests as overall volume loss with flattening of the anterior cheek and skeletonization of the zygoma. A particularly challenging aspect of midface rejuvenation is in management of malar mounds, when present. For the purposes of this chapter, we define the anterior cheek as spanning from infraorbital rim to NL fold and from the nasofacial junction to medial aspect of the malar mound. The lateral cheek overlies the zygoma, lateral to the malar mound, and is often addressed in conjunction with the submalar region. The malar mound is addressed as a separate subunit. Anterior and lateral cheek rejuvenation is primarily, and more simply, addressed with adding volume. The malar mound is more complicated due to its uneven surface contours created by adjacent osteocutaneous ligaments, and the frequent dynamic nature of its prominence due to swelling. Strategies for rejuvenating the midface, and cheek in particular, need to reestablish the union of the lower lid and cheek subunits, restore volume loss, and create a smooth full cheek convexity (minimizing the visibility of malar mounds) (Fig. 7.1.10A and B). Until recently, cheek augmentation with alloplastic implants has been the mainstay of treatment for this area. Although implants do create malar volume, they cannot create a precise correction of surface contour due to their deep subperiosteal placement. A further limitation with alloplastic implants is that with advancing age and midfacial volume loss the implants may become more visible, creating a severe and overly angular appearance. Autologous fat transfer has provided an excellent alternative for cheek augmentation creating a more individualized result and is particularly advantageous for larger-volume augmentation. Fillers also offer an excellent alternative to implants. They provide the

(A)

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Figure 7.1.10 (A) Pretreatment photo demonstrates loss of volume in inferior orbital rim and anterior cheek. (B) Following inferior orbital rim and anterior cheek augmentation with Restylane the full convex contour is reestablished from lid to cheek.

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ability to create very precise changes and tailoring of the result to the individual patient’s needs. HA fillers, Radiesse, and Sculptra, have all been used in this region with varying degrees of success. Evaluating candidates for cheek augmentation with fillers must include an understanding of the patient’s goals and assessment of overall volume loss in the cheek and adjacent areas. In patients with significant global volume deficiency, injectable fillers may not be a cost-effective option for patients. Potential patients must understand the limitations in terms of volume that can be achieved. The presence and severity of malar mounds must also be evaluated prior to treatment. The malar mounds present an obstacle to midface rejuvenation that sometimes cannot be overcome; again this emphasizes the need for counseling patients on realistic goals. The malar mound is a discrete soft tissue convexity that protrudes from the lateral aspect of the malar eminence. It is defined by the orbicularis retaining ligament superiorly, which is responsible for the tethered depression at the lateral inferior orbital rim. Inferomedially, the malar mound is defined by the malar septum, an osteocutaneous ligament creating a cutaneous crease running in an inferolateral direction across the anterior cheek (4). There is variability in the presence and degree of malar mounds. At a minimum, patients may just have a visible anterior cheek depression that corresponds at its deepest aspect with the malar septum. The prominence of the malar mound can be progressively delineated. Furthermore, patients may note fluctuating edema of the malar mound. The more defined the malar mound, and the greater the degree of variable edema, the harder they are to manage. The primary goal is to camouflage the malar mound by adding volume around it (Fig. 7.1.11A and B). Volume placed at deeper planes in the cheek will create an overall increase in malar fullness but will not address the ligamentous attachments, leaving the malar mound intact. During fat transfer to the cheek in the presence of less severe malar mounds, the cannula is used to release the septum and place fat along the depressed area. When malar septal tethering is more significant, fat transfer improves, but tends to incompletely correct the malar septal depression. Dermal fillers provide an advantage in correcting the malar septal depression. The malar septum is an osteocutaneous ligament adherent superficially to the dermis. By injecting in and expanding the dermis, superficial to the ligamentous attachment, the depression may be effaced. There is a limit to the degree of dermal expansion, such that if the mound is too high relative to the septal depression, the depression will be improved but not fully effaced (Fig. 7.1.12A and B). Injection must be done very carefully at the malar septum, if done below the dermis the material may track into the malar mound, causing augmentation of the malar mound. Additionally, in patients with very volatile malar mounds, even when injected properly in the dermis, there is a propensity for prolonged malar edema which may, if occurs, will resolve spontaneously. The goal of midface rejuvenation is also affected by the sex of the patient. In general, volume loss in the lateral and anterior cheek makes the face appear more masculine and square-shaped. The goal of midface volume replacement in the female patient is to restore the natural feminine heart shape of the face. For male patients, a lesser degree of volume augmentation (particularly in the anterior cheek) is desirable. Too much roundness to cheeks is feminizing and a more angular sculpted appearance is preferable in a man. In addition, most male patients are focused not on overall volume augmentation but more frequently are looking to address specific contour abnormalities and their associated shadows, as seen with malar mounds.

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Figure 7.1.11 (A) Malar mounds are delineated by the orbicularis retaining ligament superiorly and the malar septum inferomedially (also see Fig. 7.1.1B). (B) Depending on the severity of the malar mounds, they can be camouflaged by filling around it as demonstrated in this photo.

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Figure 7.1.12 (A) The effect of a tethered malar septum delineating the inferior aspect of the malar mound is demonstrated on this Vectra 3-D contour photograph. (B) Vectra 3-D photograph following Restylane injection in the anterior cheek, placed intradermally along the malar septum. The malar mound is less apparent with overall improvement in cheek contour. But as is common with a more tethered malar septum, the effect of the malar septum cannot be completely overcome in this patient.

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In the cheek, there is greater flexibility in terms of which injectable fillers can be used. Several factors should be weighed when choosing the appropriate material, including whether adjacent areas are being addressed concurrently, how much augmentation is needed, and the presence of and desire to correct malar mounds. Any of the HA products (Restylane, Perlane, Juvederm Ultra, or Juvederm Ultra Plus) can be used for malar augmentation. Patients who need volume added in the inferior orbital rim, where Restylane is preferred, as well as the cheek will frequently use the same product in both areas. All of the HA fillers, due to their dermal placement, are more effective for making precise contour changes in the cheek especially in the presence of malar mounds. When using NASHA fillers to add overall cheek volume the more cross-linked products (Perlane or Juvederm Ultra Plus) are recommended. Pretreatment markings are performed to outline the area to be filled. If a well-defined malar crease needs to be addressed this is marked out. Our preference is for topical anesthetic, but in contrast to the thin lid skin, the anesthesia from topical alone is less effective on the cheek. Using the HA products, a serial puncture technique is preferred to create a more uniform filling. The one location where a linear threading technique may be used is at the malar septal crease. Depth of injection for the anterior and lateral cheek is in the deep dermis except along the malar septum where more superficial placement is more effective to efface the septal crease. Deeper injection in a subdermal plane not only lowers the chance of surface irregularities but also diminishes the volume obtained. The amount of HA material needed for the cheek ranges from 1 to 3 mL per side depending on patient’s degree of volume loss and whether or not the entire cheek is being volumized or just focal regions (i.e., anterior, lateral, or just camouflage of malar mound). In our experience, HA fillers last up to nine months, and sometimes longer, in the cheek (Fig. 7.1.13A and B). The duration of effect is generally longer than that observed in the NL fold, but not as persistent as in the periorbital region, where an 18-month result is routine. In patients needing larger volume correction, reliance on HA fillers can become cost-prohibitive for patients due to the material cost and the finite duration of benefit from the procedure. In these patients, autologous fat transfer becomes a much better option and their primary reason to start with fillers instead of going directly to fat is to due to limited downtime or to test whether or not they will be pleased with the restored volume. (The role of fat in cheek augmentation will be further detailed later.) Other materials that can be used for malar augmentation include Radiesse and Sculptra. Radiesse, consisting of calcium hydroxylapatite, is more dense/viscous than the HA products. It is effective in providing a general volume augmentation of the cheek and may be advantageous for larger volume augmentation, based on the larger quantity of material per syringe and the thicker quality of the product. Radiesse needs to be placed in the immediate subdermal plane or deeper, not intradermal. As a result, it is not effective for making the precise changes in surface contour that can be achieved with the dermal fillers, which is particularly important in patients with visible malar mounds. In our experience, there has been no significant advantage in duration of the result in comparison to NASHA products. Sculptra consists of poly-L-lactic acid which is diluted into a water suspension prior to injecting. It provides a delayed effect requiring up to two months before the ultimate result from a treatment is realized and requires multiple treatment sessions. To obtain any significant volume change of the entire cheek region, an average of three to four sessions

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(B)

Figure 7.1.13 (A) Pretreatment photo demonstrates anterior malar and inferior orbital rim volume loss. (B) Post-treatment photograph 12 months after malar and inferior orbital rim augmentation using a total of 1 mL of Restylane for the bilateral treatment.

(two vials per session) is needed. Depending on the desired end result, in patients with significant volume loss, the procedure may be cost-prohibitive. A linear threading injection technique in a subcutaneous plane is recommended. A fanning technique of injection over a small region can be performed through each needle stick to minimize the number of injection sites, each of which is a potential site of nodule formation in areas with thinner skin. Care should be taken so as not to have material on the tip of the needle when entering or exiting the skin as superficial placement is a potential cause of nodule formation. With proper technique, Sculptra provides a useful option in anterior and lateral cheek volume replacement with results lasting up to two years through an increase in dermal thickness secondary to collagen deposition. The main limitations of Sculptra are the limited volume change with each treatment, difficulty in getting large volume changes, variability in result, making it a poor choice when precise correction is needed (i.e., camouflaging malar mounds), and the relatively high material cost. Although some injectors use it as a first line for cheek augmentation, we primarily use it in patients who want a diffuse softening through added volume without undergoing surgery and patients who would otherwise be ideal candidates for fat transfer, but who do not have adequate donor fat. REGION 3: BUCCAL

The buccal region is located just lateral to the inferior extent of the NL fold and below the cheek/submalar region. There exist two primary subsets of patients who show aging effects secondary to buccal volume loss. The very physically active individual in their late thirties and into their forties who have significant global facial volume loss, and the older patient

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Figure 7.1.14 (A, B) Pre- and post-treatment photographs of buccal volume replacement with Perlane in a younger patient with global facial volume loss. One milliliter of Perlane was used to fill the buccal and submalar region on each side. (C, D) Pre- and post-treatment photographs of buccal volume replacement with Juvederm Ultra (0.8 mL) in an older patient with more focal volume loss.

in their late fifties and beyond who develop more isolated buccal volume loss, creating a more skeletal appearance (Fig. 7.1.14A–D). In general, the early effects of buccal volume loss create a more angular and sculpted facial appearance (i.e., loss of baby fat). Most women and men are pleased with this early change in appearance. Progressive buccal volume loss, whether it be in the younger active individual or the older individual, contributes to the loss off the soft, less shadowed youthful appearance, resulting in a more harsh and “gaunt” appearance. Unique to the very gaunt athletic individual is the complaint of a fold of skin posterior to the NL crease. These patients often come in requesting filling

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of the NL fold; however, in our experience, they are usually dissatisfied with the result of doing just this as they still see the fold. To truly address this complaint, filling of the buccal region is required to eliminate the shadow posterior to this fold (Fig. 7.1.15A and B). Filling the buccal region does not require a large volume change over a focal area, but a small buildup of volume over a diffused region. Pretreatment marking is important as the filled area needs to be gently tapered out into all of the surrounding regions. Because this area does not need a large volume, nor does it require very precise volume addition, any of the previously mentioned fillers will do. A topical anesthetic is preferred here to minimize swelling which will otherwise impair intratreatment assessment. Our preference is to use one of the HA products as they are more malleable, can be injected with a fine gauge needle, give a quick predictable result, and can be reversed if necessary. The results from the HA products in this area again tend to be longer than that seen in the NL fold, frequently lasting at least one year. Technically, serial injections in the deep dermis are preferred, moving broadly across the delineated area. An average 0.5 to 1 mL of an HA material will be required to fill each side. Although complications are rare, the primary potential issues relate to contour irregularities either from inadequate taper at the periphery into adjacent regions, or overfilling centrally. If inadequate tapering at the periphery is noted at follow-up, this is very easily corrected with addition of more material. In our experience, overfilling has only occurred with Juvederm and is likely related to the proposed more hydrophilic nature of the product. In contrast to the periorbital region, simply underfilling the buccal area will avoid problems in this region. REGION 4: NASOLABIAL FOLD

The NL fold occurs at the transition between the anterior cheek and the upper perioral region and is a normal facial feature. As patients perceive that there is a progressive aging

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Figure 7.1.15 (A) In the presence of significant global facial volume loss patients not uncommonly complain of both visibility of the nasolabial fold and the prominence (arrow) or pouch of skin, just posterior to it. (B) To address these concerns and soften the appearance of the fullness posterior to the nasolabial fold, volume is added into the buccal region in addition to filling the nasolabial fold.

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appearance to their face, they often become focused on the NL fold because it is the facial feature most easily seen in a mirror. The global loss in facial volume is difficult to see even though this is the underlying cause of deepening in the NL fold. The relative position of the NL fold on the face is fixed by the suspensory strut of the zygomatic musculature, which inserts into the skin at the fold. As the face deflates and the maxilla rotates posterior cephalad the foundation of the tissues surrounding the NL fold is lost and this tissue hangs tethered only by the suspension of the muscular strut (5). Correction of the NL fold should be focused on minimizing any harsh shadow in order to make a softer transition from cheek to upper lip. In evaluating the NL fold, the nature of the fold should be appreciated; is it a deep concavity creating shadowing or is it finer creasing that is seen in the skin particularly toward the inferolateral aspect; further, it is also important to elicit what aspect is bothersome to the patient. Despite some patient’s insistence, the goal is not and should not be to completely obliterate any hint of indentation along the fold; to do so is to create an unnatural appearance. The superomedial concavity is corrected by adding volume in the triangular region outlined by the nasal ala medially and the NL fold superolaterally. A deep injection of filler in this region will often complete any deficits that superficial injection is unable to achieve. Correction of a deep skin crease, which is usually present inferolaterally if not along the entire fold, can be improved but not completely effaced (Fig. 7.1.16A and B). This crease is due to the dynamic muscular forces pulling on the dermis of the skin. Patient should be informed that there is a limit to improvement that can be obtained in this fine-etched crease. Any of the HA fillers, collagen materials, or Radiesse are effective for filling the NL fold. The dermal fillers, specifically HA materials, have the advantage of allowing for more plumping out of the fold and are more effective in softening the finer creases at the

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Figure 7.1.16 (A) Pretreatment photograph of a patient desiring improvement of his nasolabial folds. (B) Photograph taken one month following filling of nasolabial and labiomandibular folds using a total of 2 mL of Restylane.

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inferolateral aspect. Patients are counseled that the HA fillers typically provide a result in the range of six to nine months, but we have commonly seen patients get at least ninemonth results. Regardless of the HA material used, patients will need one to two vials of material. For very minimal folds, one vial will do, but as the depth increases and the patient wants greater degrees of effacement, the likelihood of needing two vials is more likely. For anesthesia, depending on the particular patient, either topical anesthesia, minimal infiltration of lidocaine immediately subcutaneous at the planned injection site, or an infraorbital nerve block can be performed. Our preference is for topical, otherwise we will infiltrate approximately 0.3 mL of 1% lidocaine with epinephrine (1:100,000) immediately deep to the planned treatment site. This type of local injection is very well tolerated by patients and does not give them the prolonged discomfort of a regional block. Technically, a serial puncture injection into the deeper dermis is preferred in the superomedial triangle as this reduces the chance of surface irregularity yet provides good effacement. Inferolaterally, when there is a fine crease, a linear threading technique is used with more superficial placement in the dermis. If the initial pass does not efface the fine crease, additional passes more superficially with minimal material deposition can be done. This should be done cautiously; although this superficial placement is more effective at eliminating fine creases, it comes at the risk of a greater incidence of a prolonged erythema or bluish hue (Tyndall effect). In terms of the different HA materials, Juvederm has the advantage of spreading out more smoothly, which reduces chance of visible lumps, particularly superomedially. With good technique, any of the HA materials will give a very good result. One of the more likely reasons for patient dissatisfaction is incomplete correction with an inadequate amount of material. This is avoided with proper explanation of the expected result and a realistic understanding of the amount of material that needs to be used in a particular patient. Radiesse can also provide very good results in filling the NL fold. Before the availability of the HA products, this was our preferred material for the NL fold. The disadvantage of Radiesse is that it needs to be placed deeper, so that it does not plump out the area as well. In particular, this makes it less effective for fine skin creases along the NL fold which are best approached with dermal fillers. A secondary issue is the noticeable volume loss from the carrier gel dissolving over the first three months, which led to a higher incidence of patients complaining that the result did not last. This can be minimized by explaining to patients that a touch-up procedure is commonly required. One potential advantage of Radiesse is that a larger amount is provided in a single vial, making treatment with one vial realistic in many patients; although it can be argued that a larger portion of the volume will be resorbed in the first few months diminishing this advantage. In terms of actual duration of time before patients return for retreatment, we have not found Radiesse to be advantageous over the HA fillers. POSTINJECTION CARE AND MANAGEMENT OF COMPLICATIONS

If markings were made to delineate the injection site, this should be removed with alcohol, not hydrogen peroxide. The area injected is then massaged, using a cotton gauze and Aquaphor, gently with a broad sweeping motion across the injection site in order to ensure a relatively smooth distribution of material. Patients are counseled that contour irregularities are commonly present due to swelling and thus should not massage the area at least for

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(A)

(B)

Figure 7.1.17 (A) Six weeks after Restylane injections into her nasolabial and labiomandibular folds this patient presented with erythema and inflammation isolated to the nasolabial folds that began one month after her injections. (B) Once a course of Azithromycin was started to treat atypical mycobacteria she had resolution of the erythema and inflammation. The patient is shown at four months after initial injections with resolution of infection.

the first week. Ice packs should be applied to decrease swelling and bruising. This is more important for periorbital injections; these patients are instructed to ice intermittently for the first 48 hours. Ecchymosis is very variable and patients may appear fine within a couple of days, but may take up to a week for complete resolution of bruising. Makeup can be applied in two hours after treatment, but if very bruised, will be of limited benefit. All patients having cheek or periorbital injections are scheduled for follow-up appointment in three to four weeks. It is generally recommended that the first time a patient has the NL folds filled that a follow-up be scheduled to ensure the result is appropriate; on subsequent treatment of the NL fold, this short-term follow-up is not necessary. At the follow-up visit, the result is evaluated to ensure there are no irregularities. If additional filling is required, it is performed at this time. If mild visible irregularities are present at follow-up, massage may smooth out the appearance. Should irregularities persist, hyaluronidase can be injected to flatten out any elevation. The hyaluronidase is used at a concentration of 15 units/mL, with between 1 and 3 units being injected at a time. Immediately following injections the skin tends to appear erythematous. This lessens significantly within 24 hours, but may persist up to one week. In rare circumstances, a mild degree of redness can persist beyond this time, particularly with very superficial injection. The severity of erythema and the patience of the patient will determine intervention. Interventions that have been successful in reducing persistent erythema include intense pulsed light treatment of the area or, if necessary, hyaluronidase injections will break down material and improve the appearance. Infection is very rare with injectable treatments. In one instance, we have observed delayed onset of erythema, induration, and inflammation at six weeks following injections (Fig. 7.1.17A, B). This occurred bilaterally in the NL folds; but the labiomandibular folds, which were treated simultaneously, were unaffected. There was no associated pain in the

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involved region. This presentation is consistent with atypical mycobacterial infection. This can be easily confused as a type IV (delayed hypersensitivity) inflammatory reaction but does not respond to topical corticosteroids. Treatment with oral macrolide antibiotics such as Azithromycin is recommended for one to two weeks and has led to complete resolution of the infection in these cases (6). AUTOLOGOUS FAT TRANSFER

Autologous fat transfer is primarily used to provide larger volume augmentation in midfacial rejuvenation. It has proven efficacy in midfacial rejuvenation with quantitative measured volume of around 30% retention of initial volume injected at nearly 1.5 years follow-up with clinical results lasting up to 10 years or longer (4). It can be used in conjunction with other surgical procedures with excellent results (Fig. 7.1.12A,B). However, autologous fat grafting does have limitations including some variability in the retained amount, which may require touch-up procedures. One of the main limitations of fat grafting is in obtaining precise small-volume augmentation. Dermal fillers can efface fine rhytids and hollows with the small volumes and precise technique described earlier. Injectable fillers also have the advantage in overcoming and effacing depressions corresponding to osteocutaneous ligaments such as the malar septum and mandibular ligaments. This cannot be obtained with fat due to the deeper injection required. Also, fillers have significantly less downtime and most patients can go back to work within the same day as makeup can be applied to the region within hours after treatment. CONCLUSION

In midfacial rejuvenation, a paradigm shift in both the public’s expectations and physician practices has occurred. Soft-tissue volume augmentation is now an essential component in treating the aging face. Although surgical procedures such as rhytidectomy continue to have a major role, it is no longer acceptable to only address skin and soft tissue laxity and descent. Soft-tissue volume augmentation plays an integral and complementary role when addressing the facial signs of aging including significant volume loss from soft tissue atrophy and rhytids. The primary goal of midfacial volume contouring is to produce a natural appearance of beauty and youth by enhancing structure and creating the smooth facial contour that tends to be lost with age. Patients are increasingly in search of minimally invasive techniques with little downtime that provide natural results. With the enormous success of Botox as a minimally invasive treatment, there has been a market explosion of numerous injectables fillers for soft-tissue augmentation in recent years. Fillers have the advantage of less downtime with increased patient comfort. They also can be used as a “trial-run” before a more invasive surgical procedure is performed. Soft tissue fillers are an excellent option for midfacial rejuvenation. Each specific midface region has specific techniques and products which have demonstrated long-lasting and good results. With appropriate expectations, patients can have a high degree of satisfaction in correcting there volume deficits. These minimally invasive treatments are an excellent alternative to surgical treatment.

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REFERENCES 1. 2. 3.

4. 5.

6.

Lam SM, Glasgold MJ, Glasgold RA. Complementary Fat Grafting. Philadelphia: Lippincott, Williams & Wilkins, 2007. Meier JD, Glasgold RA, Glasgold MJ. Autologous fat grafting: long term evidence of its efficacy in midfacial rejuvenation. Arch Facial Plastic Surg 2009; 11(1): 24–8. Donath AS, Glasgold MJ, Glasgold RA. Quantitative evaluation of volume augmentation of nasojugal groove with hyaluronic acid-based filler: a 3-dimensional analysis. American Academy of Facial Plastic and Reconstructive Surgery. Fall Meeting. Washington DC, September 2007. Mendelson BC, Muzaffar AR, Adams WP. Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg 2002; 110(3): 885–96. Pessa JE, Zadoo VP, et al. Relative maxillary retrusion as a natural consequence of aging: combining skeletal and soft-tissue changes into an integrated model of midfacial aging. Plast Reconstr Surg 1998; 102(1): 205–12. Narins RS, Jewell M, Rubin M, et al. Clinical conference: management of rare events following dermal fillers: focal necrosis and angry red bumps. Dermatol Surg 2006; 32(3): 426–34.

7.2 European commentary Luitgard Wiest

During recent years, dermal fillers have demonstrated both new techniques and dimensions in facial contouring through revolumization of the aging face when volume deficits become increasingly apparent. There has been a change in the approach of correcting signs of facial aging; it is now known that patients profit more from facial enhancement when these fillers are not only used to fill up wrinkles but also to correct volume deficits below the dermal plane. Popular indications for injectable filler use in the midface are the regional volume deficiencies in areas like the tear trough/malar region, the buccal region, and the nasolabial fold, as already outlined by the authors of chapter 7.1. Volumetric enhancement of the periorbital region by restoring an uninterrupted convexity is achieved by blending the lower eyelid and malar region, which results in a greater degree of rejuvenated appearance effacing the tired look that dark circles below the eye imprints on the face. Rejuvenating this area, especially filling the tear trough has recently become very popular, as results are often dramatic and filling seems so simple to perform. Yet the periorbital region including the lateral regions of the upper and lower eyelids is a very sensitive area. Wu introduced a zone concept of the periorbital and midface area, which he called the lower eyelid midface hollow zones (1). Injections in this region have numerous pitfalls and assessment of this region is an absolutely necessary prior to the use of fillers as already outlined in chapter 11.1. Good candidates for filling are patients with modest eye bags and a more prominent tear trough due to midface sagging. The wrong choice of filler material and the wrong technique in this delicate area can lead to possible side effects. An increasing number of nodule formation has been referred to us recently, all of which had been treated with particulated HA fillers for treatment of the tear trough, and which did not respond to repeated injections of hyaluronidase. In one case, the nodules above the infraorbital rim persisted over two years and the patient insisted on surgical removal. All of these cases had a history of lower blepharoplasty in common. A previous surgical intervention in the periorbital region like a lower blepharoplasty might increase the risk of persistent swelling, lymphedema, formation of nodules, and granulomas. 80

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The choice of filler for this region would be a monophasic filler with good viscoelastic properties (2). With the use of longer-lasting fillers like Radiesse and Sculptra, the risk of nodule formation rises (3). As explained in chapter 7.1, the material is injected deeply and epiperiostally at the medial and lateral part of the infraorbital rim. At the medium part of the infraorbital rim we inject just below the orbicularis muscle according to the individual situation, skeletonization, and skin thickness. After using the push-ahead technique for several years, we changed to another technique where the needle is introduced into the skin at an angle of about 45º to 60º deep into the periosteum. The material is then injected in small boluses depositing the majority of the filler at the base and gradually injecting less while withdrawing the needle. This gives more volume to the deep levels where most of the volume deficiency has taken place. The boluses are placed side by side, spaced apart up to 5 mm depending on the area to treat and the volume that is injected. We gently massage the material immediately after the deposition of each bolus for even distribution. CHEEK

Augmentation of the malar region by fillers is one of the most popular sites of volume augmentation in exchange for an alloplastic filler and is often done in combination with tear-trough augmentation. For the definition of the different anatomical regions in this area, for example, anterior cheek, malar mound, and other regions, see chapter 7.1. Very good results have been obtained in this area over the years with autologous fat transfer (4–6), harvested from the patient and processed with filtration plus cleansing or simply reinjected. A debate continues as to the efficacy of these different methods of fat replacement injections. One problem is variable duration of the obtained result. It has been suggested that this is site-specific, with the cheek area having the best retention of injectable fat (7). There are multiple techniques for injecting in the malar region reported in the literature and via personal communication with experienced injectors, like the retrograde injection with a linear, fanning, and/or crosshatching technique. We use the technique of injection of a bolus side by side with a massage or molding of the filler to attain the desired effect and to prevent palpable nodules as described earlier. Our first choice is blunt cannulas gauge 25 (e.g., “magic needle”) to avoid fatal complications (8). We use HA fillers that are specially designed for giving more volume (Table 2.2.3), the so-called volumizers. They usually contain a higher concentration of HA, are double-crossed with a higher degree and are more viscous. The high viscosity necessitates utilization of 26- to 27-gauge needle for injection with injection depth in the subcutaneous space superior to the periosteum. Additional use of lidocaine with the filler immediately prior to injecting has added to a more comfortable patient experience. NASOLABIAL FOLD

As previously discussed in this chapter, the nature of this fold should be taken into consideration and the technique of injection should be chosen accordingly. Enhancement of the minimal and medium nasolabial fold is done primarily with the linear threading or serial puncture technique in the middermis with an HA filler whose viscosity is chosen according to the thickness of the skin; for thin skin, an HA filler with less viscosity like a monophasic filler is preferred.

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A special challenge for enhancement is the very deep nasolabial folds often encountered together with thick skin or in male patients. These folds require a layered injection because of more volume deficiency. Good results in plumping up these folds, when greater volumes of filler material is needed, have been reported by Nerwayhid (9) using the “fishbone” technique. This technique is based on a geometric approach of filling up the volume deficiency in this area by placing a long strand in the mid dermis along the fold. Transversally and vertically from lateral to medial short beams are placed below the longitudinal strand spaced 8 to 10 mm apart. These beams lift the longitudinal strand and unfold the crease at the same time. In a study with 31 patients longer results of the HA filler (Belotero basic) and less volume was needed with this geometric technique building up a structured scaffold of HA filler (7). Longer-lasting fillers like Radiesse (10), Sculptra (3), and permanent fillers (11,12) give excellent results when used to enhance deep nasolabial folds. Cohen et al. (11) demonstrated the safety of ArteFill relative to collagen control and a longer duration than collagen for correction of the nasolabial folds. After five years, the results looked better than they did during the three months to one-year period after injecting ArteFill. The longer-lasting materials are mostly more viscous and are placed with larger bore needles in the deep dermis or subcutaneously medial to the fold in order to avoid spreading of the material laterally to the nasolabial fold and further deepening it upon injection. As adjunctive measurement, treatment of the alar fibers of the levator labii superioris alaeque nasi muscle with Botulinum toxin will decrease the dynamic forces pulling up the superomedial concavity of the nasolabial fold. In order to optimize the result and patient satisfaction a subscision of the nasolabial fold with a wire scalpel can be considered to detach subcutaneously the muscular fibers that insert into the skin before filling up the cavity with a filler material. REFERENCES 1. Wu WTL. Facial rejuvenation without facelifts: personal strategies. Presented at the regional Conference in Dermatological Laser and Facial Cosmetic Surgery, Hon Kong, 13–15 September 2002. 2. Reinmüller J. Auf der Suche nach dem ultimativen Filler. J Ästhet Chir 2009; 2: 9–14. 3. Vleggaar D. Soft-tissue augmentation and the role of poly-L-lactic acid. Plast Reconstr Surg 2006; 118(3S): 46S–54S. 4. Coleman S. Facial recontouring with lipostructure. Clin Plast Surg 1997; 24: 347–67. 5. Amar R. Adipocyte microinfiltration in the face or tissue restructuration with fat tissue graft. Ann Chir Plast Esthet 1999; 44: 593–608. 6. Illouz YG. Adipoaspiration and “filling” in the face. Facial Plast Surg 1992; 8: 59–71. 7. Donofrio LM. Panfacial volume restoration with fat. Dermatol Surg 2005; 31: 1496–505. 8. Gleeson CM, Lucas S, Langrish CJ, Barlow RJ. Acute fatal fat tissue embolism after autologous fat transfer in a patient with lupus profundus. Dermatol Surg 2011; 37: 111–15. 9. Nerwayhid M. Fishbone: Eine neue Unterspritzungstechnik zur Behandlung tiefer Nasolabialfalten mit Hyaluronsäure. Plast Chir 2007; 3: 173–7. 10. Busso M, Karlsberg PL. Cheek augmentation and rejuvenation using injectable hydroxylapatite (Radiesse®). Cosmetic Dermatol 2006; 19(9): 538–88. 11. Cohen SR, Berner CF, Busso M, et al. Artefill: a long-lasting injectable wrinkle filler material: Summary of the U.S. Food and Drug Administration trials and a progress report on 4- to 5–year outcomes. Plast Reconstr Surg 2006; 118(3S): 64S–76S. 12. von Buelow S, von Heimburg D, Pallua N. Efficacy and safety of polyacrylamide hydrogel for soft tissue augmentation. Plast Reconstr Surg 2005; 116: 1137–46.

8 Anatomy of the lower face and neck Evan Ransom and Stephen A. Goldstein

An understanding of the underlying anatomy of the lower face and neck is important in the clinical practice of facial aesthetics. The lower face is defined as the inferior third of the face in the anterior projection. The superior border of the lower face is determined by an oblique line drawn from the oral commissure to the lobule of each auricle. The inferior border is formed by the mandible and its overlying soft tissues. Laterally, the lower face border is the angle and ascending ramus of the mandible. Medially, the left and right lower face aesthetic units meet at the chin, excluding the lower lip and its subunit. Although anatomically distinct, the anterior neck contributes significantly to the appearance of the lower face, particularly in the region between the two sternocleidomastoid muscles. Lower face and neck aging may contribute significantly to the appearance of aging in the face. In addition, failure to address the lower face and neck, especially in conjunction with midface rejuvenation, may lead to an uneven or incomplete result resulting in an unsatisfied patient. The process of lower face aging follows a less defined course than the midface, but some events are common. Decent of the adipose tissues of the midface paired with loss of skin turgor may produce an obvious jowl or marionette lines in some cases. Similarly, accumulation of subcutaneous fat and excess lax skin in the submental area diminishes the aesthetic contour of the cervicofacial angle. An understanding of the specific contributions of different anatomical components to the changes occurring in this complex area is integral to its rejuvenation. Lower face and anterior neck should be considered in layers, beginning with the skeletal framework and moving superficially. THE OSSEOUS LOWER FACE AND NECK

The single most dominant structure in the lower face is the mandible, which provides both support and contour for the overlying soft tissues. The mandible is generally larger in men, approximately 5 mm greater in height at the body and ramus, and approximately 5 mm thicker at the body. In the female face, the jaw line is typically softer, with a smoother

Illustrations of the lower facial anatomy can be found in Chapter 4.

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transition from the face to the upper cervical structures and has a less pronounced shadow effect than in males. Males have a greater mental protuberance, a prominent elevation of bone inferior to the symphysis. Two important anthropometric points are determined by the size and position of the mandible: the pogonion and the menton. The pogonion is the most anterior point of the mandible in the midline, while the menton is the lowest point of the mandible. A cleft chin occurs when there is incomplete inferior fusion of the right and left hemimandible during embryogenesis and fetal development. This is a heritable trait with varying penetrance. In the past, there have been varying individual and cultural preferences relating to chin clefts. With advancing age, the bone loss in the mandible may become significant and can adversely affect the shape of the lower face. As the overlying skin volume does not diminish, this creates an aesthetically noticeable change. Furthermore, loss of mandibular height can have a negative aesthetic effect on the jaw line, giving an appearance of excess soft tissue, augmenting any existing laxity or age-related descent, and exposing the contours of the submandibular glands (1). In some individuals, a relatively small mandible or inadequate projection can limit the efficacy of other cosmetic efforts. This should be considered when planning rhinoplasty procedures and is also important in nonsurgical perioral and lip rejuvenation. Superiorly, the mandible forms the inferior alveolus. This bone holds the roots of the lower teeth and provides contour to the lower lip soft tissues. In older patients, particularly those who are partially or totally edentulous, the lower alveolus may suffer significant resorption. This creates a visible change with diminishing fullness of the lips and adjacent structures. We have all seen the edentulous patient whose lips appear to be sinking in toward their mouth. Some authors specifically highlight the importance of addressing bony changes in rejuvenation (1). Implants and fillers may be used in this area, particularly in patients with pronounced bone loss in the mandible proper, such as at the chin (symphysis) and prejowl (parasymphysis) (2). The loss of mandibular projection also creates significant challenges for reconstruction. Lastly, though it is easily overlooked, the hyoid bone contributes significantly to the appearance of the lower face and neck. Deposition of fatty or loose tissue in the submental area naturally blunts the contour of the mandible and distorts the relationship between the chin and the neck. It is critical to remember, however, that the position of the hyoid determines the cervicomental angle in the youthful face (90°–105°), particularly in profile but also in oblique views. This is important to consider when planning lower face and neck rejuvenation procedures, such as submental or cervical liposuction and a variety of lifts. Removal of excess adipose tissue or redundant skin may tighten this area, but a malpositioned hyoid can dramatically limit the overall success of these efforts. Surgical procedures to reposition the hyoid are outside of the scope of this review, but are an important adjunct to consider in a small subset of patients (1,3). MUSCULATURE AND INNERVATION OF THE LOWER FACE AND NECK

The musculature of the lower face and neck is somewhat less complex than the midface but contributes significantly to the appearance of aging and may provide some excellent opportunities for neurotoxin and filler-based rejuvenation. Beginning laterally, the lower face muscles include the masseter, platysma, buccinator, orbicularis oris, depressor anguli

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oris, depressor labii inferioris, and mentalis. The masseter provides the greatest bulk of any facial muscle and may have a pronounced effect on the lower face contour in the frontal view in some patients. The other lower face muscles play an important role in mimetic function and are largely responsible for oral competence. Even minute asymmetry at this level, from uneven or improperly placed neurotoxins for example, is easily noticed and can have profound consequences on patients’ perceived beauty. The masseter muscle originates as superficial and deep components. The superficial part originates on the zygomatic bone and anterior-most zygomatic arch as a broad aponeurosis and inserts at the angle and inferior ramus of the mandible. The deep part is smaller and arises from the posterior border and entire medial surface of the zygomatic arch and inserts more superiorly on the ramus and at the coronoid process. This muscle is responsible for chewing and is among the strongest in the body. As such, masseter hypertrophy may occur, giving the lower face a “square” appearance. Though the exact etiology of masseter hypertrophy is not understood, it appears to be more common in persons of East Asian descent (4). Multiple aggressive treatment strategies for reduction in masseter volume have been tested, including open surgical reduction and radiofrequency ablation (5–7). A less invasive, first-line therapy involves targeted Botulinum toxin. Relaxation of the masseter with neurotoxin can dramatically soften the jawline in women with a more masculine or “square” jaw (4,8). As the masseter is an important muscle for mastication, injection of any neurotoxin into this muscle should be performed judiciously. Downward and lateral excursions of the angle of the mouth are performed by two overlapping muscles: the depressor anguli oris superficially, and the depressor labii inferioris below. The depressor anguli oris originates at the modiolus and inserts on the mandible, pulling the angle of the mouth down with contraction. It responds very well to neurotoxin injections. The depressor labii inferioris interlaces with the orbicularis oris fibers as they encircle the upper lip and meets its contralateral partner before attaching to the parasymphyseal region of the mandible. Medial to these muscles are the paired mentalis, small quadrangular muscles arising from the symphysis and inserting into the dermis of the chin below the lower lip border. The mentalis elevate the chin skin, as in an expression of doubt, and contribute to pouting and puckering of the lower lip. The orbicularis oris provides the tonic sphincter action of oral competence and also plays a role in articulation and expression. Perioral rhytids may result from repeated orbicularis contraction, particularly in cigarette and pipe smokers. Fine rhytids in this area may be treated quite well with laser resurfacing or chemical peels, while deeper rhytids may necessitate filler placement. Providing tone to the cheek and assisting in mastication, the buccinator muscle sweeps posterior to anterior before curving onto the superior part of the mandibular symphysis. Detailed investigation of the buccinator anatomy has shown that contralateral muscles may converge in the deepest muscle layer of the chin. Some authors have suggested that an inferior band of the buccinator contributes functionally to a “deep unit” along with the inner ring of the orbicularis oris (9). This is distinct from a “superficial unit” composed of the depressor anguli oris, zygomaticus, risorius, and outer ring of the orbicularis, which is anchored more superiorly at the modiolus (9). The role of the platysma in facial rejuvenation may be easily overlooked. Along with hyoid position, as discussed above, platysmal banding or laxity can have a detrimental effect on the lower face–neck transition and compromise the cervicofacial angle. The platysma is unique in that it is the only subcutaneous muscle in the head and neck. It arises

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from the fascia of the superior parts of the deltoid and pectoralis major muscles at the level of the second rib and sweeps superomedially over the clavicle, soft tissues of the neck, and inferior border of the mandible, before terminating in a fascial plane of the face. Recent investigation has shown that the superior extent of the platysma is variable (10). The paired platysma muscles are dehiscent in the midline neck up to the level of the submental triangle, where their fibers begin to decussate. This leaves a point of relative weakness between the chin and the hyoid, where increases in adipose tissue may become obvious. Contraction of the platysma pulls the angle of the mouth inferiorly and tightens the skin of the neck. Over time in association with associated soft tissue and skin changes, contraction of this muscle creates visible cervical banding. Furthermore, although excessively increased platysma activity is uncommon, it occurs in synkinesis patients who may be compensating for paralysis/paresis of other facial nerve branches. This can give an uneven appearance to the lower face and is an indication for neurotoxin injection (11). In some individuals, in association with aging, there can be progressive platysma weakness and skin laxity leading to a “turkey gobbler” deformity. This presents with a loose wattle of tissue suspended from the chin. Treatment of these changes associated with aging varies. Platysmal bands may be injected with neurotoxins, providing both relaxation and lifting of the cervicomental angle. Multiple surgical techniques to address cervical rejuvenation have been described for more significant laxity, including platysma Z-plasty, imbrication, resection, and suturing (1,12,13). Innervation of the muscles of the lower face and neck is provided by two nerves, the facial nerve and the motor branch of mandibular division of the trigeminal nerve (V3). Facial nerve supply to the lower face and neck comes from the marginal mandibular and cervical branches, with variable connections to the buccal branch and its arcade (14). These nerves are generally very small and can easily be injured inadvertently when dissecting soft tissue planes. The cervical branch follows a steep descent after separating from the lower trunk, passing posterior to the mandibular ramus into the neck before angling more anteriorly to broadly innervate the platysma. Injury of the cervical branch has significantly less effects on facial symmetry than comparable injury of other branches, though complete transection can produce subtle asymmetries. The marginal mandibular branch follows a curvilinear course from the lower division of the facial nerve, dipping below the platysma insertion and the edge of the mandible into the upper neck, superficial to the submandibular gland, before ascending beneath the lower face muscles. Unlike those found in the midface, connections between the marginal branch and other facial nerve branches are found in only about 15% of dissection specimens (15). Section of the marginal branch may be significant to a patient, resulting in significant lower face asymmetry, which is made even more obvious with facial expression. Facial nerve injury has been reported between 0.3% and 2.6% of rhytidectomy procedures, with the temporal and marginal nerves at greatest risk (16). Temporary paralysis resulting from neuropraxia, stretch, or electrocautery is more common than permanent injury. This is likely due to the intimate relationship of the nerve to the mandibular retaining ligament, which may be cut in open procedures, in order to increase the amount of soft tissue lift in the lower face (15). A subtle lower face asymmetry is also seen in some cases of cervical branch injury, though lower lip curling and inferior

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excursion remain possible because of an intact marginal branch. In a large case series, Daane and Owsley reported a 1.7% incidence of “pseudo-paralysis” due to cervical branch injury, though 100% of these patients fully recovered (17). The masseter and the anterior belly of the digastric muscle are innervated by the mandibular division of the trigeminal nerve (V3). This nerve exits the skull base at the foramen ovale, descends in the parapharyngeal space, and then forms multiple distal branches with motor, sensory, and parasympathetic components. The motor branch to the masseter innervates the muscle fibers from the deep surface and is generally not at risk during facial rejuvenation procedures. More anteriorly, the mandibular branch provides the motor innervation of the anterior belly of the digastric muscle, making rotation of this portion an excellent option in repair of a permanent marginal branch injury with lower face asymmetry (18). The posterior belly of the digastric muscle is innervated by a short branch off the proximal facial nerve. SMAS, LIGAMENTS, AND ADIPOSE TISSUE

The superficial musculoaponeurotic system (SMAS) is the tissue layer continuous with the platysma, which invests the mimetic muscles in the lower face. Laterally, the platysma muscle fibers reach the parotid tail before dissipating and becoming the parotid fascia. In the middle of the platysma, muscle fibers cross over the mandibular body loosely, accounting for the relative mobility of the facial skin in this area. More anteriorly, overlying the parasymphysis, the platysma is attached to the mandible at a band of tissue called the mandibular septum or mandibular retaining ligament (19,20). Similar to the malar fat pad in the midface, the jowl and submental fat in the lower face and neck play a critical role in rejuvenation. Descent of adipose tissue compartments along the mandibular border, lateral to the chin, is one of the factors that create the jowl effect. This is seen in the profile view as a double contour, though some authors have described this as three curves (20). The exact composition of the jowl area fat has been debated for years, but recent detailed cadaver dissections have led to some important conclusions. First, the jowl is independent from the buccal fat pad anatomically and functionally (20). Second, the jowl is not a single fat pad; rather, in a majority of patients, it is composed of three separate compartments. This includes the inferior and superior jowl areas, along with a submental fat pad (20). Anteriorly, jowl descent is limited by the mandibular ligament, where the labiomandibular fold reaches the inferior border of the mandible (21). Posteriorly, overlying the masseter and in the preauricular area, the SMAS is thicker and densely attached to the parotid fascia (19). This provides the posterior limit of jowl compartment descent, thus confining this process roughly to the middle third of the lower cheek (21). Jowl area rejuvenation includes traditional lifting procedures as well as using a predominantly upward vector. Targeted, judicious volume replacement, however, may also play an important role in lower face rejuvenation. This is especially true of patients with minimal jowl decent but an obvious prejowl sulcus. Loss of midface volume creates skin laxity in the cheeks, which affects both the mid and lower face. In contrast, treatment of the submental fat compartment frequently requires lipectomy or liposuction, though some excellent results with neurotoxins are possible and may delay the need for a surgical procedure.

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Relative to the forehead and midface, rhytids and pronounced soft tissue folds are less prominent in the lower face. For example, perioral rhytids are frequently finer than in the glabellar region. An exception to this is marionette lines. In some individuals, a deep sulcus following the labiomandibular fold forms with age. This is not an anatomical continuation of the nasolabial fold, but rather represents a distinct fold, generally following the arc of the depressor anguli oris inferolaterally from the modiolus. Marionette lines may be aligned with or positioned somewhat more toward the midline than nasolabial folds in patients with prominence in both areas. These folds are very difficult to address with SMAS lift and deeper plane procedures. Treatment of these folds frequently necessitates volume replacement strategies. This area is an ideal place for filler injection, with some dramatic results reported (22). Indeed, treatment of deep marionette lines and nasolabial folds in lower face and midface rejuvenation highlights the complementary nature of nonsurgical volume replacement with surgical “lifting” procedures. Combining these modalities, either concurrently or over time as the patient ages, allows the aesthetic physician to provide a three-dimensional contour improvement. As was true of the midface, an appreciation of the anatomy of the skin is important in lower face and neck rejuvenation. This is particularly important when treating issues of skin laxity and pigmentation abnormality. A complex treatment regimen employing neuromodulators, fillers, and resurfacing for example, may adequately address these concerns in the lower face. If the neck is not addressed concurrently, however, an uneven or artificial appearance may result. For further review of cutaneous anatomy, please see chapter 6 on midface anatomy. REFERENCES 1. Ramirez OM, Robertson KM. Comprehensive approach to rejuvenation of the neck. Facial Plast Surg 2001; 17(2): 129–40. 2. Romo T, Yalamanchili H, Sclafani AP. Chin & Prejowl Augmentation in the management of the aging Jawline. Facial Plast Surg 2005; 21(1): 38–46. 3. Sykes JM. Rejuvenation of the aging neck. Facial Plast Surg 2001; 17(2): 99–107. 4. Liew S, Dart A. Nonsurgical reshaping of the lower face. Aesthetic Surg J 2008; 28(3): 251–7. 5. Roncevic R. Masseter muscle hypertrophy: aetiology and therapy. J Maxillofac Surg 1986; 14(6): 344–8. 6. Ham JW. Masseter reduction procedure with radiofrequency coagulation. J Oral Maxillofac Surg 2009; 67(2): 457–63. 7. Jin Park Y, Woo Jo Y, Bang SI, et al. Radiofrequency volumetric reduction for masseteric hypertrophy. Aesthetic Plast Surg 2007; 31(1): 42–52. 8. Castro WH, Gomez RS, Oliveira J, et al. Botulinum toxin type A treatment for contouring of the lower face. J Oral Maxillofac Surg 2005; 63(1): 20–4. 9. D’Andrea E, Barbaix E. Anatomic research on the perioral muscles, functional matrix of maxillary and mandibular bones. Surg Radiol Anat 2006; 28(3): 261–6. 10. Shah AR, Rosenberg D. Defining the facial extent of the platysma muscle. Arch Facial Plast Surg 2009; 11(6): 405–8. 11. Husseman J, Mehta RP. Management of synkinesis. Facial Plast Surg 2008; 24(2): 242–9. 12. Gentile RD. Purse-string platysmaplasty: the third dimension for neck contouring. Facial Plast Surg 2005; 21(4): 296–303.

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13. Giampapa V, Bitzos I, Ramirez O, Granick M. Suture suspension platysmaplasty for neck rejuvenation revisited: technical fine points for improving outcomes. Aesth Plast Surg 2005; 29(5): 341–50. 14. Kwak HH, Park HD, Youn KH, et al. Branching patterns of the facial nerve and its communication with the auriculotemporal nerve. Surg Radiol Anat 2004; 26: 494–500. 15. Gosain AK. Surgical anatomy of the facial nerve. Clin Plast Surg 1995; 22(2): 241–51. 16. Baker DC, Conley J. Avoiding facial nerve injury in rhytidectomy: anatomical variations and pitfalls. Plast Reconstr Surg 1979; 64(6): 781–95. 17. Daane SP, Owsley JQ. Incidence of cervical branch injury with “Marginal mandibular nerve pseudo-paralysis” in patients undergoing face lift. Plast Reconstr Surg 2003; 111(7): 2414–18. 18. Conley J, Baker DC. Paralysis of the mandibular branch of the facial nerve. Plast Reconstr Surg 1982; 70: 569–77. 19. Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg 1989; 83: 11–16. 20. Reece EM, Pessa JE, Rohrich RJ. The mandibular septum: anatomical observations of the jowls in aging: implications for facial rejuvenation. Plast Reconstr Surg 2008; 121: 1414–20. 21. Mendelson BC, Freeman ME, Wu W, Huggins RJ. Surgical anatomy of the lower face: the premasseter space, the jowl, and the labiomandibular fold. Aesth Plast Surg 2008; 32: 185–95. 22. Gravier MH, Bass LS, Busso M, et al. Calcium hydroxylapatite (Radiesse) for correction of the mid- and lower face: consensus recommendations. Plast Reconstr Surg 2007; 120(6 Suppl): 55S–66S.

9.1 Volumetric approach to lower facial rejuvenation Robert A. Glasgold, Mark J. Glasgold, and Jason D. Meier

The aging process that occurs in the lower face has been well documented (1,2). Skin laxity coupled with the gradual descent of the soft tissues including facial fat, superficial musculoaponeurotic system (SMAS), and musculature result in the development of the labiomental fold, platysmal banding, and ptotic jowls that are the stigmata of the aging lower face. This process can be exacerbated by genetics, smoking, and ultraviolet light exposure. Poor bone definition of the mandible can accentuate the soft tissue descent of the face, thereby creating an accelerated impression of aging. Similar to midfacial rejuvenation, a volumetric approach to the lower face and neck plays an integral and complementary role in rejuvenation procedures. The lower face and neck has been primarily addressed with surgical techniques including rhytidectomy and mentoplasty. However, patients are increasingly looking for minimally invasive procedures that provide lasting results. With the advent of nonanimal-stabilized hyaluronic acid (NASHA) injectable fillers and the off-label expansion of their use in treating the aging lower face, patients have a variety of options to address their concerns. The lower face, defined for the purposes of this chapter, begins at the level of the oral commissure and continues inferiorly into the neck. Volume restoration for facial rejuvenation is frequently discussed in the context of midfacial rejuvenation. Traditionally there has been less focus on the role of volume in rejuvenating the lower face, outside the role of chin implants. Volume loss has a very real effect on lower face aging, and as in the midface often accounts for the initial signs of aging in younger patients (3). This chapter will review the techniques and filling materials used for jawline and lower perioral rejuvenation in our practice. Volume by no means can replace the role of surgery in jawline and neck rejuvenation but in the appropriate patient can be a very effective substitute, or even complement, for surgery (Fig. 9.1.1A and B). This chapter focuses on injectable fillers that have been used in our practice with proven success and high patient satisfaction. As in the previous chapter, this chapter will focus on anatomically defining a region and describing the specialized techniques and products recommended for that region. In addition, complications and pitfalls of various products and techniques based on our experience will be addressed.

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Figure 9.1.1 (A) Prior to treatment this patient demonstrates characteristic changes of the aging jawline including prejowl sulcus volume loss, jowl ptosis, and loss of mandibular angle volume/ definition. (B) Photograph of the same patient one month after volume rejuvenation of the jawline, with filling of the prejowl sulcus and lateral (angle) jawline. A total of two and a half vials of Juvederm were used in this patient. Two vials of Juvederm Ultra were used in the prejowl sulcus and to delineate the mandibular angle. Juvederm Ultra Plus (0.4 mL/side) was used to add bulk in the remaining area of the mandibular angle.

JAWLINE

The most common jawline complaint is development of jowls. This is manifest by the loss of the crisp uniform shadow that runs from mentum to angle of the mandible. Underlying this change is soft tissue ptosis at the jowl resulting in fullness inferior to the mandibular border. The mandibular ligament, an osteocutaneous attachment, demarcates the anterior limit of the jowl. Volume loss, both bone and soft tissue occurs at the mandibular ligament resulting in the prejowl sulcus. To a lesser degree, posterior to the jowl at the angle of the mandible, volume deficiency (age related or congenital) will further emphasize the presence of a jowl. The sum of these changes turns the youthful crisp “hockey-stick”-shaped shadow defining the jawline into an irregular “W”-shaped aged jawline (Fig. 9.1.2A and B). Jawline rejuvenation requires addressing the volume loss, anterior and posterior to the jowl, and/or lifting the jowl itself. The chosen treatment depends on a particular patient’s anatomy and their desired result. This chapter is primarily focused on volume rejuvenation of the jawline. In younger patients with minimal jowl ptosis, addition of prejowl volume can create excellent jawline restoration, possibly exceeding the result a surgical facelift would obtain (Fig. 9.1.3A and B). With more progressive jowl ptosis and prejowl sulcus deficiencies, several issues need to be assessed in order to optimize the result and patient satisfaction. A more ptotic jowl will require a greater degree of volume in order to camouflage its presence. If very significant, it may not be possible to camouflage the jowl with volume alone. This may be in part due to overly extensive jowl ptosis, but is also

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Figure 9.1.2 (A) This woman in her mid twenties demonstrates the characteristic youthful jawline defined by a “hockey stick”-shaped shadow. (B) In the aging jawline the defining shadow transitions from the “hockey stick” shape into an irregular “W”-shape, secondary to prejowl sulcus volume loss, jowl descent and loss of lateral jawline definition. (Figure 9.1.2A is reprinted with permission from Lam SM, Glasgold MJ, Glasgold RA. Complementary Fat Grafting. Lippincott Williams & Wilkins. Philadelphia, 2007.)

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Figure 9.1.3 (A) Early aging changes in the jawline are primarily related to volume loss in the prejowl sulcus and may be accompanied by lateral jawline volume loss. (B) Volume rejuvenation of the jawline with placement of Restylane in the prejowl sulcus and lateral jawline. A total of 2 mL of Restylane were used for the entire bilateral treatment.

related to the adherence of the mandibular ligament. The mandibular ligament attaches from the underside of the dermis to the mandible and delineates the prejowl sulcus. The degree of mandibular ligament adherence limits the extent to which the prejowl sulcus can be effaced. If very adherent, no amount of volume will adequately inflate it to the point of completely masking the jowl (Fig. 9.1.4A and B). If it is less adherent, the prejowl sulcus

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Figure 9.1.4 (A) This patient demonstrates both jowl descent and prejowl sulcus contraction in the presence of a very adherent mandibular ligament. (B) Jawline definition was improved with prejowl sulcus and lateral jawline volume, using a total of 3 mL of Restylane. The appearance of persistent jowling is from the inability to fully overcome the tethering effect of the mandibular ligament. In this patient the optimal result would require facelift combined with release of the mandibular ligament and filling of the prejowl sulcus.

is more amenable to a volume filling approach. Dermal fillers (hyaluronic acid (HA) fillers) offer an advantage in patients with more adherent mandibular ligaments. Filling and inflating the dermis, which is superficial to the mandibular ligament, improves the ability to overcome the ligament’s tethering effect. Mandibular ligament adherence can be assessed simply by pulling inferolaterally on the skin at the depth of the prejowl sulcus. If the skin is easily pulled down to the level of the jowl, then the ligament’s adherence should not inhibit full correction with injection alone. If it is more tethered and will not pull down to the level of the jowl easily, filling of the prejowl sulcus, and thus camouflage of the jowl, will likely be incomplete. Volume deficiency of the lateral jawline, or angle of mandible, may be due to a congenital deficit of bone or soft tissue (Fig. 9.1.5A and B) or may be a relative loss in comparison to the adjacent jowl ptosis. In most patients adding lateral jawline volume is of secondary importance relative to the benefit from volume added to the prejowl sulcus. People generally view themselves front on, or obliquely, in a mirror. From these perspectives they will appreciate the improvement of prejowl volume more readily than improvements in lateral jawline volume. Explaining to patients the role of lateral jawline volume is best done by reviewing their profile photos with them, and those of patients with similar findings who have undergone these procedures. Deciding whether or not to recommend addition of lateral jawline volume depends on the shape of the jawline shadow posterior to the jowl. If filling in the prejowl sulcus accomplishes the full “hockey-stick” shadow then the lateral jawline does not need to be addressed (Fig. 9.1.6A and B). As the degree of jowling increases the appropriate angle definition is lost and full camouflage of the jowl will require lateral jawline volume (Fig. 9.1.7A and B).

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Figure 9.1.5 (A) Prior to treatment this patient demonstrates congenitally deficient mandibular angle definition. (B) Angle definition was improved by filling the lateral jawline with 0.4 mL of Juvederm Ultra Plus on each side.

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Figure 9.1.6 (A) This patient demonstrates jawline aging primarily due to prejowl volume loss. (B) In this circumstance excellent rejuvenation of the jawline was obtained by adding volume to just the prejowl sulcus. A total of 1.2 mL of Radiesse was used for bilateral treatment.

The technique for jawline rejuvenation using HA fillers begins with marking of the planned injection sites. Conceptually the jowl is the lowest point along the jawline and the goal is to bring the adjacent areas (prejowl sulcus and lateral jawline) down to the level of the jowl. The prejowl sulcus marking is basically a triangle, tapering into the chin anteriorly and the jowl posteriorly (Fig. 9.1.8A and B). The angle marking is also a triangle with its lateral inferior corner rounded off, and its anterior corner tapering into the posterior border of the jowl. A topical anesthetic is generally used; if needed for patient comfort, a minimal (less than 1 mL) amount of 1% lidocaine with epinephrine (1:100,000) is injected subcutaneously at the planned injection sites. HA filler injections can be done either with a linear threading or serial puncture technique. Depth of injection is in the mid to deep

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Figure 9.1.7 (A) Demonstration of an aging jawline with more progressive prejowl and angle volume loss combined with jowl ptosis. (B) Prejowl sulcus filling with Restylane improved the anterior jawline contour, but the posterior aspect of the jowl is left uncamouflaged. An optimal result would be obtained through the addition of volume at the angle of mandible to complete the ideal “hockey stick” contour.

dermis, staying more superficial to overcome the most adherent part of the mandibular ligament as well as for defining the lateral jawline (Fig. 9.1.8C and D). The more superficial injections in these locations are usually done with a linear threading technique. The area is massaged with some degree of molding to ensure a smooth and appropriate contour. Bruising is less common than that which occurs in the midface. Patients are instructed to follow up in three to four weeks to evaluate the result and for a touch up injection, if needed. Filling of the prejowl sulcus will require between 0.5 and 1 mL of HA product per side, depending on the severity of the deficit. The amount of material needed for the lateral jawline is much more variable. At a minimum 0.5 cc of volume needs to be placed. As the jowl increases, in fullness and degree of descent, the amount of volume required can increase to 1 or 2 mL per side. In general, 3 to 4 mL of material will be required to complete bilateral prejowl sulcus and angle definition. Since most patients can better appreciate the prejowl result, they will usually opt to underdo the lateral jawline to reduce the total amount of material needed. In contrast to the inferior orbital rim, there is much more flexibility for the type of product that can be used here. Our early experiences were with Radiesse, prior to availability of HA fillers, with which we generally got a 10-month result before patients noted diminishing volume. One potential advantage of Radiesse is the larger amount of volume in the syringe, reducing the material costs (Fig. 9.1.9A and B). The limitation with Radiesse in the prejowl sulcus and lateral jawline is based on its requiring a deeper subdermal placement. Patients with a less adherent mandibular ligament can get a good result, but when the ligament is more adherent the result is improved by more superficial dermal placement using an HA filler. Additionally, following Radiesse injection, there was typically thickening or fibrosis that was present even after the result receded, making subsequent injection with Radiesse very difficult. In the lateral jawline, our original

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Figure 9.1.8 (A) Appearance immediately prior to volume rejuvenation of the jawline. (B) The injection plan is marked out. The prejowl sulcus is filled inferiorly, dropping it down to the level of the jowl and mentum to create a straight jawline. The angle is defined by filling out the delineated triangular region, carefully tapering the added volume into the posterior border of the jowl. (C) Technique and depth of injections. The green indicates where more superficial dermal injection is performed; including at the mandibular ligament (at the apex of the prejowl sulcus) and to outline the angle definition. A linear injection technique is often used in these areas. The blue indicates where deeper dermal injection is used for filling the remainder of the prejowl sulcus and the lateral jawline. This is usually performed with a serial puncture injection technique. (D) The patient is shown immediately following Restylane (using a total of 3mL) injections in the prejowl sulcus and lateral jawline with recreation of the uniform “hockey stick”-shaped jawline.

thinking was that the thicker material would be beneficial for the bulk required to address this area. In practice, more important than just bulk is creation of a well-defined shadow that delineates the angle. Again, dermal injection can create the type of ridge that is necessary to optimize jawline definition in this area. For these reasons, the HA fillers have become our primary choice for jawline rejuvenation.

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Figure 9.1.9 (A, B) Pre and posttreatment photographs showing the result obtained from isolated filling of the prejowl sulcus. One vial of Radiesse was adequate for bilateral treatment. Evaluation revealed very little resistance to filling from the mandibular ligament allowing for adequate correction with Radiesse. This result also demonstrates how lowering the height of the jawline at the prejowl sulcus hides submental fullness giving the appearance of an improved submental contour.

In terms of which HA filler to use, we have used with good success Restylane, Perlane, Juvederm Ultra, and Juvederm Ultra Plus. We have noted some benefits of the individual products that can influence which one to use. In areas where material is placed more superficially in the dermis (i.e. mandibular ligament and angle definition) a less viscous material, such as Restylane or Juvederm, is preferred. In distinguishing between Restylane and Juvederm family of products we have found that Juvederm spreads out over an area more readily and seems to be more hydrophilic, giving a more inflated appearance (which is the very reason we do not use it in the periorbital region). In contrast, Restylane does not seem to spread over the area as readily and is therefore better at creating very defined elevations. Clinically this has led to a preference for Restylane in thicker skin types where it is more difficult to create the “ridge” or definition of the jawline, and a preference for Juvederm in thinner more crepe-paper like skin where Restylane may be more visible and the “inflating” effect of Juvederm gives a nice full appearance to the skin (Fig. 9.1.10A–D). Jawline correction with injectable HA fillers can be expected to last around nine months to a year. LABIOMANDIBULAR FOLD (MARIONETTE LINES)

The labiomandibular folds (LMF), often referred to as “marionette lines,” begin at the oral commissure and run in an inferolateral direction toward the jawline. This region is of particular concern to patients, who note that the corners of their mouth turn down. The labiomandibular fold defines the anterior border of the jowl. As one ages, the labiomandibular fold deepens, accentuating the appearance of the jowl. The volume loss in this fold is often accompanied by volume loss in the lateral superior aspect of the chin, lateral to the labiomental sulcus. Results from filling of LMF are often optimized by placing material both at the depth of the fold and anterior to it, creating a smooth contour from jowl to lateral

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Figure 9.1.10 (A, B) Restylane (2 mL) and Perlane (1 mL) were used for volume rejuvenation of the jawline by filling the prejowl sulcus and lateral jawline. This patient demonstrates the type of result obtained with thicker skin types where Restylane is often preferred for creating jawline definition. (C, D) Juvederm Ultra (2 syringe) and Ultra Plus (1 syringe) were used for volume rejuvenation of jawline by filling the prejowl sulcus and lateral jawline. The nasolabial folds and perioral rhytids were also filled with Juvederm. This patient demonstrates the thinner more crepe-paper like skin that often obtains a nicer result with Juvederm.

chin (Fig. 9.1.11A and B). HA fillers are our preferred material for this area as they can provide excellent and precise correction of the volume loss. As in other areas, dermal placement facilitates effacement of the fold (Fig. 9.1.12A and B). The injection technique begins with marking the planned injection area along the labiomandibular fold along with the triangular shaped region of volume loss just medial to the fold (Fig. 9.1.11). Topical anesthetic is applied. A serial puncture injection technique is preferred in this area. Injection should remain in the mid to deep dermis, particularly in the

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Figure 9.1.11 (A) The labiomandibular fold delineates the anterior border of the jowl. Volume loss at the fold itself should be restored, in addition to the lateral chin depression anteromedially, to create a smooth contour. (B) The planned injection site is marked in the diagram.

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Figure 9.1.12 (A, B) Pre- and posttreatment photograph demonstrates the effect of filling the labiomandibular fold to create a uniform contour from the jowl into chin.

superomedial aspect of the fold, where too superficial injection is more likely to result in prolonged erythema or a bluish hue (Tyndall effect). On average, 0.3 to 0.5 mL of HA product per side is typically required to correct this region. It is important to inject only at or medial to the fold as injection lateral to it will worsen the appearance of the jowl and LMF. After correction, gentle massage of the area is performed with petrolatum-based ointment to ensure a smooth contour. The result can be expected to last between six and nine months. For patients who are very focused on the downward turn at the oral commissure,

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ancillary use of Botulinum toxin injection of the depressor anguli oris (DAO) muscles, 2 to 4 units/side, can enhance the resulting of LMF filling. These injections are done into the inferior portion of the DAO muscle, at the anterior face of the mandible, so as to prevent inadvertent weakening of the orbicularis oris muscle. Patients are asked to show their bottom teeth, activating the DAO muscle for identification of its location prior to injection with Botulinum toxin. CHIN

The primary patient concerns related to the chin involve projection and contour. Microgenia (under projection) is not an uncommon complaint even in the younger patient; but agerelated volume loss of bone and soft tissue may unmask or exaggerate a long-standing microgenia. The contour changes in the chin are secondary to soft tissue volume loss over the highly dynamic mentalis muscle in combination with decreased skin elasticity. The resulting change in the chin surface contour, commonly referred to as “peau d’orange,” has a very aging effect on the lower face. Injectable fillers have a limited role in correction of chin projection. Alloplastic implants remain our gold standard for chin augmentation. These implants have a long history of use with proven efficacy, providing predictable and safe long-term results. The limitations of injectable fillers for chin augmentation relate to their finite duration of effect and the difficulty in obtaining significant projection without using very large volumes. The advantages offered by injectable fillers include the ability to demonstrate the result of chin augmentation in patients who are considering an implant or do not want to undergo surgery, and the ability to precisely contour chin irregularities or asymmetries (Fig. 9.1.13A and B).

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Figure 9.1.13 (A) This patient demonstrates significant microgenia and is an ideal candidate for an alloplastic implant. The patient wanted a nonsurgical solution and only a mild increase in chin projection. (B) Result at two months following treatment with a total of 2 mL of Perlane and 1 mL of Restylane used to fill the anterior chin, labiomandibular fold, lateral chin depressions, and prejowl sulcus.

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Due to the limited projection that can be achieved with injections this treatment is usually reserved for patients with smaller degrees of microgenia. Treatment begins with marking the planned area for injection. If projection is the central goal, the central mentum is marked out with plan for lateral extension into the prejowl sulcus to mimic the effect of an extended anatomical implant. The injections may also be tapered into the adjacent lateral chin depressions that span from the labiomandibular fold to the labiomental sulcus. When correcting “peau d’orange” skin texture the involved area, generally the central mentum, is outlined. Anesthesia is obtained using small amounts (1 mL) of 1% lidocaine with epinephrine 1:100.000 layered subcutaneously in the chin, as topical anesthetics are generally insufficient for analgesia of the chin. Chin projection can be accomplished with any of the HA fillers or with Radiesse. The main advantage of Radiesse is the larger volume per syringe. In contrast, despite smaller volume, the ability to place HA fillers in both the dermis and subdermis actually helps to increase the amount of obtainable projection. Additionally, since most aging patients have some degree of contour irregularity in the chin, this will be simultaneously addressed with dermal (HA) fillers. Perlane or Juvederm Ultra Plus is generally used when trying to increase projection. Regardless of the goal, injection of the HA fillers can be done with either a serial puncture or linear threading technique. For correction of “peau d’orange,” the HA filler is distributed evenly throughout the involved dermis. Clinically this effect on surface contour was an incidental benefit realized in a patient undergoing injectable chin augmentation (Fig. 9.1.14A and B). Prior to this, the primary treatment for the surface irregularity was Botulinum toxin injection (2–4 units) into the mentalis muscle. To maximize contour results, Botulinum toxin and filler treatment can be combined and a result lasting nine months or longer can be obtained. Further, patients can get a longer and still very good result even with use of an HA filler alone.

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Figure 9.1.14 (A) The patient (also seen in figure 9.1.13A and B on profile) demonstrates significant “peau d’orange” changes to the chin. (B) Dermal injection across the involved area improved the skin texture. This result was obtained without using Botulinum toxin in the mentalis muscle, but can be further improved with its addition.

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LOWER LIP VERTICAL RHYTIDS

Lower lip vertical rhytids are particularly bothersome for many patients. In addition to genetic and general aging factors, smoking and solar damage play an important role in the genesis of perioral vertical rhytids. Smoking causes repeated mimetic motion of the orbicularis oris musculature, which usually defines and worsens the vertical lines. These rhytids usually begin at the vermillion border and have varying depth and length. Vertical rhytids in the lower lip are usually less prominent than those present in the upper lip; however, if present both regions should be addressed in the same session. HA fillers are the mainstay of treatment for correction of vertical rhytids and volume loss. Marking out each deep vertical rhytid with a fine-tipped marker is beneficial prior to application of topical anesthetic. Superficial injection of HA filler in a linear threading technique is recommended for treatment of the individual deep vertical rhytid. The needle should be visible with only a thin tissue layer between it and the skin surface. In addition, injection of the vermillion border provides for some effacement of the vertical rhytids along the entire length of the lower lip and a linear threading technique is preferred. Juvederm Ultra or Restylane are preferred for direct injection into the deep vertical lip rhytid and for the vermillion border. If volume augmentation of the body of the lip is being performed, then Juvederm is preferred as it provides a smoother augmentation with more of a plumping effect. Longevity of the result in the perioral region tends to be less than other facial regions, but still can frequently last up to nine months. LABIOMENTAL SULCUS

The labiomental sulcus is the depression that divides the lower lip from the chin. It has a hyperbolic shape and usually terminates in the lateral chin area. Deepening of the labiomental sulcus occurs with age and can be of concern to some patients. Correction and effacement of this sulcus can be obtained with a variety of injectable fillers. If a deep well-demarcated crease is present, then superficial injection with a HA filler is preferred. Either Restylane or Juvederm works well using a linear threading deep dermal injection to “unfold” the crease. A broad depression in the labiomental sulcus can be corrected with thicker formulations of HA such as Juvederm Ultra Plus or Perlane or can be corrected with Radiesse. Less than 0.5 mL of an HA filler is usually all that is required for correction of this region. POSTINJECTION CARE AND MANAGEMENT OF COMPLICATIONS

After injection of HA fillers, the skin markings should be removed with alcohol. After superficial injections, especially when there is even minimal blanching of the skin, hydrogen peroxide should never be used to clean the skin. We have seen two instances of minimal focal superficial skin necrosis that occurred immediately after cleaning the site with hydrogen peroxide. Both cases healed without complication, but with the avoidance of hydrogen peroxide, focal superficial skin necrosis has not been seen. Application of Aquaphor ointment and a gentle but firm massage is recommended to smooth out any palpable or visible lumps. Ice packs are applied to decrease swelling and bruising. Bruising, if

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it occurs, may take up to five to seven days to completely resolve. Makeup can be applied within two hours after treatment. Immediately following injections the skin appears erythematous. This lessens significantly within 24 hours, but may persist up to one week. In rare circumstances, a mild degree of redness can persist, particularly with very superficial injection. The severity of erythema and the patience of the patient will determine intervention. Interventions that have been successful in reducing persistent erythema include intense pulsed light treatment of the area or, if necessary, hyaluronidase injections will break down material and improve the appearance. Patients are instructed not to massage the area treated. If visible irregularities are still present after one week from the time of injection, the patient can gently massage the area if they are very concerned. Palpability of the material is normal and expected, this will soften with time; but the degree of palpability does not correlate with persistence of result. Patients are scheduled for a follow-up visit in approximately three to four weeks after injections to assess the result and determine any need for a touch-up procedure. This also allows for photographic documentation of the patient’s result. If mild visible irregularities are present at follow-up, massage may smooth out the appearance. Should irregularities persist, hyaluronidase can be injected to flatten out any elevation. The hyaluronidase is used at a concentration of 15 units/mL, with 1 to 3 units being injected at a time. Infection is very rare with injectable treatments. In one instance we have observed delayed onset of erythema, induration, and inflammation at six weeks following injections (Fig. 7.1.17A and B). This was not associated with any significant pain. This presentation is consistent with atypical mycobacterial infection. This can be easily confused as a type IV (delayed hypersensitivity) inflammatory reaction but does not respond to topical corticosteroids. Treatment with oral macrolide antibiotics such as Azithromycin is recommended for one to two weeks and will lead to complete resolution of the infection (4). AUTOLOGOUS FAT TRANSFER

Our experience with autologous fat transfer in the lower face has demonstrated good results in specific regions. It is very useful for jawline correction of both prejowl sulcus and angle of mandible. It is an appealing option for patients with significant lateral jawline deficiencies where larger volumes of material are required. Autologous fat offers a very long-term result, but does require more downtime following treatment due to bruising and swelling. Autologous fat augmentation of the chin is useful for smaller augmentations, but, as with fillers, the results from alloplastic implants are usually superior and provide predictable long-term results. In other areas of the lower face, such as the labiomandibular fold, improvements can be made with fat but where very precise and complete effacement is desired the HA fillers are often a better alternative (5). CONCLUSION

Utilizing a volumetric approach for lower facial rejuvenation, soft tissue fillers provide long-lasting excellent results with minimal downtime. Each lower facial region has specific techniques and products, which have demonstrated long-lasting and good results. With appropriate expectations, patients can have a high degree of satisfaction with soft tissue

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fillers. These minimally invasive procedures are an excellent alternative or can be used in conjunction with surgical treatment. REFERENCES 1.

2. 3. 4. 5.

Mendelson BC, Freeman ME, Wu W, Huggins RJ. Surgical anatomy of the lower face: the premasseter space, the jowl, and the labiomandibular fold. Aesthetic Plast Surg 2008; 32(2): 185–95. Reece EM, Rohrich RJ. The aesthetic jawline: management of the aging jowl. Aesthet Surg J 2008; 28(6): 668–74. Lam SM, Glasgold MJ, Glasgold RA. Complementary Fat Grafting. Philadelphia: Lippincott, Williams & Wilkins, 2007. Narins RS, Jewell M, Rubin M, et al. Clinical conference: management of rare events following dermal fillers: focal necrosis and angry red bumps. Dermatol Surg 2006; 32(3): 426–34. Glasgold MJ, Lam SM, Glasgold RA. Autologous fat grafting for cosmetic enhancement of the perioral region. Facial Plast Surg Clin North Am 2007; 15: 461–70.

9.2 European commentary Luitgard Wiest

The authors of chapter 9.1, which focuses on the lower face, have described the challenges encountered in using injectable fillers in the lower face. If jawline ptosis is not too progressive and rejuvenation of the jawline can be restored with an injectable filler, then assessment of the anatomical situation and the adherence of the mandibular ligament are necessary before enhancement with fillers. Although the jowl compartment is clearly demarcated from adjacent compartments, Pilsl and Anderhuber (1) have demonstrated in a study with 30 anatomic specimens that the retaining ligaments have different origins and are differently formed. At sites where the ligaments of the skin do not reach skeletal structures (false ligaments), the skin is not effectively anchored, and age-related changes are more prominent. These anatomic variations might contribute to variable results when using fillers. In our practice we have abandoned the use of more viscous materials like Radiesse for rejuvenation of the jawline and obtained good results with hyaluronic acid (HA) volumizing agents (Table 2.2.3) that are more viscous and have a higher degree of crosslinking. In areas where the material has to be placed more superficially and intradermally and in thinner skin our preference is a monophasic HA filler gel that has greater flow capacity. Most of the HA filler manufacturers have recently introduced a variety of their preparations, which are bioengineered materials that can be used interchangeably for many different applications and which allow a choice of filler from the same family that is specially designed for different indications, different areas, and levels to be injected. Vleggar (2) showed excellent results with poly-L-lactic acid in recontouring the midand lower face, particularly around the jowls after three to four treatment sessions. In the lower face enhancement of marionette lines, the chin, and labiomental sulcus with injectable fillers should, if possible, include the relaxation with Botulinum toxin of the facial muscles that contribute to the formation of wrinkles or deficiencies in the lower face. The highly dynamic muscles of the lower face are responsible for speech, eating, and communication and thus are much more active than the facial muscles in the upper face. The depressor anguli oris m., the mentalis m. and the orbicularis m., even the platysma play a great role in contributing to the formation of marionette lines, the vertical lines of the lower lip, and the labomental sulcus, which contribute to giving the patients a sad and 105

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dissatisfied look. Several authors (3–5) demonstrated that the outcome of wrinkle treatment with injectable fillers is clearly improved when Botulinum toxin was injected beforehand. They were able to achieve longer durability of the filler material and better results on the wrinkle score. The muscular relaxation provided by the Botulinum toxin may act to promote longevity of the filler by preventing deformation of the hyaluronic acid residing in the dermis (6). Various techniques can be used for volume enhancement of the marionette lines. If more volume is needed the cross-hatching technique can be used along with the linear threading or serial puncture technique. In older patients and in thicker skin, more viscous material like volumizing agents (Table 2.2.3) or fillers with a longer benefit like Radiesse are required. The limitations of injectable fillers for chin augmentation have been described in chapter 9.1. We find it also extremely difficult to enhance the “peau d’orange” skin texture of the chin or the labiomental sulcus with injectable fillers in the presence of a very dynamic mentalis muscle. Other modalities like skin resurfacing give better results in combination with Botulinum toxin than with injectable fillers. REFERENCES 1. 2. 3. 4. 5. 6.

Pilsl U, Anderhuber F. The chin and adjacent fat compartments. Dermatol Surg 2010; 36: 214–18. Vleggar D. Soft-tissue augmentation and the role of Poly-L-Lactic Acid. Plast Reconstr Surg 2006; 118(3S): 46S–54S. Carruthers J, Carruthers A. The adjunctive usage of botulinum toxin. Dermatol Surg 1998; 24: 1244–7. Sommer B, Sattler G. Cosmetic indications according to anatomic region (Ch 3). In: Sommer B, Sattler G, eds. Botulinum Toxin in Aesthetic Medicine. Berlin: Blackwell Science, 2001. Ascher B, Wibault-Collange C. Botulinum toxin (Dysport®) and hyaluronic acid (Hylaform®) association in the treatment of lines. A preliminary evaluation. Inamed Aesthet News 2002: 1. Tierney EP, Hanke CW. Recent advances in combination treatments for photoaging. Review of the literature. Dermatol Surg 2010; 36: 829–40.

10.1 Volumetric approach to the lips Mary P. Lupo

INTRODUCTION

A youthful face has several notable features: smooth skin with no wrinkles or discolorations, central facial volume that prevents sagging of the lower face, and full, well-demarcated lips (Fig. 10.1.1). As we age, loss of dermal volume, loss of bone mass, realignment and/or loss of fat pockets, and changes in dentition result in changes of the lips and the surrounding perioral unit. The distance from the nose to the upper lip lengthens due to volumetric loss of bone and dermis in the nasolabial area and canine fossa, while the distance from the lower lip to the tip of the chin shortens from loss of bone and dentition. This will result in a forward pivoting of the chin and a relative involution of the entire mouth that would be especially prominent in the edentulous. Aging lips have a loss of volume that results in a shrinking of the visible pink “show” of the lips, making the lips pencil thin on anterior view. Additionally, decreased prominence and definition of the philtral columns and Cupid’s bow over time flattens the lips in profile. Photoaging and repeated life-long purse-string movement of the orbicularis oris muscle results in perioral rhytids known as “lipstick” lines (Fig. 10.1.2). All these factors must be assessed and corrected for rejuvenation of the lower face and lips. This chapter will address the author’s methods to revolumize, reshape, and rejuvenate the lips. INJECTION METHODS

For purposes of this discussion, we must first describe and discuss the nomenclature and anatomy of the lips. The wet–dry border is where the mucosa inside the mouth meets the externally visible lip (Fig. 10.1.3). This area is the most important for revolumizing the lips as proper technique will externally rotate the visible lip “show” and make the lips look fuller. Placing the needle’s bevel up and slightly bending the needle to push the material more toward the surface can project the lips out more—with less material. The injection level for optimal revolumizing is the muscle layer. Immediate massage will insure a smooth result (Figs. 10.1.4 and 10.1.5). But increasing size alone is not rejuvenating. A naturally youthful lip has undulations and prominences called tubercles (Fig. 10.1.6). Typically the 107

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Figure 10.1.1

Lips in a 24-year-old, showing fullness, shape, and youthful perioral unit.

Figure 10.1.2 Aged lips in 72-year-old, showing loss of lip volume and shape, surrounding dermal atrophy and resulting fine rhytids, and loss of bone causing involution of the lips, deep folds, and forward pivot of the chin.

Figure 10.1.3 Needle placement into the wet–dry border to achieve volume. Injection is in the muscular layer.

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Figure 10.1.4

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Before injection photograph of 32-year-old female with moderate photoaging.

Figure 10.1.5 After reshaping and revolumizing the lips, filling the nasolabial fold and correcting the perioral scar using 0.8 cc of hyaluronic acid gel filler.

upper lip has three: the center and two lateral. The lower lip has one on each side. This anatomy should be maintained to prevent the unattractive “sausage” lips (Fig. 10.1.7). Well-balanced lips also have the lower lip slightly larger than the upper. In addition to a youthful shape, attractive lips have a well-defined border. The vermillion border or “white roll” is where the pink mucosa meets the cornified epithelium of facial skin (Fig. 10.1.8). This area must be defined, not volumized. If the vermillion alone is injected, it can actually roll the lip inward and decrease the pink show that our patients desire. Even worse, overcorrection of the vermillion alone without some volumization of the body of the lips can result in “duck” lips. This is more likely if the upper lip platform has dermal atrophy and flattening of philtral columns. This emphasizes again the importance of looking at the entire perioral unit rather than just lip size (Figs. 10.1.9 and 10.1.10). Ideally, for vermillion correction, the dermal filler is injected into the potential space just beneath the dermis. When injected in this plane, the material dissects along the border, does not lump, and requires fewer sticks of the needle.

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Figure 10.1.6

Figure 10.1.7

Injection into lower lip tubercle for shape.

Overinjected lips showing loss of lip landmarks and an artificial look.

Figure 10.1.8

Injection into the white roll for definition.

The lateral corners of the lips often require dermal filler to turn the mouth corner up. In addition, dermal injections of filler inferior and just lateral to the mouth corner will support and “buttress” the lateral mouth and diminish the marionette or “puppet” lines (Fig. 10.1.11).

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Figure 10.1.9

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Side view of lip flattening and lengthening and flattening of upper lip platform.

Figure 10.1.10 After 0.5 cc HA filler into lip, nasolabial fold, and into cupid’s bow to project lips and shorten distance from nose to upper lip.

Figure 10.1.11

Injection into the lateral support of mouth corner to buttress and lift mouth corner.

This correction is better achieved with the complementing benefits of neurotoxin injection into the depressor angularis oris as well as injection of filler into the prejowl sulcus as needed (Figs. 10.1.12 and 10.1.13) (1).

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Figure 10.1.12 perioral unit.

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Before treatment: 44-year old showing shadowing of the chin area that ages the

Figure 10.1.13 After injection with 0.8 cc of HA filler into lips, nasolabial fold, and marionette; 4 units into each DAO; and 4 units into mentalis to relax and reshape the oral unit and complement filler.

Lipstick lines are often stretched out and improved when the body of the lips is revolumized. Older patients, those with profound photoaging, smokers, whistlers, lip pursers, and musicians will often require additional filling directly into these radial perioral “lipstick” lines. The level of these injections here is into the dermis (Figs. 10.1.14–10.1.17). The addition of neurotoxin in small quantities will dramatically improve the result and its duration (1). Care must be taken to make the injections symmetrical and they should be omitted in those for whom mouth movement is critical such as television personnel, singers, and musicians. MATERIALS FOR INJECTION

Hyaluronic acid (HA) fillers, as of writing, are the safest, most versatile, and most durable products for injecting into the lips. It has great patient acceptance and popularity (2).

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Figure 10.1.14 A 55-year-old female with full lips but profound solar elastosis resulting in significant lipstick lines.

Figure 10.1.15 After 0.8 cc HA filler into perioral lines only.

HA fillers can be injected into all planes: dermal, subcutaneous, and muscular (Figs. 10.1.18 and 10.1.19). Care must be taken with the dermal injections to prevent lumping and the blue hue or Tyndall effect from superficial dermal placement. This can be easily corrected by nicking the skin and extruding the material. It is noteworthy that although lip augmentation and rejuvenation is very popular, there is technically no FDA-approved product for injections into the lips. Practicing physicians do lip injections “off-label” and as such, it is accepted as effective and safe based on years of experience using bovine and human collagen as well as HA fillers (3,4). For many years, bovine collagen was injected into and around the lips with very nice results but the duration was not acceptable. In 2003, human collagen became available, but its only advantage was that allergy testing was not necessary. HA fillers became the

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Figure 10.1.16 A 59-year-old female with more intrinsic aging but profound lipstick lines.

Figure 10.1.17 After correction of lipstick lines using 0.8 cc HA.

workhorse for lip injections and remain so to this day. HA can be reversed with hyaluronidase if there is a problem (5). Newer fillers such as porcine collagen, calcium hydroxylapatite, and poly-L-lactic acid are contraindicated in the lips because of the high incidence of nodules and lumps (Fig. 10.1.20). COMPLICATIONS

Bruising is the most common complication of lip augmentation (Fig. 10.1.21). It can be reduced by having patients discontinue blood thinners and anticoagulants (as appropriate to the patient’s medical history). Aspirin, vitamin E, fish oil, and many herbal remedies are known to increase bruising. If bruises occur, they can often be easily hidden by lipstick,

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Figure 10.1.18

Before injection of 1.0 cc HA filler into lips.

Figure 10.1.19 After, showing overall natural correction.

Figure 10.1.20 Two years after calcium hydroxylapatite injection for lip augmentation. Nodules eventually dissipated after three years.

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Figure 10.1.21

Figure 10.1.22

Mild bruise after injection from percutaneous approach into lips.

Severe hematoma two hours after injection, likely the result of an arterial nick.

especially when the injection approach is through the mucosa rather than the skin. Posttreatment ice, and pressure as well as the use of bruise reduction creams or arnica might be of value (6). The technique coined by Dr Jean Carruthers as the “push ahead” technique can reduce tissue trauma and bruise by using the filler to push small vessels out of the way of the needle (7). The author also “primes” the needle to place HA at the beveled edge to further reduce tissue tear and trauma. Finally, using a slow injection rate and lower product volume has been found to decrease bruising (8). Hematoma is possible if an artery is nicked (Fig. 10.1.22). If severe, evacuation may be necessary, but they usually resolve without sequelae. As mentioned earlier, superficial placement of HA filler will result in lumping and/ or Tyndall effect. Nick and extrusion is the optimal treatment for this. Hyaluronidase is for deeper lumps, excess correction, and asymmetry. Asymmetry is usually the result of injection by nonphysician injectors and is often amenable to correction with more filler

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Figure 10.1.23 Asymmetrical result from HA injection by nonphysician provider.

Figure 10.1.24 After correction with 0.8 cc HA filler.

(Figs. 10.1.23 and 10.1.24). Swelling can occur within hours to a day after injection. Idiosyncratic angioedema has also been reported (9). Avoidance of salt and sleeping on the back on two to three pillows might be beneficial, but the best way to avoid swelling is to not overcorrect or over massage. The use of oral or intramuscular corticosteroids might also be beneficial (10,11). Prophylaxis against herpes simplex is always a good idea when doing procedures around the mouth (10). There have been reports of granulomatous nodules from HA injections for lip augmentation (12,13). The treatment of choice to reverse this type of reaction would be hyaluronidase (5). Finally, techniques to reduce pain are critical to patient happiness and continued injections in the future. One of the best ways to retain patients and to have them refer their friends for treatment is to improve the patients’ experience. Ice, nerve blocks, vibration distraction, topical anesthetics, and mixing the filler directly with lidocaine can all reduce the patient’s discomfort (7,11,14). A good cosmetic result, little or no complications, and good pain management are the keys to success (Figs. 10.1.25–10.1.27).

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Figure 10.1.25 and 10.1.11.

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Before picture of patient shown getting injections in Figures 10.1.3, 10.1.6, 10.1.8,

Figure 10.1.26

Immediately after injection of 0.8 cc HA.

Figure 10.1.27

Eight months after the treatment.

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SUMMARY

The lips are an important facial landmark for a youthful face. The use of dermal fillers such as the HA family can restore volume, definition, and shape. When combined with filler into the upper lip platform, perioral rhytids and the chin to lift and support the mouth, as well as careful placement of complementing Botulinum toxin, an overall youthful appearance to the entire lower face can be restored. REFERENCES 1. Carruthers J, Glogau R, Blitzer A, et al. Advances in facial rejuvenation: botulinum toxin type A, hyaluronic acid dermal fillers, and combination therapies: consensus recommendations. Plast Reconstruct Surg 2008; 121(Suppl): 5S–30S. 2. Bosniak S, Cantisano-Zilkha M, Glavas I. Non-stabilized hyaluronic acid for lip augmentation and facial rhytid ablation. Arch Facial Plast Surg 2004; 6: 379–83. 3. Lupo MP. Hyaluronic acid fillers in facial rejuvenation. Semin Cutan Med Surg 2006; 25: 122–6. 4. Sarnoff DS, Saini R, Gotkin RH. Comparison of filling agents for lip augmentation. Aesthetic Surg J 2008; 28: 556–63. 5. Brody HJ. Use of hyaluronidase in the treatment of granulomatous hyaluronic acid reactions or unwanted hyaluronic acid placement. Dermatol Surg 2005; 31: 893–7. 6. Lupo MP. A double-blinded, randomized, placebo-controlled split faced within subject evaluation of a bruise reduction serum. Poster Exhibit, Cosmetic Boot Camp, Aspen Co., 2009. 7. Carruthers J, Carruthers A. Hyaluronic acid gel in skin rejuvenation. J Drugs Dermatol 2006; 5: 959–64. 8. Glogau R, Kane M. Effect of injection techniques on the rate of local adverse events in patients implanted with nonanimal hyaluronic acid gel dermal fillers. Dermatol Surg 2008; 34: S105–S109. 9. Leonhardt J, Lawrence N, Narins R. Angioedema acute hypersensitivity reaction to injectable hyaluronic acid. Dermatol Surg 2005; 31: 577. 10. Carruthers A, Carruthers J. Non-animal-based hyaluronic acid fillers: scientific and technical considerations. Plast Reconstruc Surg 2007; 120(Suppl): 33S–40S. 11. Dover J, Carruthers A, Carruthers J, et al. Clinical use of Restylane. Skin Ther Lett 2005; 10: 5–7. 12. Fernandez-Acenero M, Zamora E, Borbujo J. Granulomatous foreign body reaction against hyaluronic acid: report of a case after lip augmentation. Dermatol Surg 2003; 29: 1225. 13. Saylan Z. Facial fillers and their complications. Aesthetic Surg J 2003; 23: 221. 14. Swetman G, Lupo MP, Waller W. Comparison of the efficacy and tolerability of non-animal stabilized hyaluronic acid filler with and without lidocaine hydrochloride 2% for the correction of nasolabial folds. Poster Exhibit, Cosmetic Boot Camp, Aspen Co, 2009.

10.2 European commentary Luitgard Wiest

The author of chapter 10.1 emphasizes the importance of looking at the entire perioral unit, when restoring volume to the lips. Except for the younger patient group who require lip augmentation only, older patients with aging lips will benefit from other modalities for rejuvenation of the entire perioral unit. It should be remembered that a “nonexisting lip” or a very small lip cannot be restored by dermal fillers and should be approached with surgical techniques. An understanding of the embryology of lips serves as a foundation for lip augmentation and for choosing the best technique to obtain a natural fullness of the lip. During embryonal development the lateral maxillary swellings fuse with the paired medial nasal swellings to form the upper lip. The union of these different structures is reflected by the characteristic undulations of the philtral ridge and Cupid’s bow. The lower lip is a simpler and less defined structure, it forms from the merger of the paired mandibular swellings. The difference between upper and lower lip has to be considered in the volumetric approach to lips. The correction especially of aging lips has to address the whole perioral unit like perioral rhytids, the drooping angles of the mouth, as well as restoring the flattened philtral ridges and the Cupid’s bow. Other deficiencies like dentition should be restored. Photoaged skin is best rejuvenated with different laser methods or chemical peel. Regarding the technique of restoring the vermillion border it should be defined, not volumized as already mentioned earlier in chapter 10.1. In order to get a better definition we pinch the border between the thumb and forefinger of the nondominant hand while injecting and withdrawing the needle. To volumize the lips it is best not to use a permanent filler that might result in nodule formation, which is difficult to treat. A much better option is to use a resorbable filler that can be corrected in the case of overcorrection or if nodules occur. We have found that pretreatment with small amounts of Botulinum toxin distributed evenly in four injection points along the vermillion boarder prior to filler treatment helps to prevent nodule formation in this area with constant movement of the M. orbicularis oris. In addition to relaxing the pars marginalis of the orbicularis muscle that forms the red lip, it adds a very natural pseudo-volume to the lip of about 1 mm, it improves the ease of injection into the relaxed muscle and the injected filler material is dispersed easier without

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forming lumps. There is a wide range of HA fillers available in Europe especially designed for the use of volumizing lips (Table 2.2.2) (1). Many techniques have been described to prevent the “sausage look” of the lips after augmentation (2,3). Injecting the filler above the muscle will result in outward rotation of the lip, injecting under the muscle at the wet border will result in projection of the lip. Considering the embryologic features and respecting the anatomy of the lip “sausage lips” can be prevented and an individual approach can be performed. Most patients require volume enhancement only along the central three-fifth of the lip. We prefer vertical injections starting at the vermillion border of the lip until the wet–dry border of the lip proceeding from medial to lateral. Upon withdrawing the filler is injected, depositing volume in the muscular part of the lip, if necessary in an additional layer. The vertical injections are repeated every few millimeters as needed to reach the desired volume. The perioral unit, especially the upper lip, is one of the most sensitive areas of the face and excellent anesthetist an absolute requirement. We prefer an infraorbital and/or mental nerve block for more comfort for the patient during the procedure as topical agents are not as effective in this area. CONCLUSION

In Europe quite a few HA-fillers are specially designed for lip enhancement, the choice lies between monophasic HA-gels and biphasic particulated fillers with different viscosities proving dermal fillers are important tools in this area and in the whole perioral unit. This is especially effective in older patients combined with the treatment of Botulinum toxin to relax the depressor muscles resulting in a lift of the perioral area. Several newer techniques of lip augmentation have been introduced recently, leading away from those techniques that were applied in a horizontal fashion across the entire lip, resulting in the so-called “sausage lip”. For more comfort for the patient nerve blocks are preferred. REFERENCES 1. 2. 3.

Sanoff DS, Saini R, Gotkin RH. Comparison of filling agents for lip augmentation. Aesthet Surg J 2008; 28(5): 556–63. Braun M, Braun S, van Eijik T. Lip tenting: a simple technique for better lip enhancement. J Drugs Dermatol 2010; 9: 559–60. Klein AW. In search of the perfect lip. Dermatol Surg 2005; 31: 1599–603.

11.1 Volumetric approach to rejuvenation of the hands Anetta E. Reszko and Neil S. Sadick

INTRODUCTION

The aging process is commonly accelerated in the hands due to their intense and continuous usage and constant exposure to environmental pressures. After the face, hands are the most visible body part and as such are of major aesthetic importance. Increasing numbers of patients are seeking treatments that would restore a more youthful appearance to their hands based on a common belief that hands’ appearance can be used to determine a true chronological age (1). COMPONENTS OF THE AGING HAND

The principles of hand aesthetics are based on normal anatomy, adequate proportions, even skin pigmentation, sufficient subcutaneous tissue volume, adequate elasticity, and minimal skin wrinkling. The aging process of hands has extrinsic and intrinsic bases. Extrinsic aging encompasses superficial epidermal changes such as actinic and seborrheic keratoses, dyschromia, solar lentigines, solar purpura, and perceived skin roughness. Skin roughness may be the result of irregular epidermal contours and aberrations of cell proliferation and turnover. Intrinsic aging involves deep soft-tissue planes and comprises skin textual changes such as dermal atrophy and wrinkling, and muscular, bone, and fat atrophy (1). Clinically visible manifestations of intrinsic aging are skin laxity, loss of skin elasticity, volume loss with concomitant protuberant tendons, bones, and hand veins. Overall, intrinsic and extrinsic aging processes of the hands can be divided into three broad categories (Fig. 11.1.1). Type I—epidermal and superficial dermal; clinically apparent as pigmentary skin alterations such as lentigines, postinflammatory dyschromia, skin roughness, and vascular aberrations (telangiectasias, purpura). Type II—dermal; results from architectural changes involving collagen, elastin, and glycosaminoglycans. Type II aging is clinically characterized by formation of rhytids. 122

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Figure 11.1.1 Aging hand demonstrating Type I (epidermal), Type II (dermal), and Type III (subcutaneous) changes. Appropriate Type III rejuvenation protocol with fillers would target loss of volume and resulting skin laxity as well as deepened interosseous sulci.

Type III—subcutaneous involving bone, muscle, and fat atrophy. This type of aging is clinically visible as skin laxity, loss of elasticity, volume loss due to osteoporosis of carpal bones and subsequently to clinically widened and deepened interosseous sulci that may be further exacerbated by atrophy of interossei and lumbrical muscles. To restore and refine a youthful hand appearance, the clinical type of aging must be matched to an appropriate rejuvenation program, with both intrinsic and extrinsic factors being taken into account. This chapter provides a review of current literature and data from our clinical practice on the use of soft-tissue fillers for treatment as an outpatient, which are minimally invasive and an efficacious procedure for type III hands rejuvenation. The ideal soft-tissue filler/semipermanent soft-tissue volumizer for type III hands rejuvenation should have several basic properties. It should be safe, completely nonallergenic, produce a smooth and natural looking effect, should be easy to inject, easy to store, readily prepared, affordable, and have a long duration of effects, but not permanent so that potential errors could be corrected. Currently available soft-tissue fillers are: harvested autologous fat, collagen, hyaluronic acid (HA), poly-L-lactic acid (PLLA), and calcium hydroxylapatite (CaHA). Few general principles apply for volumetric rejuvenation with various filler materials. First, preoperative evaluation for all soft-tissue injectables should include a prior history of injectables, medical history, review of current medications, and a coagulopathy history. Medications that lessen blood coagulation, such as aspirin, ibuprofen, and platelet inhibitors, are contraindicated for five to seven days before treatment to minimize intraand perioperative bruising. Bruising may be further reduced by supplementation with arnica and Bromelain for one to two days perioperatively (2–4). Second, sterile technique should be followed at all times.

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Third, topical anesthetics and/or regional nerve blocks may be used for the anesthesia of the hands prior to filler injection. Other methods such as distraction, vibration, and cooling might be used. Fourth, patient may be placed in Trendelenburg position to reduce dorsal hand venous pressure and possibly minimize the risk of venous puncture. AUTOLOGOUS FAT

Autologous fat augmentation has been performed for facial rejuvenation and reconstruction for over 100 years. Fournier was the first to describe the use of autologous fat for the dorsal hand rejuvenation (5). Fournier’s technique centered on the injection of the bolus of fat though a single incision in the dorsum of the hand and subsequent digital manipulation over entire dorsum of the hand and, in special cases, into the fingers. In 2001, Coleman introduced the idea of “structural fat grafting” to describe the process in which small amounts of intact fat are placed in a structured method into the subcutaneous dorsal hand (6). Autologous fat transfer comprises of several steps: fat harvesting, fat preparation/ refinement, fat transfer, and finally structural fat placement. Strictly sterile technique is required for all aforementioned steps. AUTOLOGOUS FAT HARVESTING

Fat harvesting involves aspiration of fat from a donor site (hips, inner and outer thighs, medial knees) infiltrated with tumescent anesthesia with a blunt-tipped cannula or a blunt Lamis infiltrator (Byron Medical Inc., Tucson, AZ, U.S.) attached to a 10 mL Luer-Lok syringe. On an average, 1 mL of tumescent anesthetic is required per 1 mL of the fat to be harvested. Commonly employed harvesting cannulas have a diameter of 3 mm and a length between 15 and 23 cm; commercially available harvesting cannulas have a blunt tip in the shape of a bucket handle for harvesting very small fragments of fat. During the harvesting process, as the light negative pressure is applied to the plunger, the cannula is advanced and retracted through the harvested tissue. Alternatively, highvacuum suction systems used for liposuction may be employed for tissue harvesting, although the risk of marked damage to the delicate fatty tissue is markedly increased with higher pressure systems. Extracted fat is centrifuged at 3000 rpm for three minutes in harvesting syringes after securing the Luer-Lok end and removing the plunger. The centrifugation process separates the harvested material into three separate layers. The top layer (lowest density) is comprised primarily of oils and ruptured adipocytes. The mid portion (mid density) and lower portion (highest density) consist of a viable adipocytes/fat particles and mixture of blood, lidocaine, and water, respectively. After decanting the top layer (cotton surgical strips (Codman & Shurtleff, Rayham, MA, U.S.) may be used to wick oil remaining after initial decanting), and draining the aqueous (bottom) portion, the midportion is ready for harvesting (7). In an alternative protocol, harvested fat may be subjected to gravitational separation for up to 15 minutes in the harvesting syringe in the upright position, with infranatant fluid discarded and the remaining supernatant centrifuged at 3600 rpm for three minutes (8).

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Generally, approximately 30 to 40 mL of centrifuged fat must be harvested per hand to ensure adequate treatment volume. Exposure to atmospheric air should be minimized during the harvesting process to avoid cytoplasmic lysis of adipocytes. Histological analysis of the harvested fat demonstrates cytoplasmic lysis of up to 50% of the adipocytes exposed to air for a period of 15 minutes (6). Centrifuged fat is then transferred to 1 mL syringes for injection. Compared with larger volume syringe, a 1 mL syringe confers more control and delivers smaller particles of fat with less pressure. Care should be taken to minimize trauma to the harvested fat and the introduction of air bubbles. AUTOLOGOUS FAT GRAFTING

Topical anesthetics and/or regional nerve blocks may be used for the anesthesia of the hands prior to structural fat grafting. In addition, tumescent anesthesia (3–5 mL) is injected in the dorsal wrist crease (and more proximally as required). An injection needle (#10 Amay, Byron) or a microcannula is inserted into the area to be treated through small incisions or an 18-gauge needle-entry port in the dorsal crease. Any sharp instruments such as needles should be avoided to minimize potential damage to the hand vasculature and nerves. The level of fat placement for rejuvenation of the hand is in the immediate subdermal plane superficial to the veins and tendons. Fat is then injected in the retrograde fashion with approximately 0.02 to 0.3 mL deposited as the cannula is withdrawn. To cover the entire dorsum of the hand, the cannula is redirected in the fanning fashion. To ensure uniform final effect, continued passes are made in a weaving crisscross pattern and 10 to 20 mL of centrifuged fat is deposited. Accuracy of the initial placement is essential since the manual molding of the placed material is rather difficult without creating surface irregularities. The size of the area of grafting should be adjusted based on the physical appearance and patient’s expectations. Care must be taken to uniformly fill the intercarpal spaces, both sides of the hand, and the proximal web spaces. Coleman proposed six cannula entry points spaced around the periphery of the hand for optimal final cosmetic effect (6). These include: ulnar and radial wrist, the metacarpophalangeal joint of the 5th digit, the web space between the 3rd and 4th digit, radial 2nd finger and the radial thumb. Structural fat grafting should not be performed directly over the metacarpophalangeal or proximal interphalangeal joints to decrease the likelihood of the clinical appearance of an enlarged joint. If reconstitution of volume around the metacarpophalangeal joints is desired, transplanted fat should be feathered to at the proximal half of the proximal phalanx. For optimal long-lasting cosmetic result, the hand should appear slightly overfilled upon completion of the fat transplant. Fair estimate of the amount of the fat placed can be determined four months after the procedure with even more accurate estimate at six to eight months. Systemic antibiotics prophylaxis is recommended a day before and up to 10 days postprocedure (8). Postoperative care includes application of ice/cold compresses, the elevation of hands for 24 hours, and slight compression to minimize postprocedure edema. Patients

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should avoid touching dorsal hand and limit manual activity for approximately one week. Edema is the most frequently encountered side effect and its extent is proportional to the volume of the autologous fat transplanted. Edema is self-limited and usually resolves within one to two weeks postprocedure. Rare complications of autologous fat transfer are infection (including Mycobacterium abscessus (9)), cyst formation, and temporary dysthesia. Bruising is minimal with the use of a blunt tip cannula. Technique-related complications include small lumps secondary to uneven deposition of the fat or fat migration. Several factors contribute to adipocyte survival and long-term cosmetic improvement. These include harvesting method, recipient site, manipulations and exposure of harvested adipocytes to blood, anesthetic and air, centrifugation of fat, diameter of the injection device (needle or cannula), volume of the injected fat, and the degree of overcorrection. Butterwick showed better patient-assessed clinical outcomes with centrifuged versus noncentrifuged fat at three and five months posttreatment (8). In a pilot study of 10 patients, frozen autologous fat had improved results with respect to longevity and aesthetic appearance versus fresh fat at one, three, and five months. In an extensive review comparing various reported harvesting techniques, Sommer and Sattler concluded that, in most cases, good results are reported regardless of technique if small transplant volumes were used (10). Lower injection volumes were shown to be associated with more efficient neovascularization and better graft survival. Only 40% of grafted tissue is viable 1 mm from the edge of the graft at 60 days (11). In most current reports, an average of 5 to 12 mL of fat is implanted per hand per session. In some reports, up to 20 to 30 mL of centrifuged fat was used per hand per session (6). A noted complication of large injection volume is persistent (up to 16 weeks) edema. Longevity of the injected fat remains a subject of literary debate. Effects are reported to last from six to eight months (12) to up to one to five years (6,13) although studies specifically designed to study longevity of autologous fat for hand rejuvenation are lacking. Generally, autologous fat was observed to absorb slower when placed in the hand compared with fat placed in facial areas presumably due to relative immobility of the dorsal hand. Autologous fat transfer is generally well tolerated with high patient satisfaction rates reported. Aboudib et al. reported a 98% satisfaction in 72 patients (14). The benefits of autologous fat transfer relate to the fact that the filler material is accessible, autologous, natural, and nonantigenic. Albeit, autologous fat requires donor harvesting, an invasive surgical procedure with a risk of morbidity and infection. The limitations are unpredictable longevity and relatively complex preparation protocol. However, when used properly fat may restore a long-lasting youthful fullness to the dorsum of the hand. INJECTABLE FILLERS

Injectable synthetic, biocompatible fillers discussed in this section include: collagen, HA, CaHA, and PLLA. Depending on the material injected, injection needle might vary from 25- to 32-gauge and from 0.5 to 1.25 inches in length. Due to the significant pain associated with injection of viscous filler materials, it is recommended that the patient should undergo some form of anesthesia (topical, nerve block, other) prior to the product placement.

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Collagen

Bovine-derived collagen was the first Food and Drug Administration (FDA)-approved prepackaged injectable soft-tissue augmentation material. Two major drawbacks of bovinederived collagen were a short duration of action and the risk of allergy, requiring preimplantation testing. In 2003, human-derived (neonatal foreskin) collagen preparations gained FDA approval. One major advantage of human-derived collagen was lower potential for an allergic reaction and therefore no need for preinjection testing. Human-derived injectable collagen preparations for aesthetic use are CosmoPlast and CosmoDerm (Inamed Aesthetics, Santa Barbara, CA, U.S.). Equivalent bovine-derived collagen preparations are Zyplast, Zyderm I, and Zyderm II. Injectable human collagen is approved for correction of facial wrinkles, lip augmentation, acne scars, and other soft-tissue defects. CosmoDerm and Zyderm are approved for the correction of papillary dermal rhytids and defects such as scars, and CosmoPlast and Zyplast for mid- to deep-dermal lesions. Collagen is a short-acting filler, with most of the cosmetic effect lasting two to three months. Due to the presence of the aqueous component, slight overcorrection is desired. Prepackaged material must be stored in the refrigerator, but not frozen. Usually a 30-gauge needle with the bevel pointing downwards is used to deliver material into the superficial dermis (CosmoDerm and Zyderm) or mid- to deep-dermis (CosmoPlast and Zyplast). Minimal postprocedure erythema and edema usually fully subsides within one to two days. Postprocedure application of ice may decrease edema and bruising. Clinical Data

In a double-blind comparative study of nonanimal stabilized HA (see below) (Restylane; total injection volume of 1.4 mL per hand) versus human collagen (CosmoPlast; total injection volume of 2 mL per hand) for soft-tissue augmentation of the dorsal hands, HA was found to be significantly superior to collagen in general clearance of rhytids, veins, bony prominence, dermal and subcutaneous atrophy, and patient satisfaction. Compared with collagen, HA injection was associated with overall higher patient discomfort although discomfort score did not reach statistical significance (15). Lower patient discomfort rates associated with collagen injection likely relates to the presence of 0.3% lidocaine in collagen preparation (16). Hyaluronic Acid

Hyaluronic acid (HA) is highly biocompatible dermal filler used successfully for several decades for volume restoration. The common sources of the substrate for HA preparations are vitreous humor, rooster combs, umbilical cord, tendons, and more recently bacterial cultures. HA is approved by the FDA for facial soft-tissue augmentation of the nasolabial folds. Off-label use is well documented when used for the lips, glabellar lines, cheeks, tear troughs, chin and jaw lines, depressed scars, marionette lines, oral commissures, and HIVassociated lipoatrophy. Injected HA is hydrophilic and undergoes isovolumetric degradation over the period of five to nine months depending on the treated site (15). Various HA

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products differ in viscosity, gel hardness, particle size, swelling (the gel’s ability to resist dilution), concentration, and the ratio of soluble to insoluble HA (particulate vs. fluid component) (17). HAs should be stored at room temperature, out of direct sunlight. The first HA derivative that gained FDA approval in the United States for cosmetic indications was Restylane. Because current HA preparations do not contain anesthetic, other forms of dorsal hand anesthesia might be required. HA for the hand rejuvenation is placed at the level of the mid- to deep-dermis. Four techniques for the injection of HA are: serial puncture, fanning, linear/serial threading, and cross-hatching. Compared with other injection methods, the serial puncture technique may increase the risk of bruising. Once the needle is placed into a desired plane (mid- to deep-dermal), even pressure is applied onto the plunger while the syringe is withdrawn. Injection should be terminated before the needle is completely withdrawn to avoid injection into superficial dermal planes. The goal of the treatment is to correct the rhytid without significant overfilling. Treated area may be manually massaged with or without a lubricant (Aquaphor, Petrolatum, and others) to smooth out and uniformly distribute the HA. In instances where blanching occurs the injection should be stopped and the area should be massaged until blanching is resolved. Clinically apparent blanching signifies inadvertent injection into superficial vasculature, vascular compromise, and possibly tissue necrosis. The amount of HA injected depends on the amount of correction desired. In the authors’ experience, one to two syringes of HA can be implanted into both hands, depending on the degree of volume required. When injected in dorsal hands, HA’s cosmetic effects last between six and nine months (13). Posttreatment care instructions should include application of ice to reduce bruising, swelling and pain, avoidance of heavy exercise for few hours after injection to further prevent soft-tissue swelling, and systemic acetaminophen for associated discomfort. Use of nonsteroidal antiinflammatory drugs (NSAIDs) and acetylsalicylic acid (aspirin) is contraindicated. Touch-up treatments, if needed, can be done at two weeks following the initial procedure. Common side effects of HA injection include edema, erythema, bruising and pain. Rare complications include nodule formation, allergic reactions, vascular occlusion, infection, over- or undercorrection, and blue-gray discoloration. Calcium Hydroxylapatite

A semipermanent filler CaHA (Radiesse; Bioform, San Mateo, CA, U.S.) has been used off-label in facial aesthetics since 2002. In 2006, Radiesse gained FDA approval for use in facial aesthetics for the correction of moderate to severe facial wrinkles and folds, such as nasolabial folds and in treating HIV-associated lipoatrophy (18,19). Radiesse consists of 25 to 45 µm microspheres of CaHA in a carrier gel comprised of glycerin, sterile water, and sodium carboxymethylcellulose. The carrier solution undergoes resorption over a period of 4 to 12 weeks, leaving a scaffolding of CaHA microspheres for fibroblast-mediated soft-tissue in-growth. Matrix deposition provides long-lasting filling effect. CaHA microspheres are biodegradable. In an aqueous environment, the particles break down into submicron subparticles that subsequently undergo phagocytosis by tissue macrophages.

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Synthetic CaHA shares the same biocompatibility profile as the naturally occurring CaHA. Use of Radiesse does not require prior skin testing, does not show evidence of migration, calcification, or ossification when placed subdermally. No severe adverse events such as delayed granulomas, allergic reactions, or tissue necrosis have been reported (18). In theory the duration of cosmetic correction after Radiesse injection depends on three main factors: 1. Rate of dissolution of CaHA microspheres 2. Degree of soft-tissue in-growth 3. Presence or absence of microparticle dislocation Therefore, different anatomical locations and individual patient variation will result in different degrees of tissue persistence. In a clinical trial of Radiesse for nasolabial fold correction, adequate correction was maintained at six months follow-up. Long-lasting results (18–24 months) are seen in the areas of relative stasis, such as those overlying bony prominences (zygomatic arch, infraorbital rim, mentum, dorsal aspect of the nose and jaw). Studies on longevity of CaHA in dorsal hands are lacking. Procedure Protocol

CaHA is supplied in 1.3 and 0.3 mL prefilled syringes. The material may be stored at room temperature. To increase patient comfort levels, 0.8 mL of Radiesse may be combined with 0.2 mL of 1% plain lidocaine. Injection Technique and Clinical Results

A 25- to 27-gauge, 1.25-inch needle is preferred for smooth correction. Multiple linear threads are placed in three-dimensional, double-fanning motion across the dorsum of the hand the fifth metacarpal, medially by the second metacarpal, proximally by the dorsal wrist crease, and distally by the metacarpophalangeal joints. Cross-hatching of material in multiple planes is essential to provide optimal structural support. The targeted placement depth is subcutis. Only small volumes of CaHA are required during each thread deposition, typically, 50 µL or 0.05 mL per pass. Following injection, the implanted material can be easily massaged and molded to provide the desired end result. Therapy with CaHA does not require overcorrection. Alternatively, skin tenting (bolus) technique might be employed. Skin tenting is used to separate skin from vascular and tendinous structures by lifting the skin with thumb and forefinger over the dorsal aspect of the hand being treated. Filler–lidocaine mixture is injected as a bolus in the superficial subcutaneous plane. Immediately following injection, the entire injection area should be gently massaged to ensure even distribution. Skin tenting results in high patient satisfaction rates (20). For optimal cosmetic result, 1.3 mL of Radiesse is required per treatment per hand (Fig. 11.1.2).

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(B)

Figure 11.1.2 Hand rejuvenation with Radiesse: (A) 1.95 mL of Radiesse was injected in the left dorsum; 1.95 mL of Radiesse was injected into the right dorsum. (B) Follow-up at two months.

Poly-L-Lactic Acid

PLLA is an immunologically inert aliphatic polymer of L-lactic acid with a molecular weight of 170 kDa. It is a biodegradable and resorbable synthetic material that has been used for over 25 years in resorbable sutures, plates and screws, soft tissue, bone implants, and in drug delivery devices (21). In 1999, injectable PLLA (NewFill, Medifill, London, U.K.; Biotech Industrie SA, Luxembourg) gained approval in Europe for treatment of scars and rhytides. In 2004, PLLA (Sculptra, Dermik Laboratories, Berwyn, PA, U.S.) was approved by the FDA for the treatment of HIV-associated facial lipoatrophy (22). PLLA is currently widely used off-label for a number of other cosmetic interventions, including hand rejuvenation. When injected into the subcutaneous plane, PLLA causes immediate tissue expansion due to volume expansion by the carrier solution (mannitol/carbomethoxycellulose). The long-term volumetric improvement, however, results from the PLLA microsphereinduced fibroblast proliferation and subsequent stimulation of de novo collagen I synthesis (22,23). The resulting dermal fibroplasia leads ultimately to dermal thickening. The resorption of the PLLA microspheres when used for facial lipoatrophy is estimated to occur between seven months and two years with a mean of 10 to 12 months (24). PLLA for hand rejuvenation has demonstrated both versatility and durability for up to two years (25,26). When injected correctly, PLLA is associated with a very favorable risk/benefit profile (26). Short-term adverse reactions to PLLA injections reported in the literature include pain, edema, bleeding, ecchymosis, dyschromia, overcorrection, embolism, and localized cellulites (27,28). These side effects usually occur within days following injection and resolve spontaneously within one to two weeks. Localized cellulites require treatment with systemic antibiotics.

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Figure 11.1.3

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Sculptra reconstitution process.

Techniques Used for Injecting PLLA in a Clinical Setting PLLA Reconstitution

Injectable PLLA is supplied in a glass vial as a lyophilized powder that must be reconstituted prior to use. Per manufactures guidelines, the dry material must be reconstituted with sterile water for injection (SWFI) for at least two hours prior to injection and the material should be used within 72 hours following reconstitution. Dilution techniques reported in the literature range from 5 mL SWFI plus 5 mL of 1% lidocaine for a final volume of 10 to 6 mL SWFI plus 2 mL of 1% lidocaine for a final volume of 8 mL per vial per hand (Fig. 11.1.3). Prior to injection, the material must be vigorously shaken to ensure a uniform and translucent suspension. Injection

Two injection techniques discussed in the literature for PLLA hand rejuvenation are linear treading and bolus techniques. When using a linear treading technique, the skin of the dorsal hand is tented and PLLA is injected proximally from the metacarpophalangeal joint subcutaneously above the fascial plane, using a 25-gauge, 1.5-inch needle, 1 and 3 mL syringe size. The needle is guided into the subcutaneous space, between the tendons and muscle bundles of the hand. Care must be taken to avoid deposition of the PLLA more superficially (mid- and superficial-dermal) to prevent early- and late-onset papule and nodule formation. The snuff box region between the thumb and index finger is to be avoided so that undue compression does not cause any neurovascular compromise. In the midhand, the skin is tented, but the needle is inserted into the middorsal intertendinous region of the hand and a depot of 0.3 to 0.5 mL is injected into the three to four regions in the mid-hand (Fig. 11.1.4). Alternatively, a bolus technique can be utilized. Utilizing 1 cc syringes and 27-gauge 1-1/2 inch needles, 4 to 12 boluses are implanted subcutaneously in the dorsum of the hand (Fig. 11.1.5).

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Figure 11.1.4 injection.

Hand rejuvenation with PLLA: (A) tenting of the dorsal skin and (B) bolus

Figure 11.1.5 space.

Hand rejuvenation with PLLA—immediate postinjection bolus in interosseous

After implantation the treatment area is gently massaged with or without lubricant (Aquaphor or Biafine) until a uniform distribution of material is achieved. It is crucial for the material to be uniformly distributed from the wrist to include proximal digits as well as the interosseous spaces. Avoidance of the cursive dorsal arch veins will minimize procedure-related bruising. In the case of intrinsic muscle wasting (interossei and lumbricals) the approach is to inject the product into the interosseous spaces of the hand in a “fist” maneuver. Material is injected into the muscle belly with a 25-gauge, 1.5-inch needle, 1 and 3 mL syringe size. The treated area is subsequently massaged prior to application of ice packs. For optimal final result, all patients are advised to massage the treated area for five minutes, five times a day for five days. Two to three treatment sessions are usually carried out at four to eight weeks intervals, affording the patient and the physician the opportunity to assess the effects of each

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(B)

Figure 11.1.6 Hand rejuvenation with PLLA: (A) 8 mL of PLLA was injected into the dorsum of the hand in two sessions. (B) Follow-up at 10 months.

treatment. Using the aforementioned protocol, the duration of clinical effect is 18 to 36 months (Fig. 11.1.6). Optimizing the injection technique for PLLA, that is, correct depth of the filler placement, appropriate dilution, and thorough postinjection massage by the physician is crucial for optimal outcome and low risk of potential side effects such as early- and lateonset papules and nodules. Clinical Data

In a recent review of our clinical experience of 26 patients, an average of 2.38 treatments was administered, with an average of 3.06 vials per patient (29). The majority of patients reported high rates of satisfaction with clinical results. Bruising and swelling were the most commonly reported adverse events (30.8%), followed by pain (15.4%), pruritus (3.8%), and an arterial spasm (3.8%). No subcutaneous papules or nodules were reported. All side effects listed above were injection-related, transient, and resolved within a few days of treatment. In an Italian case series of 27 patients, Redaelli found a measurable decrease in the tortuosity of veins and decreased visibility of the extensor tendons using a definite graduated score with repeated PLLA injections (30). The clinical improvement was greatest at the maximal follow-up period of 15 months. The average number of injections for a final desired cosmetic outcome was four per patient, with an average injection volume of 2 mL

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Figure 11.1.7 (A, B) Complications post hand rejuvenation with PLLA demonstrating fine subcutaneous nodules.

of 5 mL per hand dilution for the first treatment session, followed by 1.5 to 2 mL per hand of 6 to 8 mL dilution for subsequent treatments spaced one-month apart (30). PLLA was injected using a linear treading technique with 0.05 mL PLLA deposited per injection parallel to and perpendicular to metacarpal bones. Side effects profiled in the study were minimal and largely injection related. Visually nondetectable, fine subcutaneous nodules without any associated signs of inflammation were detected in one of 27 patients (Fig. 11.1.7). Overall, PLLA is well-tolerated soft-tissue filler; patients reported high-satisfaction rates with cosmetic outcome and experienced mainly minor and short-term largely injection-related adverse events. CONCLUSION

Visible aging of the hands are a significant visual marker of the chronological aging process and correction is often sought by patients who wish to restore a more youthful appearance. Understanding and matching patient concerns and treatment requirements with specific therapies yields optimal patient satisfaction rates. A combination approach using multiple modalities targeting dyschromia, rhytids, skin laxity, and volume loss is often necessary in order to achieve optimal results. In cases of volume loss and secondary prominence of hand veins, tendons, and bones, volumetric restoration alone with soft-tissue augmentation using autologous fat, PLLA, or CaHA may offer synergistic benefit and translate into high rates of patient satisfaction. REFERENCES 1. Jakubietz RG, Jakubietz MG, Kloss D, Gruenert JG. Defining the basic aesthetics of the hand. Aesthetic Plast Surg 2005; 29: 546–51. 2. Seeley BM, Denton AB, Ahn MS, Maas CS. Effect of homeopathic Arnica montana on bruising in face-lifts: results of a randomized, double-blind, placebo-controlled clinical trial. Arch Facial Plast Surg 2006; 8: 54–9. 3. Totonchi A, Guyuron B. A randomized, controlled comparison between arnica and steroids in the management of postrhinoplasty ecchymosis and edema. Plast Reconstr Surg 2007; 120: 271–4.

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4. Orsini RA. Bromelain. Plast Reconstr Surg 2006; 118: 1640–4. 5. Fournier PF. Fat grafting: my technique. Dermatol Surg 2000; 26: 1117–28. 6. Coleman SR. Hand rejuvenation with structural fat grafting. Plast Reconstr Surg 2002; 110: 1731–44. 7. Carraway JH, Mellow CG. Syringe aspiration and fat concentration: a simple technique for autologous fat injection. Ann Plast Surg 1990; 24: 293–6. 8. Butterwick KJ. Lipoaugmentation for aging hands: a comparison of the longevity and aesthetic results of centrifuged versus noncentrifuged fat. Dermatol Surg 2002; 28: 987–91. 9. Galea LA, Nicklin S. Mycobacterium abscessus infection complicating hand rejuvenation with structural fat grafting. J Plast Reconstr Aesthet Surg 2009: 62(2): e15–6. Epub 2008 May 9. 10. Sommer B, Sattler G. Current concepts of fat graft survival: histology of aspirated adipose tissue and review of the literature. Dermatol Surg 2000; 26: 1159–66. 11. Carpaneda CA, Ribeiro MT. Percentage of graft viability versus injected volume in adipose autotransplants. Aesthetic Plast Surg 1994; 18: 17–19. 12. Coleman III WP. Fat transplantation. Dermatol Clin 1999; 17: 891–8, viii. 13. Werschler WP, Weinkle S. Longevity of effects of injectable products for soft-tissue augmentation. J Drugs Dermatol 2005; 4: 20–7. 14. Boudib Jr JH, de Castro CC, Gradel J. Hand rejuvenescence by fat filling. Ann Plast Surg 1992; 28: 559–64. 15. Man J, Rao J, Goldman M. A double-blind, comparative study of nonanimal-stabilized hyaluronic acid versus human collagen for tissue augmentation of the dorsal hands. Dermatol Surg 2008; 34: 1026–31. 16. Baumann L. Dermal fillers. J Cosmet Dermatol 2004; 3: 249–50. 17. Monheit GD, Coleman KM. Hyaluronic acid fillers. Dermatol Ther 2006; 19: 141–50. 18. Ahn MS. Calcium hydroxylapatite: Radiesse. Facial Plast Surg Clin North Am 2007; 15: 85–90, vii. 19. Jansen DA, Graivier MH. Evaluation of a calcium hydroxylapatite-based implant (Radiesse) for facial soft-tissue augmentation. Plast Reconstr Surg 2006; 118: 22S–30S; discussion. 20. Busso M, Applebaum D. Hand augmentation with Radiesse (calcium hydroxylapatite). Dermatol Ther 2007; 20: 385–7. 21. Broder KW, Cohen SR. An overview of permanent and semipermanent fillers. Plast Reconstr Surg 2006; 118: 7S–14S. 22. Burgess CM, Quiroga RM. Assessment of the safety and efficacy of poly-L-lactic acid for the treatment of HIV-associated facial lipoatrophy. J Am Acad Dermatol 2005; 52: 233–9. 23. Vert M, Li SM, Garreau H. Attempts to map the structure and degradation characteristics of aliphatic polyesters derived from lactic and glycolic acids. J Biomater Sci Polym Ed 1994; 6: 639–49. 24. Lombardi T, Samson J, Plantier F, Husson C, Kuffer R. Orofacial granulomas after injection of cosmetic fillers. Histopathologic and clinical study of 11 cases. J Oral Pathol Med 2004; 33: 115–20. 25. Vleggaar D. Facial volumetric correction with injectable poly-L-lactic acid. Dermatol Surg 2005; 31: 1511–17. 26. Woerle B, Hanke CW, Sattler G. Poly-L-lactic acid: a temporary filler for soft tissue augmentation. J Drugs Dermatol 2004; 3: 385–9. 27. Moyle GJ, Brown S, Lysakova L, Barton SE. Long-term safety and efficacy of poly-L-lactic acid in the treatment of HIV-related facial lipoatrophy. HIV Med 2006; 7: 181–5. 28. Lemperle G, Morhenn V, Charrier U. Human histology and persistence of various injectable filler substances for soft tissue augmentation. Aesthetic Plast Surg 2003; 27: 354–66. 29. Sadick NS. Poly-L-lactic acid: a perspective from my practice. J Cosmet Dermatol 2008; 7: 55–60. 30. Redaelli A. Cosmetic use of polylactic acid for hand rejuvenation: report on 27 patients. J Cosmet Dermatol 2006; 5: 233–8.

11.2 European commentary Luitgard Wiest

In recent years, rejuvenation that was traditionally focused on the face has now been recognized to be just as important for aging hands. Most patients seek treatments for their aging hands when the aging process appears visible caused by epidermal changes, loss of elasticity, appearance of solar lentigines, and loss of volume with protuberant tendons and veins. One has to take into consideration that these two main processes in aging hands: change in skin texture and loss of volume have to be addressed by different modalities. In the face deep chemical peels or laser peels give excellent results in restoring skin elasticity and in reducing solar lentigines. The possibilities on the dorsum of the hands are limited and risk of scar formation is increased due to the very sparse distribution of hair follicles from which the regeneration of the epidermis arises after an ablative procedure. Best results are obtained when the aging processes are addressed in a combined procedure. In chapter 11.1, the authors have focused on the age-induced volume loss in hands classified as type III (Fig. 11.1.1). Since the beginning of the 1990s autologous fat grafting was also used for the hands (1).With the Fournier’s technique good results were obtained when fat graft was placed through a single small incision above the lateral wrist crease in one bolus just above the superficial dorsal fascia The bolus of fat, which is placed right above the fascia dorsalis manus, has to be massaged and can be easily spread and distributed along the entire dorsum of the hand. With Fourniers method, as well as with Coleman’s structural fat grafting (see chapter 11.1), the hands have to be overcorrected and immediately after the procedure have a clinical appearance of puffy hands, which generally takes three to four weeks to dissolve. The fat injection procedures require fat harvesting from a donor site. The adipocyte survival rate and the longevity of the result is dependent on the skills of the physician, the harvesting method, manipulation of harvested fat, and several other factors (see chapter 11.1). Since the autologous fat transfer is generally well tolerated, with variable longlasting effects reported it is a very popular rejuvenation method for hands in Europe, due to the low cost for the larger volumes needed. Interestingly a much larger volume of fat grafts is needed to achieve a satisfactory result in filling up the volume loss of the hands as with semipermanent fillers (see chapter 11.1). 136

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In search for a readily available filler studies with HA fillers versus human collagen (chapter 11.1) fillers have been performed in hand rejuvenation. Despite the long-lasting effect described by Werschler and Weinkle for six to nine months, our own clinical experience with the earlier HA fillers, either monophasic or particulated did not yield long-lasting effects, even when 2 to 3 mL of HA fillers were injected per hand. Better results are noted with the HA volumizers (Table 2.2.3) that were put on the market recently, although extensive studies have not yet been published for the use of volumizers in the dorsum of the hands. The most satisfying results in addressing the process of volume loss of the dorsum of the hand in terms of efficacy and safety have been recently reported with the semipermanent filler Radiesse® (see chapter 11.1) (2,3). Busso (4) in a multicenter, randomized study in the United States and Germany reported on the effectiveness up to 12 months. Various techniques have been described (2,5,6) (see chapter 11.1). Placing a small lidocaine bleb between the metacarpophalangeal joints and mixing each CaHA syringe 1.3 mL with 0.2 mL of lidocaine leads to an almost painless procedure and to maximum patient comfort. After tenting the skin, the material is injected very conservatively and very slowly subcutaneously above the fascia dorsalis manus using a 26-gauge, 1.5 inch needle by the pushahead technique in order to avoid hematomas. The volume required per hand depends on the volume loss and varies between 1.5 and 2.5 mL Radiesse per hand. Poly-L-lactic acid (PLLA), marketed as Sculptra® has been safely used for more than 30 years in a variety of medical devices. PLLA (see chapter 11.1) elicits increased collagen production from the fibroblasts when injected into the deep dermis, leading to dermal thickening. Various injection techniques have been described. With the appropriate reconstitution injected into the correct plane, it addresses several processes of the aging hands. PLLA can improve both, the skin texture and the loss of volume. Usually two to three treatments (7) spaced apart six to eight weeks are necessary for optimal results lasting up to two years. Although PLLA injections have been associated with the manifestation of subcutaneous papules in hand rejuvenation [(8), and Becker-Wegerich, personal communication] it has been demonstrated that thorough massage significantly reduces the incidence of subcutaneous nodules and papules. The main limitations of Sculptra are variability in result and difficulty in getting large volume changes with each treatment. CONCLUSION

More data about longevity of dermal fillers for rejuvenation of the aging hand with loss of volume will be available in the future. With the already existing semipermanent fillers and with the newer HA fillers designed as “Volumizers” that are used to augment larger areas, volume replacement of the dorsum of the hand will become an attractive option. REFERENCES 1. 2. 3.

Fournier PF. Fat grafting: my technique. Dermatol Surg 2000; 26: 1117–28. Marmur ES, Al Quran H, de SA Earp AP, Yoo JY. A five-patient satisfaction pilot study of calcium hydroxylapatite injection for the treatment of aging hands. Dermatol Surg 2009; 35: 1978–84. Lizzul PF, Narurkar VA. The role of calcium hydroxylapatite (Radiesse) in nonsurgical aesthetic rejuvenation. J Derm Drug 2010; 9: 446–50.

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5. 6. 7. 8.

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Busso M, Moers-Carpi M, Storck R, Ogilvie P, Ogilvie A. Multicenter, randomized trial assessing the effectiveness and safety of calcium hydroxylapatite for hand rejuvenation. Dermatol Surg 2010; 36(Suppl 1): 790–7. Bank D. A novel approach to treatment of the aging hand with Radiesse. J Dermatol Ther 2009; 8: 1122–6. Edelson K. Hand recontouring with calcium hydroxylapatite (Radiesse®). J Cosmet Dermatol 2009; 8: 44–51. Vleggar D. Soft-tissue augmentation and the role of poly-L-lactic acid. Plast Reconstr Surg 2006; 118(Suppl 3): 46S–54S. Palm MD, Woodhall KW, Butterwick KJ, Goldman MP. Cosmetic use of poly-L-lactic acid: a retrospective study of 130 patients. Dermatol Surg 2010; 36: 161–70.

12 Complications and their management Jason Emer, Heidi Waldorf, and Joel L. Cohen

INTRODUCTION

Cosmetic procedures, specifically those that are minimally invasive, have become increasingly more popular in the past decade. There were close to 10 million cosmetic procedures performed in the United States in 2009 alone, which is an increase of over 147% in the total number of cosmetic procedures performed in 1997 (1). In this time frame, surgical procedures have increased by almost 50% and nonsurgical procedures have increased by over 231%. According to statistics published by the American Society for Aesthetic Plastic Surgery (ASAPS), of the top five nonsurgical procedures performed in 2009, dermal fillers ranked second to Botulinum toxin injections with over 1 million injections (1). Soft tissue augmentation is a noninvasive procedure that is particularly attractive to patients wanting a quick and satisfying aesthetic result with fairly predictable longevity. Increased public interest, multiple product options, diminished social stigma, affordability, and increased effectiveness and versatility are the major factors that have influenced their rapid popularity. Most clinicians regard soft tissue fillers as having an impressive safety profile, with the majority of reported side effects being mild and transitory such as local injection-site reactions (redness, swelling, bruising, and pain) or abnormal skin tightness/sensation (2–5). Unfortunately, in the minority of cases more severe adverse outcomes and unforeseen events can occur and have been reported in the literature (6–20). One study asked dermatologists, plastic surgeons, and maxillofacial surgeons in Berlin to report patients with adverse reactions by using a standardized questionnaire to collect all data. Fifty-six patients who had been treated with nine different fillers were assessed and symptoms such as continuing pain, swelling, nodules, pigmentation, abscess formation, and erythema were discovered as adverse reactions (21). Nevertheless, with proper patient selection and expectations, injection techniques, and product selection, clinicians can prevent complications and/or treat issues appropriately if the situation arises (22–24). This chapter will focus on the prevention, recognition, and treatment of complications associated with soft tissue filling agents with emphasis on the key characteristics to consider before, during, and after procedure completion.

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PRIOR TO THE PROCEDURE Patient Selection and Expectations

A proper initial evaluation is essential when performing elective cosmetic procedures. During the aesthetic evaluation, it is important that the patient’s satisfaction is priority, thus photographs should be taken and asymmetries identified to document the patient’s initial appearance and to facilitate a clear and frank discussion addressing the concerns, desires, and/or wants of the patient in order to help devise a realistic treatment plan to achieve these goals. During this discussion a distinction should be made between lines of expression, static and dynamic wrinkling, and volume loss that may or may not be augmented by filling agents (25). Once clear and practical treatment goals have been discussed and agreed upon, the practitioner should determine which filling agent is best for the cosmetic concerns of the patient and discuss the potential limitations and expectations. In general, fillers can fill defects such as folds, scars, and/or depressions, or augment existing facial structures or contour abnormalities. These procedures are not meant to take the place of surgical procedures, but may help to postpone or complement them (26–29). Common postoperative side effects such as bruising, swelling, pain, nodularities, redness, and abnormal sensation/feeling should be discussed and patients should be advised to avoid these procedures immediately prior to any significant social or professional event. Rare, potentially serious adverse side effects should be discussed if indicated, particularly in patients who have previously had adverse events, who have undergone facial surgeries or facial trauma that may have changed typical anatomy, or those undergoing treatment for off-label indications. Lastly, the clinician should discuss the financial commitment involved in order to achieve the patient’s overall aesthetic goal. Skin Testing

After choosing the appropriate filler, the potential for allergy or reactivity should at very least be discussed. Given that all fillers (with the exception of autologous fat) are composed of foreign-body material, varying degrees of immune system reactivity can potentially occur and have important aesthetic implications (9,23). Historically, bovine collagen (Zyderm I, Zyderm II, Zyplast; Allergan Inc., Santa Barbara, CA, U.S.) was the most frequently used packaged filler because it was relatively inexpensive, easy to inject, and versatile; however, significant disadvantages included the potential for allergic reactions that necessitated two separate skin tests and limited cosmetic satisfaction due to its shortterm persistence (25). These specific bovine collagen products are no longer being manufactured, but the skin test for bovine collagen used to be performed with an intradermal injection of 0.1 mL of product into the antecubital area and 30 days later injecting a separate area (such as the scalp line). Approximately 3.5% of patients did have a positive first reaction (local wheal and flare reaction), with 70% of these reactions manifesting in the first 48 to 72 hours (30,31). A negative second test lowered the risk of a subsequent collagen hypersensitivity reaction to less than 0.5%. Granulomatous foreign body reactions against animal-derived bovine collagens are well documented, with incidence reaching as high as 1.3% in some series (32). Overall, bovine collagen has an incidence of acute hypersensitivity of 3.5% and delayed hypersensitivity rates ranging from 3% to 10% (31,33).

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Not all collagen fillers require a skin test. Human-derived collagen (CosmoDerm, CosmoPlast; Allergan Inc., Santa Barbara, CA, U.S.) was approved without skin testing because it carried a very low risk of reactivity, but had a similar relatively short duration (2–6 months) as compared with bovine collagen (26,34–36). These human collagen products are also no longer being produced. In June 2008, a porcine-derived collagen product (Evolence and Evolence Breeze; Colbar LifeScience Ltd., Herzliya, Israel and OrthoNeutrogena, Louisville, KY, U.S.) comprised of 3.5% purified porcine type I collagen was also approved by the Food and Drug Administration (FDA) without skin testing because removal of the primary antigenic components of the product during processing significantly reduced collagen-sensitivity reactions (37). A 2007 study by Shoshani et al indicated the hypersensitivity of Evolence had a calculated risk equal to 0.58% and was lower than estimated for both bovine and human collagen. Interestingly, the hypersensitivity after injecting Evolence was also lower than what was observed with nonanimal hyaluronic acid (HA), which had a calculated risk equal to 0.74% (38,39). Unlike the human collagen products, this porcine collagen offered more duration with 6 to 12 months of aesthetic effect due to a unique cross-linking with D-ribose using a Glymatrix technology. At this time, production has also ceased on porcine collagen products as well, and all remaining bovine, human and porcine collagen product has expired. Among the products currently available in the United States, only polymethylmethacrylate (PMMA; ArteFill; Suneva Medical, San Diego, CA, U.S.) contains collagen (the exact composition is 20% nonbiodegradable PMMA microspheres and 80% purified bovine collagen) and requires skin testing (40). The collagen carrier of this product is of bovine origin and thus carries the same potential allergenicity of 1% to 5% reported in the literature for bovine collagen (33,41) Product sensitivity in the form of delayed granulomas, although rare, have been reported with the precursor to this product (Artecoll) as 0.01% (15/200,000) from 1995 to 2000 (42). These granulomas have generally occurred 6 to 24 months posttreatment and frequently after multiple procedures (second to third transplantation of product), although one report has documented granulomas or nodules up to six years after gel injection (43). No acute sensitivity reactions have been documented to date (44–46). Skin testing consists of the patient receiving a 0.1 mL intradermal injection of collagen into the volar forearm four weeks prior to treatment. A positive response consists of erythema to any degree, induration, tenderness, and swelling, with or without pruritus. An equivocal response is where no localized skin reaction occurs but the patient develops a systemic reaction such as a rash, arthralgia, or myalgia any time during the fourweek observation period. Patients demonstrating a positive skin test or two equivocal skin tests should not receive treatment. In the 1990s, published articles suggested a causal relationship between collagen dermal implants and autoimmune disease, in particular, polymyositis (47–49). Epidemiologic review of the literature, reports to the manufacturer, and litigation refuted this alleged link (50). However, collagen-containing products are contraindicated in patients with a known history of collagen-reactive autoimmune disorders such as systemic lupus erythematosus and scleroderma. These patients can safely be treated with noncollagen filling agents. Consultation with the patient’s rheumatologist is often recommended before use (51–54). HA fillers are still the most popular injectable filler in the United States (55–57). Significant hypersensitivity has been reported only rarely with HA products. Whether bacterial or

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avian in origin, these products are extremely purified and the rate of severe immunologic reactions is low (58–64). The avian product itself is actually no longer being manufactured for aesthetic use, but is still available for orthopedic use in joints. A severe angioedema-type hypersensitivity reaction was documented following injection with nonanimal stabilized HA gel (Restylane; Medicis Aesthetics Inc., Scottsdale, AZ, U.S.) into the upper lip (13). Another case reported persistent discrete nodules in the form of a granulomatous foreign-body reaction in a female who received a HA agent in the lips for the purposes of augmentation (65). In a retrospective study from 1997 to 2001 evaluating the safety of nonanimal-stabilized HA in European countries, the incidence of hypersensitivity reaction was found to be 0.3% to 0.6%. Half of these reactions were immediate and resolved within three weeks (2,66). One HA filler containing both lidocaine and sulfites (Elevess; Anika Therapeutics Inc., Bedford, MA, U.S.) has a higher reported incidence of reactivity and is typically avoided in patients with a history of multiple hypersensitivities or allergy to these components (67). Prevention of Local Common Reactions

Local injection site reactions are the most common adverse event associated with soft tissue augmentation since injection requires skin piercing and implantation of a foreign substance. The potential to bruise can be affected by needle size, location, technique, and speed of injection, as well as filler choice (67). The most commonly seen complications are swelling, redness, tenderness, pain, bruising, and itchiness (Fig. 12.1). In a randomized, double-blind, multicenter comparison of HA (Restylane) versus collagen (Zyplast) for the treatment of nasolabial folds in contralateral sides of each patient (n = 138), injection-site reactions occurred at 93.5% (129/138) and 90.6% (125/138) of the HA- and collagentreated sites, respectively (68). These reactions were less than seven days in duration, were mild to moderate, and were similar between treatments. Thus, it is important patients be aware of the likelihood of injection-site reactions most specifically ecchymoses (bruising) and edema (swelling) that may persist for up to one week posttreatment or longer especially in patients on anticoagulant therapy.

Figure 12.1 Large ecchymosis on the superior aspect of the left cutaneous lip three days after HA filler placement.

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The majority of edema and ecchymoses is due to injection technique and can be minimized with slow, precise injections. It is important to note that as hydrophilic sugar molecules, HA-based filling agents intrinsically cause more swelling than other classes of fillers. While certainly apples-to-apples comparisons with studies being performed by different injectors on different patients with different needle sizes, some juxtaposition of pivotal FDA data on products is something commonly seen amid commercial banter. One HA filler (Juvederm Ultra; Allergan, Santa Barbara, CA, U.S.) has a reported 86% incidence of swelling and 59% incidence of bruising on their package insert compared with 4% to 7% incidence of swelling and 6% to 38% incidence of bruising on the package insert for polyL-lactic acid (PLLA; Sculptra; Dermik Laboratories, Bridgewater, NJ, U.S.) and 69.2% incidence of swelling and 63.2% incidence of bruising on the package insert for calcium hydroxylapatite (CaHA; Radiesse; Bioform Medical Inc., Franksville, WI, U.S.) (69–71). Fortunately, regardless of the product injected the swelling and bruising are typically localized, minor, and self-limiting. Some of these problems can be reduced with proper patient selection and detailed preoperative instructions. Patients who do not have a history of heart attack, stroke, blood clots, or other medical indication for aspirin therapy should discontinue aspirin 7 to 10 days prior to the procedure. Patients on warfarin or clopidogrel should be warned of the potential for more serious bruising, swelling, and potential for unsatisfactory correction. However, these anticoagulant patients and those taking aspirin or any other blood thinner for medical indication should not stop treatment prior to a filling procedure. Generally, if the international normalized ratio (INR) is between two and three for patients taking warfarin, the risk of hematoma or excessive bruising from injection is relatively low, and most practitioners would feel comfortable performing injections judiciously. Other aspirin-containing products, nonsteroidal antiinflammatory drugs (NSAIDs), and vitamin/ herbal supplements associated with anticoagulation (vitamin E, ginseng, ginger, ginkgo, garlic, kava kava, celery root, fish oils, St. John’s Wart) should be discontinued 7 to 10 days prior to treatment as well, to reduce the risk of bruising and unanticipated events (72–74). Alcohol may be discontinued about five days prior to treatment as the potential for vasodilation and alteration in liver coagulation factors is diminished after this time. When assessing patients with cardiovascular stents and/or patients who are on anticoagulation (warfarin, clopidogrel, enoxaparin), it is important to consider the time frame the patient will be taking the medication and their risk of suffering if the medication is stopped (75). One study reviewed all the patients (n = 16) who maintained warfarin therapy during excisional and Mohs surgeries in a practice from 1999 to 2000 (76). Perioperative complications such as bleeding and cosmetic outcomes were evaluated and it was concluded that warfarin treatment (INR 2–3.5) should be continued in patients undergoing cutaneous surgery to reduce the risk of thromboembolic events while still maintaining adequate wound healing without any complications. In general, it is not recommended that patients taking therapeutic anticoagulation alter their regimens for elective cutaneous soft tissue augmentation as clearly this risk outweighs the benefits (77–81). If the medication usage is for a limited time period, it may be prudent to wait until the medications can be discontinued—for example, in the case of anticoagulation for initial attack of venous thromboembolism. The recent guidelines from the American College of Chest Physicians (ACCP) recommends, for minor dermatological/cutaneous procedures with low risk for bleeding, the continuance of anticoagulation through the procedure as these patients are at a significantly higher risk of adverse events from thrombosis as high as 50% (82).

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An advantage of soft tissue augmentation using filling agents over more invasive cosmetic procedures is that anticoagulants are not an absolute contraindication to use. In clinical practice, patients often accept the risk of increased transient local complications for the convenience of continuing their medications. Successful treatment of patients who either cannot or will not discontinue anticoagulants may be facilitated by the use of local anesthetics containing epinephrine, liberal use of ice packs, slow and precise technique that limits the number of skin punctures and minimizes the need for aggressive posttreatment manipulation. Opaque makeup is useful to conceal discoloration and there are several excellent commercially available products (CoverFx, Toronto, Ontario, Canada; Dermablend Professional, New York, NY, U.S.; Physician’s Formula, Azusa, CA, U.S.) appropriate for a range of skin colors. Treatment with the 595-nm pulsed dye laser can expedite resolution of postoperative ecchymoses by several days with high patient satisfaction (83). Perioperative use of oral homeopathic medications containing Arnica montana and Bromelain (plant family Bromeliaceae, which includes pineapple) have been advocated to reduce bruising, but further investigation is needed to substantiate their effect and patients with cardiovascular disease and/or on anticoagulation therapy should consult their primary physician before starting (84,85). Prevention of Infection

Infection following the use of soft tissue fillers is low. Antimicrobial preparations to the field, prior to injections, helps limit these issues. It is unclear if the incidence of infection correlates to the degree of skin penetration and implantation of foreign material into the skin. Two infections have been associated with dermal fillers: herpes simplex virus and Mycobacterium abscessus (10,23) (Fig. 12.2). In patients with a strong history of perioral herpes simplex virus, prophylactic treatment with antiviral treatment (valacyclovir, famciclovir, and acyclovir) is often recommended before and after lip augmentation. Injection in the presence of active infection is contraindicated. Product contamination is a concern, especially if the products are non-FDA approved as reported by Toy and Frank in 2002

Figure 12.2 Herpes labials infection on the upper cutaneous lip and small ecchymosis on the lower cutaneous lip seven days after HA filler placement.

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where an outbreak of Mycobacterium abscessus originated in New York city following soft tissue augmentation with an unapproved HA product called Hyacell illegally brought into the United States from South America and injected illicitly (10). Another infectious risk that has attracted a lot of recent attention is a biofilm reaction, a complex aggregation of microorganisms marked by the excretion of an extracellular protective adhesive matrix that allow for the development of a community of antibioticresistant microorganisms (86,87). Clinically, biofilms present as late-onset deeply erythematous nodules (Fig. 12.3). These lesions were previously assumed to be foreign body granulomas or allergic reactions (so-called sterile abscesses) on the basis of negative bacterial cultures and were treated incorrectly with intralesional corticosteroid injections instead of antibiotics (88–90). Biofilms have complex chemical communications that can shift aggregates from active to dormant depending on exogenous threats and when cell metabolism is halted, the communities are antibiotic resistant and quite often impossible to culture as well as treat. The clinical presentation is that of a local infection such as abscess, cellulitis, granulomatous foreign body reaction, allergic reactions, or, if the biofilm covers a large implant or prosthetic joint or heart valve, systemic infection with sepsis (17). Asymptomatic nodules seen or felt shortly after treatment can be followed or massaged out. However, acutely painful nodules or late-onset nodules are most likely due to infection and subsequent biofilm formation, and must be treated immediately with oral antibiotics (quinolone and a third-general macrolide and/or minocycline). A biopsy and/or aspiration may be necessary if initial treatment is unsuccessful (91) (Fig. 12.3). The length of treatment with systemic antibiotics depends on the severity of the infection, typically four to eight weeks but may

(A)

(B)

Figure 12.3 (A) Late-onset painful erythematous fluctuant nodule over the right nasolabial fold following treatment with human collagen. (B) Purulent discharge revealed after incision and drainage.

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require significantly longer treatment in severe cases. Local injection of hyaluronidase can reduce the quantity of filler and therefore reduce the nidus of infection in cases when the filling agent used was a HA. Incision and drainage can be used for both therapeutic (product removal, disruption of biofilm) and diagnostic (culture with special techniques for biofilm detection) reasons for lesions that are fluctuant (92,93). Intradermal injection of corticosteroid is becoming much less commonly used, and really should only be considered in this type of infection scenario if the patient is already on an antibiotic regimen (94). Measures to prevent infection and potential biofilm formation include taking a full history including any previous treatments, bleeding disorders, an immunocompromised state, and previous infections. Skin preparation is essential in preventing soft tissue infections; a number of antiseptics are available. Currently, no specific guidelines are available on the appropriate method to prepare the skin prior to a procedure. Data are limited to that published regarding clinical experiences with central lines and other implantable devices. Calfee et al. compared the efficacies of 10% providone-iodine, 70% isopropyl alcohol, tincture of iodine, or providone-iodine with 70% ethyl alcohol in the prevention of blood culture contamination and detected no significant differences although some evidence suggested greater efficacy with alcohol-containing products (95,96). Chlorhexidine has the ability to treat resistant strains of the gram-positive bacteria Staphylococcus aureus and some gram-negative, viral, and fungal microbes. Chlorhexidine-based agents have become popular due to their longer durability and efficacy, but should be avoided in the periocular area due to the potential risk of keratitis and ocular injury (97–101). Chlorhexidine can also induce skin sensitivity reactions, including skin breakdown. For this reason, one of the book editors (P.J.C.) does not use chlorhexidine for this. In addition to following proper technique, prophylactic antibiotics are sometimes prescribed to patients when semipermanent or permanent fillers are used, although this has not been validated. Other measures to limit infectious complications include: maintaining injection depths appropriate for the given filling agent and anatomic location, limiting the placement of multiple filler types overlying each other (“filler stacking”) at an individual treatment, avoiding large-volume injections, and avoiding injections into active infections or inflammatory acne lesions (102). Once the skin has been prepared, it is essential to avoid contamination of the syringe and needle. Filling agents can become contaminated in five ways: (i) during manufacture, (ii) during reconstitution/packaging, (iii) during dilution with lidocaine, (iv) during injection by surface bacteria, or (v) by topical contamination immediately postprocedure through needle puncture sites (such as via contact with a patient’s unclean finger tips during makeup application). Needle size may play a role; smaller needles (30- or 32-gauge) may reduce the risk of injection by providing a smaller conduit for skin bacteria to penetrate. However, higher viscosity fillers require larger needle sizes (27-gauge for CaHA and 25-gauge for PLLA) to avoid high extrusion forces that predispose to clumping or clogging, increase bruising and swelling, and may influence incorrect placement or amount deposited (103,104). General recommendations for the prevention of short- and long-term infectious complications include (i) washing hands thoroughly before applying gloves, (ii) maintaining proper contact precautions, (iii) ensuring removal of all makeup and other skin contaminants, (iv) cleansing the skin using prior to injection, (v) maintaining a clean injection tray, (vi) avoiding injection during an active skin infection, and (vii) and using the smallest gauge needle appropriate during injection.

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DURING THE PROCEDURE

The key to optimizing results starts with the initial evaluation, but the major step in decreasing the chance for problems is proper placement of product. Appropriate placement of product requires detailed knowledge of anatomy, injection techniques, and the unique characteristics of individual filling agents.

Placement of Product

Too superficial placement of dermal fillers is a common error associated with visible product, nodule formation, and sometimes scarring (42,94,105). Many of these complications can be avoided with proper depth of injection, although this is often imprecise. A study comparing perceived versus actual depth of injection of HA fillers into the nasolabial fold skin revealed that the majority did not match. The results suggested however that the exact location of HA product was not required for excellent cosmetic results (106). Another study of histology of excised tissue samples injected with HA fillers in vivo (Restylane, Perlane, or layered Restylane/Perlane; Medicis Aesthetics Inc., Scottsdale, AZ, U.S.) found the exogenous HA primarily in the lower reticular dermis and subcutis and clinically appeared similar regardless of the HA product used (107). Most injectors are actually placing product deeper than they believe, including below the dermis. Visible signs of depth during injection include the appearance of the color and shape of the needle as well as the response of the skin. In the more superficial plane (intradermal) the “gray” of the needle can be seen and the skin may blanch focally, especially if the needle is lifted slightly once situated (94,105,106,108). Although this plane is typically too superficial for most filler indications, it may be necessary for acne scarring and fine lines. Thin particle fillers such as CosmoDerm, Zyderm, and Evolence Breeze were useful for these situations, but are no longer available. A new superficial HA filler is expected to gain FDA clearance in late 2010 (Belotero; Merz Pharmaceuticals, Greensboro, NC, U.S.). Alternatively, using small-gauge needles (such as a 32-gauge needle with some HA fillers prepackaged with a 30 gauge including Juvederm Ultra and Restylane) to “thin” out the filler during extrusion may decrease the risks associated with superficial placement, but still allowing for treatment in these locations. One of the editors (P.J.C.) does not place fillers not designed for superficial placement superficially even using a fine needle for injection. Most filling agents are indicated for mid-to-deep dermal placement, but placement subdermally or periosteally is frequently done to improve longevity and reduce the risk of seeing the product through the skin. Clues to confirm placement into the deep dermal or subdermal levels are: (i) “gray” of the needle is not visible, (ii) the location and shape of the needle is apparent, and (iii) the fat should be able to be pressed down by pointing the tip of the needle down (105,108). Dermal filling agents should never be placed intramuscularly due to the potential for nodule formation from uncontrolled displacement of the filler during routine muscle movement. CaHA has been reported in one case to cause a nodule distant from the injection site. Because of frequent nodule formation after direct injection into the orbicularis oris, CaHA is no longer recommended for lip augmentation (109,110). Periosteal placement of filler substances involves a strong knowledge of anatomy as the needle must be inserted through the skin, subcutaneous tissue, and musculature until

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the periosteum is felt with the tip of the needle. Careful localization of the preperiosteal plane is essential as the periosteum can be disrupted leading to hemorrhage and pain (111). Proper placement directly onto bone and beneath the overlying musculature can be obtained by slightly pulling back on the needle once the periosteum is felt. Repetitive contact with the periosteum will result in dulling of the needle and patient discomfort. Periosteal placement is not for novice injectors. Deep injection into high-risk locations (temple, lateral brow, suprabrow, angle of the mandible, base of nasal alae, tear trough, glabella) where nerves and vessels can be easily compromised should also be avoided until a thorough understanding of facial anatomy and injection techniques is mastered. Manifestation of Superficial Filler Placement

Superficial placement is avoidable with the proper knowledge and technique. Caution should be maintained when injecting any filler superficially; however, areas that are particularly high-risk for product visibility (lower eyelids, tear trough, periorbital, lips, nose) should only be performed by those experienced and with a complete understanding of filler anatomy (91,112–114). Hyaluronic Acid

The currently available HAs are indicated for injection into mid-to-deep dermis or subdermal planes, as superficial placement can result impalpable and/or visible nodules. In general, the formation of bumps under the skin occurs due to the consistency of the filler itself when placed superficially with poor technique, but can also far less commonly occur with reaction to the product (67). Most injectors massage the material upon placement to ensure the smooth nature of the clear gel and mold it to facial contours. If superficial, HA bumps will sometimes appear blue and may be confused with postinjection edema or ecchymoses. The bluish-gray appearance, called the Tyndall effect, is a result of scattered light of various wavelengths through the chamber of clear gel it encounters in the dermis (115,116). Common areas to see this effect include the central face (nasojugal fold, nasal dorsum, lip), periorbital area including tear troughs, and fine superficial lines such as periorbital and perioral rhytides (“crow’s feet” and “pucker lines”) (117,118) (Fig. 12.4). If caught early, the gel can be firmly massaged to flatten and disperse excessive material and distribute more evenly (119). If massage is not effective, the superficial HA product can often be expressed after nicking the skin with a #11 blade or 18-gauge needle. In addition, inappropriately placed HA filler product can be dissolved with hyaluronidase enzyme, making it an ideal filler for novice injectors and patients who are unsure if they will be pleased with the results. The treatment of choice for persistent unwanted HA is hyaluronidase (commercially available as Amphadase, Hydase, Hylenex, or Vitrase) (93,120). Hyaluronidase is a soluble protein enzyme that acts locally to break down and hydrolyze HA. The enzyme hydrolyzes HA by splitting the glucosaminidic bond between C1 of the glucosamine moiety and the C4 of the glucuronic acid in the ground substance (117). The first successful report of hyaluronidase used to reverse the effects of HA filler excess used 75 units mixed with 1.5 cc of 0.5% lidocaine (with or without epinephrine). Ninety percent of the lumpiness caused by the gel resolved in 24 hours (92). In another report, 15 units caused complete resolution of a nodule in 24 hours (121). Most preparations are animal based (except Hylenex) and carry the

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risk of hypersensitivity reaction so skin testing is recommended. An intradermal injection of three units should be placed in the volar forearm while the patient is monitored for a minimum period of 20 minutes (23). A positive reaction is when a wheal or flare occurs at the testing site and may be due to the animal protein or the ingredient thimerisol. Bee venom contains hyaluronidase and patients with beesting allergies may be highly sensitive. Some authors have reported cases of HA nodules resistant to hyaluronidase (Fig. 12.5), therefore incision and drainage with an 18-gauge needle or #11 blade is still a common and

Figure 12.4 thread.

Superficial placement of HA filler under the right eye with visible material in a linear

Figure 12.5 This is the histologic image of a 65-year-old female who presented with a nodule two years after injection of a biphasic HA preparation into the lower periorbital region. Amorphous deposits of various sizes are surrounded by multinucleated giant cells in the dermis. The team contributing this image has had eight cases resistant to hyaluronidase referred to them after injection of various preparations of HA in the lower periorbital region. All the patients have had previous lower blepharoplasty, which might be speculated to have increased the risk of nodule formation in this area. Source: Courtesy of Prof. Dr. W. Stolz, Ludwig-Maximilians-University, Munich, Germany.

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cost-effective method to extrude unwanted HA product from the dermis and avoid the potential risk of hypersensitivity to the hyaluronidase enzyme (17,121). Finally, 1064-nm Q-switched Nd:YAG laser has also been reported as a treatment modality of HA product placed quite superficially, but may have more efficacy for associated postinflammatory hyperpigmentation than for primary reduction of HA (116). The potential risks of 1064-nm laser treatment should be considered before initiating treatment. Calcium Hydroxylapatite

CaHA is indicated for placement into the deep dermis or subdermis. Superficial placement is contraindicated because of the risk visible and/or palpable white nodules. As described previously, the tear troughs, malar eminence, lateral zygoma, and mental crease are particularly vulnerable to filler visibility. In order to avoid this some physicians have performed treatment of these areas with CaHA subperiosteal placement. One of the editors (P.J.C.) will not place this filler in the subperiosteal plane in the tear trough, or in the mental crease regions. The risks of injecting into the tear-trough region should be considered before placing fillers in this region. Also as discussed, nodule formation may occur if CaHA is injected in areas that are frequently mobile such as the lips due to the “pumping action” of orbicularis oris muscle coalescing product so this area should be avoided (109,110,122). Increasing the volume of lidocaine that is mixed in standard to CaHA, before treatment, may also reduce the risk of nodule formation by reducing viscosity. The decreased viscosity translates into reduced extrusion force and more malleable product for massage (123). This may be particularly helpful in areas such as the hands and around the mouth, where nodule formation is more common with localized accumulation of filler. After injection, aggressive immediate massage may help to ensure adequate dispersion and prevent clumping of product. When they occur, nodules may be punctured with an 18-gauge needle or a #11 blade to facilitate extrusion of the material. Unfortunately, unlike hyaluronidase for HA agents, there is no “antidote” available to dissolve unwanted CaHA. The use of intralesional saline injection followed by massage in order to mechanically break up the product has been described. Intralesional corticosteroids have also been used; however, they carry a risk of atrophy peripheral to the retained filler making it more, rather than less visible. Finally, injecting additional filler, for example an HA, around the nodule to blend the surface with the surrounding skin contours can reduce the appearance of the nodule until it resolves over time. Polymethylmethacrylate

The PMMA (ArteFill) available in the United States differs from that available in Europe (Artecoll) as it derived from a closed U.S. bovine herd, has a more consistent particle size, and has a larger particle size (40). The larger particle size helps carry a lower risk of immunogenicity and digestion by macrophages. This filler is preferentially placed deeper, into the deep dermis since superficial placement can be associated with long-lasting pruritus, redness, and hypertrophic scarring in association with delayed-onset inflammatory nodules or hypersensitivity reactions. Fortunately, localized pruritus and redness can be treated with topical or injectable corticosteroids and/or topical calcineurin inhibitors.

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Hypertrophic scarring can sometimes be softened by topical or injectable corticosteroids, topical silicone, topical 5-fluorouracil, topical imiquimod, cryotherapy, or various laser technologies such as pulsed dye, fractional, or ablative resurfacing (124–126). It is important to avoid a big, localized accumulation of product, especially with filler products that are particulate or more permanent. Skin testing four weeks prior to the planned procedure as well as using cautious and conservative treatment sessions with appropriate injection techniques, can give optimal results with high patient satisfaction because of its durability. If nodules arise, the only option is surgical removal. Injection Patterns and Injection Technique

Appropriate injection technique can help ensure successful outcome and limit the risk of contour irregularities and subsequent patient dissatisfaction. Many patterns are recognized such as fanning, serial puncture, cross-hatching, linear threading, and the choice of pattern is based on the location to be injected and the product utilized. The proper use of these patterns can help the injector more uniformly treat the desired areas. Glogau et al. found in a prospective, blinded, randomized, controlled study of 283 patients, having midface volume correction of the nasolabial folds and oral commissures with HA-filling agents (Restylane or Perlane) that local adverse events following injection were related to investigator technique and not to differences in the intrinsic properties of the filler or needle size (127). The elements that were found to be associated with an increased risk of adverse events included injection techniques that increased the dissection of the subepidermal plane such as a fanlike projection, rapid injection, rapid flow rates, and higher volumes. Interestingly, injection techniques that increased epidermal damage or subcutaneous contact such as serial puncture or deep depot injections had no effect on adverse events. Thus, proper technique is essential to successful outcomes. The nasolabial folds, glabella, philtral columns, fine perioral and periocular rhytides, lips, and forehead lines do well with serial puncture or linear threading techniques. With serial puncture, multiple small depot injections are made along a wrinkle or crease, this allows for accurate material placement. Care must be taken to ensure each injection is of equal volume and sequential so the overall picture is that of a smooth, continuous line that lifts or fills out the fold. Molding and massaging can help to ensure gaps are filled in and soften minor irregularities posttreatment. Linear threading works well for the lips (along the “white roll”), nasolabial folds, lateral zygoma, angle of the mandible, and preauricular areas. The correct technique involves inserting the full length of the needle in the middle of the wrinkle or area to be enhanced and creating a tunnel that will be filled with the product by either an anterograde (while needle is advanced) or retrograde injection (while need is withdrawn). Both techniques are acceptable and give excellent cosmetic results. Some may feel the anterograde method is safer as it allows the material being injected to “push away” small cutaneous vessels and nerves and may decrease complications, most notably bruising and swelling. However, in areas that are highly vascular such as the glabella or lip, a retrograde method may be a better choice as it decreases the likelihood of an intraarterial injection. The vermillion boarder (“white roll”), philtral columns, and lateral eyebrow are great places for an anterograde approach as the potential spaces in these locations may allow easy product flow and placement.

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For very large areas such as the cheek, midface, and marionette lines, the cross-hatching or fanning technique may be very effective. Cross-hatching works by creating a series of linear threads evenly spaced in a progressive grid similar to a scaffold that works to ensure a large space is supported and filled. Several levels may be needed to help fill and lift the area of treatment, especially in the midface where there is no osseous backing of facial support. Fanning is similar in fashion to linear threading except that the needle is not completely withdrawn and is advanced in a different location (clockwise or counterclockwise) allowing for the same injection site to be used to fill a particular area. This method limits the amount of skin punctures needed and may decrease the risk of surface bruising and swelling (128,129). However, the process of fanning the needle horizontally through the skin increases the change of encountering small vessels and therefore deeper bruising. Alternatively, use of the depot method, where larger volumes of lowviscosity product are injected and then massaged or molded to facial contours limits both surface and deeper needle movement. Special Considerations: Expectations, High-Risk Areas, Skin of Color

Ultimately, patient satisfaction is the primary goal of any cosmetic therapy. Thorough patient counseling regarding realistic patient expectations is essential. This discussion should include expected perioperative side effects as well as possible adverse effects. In addition, an overall short and long-term rejuvenation plan should be outlined at the first visit. Many patients will require multiple treatments with numerous syringes or vials of filler, often in combination with other noninvasive cosmetic procedures. Filler longevity is also a common patient concern and the need for return visits at intervals discussed. Patients need to understand what physical and financial undertaking is entailed prior to starting therapy to avoid frustration and animosity toward the physician. Pre- and posttreatment photographs are important to document results for both the patient and the physician. As explained previously, certain anatomical regions are more sensitive to injury either due to the nature of the skin at that location (thickness) or the structures that lie beneath (vessels or nerves). The major anatomic vessels of concern for soft tissue augmentation of the face includes (i) supratrochlear artery, (ii) superior and inferior labial arteries, (iii) angular artery, and (iv) the parotid duct (130). With the recent popularity of filling temple concavities as well as correcting nasal contour irregularities, clearly the superficial temporal artery and the dorsal nasal artery are also areas of concern and caution (Fig. 12.6). The periocular area and tear trough, temple and lateral brow, and angle of the mandible, may be more difficult to treat and challenging to a novice injector. Strict adherence to proper technique can help limit serious side effects in these locations, but sometimes minor side effects may be unavoidable and should be explained completely prior to treatment. For example, the periorbital area is surrounded by several major vessels and nerves that can be injured during careless injection or simple bad luck, and this type of injury could potentially result in visual impairment or blindness (130–132). Injections above the bony border of the orbit can result in septal damage and possibly injury to the globe that may be irreversible. The supratrochlear artery is particularly at high risk of injury from injection in the glabellar region and/or superior medial bony orbit. The superficial temporal artery is

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Figure 12.6 Caution is required in areas with vessels, such as in the temporal area as well as the glabella, alar groove, and lips.

particularly vulnerable in the preauricular, lateral zygoma, and temporal locations. Vessel damage here can potentially lead to the devastating complication of unilateral scalp necrosis. The superior and inferior labial arteries are at particular risk of injury with augmentation of the perioral area and lips, as these arteries supply the upper lip including some of the nasal ala and the lower lip and superior part of the chin, respectively. The angular artery (continuation of the facial artery) provides blood to the medial cheek, nasal ala, nasal sidewall, and dorsum of the nose. Care should be exercised when injecting near the alar groove, as excessive compression with large volumes of filler or frank injection directly into the vessel at this point can lead to nasal ala, nasal tip, nasolabial fold, and upper lip necrosis. Clinicians should take every precaution to avoid vascular compromise. If possible, aspirating prior to injection in anatomic danger zones can be helpful but proves quite difficult with viscous fillers and may only be more reliable in circumstances like when using Sculptra. Intravascular injection may lead to immediate blanching followed by ischemia and necrosis. When using local anesthesia separately or mixed into a filling agent, it is important to know if it contains epinephrine so that the cause of blanching can be determined quickly. This is one reason that some clinicians prefer to use lidocaine without epinephrine during tissue augmentation. Other structures can also be at risk. Like the artery, the superficial temporal nerve is vulnerable in the preauricular, lateral zygoma, and temporal locations. The temporal branch of the facial nerve is at risk over the lateral brow and the zygomatic branch of the facial nerve is at risk over the zygoma. Injury to the nerves in this location can lead to the inability to move the unilateral eyebrow or close the unilateral eye completely. Injections near the angle of the mandible put the marginal mandibular branch of the facial nerve at risk, and injury to this nerve causes denervation of the depressors of the lip/mouth, which in turn can cause chronic drooling or the inability to chew/eat correctly. Finally, the parotid duct (Stenson’s duct) enters the mouth at the level of the second molar and is vulnerable to trauma during midface and cheek augmentation, especially in patients with more significant

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degree of aging, extreme weight loss, and HIV lipoatrophy. Less subcutaneous volume makes the duct more susceptible to injury. Recently, there has been more awareness of complications specific to the use of filling agents in patients with skin of color (Fitzpatrick skin types IV–VI). Darker skin types have increased melanin content and their fibroblasts are larger and more numerous, which may predispose them to dyspigmentation, hypersensitivity reactions, keloids, or hypertrophic scar formation (133). Published data on the safety and efficacy of soft tissue fillers in ethnic skin is limited due to an underrepresentation of darker skin types in clinical trials. However a recent, multicenter, open-label, nonrandomized, prospective trial evaluated the use of CaHA in the nasolabial folds of dark skin individuals (Fitzpatrick skin types IV–VI) and found no significant increase in keloid formation, hypertrophic scarring, or dyspigmentation (134). Other studies have validated these findings with the use of HA and collagen products (135–138). Thus, a theoretical concern of increased adverse events in patients with darker skin has not been demonstrated, and patients with skin of color should be treated with the same precision as any other patient without these concerns of scar abnormalities or dyspigmentation until more data is available. EARLY POSTPROCEDURE Allergic Reactions and other Hypersensitivity Reactions

As discussed above, any filling agent composed of foreign materials can theoretically trigger immune activity to a variable degree from mild irritation and redness to extremely rare anaphylaxis. Despite adequate skin testing (bovine collagen and PMMA) and using fillers with low-reactivity profile (HA, CaHA, PLLA), reactions can occur albeit rarely. Stolman and Nijhawan have reported cases of allergic reactions to human collagen products presenting with erythema, induration, burning, and nonerythematous subcutaneous lumps (139,140). These reactions have been treated with topical calcineurin inhibitors, intralesional corticosteroid injections, systemic corticosteroids, and/or antihistamines. A rare case of angioedema-type hypersensitivity reaction has been reported after HA injection (Restylane) into the lips and resolved after treatment with intramuscular dexamethasone and with an oral prednisone taper (13). Skin Necrosis

Typically, necrosis is a rare occurrence, especially with proper education and injection technique (7). Vascular occlusion can occur either by external compression of the blood supply by surrounding filler material or swelling, by direct intraarterial injection of product, or by vascular injury. Arterial occlusion is characterized by extreme pain and blanching, but it may present as a painless patchy cutaneous erythema or an expanding violaceous reticulated patch; if these symptoms do occur they should not be ignored. The area most regarded as high risk is the glabella as the vessels are of small caliber and do not have a good source of collateral circulation (7,8). The skin of the alar region of the nose is supplied by small branches of the facial artery (dorsal nasal, angular, lateral nasal) and is also at risk (141,142). Injection necrosis of the glabella can theoretically best be prevented by (i) knowledge of local anatomy, (ii) utilizing lower volumes and use of serial injections,

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(iii) injecting in a more medial and superficial plane, (iv) utilizing less viscous filling agents by choosing a “thinner” or low-concentration filler or improving viscosity of fillers with extra plain lidocaine, (v) treating one side at a time and the other side done at a different session (to decrease the likelihood of large volumes plus or minus significant swelling superseding arteriole local pressure), (vi) pinching/tenting the skin to provide more space to the superficial branches of the main arteries and to move away the underlying vasculature, (vii) manual occlusion of the origin of the supratrochlear vessels with the nondominant finger, (viii) using the smallest gauge needle possible, (ix) avoiding anesthesia near a vascular bundle that may induce vascular spasm, such as those containing epinephrine, and (x) attempting to aspirate some products prior to injecting (23,130). It is also generally recommended to limit treatment of the glabellar area to an HA product, as it can at least be attempted to be removed with hyaluronidase enzyme should necrosis be imminent. Although the incidence of actual skin necrosis is low, all injectors should be familiar with the signs of skin necrosis and the appropriate therapy, as the time to treatment and type of treatment are good determinants of morbidity in these devastating situations (17). The goal of treatment is to promote increased blood flow to the affected area and this can be accomplished by applying warm gauze (avoiding ice), tapping or massaging the area to facilitate vasodilation and dispersion of material, applying 2% nitroglycerin paste (NitroBid; Fougera, Melville, NY, U.S.), and taking oral aspirin (19). Hyaluronidase injection is recommended in cases of impending necrosis after HA use, and there are cases documenting careful injection along the distribution of the underlying vessel showing improvement by likely decompressing the vessel. In some of these circumstances, a Doppler device may be helpful in pinpointing proximal placement into the suspected compromised vessel. For extreme cases of unresponsive necrosis, subcutaneous injections of low molecular weight heparin may be useful (143). If necrosis ensues, as demonstrated by an ulceration and/or eschar formation at the site of injection, diligent wound care management with hydrocolloidal dressings (Duoderm Ultra Thin Sheets; Convatec, NJ, U.S.), emollients, and topical antibiotics are the primary treatment and if necessary surgical debridement or possibly hyperbaric oxygen therapy. “Watchful waiting” is all that can be done once treatments have been initiated and the utmost importance is to minimize scarring. Once healed, the resultant scar can be treated with silicone pads and/or dermabrasion, excision, pulse dye laser, 1450-nm diode laser, or laser resurfacing depending upon the severity, texture, and color (7). LATE POSTPROCEDURE Nodule Formation and Granulomatous Reactions

As previously discussed, delayed-onset nodule and granulomatous reactions have been reported with several filling agents. Hyaluronic Acid

Nodule formation following injection of HA fillers is most commonly due to superficial placement (Fig. 12.7). Granulomatous reactions or inflammatory nodules are of a different nature and have been reported in the literature as persistent nodules and/or delayed-onset erythematous nodules (“angry red bumps”). These bumps may or may not be tender and are

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regarded as possible allergic reactions, foreign body reactions, infections, and/or sterile abscesses (Fig. 12.8). A granuloma can sometimes be differentiated from a fibrotic foreign body reaction by its later onset, tenderness, swelling, and suppuration (144). Biofilms (chronic indolent infections) may play a role in the presentation of delayed-onset nodule formation and as noted previously are often resistant to treatment (145–148). Case reports describe some that fail to improve with standard measures such as topical, oral, or injectable corticosteroids. Others have reported success with injection of hyaluronidase. Overall, the management of “angry red bumps” has been well outlined with the use of empiric antibiotics, incision and drainage with culture, and close observation (17).

Figure 12.7 Nodule formation 10 days after HA filler placement for lip rejuvenation. Product is more palpable than visible and most likely due to improper placement or too large an aliquot of material without adequate manipulation postprocedure.

Figure 12.8 Six months after injection with Varioderm (HA) for correction of tear troughs, an oval hard nodule about 1 cm in length developed, slowly increasing in size. Several attempts with treatment of hyaluronidase were without results. The patient wanted to have the nodule removed. Source: Courtesy of Prof. Dr. W. Stolz, Ludwig-Maximilians-University, Munich, Germany.

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Poly-L-Lactic Acid

Nodule formation with PLLA was quite common initially with a rate of 31% to 52% in early European studies of patients with HIV lipodystrophy (70,149). Lower instances have been reported by several U.S. authors and ranged between 6% and 13% (23,150,151). Treatment protocols incorporating higher dilution volumes (8–12 mL total; 5–10 mL of sterile water plus 1–2 mL of 1% lidocaine with epinephrine), precise injection into a deeper plane (subcutaneous plane avoiding dermal and intramuscular placement), fewer vials used at each session with adequate reconstitution times (12–24 hours or more), adequate time between injection sessions (six to eight weeks), and aggressive postinjection patient massage should decrease the risks and avoid the potential complications associated with PLLA injection (90,104,152). Butterwick et al. recommend a dilution of 5 mL or more of sterile water with additional 1 mL of lidocaine prior to injection with reconstitution time to at least overnight (153). The periorbital area is a particularly sensitive area to the formation of nodules and foreign body granulomas and it is suggested that only experienced injectors use PLLA in this area (Fig. 12.9). Similarly, due to thin skin and meager subcutaneous tissue, the dorsal hands should only be approached with caution and by experienced injectors (20,154). In addition, in the hands, PLLA should be injected in a “depot” method below the muscle at a significantly diluted volume to avoid complications (155). A retrospective, single-center study of 130 HIV-negative patients treated with PLLA from 2003 to 2008 found that the highest incidence of posttreatment nodules were located in the hands (12.5%) and cheeks (7.2%), but the majority of patients (68%) were satisfied and would repeat the procedure again despite the possibilities of further complications (156). A review of the literature suggests that the use of appropriate injection technique (subcutaneous plane injection with even distribution of product and no more than 0.1–0.2 mL of product per pass of the needle), increased dilution volumes, and posttreatment massage are the most helpful in reducing nodule formation (157–163). Fortunately most nodules are palpable but not visible; however, if nodules are visible or symptomatic in any way, treatment of proves very difficult, for example, PLLA nodules (Fig. 12.10). Intralesional corticosteroid or

Figure 12.9 Nodule formations after treatment with PLLA over the lateral zygoma, most likely from improper superficial placement of product or low dilution volume.

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Figure 12.10 PLLA nodules visible from inside the mouth as a result of abnormal placement during cheek injections.

saline injections in combination with topical 5% imiquimod cream and/or 5-fluorouracil cream may be helpful. Surgical excision is an option in long-lasting cases, but may yield a poor cosmetic result. Most PLLA nodules encountered are noninflammatory, but one case series of 10 patients reported delayed inflammatory nodules marked by edema, induration, and tenderness, with or without pus or filler material with the use of PLLA (164). Previous thinking was that PLLA injections did not have inflammatory-related side effects, and to date no additional inflammatory PLLA reports have been published. Calcium Hydroxylapatite

Nodule formation with CaHA has also been reported with most noted cases occurring during lip and perioral injection. Thus, lip injection has been abandoned and many injectors take caution when using this product in the perioral area. In other areas of the face, CaHA is very safe and effective especially for the nasolabial folds, oral commissures, and cheeks. Some experienced injectors use CaHA to augment the mandible, lateral brow, and temples as well, with excellent results (24,165). Thus far, serious complications reported have been minimal especially if injected into the deep dermis or above the periosteum (166). One recent study has shown excellent six-month safety results in patients with skin of color (Fitzpatrick skin types IV–VI) without any increase in keloid formation, hypertrophic scarring, dyspigmentation, or other complications (134). There is one report of a CaHA nodule appearing 2 cm distal to the site of injection (109). As outlined previously, if nodules do occur, they can be treated in part with intralesional injection and/or surgical excision. Theoretical concerns of bone stimulation following CaHA injection have been raised, but to date no studies have shown this theory to be true (167). Nonetheless, it is still recommended that this filler not come in direct contact with bone when injecting into the preperiosteal plane (5).

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Polymethylmethacrylate

Delayed granuloma formation has been associated with PMMA mainly in the form commercially available in Europe (Artecoll). The rate is quite low (0.1%), but can be troublesome because of its delayed appearance (6–24 months following injection) (44,168,169). Generally, treatment includes repeated intralesional corticosteroid injections at increasing concentrations every three to four weeks (23,42). It is important to distinguish this type of nodule formation versus superficial beading and ridging representing a hypertrophic scar due to superficial placement of PMMA, as the latter may require more aggressive therapies such as laser or excision (129). CONCLUSION

As soft tissue augmentation with filling agents becomes more popular, there is need for practitioners to have proper training in order to provide a safe means of facial rejuvenation. Understanding and knowledge of regional anatomy, product characteristics, and injection techniques can help give optimal results with the least complications. Nonetheless, circumstances may arise and the practitioner needs a thorough understanding of the correct means to diagnose a complication in order to quickly initiate the proper treatment algorithm. The goal of all facial rejuvenation procedures should be patient satisfaction with minimal sequelae. Proper patient selection and counseling will provide realistic expectations that will lead to lasting fulfillment. Practitioners of all levels should be familiar with the most commonly available filling agents and their characteristics in order to successfully avoid adverse effects and accurately diagnose and effectively manage complications if they do occur. REFERENCES 1. The American Society for Aesthetic Plastic Surgery. Cosmetic Surgery National Data Bank Statistics. [Available from: http://www.surgery.org/media/statistics]. Accessed July 31, 2010. 2. André P. Evaluation of the safety of a non-animal stabilized hyaluronic acid (NASHA: Q-Medical, Sweden) in European countries: a retrospective study from 1997 to 2001. J Eur Acad Dermatol Venereol 2004; 18: 422–5. 3. DeLorenzi C, Weinberg M, Solish N, Swift A. Multicenter study of the efficacy and safety of subcutaneous non-animal-stabilized hyaluronic acid in aesthetic facial contouring: interim report. Dermatol Surg 2006; 32: 205–11. 4. Godin MS, Majmundar MV, Chrzanowski DS, Dodson KM. Use of Radiesse in combination with Restylane for facial augmentation. Arch Facial Plast Surg 2006; 8: 92–7. 5. Berlin A, Cohen JL, Goldberg DJ. Calcium hydroxylapatite for facial rejuvenation. Semin Cutan Med Surg 2006; 25: 132–7. 6. Georgescu D, Jones Y, McCann JD, Anderson RL. Skin necrosis after calcium hydroxylapatite injection into the glabellar and nasolabial folds. Ophthal Plast Reconstr Surg 2009; 25: 498–9. 7. Glaich AS, Cohen JL, Goldberg LH. Injection necrosis of the glabella: protocol for prevention and treatment after use of dermal fillers. Dermatol Surg 2006; 32: 276–81. 8. Bachmann F, Erdmann R, Hartmann V, et al. The spectrum of adverse reactions after treatment with injectable fillers in the glabellar region: results from the Injectable Filler Safety Study. Dermatol Surg 2009; 35: 1629–34. 9. Beljaards RC, de Roos KP, Bruins FG. NewFill for skin augmentation: a new filler or failure? Dermatol Surg 2005; 31: 772–6.

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10. Toy BR, Frank PJ. Outbreak of Mycobacterium abscessus infection after soft tissue augmentation. Dermatol Surg 2003; 29: 971–3. 11. Inoue K, Sato K, Matsumoto D, Gonda K, Yoshimura K. Arterial embolization and skin necrosis of the nasal ala following injection of dermal fillers. Plast Reconstr Surg 2008; 121: 127e–128e. 12. Jham BC, Nikitakis NG, Scheper MA, et al. Granulomatous foreign-body reaction involving oral and perioral tissues after injection of biomaterials: a series of 7 cases and review of the literature. J Oral Maxillofac Surg 2009; 67: 280–5. 13. Leonhardt JM, Lawrence N, Narins RS. Angioedema acute hypersensitivity reaction to injectable hyaluronic acid. Dermatol Surg 2005; 31: 577–9. 14. Al-Shraim M, Jaragh M, Geddie W. Granulomatous reaction to injectable hyaluronic acid (Restylane) diagnosed by fine needle biopsy. J Clin Pathol 2007; 60:1060–1. 15. Ghislanzoni M, Bianchi F, Barbareschi M, Alessi E. Cutaneous granulomatous reaction to injectable hyaluronic acid gel. Br J Dermatol 2006; 154: 755–8. 16. Massone C, Horn M, Kerl H, et al. Foreign body granuloma due to Matridex injection for cosmetic purposes. Am J Dermatopathol 2009; 31: 197–9. 17. Narins RS, Jewell M, Rubin M, et al. Clinical conference: management of rare events following dermal fillers: focal necrosis and angry red bumps. Dermatol Surg 2006; 32: 426–34. 18. Parada MB, Michalany NS, Hassun KM, et al. A histologic study of adverse effects of different cosmetic skin fillers. Skinmed 2005; 4: 345–9. 19. Hirsch RJ, Cohen JL, Carruthers JD. Successful management of an unusual presentation of impending necrosis following a hyaluronic acid injection embolus and a proposed algorithm for management with hyaluronidase. Dermatol Surg 2007; 33: 357–60. 20. Stewart DB, Morganroth GS, Mooney MA, et al. Management of visible granulomas following periorbital injection of poly-L-lactic acid. Ophthal Plast Reconstr Surg 2007; 23: 298–301. 21. Zielke H, Wölber L, Wiest L, Rzany B. Risk profiles of different injectable fillers: results from the Injectable Filler Safety Study (IFS Study). Dermatol Surg 2008; 34: 326–35. 22. Matarasso SL, Carruthers JD, Jewell ML; Restylane Consensus Group. Consensus recommendations for soft-tissue augmentation with nonanimal stabilized hyaluronic acid (Restylane). Plast Reconstr Surg 2006; 117: 3S–34S. 23. Cohen JL. Understanding, avoiding, and managing dermal filler complications. Dermatol Surg 2008; 34: S92–S99. 24. Graivier MH, Bass LS, Busso M, et al. Calcium hydroxylapatite (Radiesse) for correction of the mid- and lower face: consensus recommendations. Plast Reconstr Surg 2007; 120: 55S–66S. 25. Alam M, Gladstone H, Kramer EM, et al.; American Society for Dermatologic Surgery. ASDS guidelines of care: injectable fillers. Dermatol Surg 2008; 34: S115–S148. 26. Eppley BL, Dadvand B. Injectable soft-tissue fillers: clinical overview. Plast Reconstr Surg 2006; 118: 98e–106e. 27. Johl SS, Burgett RA. Dermal filler agents: a practical review. Curr Opin Ophthalmol 2006; 17: 471–9. 28. Murray CA, Zloty D, Warshawski L. The evolution of soft tissue fillers in clinical practice. Dermatol Clin 2005; 23: 343–63. 29. Rohrich RJ, Rios JL, Fagien S. Role of new fillers in facial rejuvenation: a cautious outlook. Plast Reconstr Surg 2003; 112: 1899–902. 30. Klein AW. Skin filling. Collagen and other injectables of the skin. Dermatol Clin 2001; 19: 491–508. 31. Cockerham K, Hsu VJ. Collagen-based dermal fillers: past, present, future. Facial Plast Surg 2009; 25: 106–13. 32. Raulin C, Greve B, Hartschuh W, Soegding K. Exudative granulomatous reaction to hyaluronic acid (Hylaform). Contact Dermatitis 2000; 43: 178–9. 33. Kamer FM, Churukian MM. Clinical use of injectable collagen. A three-year retrospective review. Arch Otolaryngol 1984; 110: 93–8. 34. Baumann L. Collagen-containing fillers: alone and in combination. Clin Plast Surg 2006; 33: 587–96.

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35. Baumann L, Kaufman J, Saghari S. Collagen fillers. Dermatol Ther 2006; 19: 134–40. 36. Rostan E. Collagen fillers. Facial Plast Surg Clin North Am 2007; 15: 55–61. 37. Goldberg DJ. Breakthroughs in US dermal fillers for facial soft-tissue augmentation. J Cosmet Laser Ther 2009; 11: 240–7. 38. Shoshani D, Markovitz E, Cohen Y, et al. Skin test hypersensitivity study of a cross-linked, porcine collagen implant for aesthetic surgery. Dermatol Surg 2007; 33: S152–S158. 39. Narins RS, Brandt FS, Lorenc ZP, et al. Twelve-month persistency of a novel ribose-crosslinked collagen dermal filler. Dermatol Surg. 2008; 34: S31–S39. 40. Artefill package insert. [Available from http://www.artefill.com/pdf/Artefill%20Product%20 Sheet%20SM1006rev00.pdf]. Accessed July 31, 2010. 41. Krauss MC. Recent advances in soft tissue augmentation. Semin Cutan Med Surg 1999; 18: 119–28. 42. Lemperle G, Romano JJ, Busso M. Soft tissue augmentation with Artecoll: 10-year history, indications, techniques, and complications. Dermatol Surg 2003; 29: 573–87. 43. Reisberger EM, Landthaler M, Wiest L, et al. Foreign body granulomas caused by polymethylmethacrylate microspheres: successful treatment with allopurinol. Arch Dermatol 2003; 139: 17–20. 44. Cohen SR, Berner CF, Busso M, et al. ArteFill: a long-lasting injectable wrinkle filler material: summary of the U.S. Food and Drug Administration trials and a progress report on 4- to 5-year outcomes. Plast Reconstr Surg 2006; 118: 64S–76S. 45. Cohen SR, Berner CF, Busso M, et al Five-year safety and efficacy of a novel polymethylmethacrylate aesthetic soft tissue filler for the correction of nasolabial folds. Dermatol Surg 2007; 33: S222–S230. 46. Cohen SR, Holmes RE. Artecoll: a long-lasting injectable wrinkle filler material: report of a controlled, randomized, multicenter clinical trial of 251 subjects. Plast Reconstr Surg 2004; 114: 964–76. 47. Lewy RI. Autoimmune disease and collagen dermal implants. Ann Intern Med 1994; 120: 525–6. 48. Singh G, Fries JF. Autoimmune disease and collagen dermal implants. Ann Intern Med 1994; 120: 524–5. 49. Cukier J, Beauchamp RA, Spindler S, et al. Association between bovine collagen dermal implants and a dermatomyositis or a polymyositis-like syndrome. Ann Intern Med 1993; 118: 920–8. 50. Elson ML. Injectable collagen and autoimmune disease. J Dermatolog Surg Oncol 1993; 19: 165–8. 51. Hochberg MC. Cosmetic surgical procedures and connective tissue disease: the Cleopatra syndrome revisited. Ann Intern Med 1993; 118: 981–3. 52. Brody GS, Conway DP, Deapen DM, et al. Consensus statement on the relationship of breast implants to connective-tissue disorders. Plast Reconstr Surg 1992; 90: 1102–5. 53. Tinkler J, Gott D, Ludgate S. Breast implants: is there an association with connective tissue disease? Health Trends 1994; 26: 25–6. 54. Englert HJ, Howe GB, Penny R, Brooks P. Scleroderma and silicone breast implants. Br J Rheumatol 1994; 33: 397–9. 55. Beasley KL, Weiss MA, Weiss RA. Hyaluronic acid fillers: a comprehensive review. Facial Plast Surg 2009; 25: 86–94. 56. Bogdan Allemann I, Baumann L. Hyaluronic acid gel (Juvéderm) preparations in the treatment of facial wrinkles and folds. Clin Interv Aging 2008; 3: 629–34. 57. The American Society for Aesthetic Plastic Surgery. Cosmetic Surgery National Data Bank Statistics. [Available from: http://media.lasvegassun.com/media/pdfs/blogs/documents/ 2009/03/25/2008stats.pdf]. Accessed July 31, 2010. 58. Sage RJ, Chaffins ML, Kouba DJ. Granulomatous foreign body reaction to hyaluronic acid: report of a case after melolabial fold augmentation and review of management. Dermatol Surg 2009; 35: 1696–700.

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59. Sanchis-Bielsa JM, Bagán JV, Poveda R, Salvador I. Foreign body granulomatous reactions to cosmetic fillers: a clinical study of 15 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009; 108: 237–41. 60. Alijotas-Reig J, Garcia-Gimenez V. Delayed immune-mediated adverse effects related to hyaluronic acid and acrylic hydrogel dermal fillers: clinical findings, long-term follow-up and review of the literature. J Eur Acad Dermatol Venereol 2008; 22: 150–61. 61. Bardazzi F, Ruffato A, Antonucci A, et al. Cutaneous granulomatous reaction to injectable hyaluronic acid gel: another case. J Dermatolog Treat 2007; 18: 59–62. 62. Bellman B. Immediate and delayed hypersensitivity reactions to Restylane. Aesthet Surg J 2005; 25: 489–91. 63. Grossman KL. Hyaluronic acid gel fillers: hypersensitivity reactions. Aesthet Surg J 2005; 25: 403–5. 64. Homicz MR, Watson D. Review of injectable materials for soft tissue augmentation. Facial Plast Surg 2004; 20: 21–9. 65. Fernández-Aceñero MJ, Zamora E, Borbujo J. Granulomatous foreign body reaction against hyaluronic acid: report of a case after lip augmentation. Dermatol Surg 2003; 29: 1225–6. 66. Friedman PM, Mafong EA, Kauvar AN, Geronemus RG. Safety data of injectable nonanimal stabilized hyaluronic acid gel for soft tissue augmentation. Dermatol Surg 2002; 28: 491–4. 67. Winslow CP. The management of dermal filler complications. Facial Plast Surg 2009; 25: 124–8. 68. Narins RS, Brandt F, Leyden J, et al. A randomized, double-blind, multicenter comparison of the efficacy and tolerability of Restylane versus Zyplast for the correction of nasolabial folds. Dermatol Surg 2003; 29: 588–95. 69. Juvederm package insert. [Available from: http://www3.juvederm.com/professionals/pdf/ juvederm_dfu.pdf]. Accessed July 31, 2010. 70. Sculptra package insert. [Available from: http://products.sanofi-aventis.us/sculptra/sculptra. html]. Accessed July 31, 2010. 71. Radiesse Injectable Implant Instructions For Use. [Available from: http://www.accessdata.fda. gov/cdrh_docs/pdf5/P050037c.pdf]. Accessed July 31, 2010. 72. Dinehart SM, Henry L. Dietary supplements: altered coagulation and effects on bruising. Dermatol Surg 2005; 31: 819–26. 73. Broughton II G, Crosby MA, Coleman J, Rohrich RJ. Use of herbal supplements and vitamins in plastic surgery: a practical review. Plast Reconstr Surg 2007; 119: 48e–66e. 74. Ciocon JO, Ciocon DG, Galindo DJ. Dietary supplements in primary care. Botanicals can affect surgical outcomes and follow-up. Geriatrics 2004; 59: 20–4. 75. Khalifeh MR, Redett RJ. The management of patients on anticoagulants prior to cutaneous surgery: case report of a thromboembolic complication, review of the literature, and evidencebased recommendations. Plast Reconstr Surg 2006; 118: 110e–117e. 76. Alcalay J. Cutaneous surgery in patients receiving warfarin therapy. Dermatol Surg 2001; 27: 756–8. 77. Ong AT, Hoye A, Aoki J, et al. Thirty-day incidence and six-month clinical outcome of thrombotic stent occlusion after bare-metal, sirolimus, or paclitaxel stent implantation. J Am Coll Cardiol 2005; 45: 947–53. 78. Silber S, Albertsson P, Avilés FF, et al; Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Guidelines for percutaneous coronary interventions. The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Eur Heart J 2005; 26: 804–47. 79. King III SB, Smith Jr SC, Hirshfeld Jr JW, et al. 2007 focused update of the ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice guidelines. J Am Coll Cardiol 2008; 51: 172–209. 80. Stone GW, Aronow HD. Long-term care after percutaneous coronary intervention: focus on the role of antiplatelet therapy. Mayo Clin Proc 2006; 81: 641–52.

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81. Zimarino M, Renda G, De Caterina R. Optimal duration of antiplatelet therapy in recipients of coronary drug-eluting stents. Drugs 2005; 65: 725–32. 82. Douketis JD, Berger PB, Dunn AS, et al. American College of Chest Physicians. The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133: 299S–339S. 83. DeFatta RJ, Krishna S, Williams III EF. Pulsed-dye laser for treating ecchymoses after facial cosmetic procedures. Arch Facial Plast Surg 2009; 11: 99–103. 84. Kouzi SA, Nuzum DS. Arnica for bruising and swelling. Am J Health Syst Pharm 20071; 64: 2434–43. 85. MacKay D, Miller AL. Nutritional support for wound healing. Altern Med Rev 2003; 8: 359–77. 86. Narins RS, Coleman III WP, Glogau RG. Recommendations and treatment options for nodules and other filler complications. Dermatol Surg 2009; 35: 1667–71. 87. Rohrich RJ, Monheit G, Nguyen AT, et al. Soft-tissue filler complications: the important role of biofilms. Plast Reconstr Surg 2010; 125: 1250–66. 88. Wiest LG, Stolz W, Schroeder JA. Electron microscopic documentation of late changes in permanent fillers and clinical management of granulomas in affected patients. Dermatol Surg 2009; 35: 1681–8. 89. Christensen LH. Host tissue interaction, fate, and risks of degradable and nondegradable gel fillers. Dermatol Surg 2009; 35: 1612–19. 90. Narins RS. Minimizing adverse events associated with poly-L-lactic acid injection. Dermatol Surg 2008; 34: S100–S104. 91. Sclafani AP, Fagien S. Treatment of injectable soft tissue filler complications. Dermatol Surg 2009; 35: 1672–80. 92. Lambros V. The use of hyaluronidase to reverse the effects of hyaluronic acid filler. Plast Reconstr Surg 2004; 114: 277. 93. Lee A, Grummer SE, Kriegel D, Marmur E. Hyaluronidase. Dermatol Surg 2010; 36: 1071–7. 94. Lemperle G, Rullan PP, Gauthier-Hazan N. Avoiding and treating dermal filler complications. Plast Reconstr Surg 2006; 118: 92S–107S. 95. Calfee DP, Farr BM. Comparison of four antiseptic preparations for skin in the prevention of contamination of percutaneously drawn blood cultures: a randomized trial. J Clin Microbiol 2002; 40: 1660–5. 96. Reichel M, Heisig P, Kohlmann T, Kampf G. Alcohols for skin antisepsis at clinically relevant skin sites. Antimicrob Agents Chemother 2009; 53: 4778–82. 97. Tanner J, Swarbrook S, Stuart J. Surgical hand antisepsis to reduce surgical site infection. Cochrane Database Syst Rev 2008; 1: CD004288. 98. Hibbard JS, Mulberry GK, Brady AR. A clinical study comparing the skin antisepsis and safety of ChloraPrep, 70% isopropyl alcohol, and 2% aqueous chlorhexidine. J Infus Nurs 2002; 25: 244–9. 99. Soothill JS, Bravery K, Ho A, et al. A fall in bloodstream infections followed a change to 2% chlorhexidine in 70% isopropanol for catheter connection antisepsis: a pediatric single center before/after study on a hemopoietic stem cell transplant ward. Am J Infect Control 2009; 37: 626–30. 100. Ryssel H, Kloeters O, Germann G, et al. The antimicrobial effect of acetic acid: an alternative to common local antiseptics? Burns 2009; 35: 695–700. 101. Evans HL, Dellit TH, Chan J, et al. Effect of chlorhexidine whole-body bathing on hospitalacquired infections among trauma patients. Arch Surg 2010; 145: 240–6. 102. Gelfer A, Carruthers A, Carruthers J, et al. The natural history of polymethylmethacrylate microspheres granulomas. Dermatol Surg 2007; 33: 614–20. 103. Alam M, Yoo SS. Technique for calcium hydroxylapatite injection for correction of nasolabial fold depressions. J Am Acad Dermatol 2007; 56: 285–9. 104. Lam SM, Azizzadeh B, Graivier M. Injectable poly-L-lactic acid (Sculptra): technical considerations in soft-tissue contouring. Plast Reconstr Surg 2006; 118: 55S–63S.

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105. Buck II DW, Alam M, Kim JY. Injectable fillers for facial rejuvenation: a review. J Plast Reconstr Aesthet Surg 2009; 62: 11–18. 106. Arlette JP, Trotter MJ. Anatomic location of hyaluronic acid filler material injected into nasolabial fold: a histologic study. Dermatol Surg 2008; 34: S56–S62. 107. Greco TM, Elenitsas R. Localization and histological characterization of injected hyaluronic acid in excised nasolabial fold tissue. J Drugs Dermatol 2010; 9: 399–404. 108. Narins RS, Bowman PH. Injectable skin fillers. Clin Plast Surg 2005; 32: 151–62. 109. Beer KR. Radiesse nodule of the lips from a distant injection site: report of a case and consideration of etiology and management. J Drugs Dermatol 2007; 6: 846–7. 110. Ridenour B, Kontis TC. Injectable calcium hydroxylapatite microspheres (Radiesse). Facial Plast Surg 2009; 25: 100–5. 111. Werschler WP. Advanced injection techniques of poly-L-lactic acid: a case-based presentation. Dermatol Ther 2007; 20: S16–S19. 112. Kusin S, Lippitz J. Skin fillers. Dis Mon 2009; 55: 236–56. 113. Nicolau PJ. Long-lasting and permanent fillers: biomaterial influence over host tissue response. Plast Reconstr Surg 2007; 119: 2271–86. 114. Humphrey CD, Arkins JP, Dayan SH. Soft tissue fillers in the nose. Aesthet Surg J 2009; 29: 477–84. 115. Hirsch RJ, Carruthers JD, Carruthers A. Infraorbital hollow treatment by dermal fillers. Dermatol Surg 2007; 33: 1116–19. 116. Hirsch RJ, Narurkar V, Carruthers J. Management of injected hyaluronic acid induced Tyndall effects. Lasers Surg Med 2006; 38: 202–4. 117. Hirsch RJ, Stier M. Complications of soft tissue augmentation. J Drugs Dermatol 2008; 7: 841–5. 118. Hirsch R, Stier M. Complications and their management in cosmetic dermatology. Dermatol Clin 2009; 27: 507–20. 119. Douse-Dean T, Jacob CI. Fast and easy treatment for reduction of the Tyndall effect secondary to cosmetic use of hyaluronic acid. J Drugs Dermatol 2008; 7: 281–3. 120. Hirsch RJ, Brody HJ, Carruthers JD. Hyaluronidase in the office: a necessity for every dermasurgeon that injects hyaluronic acid. J Cosmet Laser Ther 2007; 9: 182–5. 121. Brody HJ. Use of hyaluronidase in the treatment of granulomatous hyaluronic acid reactions or unwanted hyaluronic acid misplacement. Dermatol Surg 2005; 31: 893–7. 122. Sadick NS, Katz BE, Roy D. A multicenter, 47-month study of safety and efficacy of calcium hydroxylapatite for soft tissue augmentation of nasolabial folds and other areas of the face. Dermatol Surg 2007; 33: S122–S126. 123. Busso M, Voigts R. An investigation of changes in physical properties of injectable calcium hydroxylapatite in a carrier gel when mixed with lidocaine and with lidocaine/epinephrine. Dermatol Surg 2008; 34: S16–S23. 124. Juckett G, Hartman-Adams H. Management of keloids and hypertrophic scars. Am Fam Physician 2009; 80: 253–60. 125. Kelly AP. Update on the management of keloids. Semin Cutan Med Surg 2009; 28: 71–6. 126. Mrowietz U, Seifert O. Keloid scarring: new treatments ahead. Actas Dermosifiliogr 2009; 100: 75–83. 127. Glogau RG, Kane MA. Effect of injection techniques on the rate of local adverse events in patients implanted with nonanimal hyaluronic acid gel dermal fillers. Dermatol Surg 2008; 34: S105–S109. 128. Rohrich RJ, Ghavami A, Crosby MA. The role of hyaluronic acid fillers (Restylane) in facial cosmetic surgery: review and technical considerations. Plast Reconstr Surg 2007; 120: 41S–54S. 129. Carruthers JD, Carruthers A. Facial sculpting and tissue augmentation. Dermatol Surg 2005; 31: 1604–12. 130. Cohen JL, Brown MR. Anatomic considerations for soft tissue augmentation of the face. J Drugs Dermatol 2009; 8: 13–16.

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131. Sung MS, Kim HG, Woo KI, Kim YD. Ocular ischemia and ischemic oculomotor nerve palsy after vascular embolization of injectable calcium hydroxylapatite filler. Ophthal Plast Reconstr Surg 2010; 26: 289–91. 132. Silva MT, Curi AL. Blindness and total ophthalmoplegia after aesthetic polymethylmethacrylate injection: case report. Arq Neuropsiquiatr 2004; 62: 873–4. 133. Emer J, Marmur E. Filler complications in skin of color. [Available from: http://www. dermquest.com/Expert_Opinions/Surgery__Cosmetics/Filler_complications_in_skin_of_ color.html]. Accessed July 31, 2010. 134. Marmur ES, Taylor SC, Grimes PE, et al. Six-month safety results of calcium hydroxylapatite for treatment of nasolabial folds in Fitzpatrick skin types IV to VI. Dermatol Surg 2009; 35: 1641–5. 135. Grimes PE, Taylor SC, Grekin SD, et al. Safety and effectiveness of low concentration hyaluronic acid fillers in skin of color. Poster presented at the 2007 American Academy of Dermatology Meeting; New York, NY. 136. Grimes PE, Thomas JA, Murphy DK, Walker PS. Efficacy and safety of novel hyaluronic acid-cased fillers and cross-linked bovine collagen in Caucasians and persons of color. Poster presented at the 2006 Annual Meeting of the American Academy of Dermatology; San Diego, CA. 137. Baumann LS, Shamban AT, Lupo MP, et al. JUVEDERM vs. ZYPLAST Nasolabial Fold Study Group. Comparison of smooth-gel hyaluronic acid dermal fillers with cross-linked bovine collagen: a multicenter, double-masked, randomized, within-subject study. Dermatol Surg 2007; 33: S128–S135. 138. Taylor SC, Burgess CM, Callender VD. Safety of nonanimal stabilized hyaluronic acid dermal fillers in patients with skin of color: a randomized, evaluator-blinded comparative trial. Dermatol Surg 2009; 35: 1653–60. 139. Stolman LP. Human collagen reactions. Dermatol Surg 2005; 31: 1634. 140. Nijhawan RI, Cohen JL, Joely K. Persistent erythema after human collagen injections. Cosmet Dermatol 2008; 21: 90–4. 141. Grunebaum LD, Bogdan Allemann I, Dayan S, Mandy S, Baumann L. The risk of alar necrosis associated with dermal filler injection. Dermatol Surg 2009; 35: 1635–40. 142. Siclovan HR, Jomah JA. Injectable calcium hydroxylapatite for correction of nasal bridge deformities. Aesthetic Plast Surg 2009; 33: 544–8. 143. Schanz S, Schippert W, Ulmer A, et al. Arterial embolization caused by injection of hyaluronic acid (Restylane). Br J Dermatol 2002; 146: 928–9. 144. Monheit GD, Rohrich RJ. The nature of long-term fillers and the risk of complications. Dermatol Surg 2009; 35: 1598–604. 145. Lemperle G, Gauthier-Hazan N, Wolters M, et al. Foreign body granulomas after all injectable dermal fillers: part 1. Possible causes. Plast Reconstr Surg 2009; 123: 1842–63. 146. Bentkover SH. The biology of facial fillers. Facial Plast Surg 2009; 25: 73–85. 147. Christensen L, Breiting V, Janssen M, et al. Adverse reactions to injectable soft tissue permanent fillers. Aesthetic Plast Surg 2005; 29: 34–48. 148. Christensen L. Normal and pathologic tissue reactions to soft tissue gel fillers. Dermatol Surg 2007; 33: S168–S175. 149. Werschler P. The Cosmetic Study Investigator Group. Efficacy of injectable poly-L-lactic acid versus human collagen for the correction of nasolabial fold wrinkles. Presented at the American Society for Dermatologic Surgery; October 28, 2006; Palm Desert, California; Abstract CS359. 150. Hamilton DG, Gauthier N, Robertson BF. Late-onset, recurrent facial nodules associated with injection of poly-L-lactic acid. Dermatol Surg 2008; 34: 123–6. 151. Reszko AE, Sadick NS, Magro CM, Farber J. Late-onset subcutaneous nodules after poly-Llactic acid injection. Dermatol Surg 2009; 35: 380–4. 152. Woerle B, Hanke CW, Sattler G. Poly-L-lactic acid: a temporary filler for soft tissue augmentation. J Drugs Dermatol 2004; 3: 385–9.

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ILLUSTRATED MANUAL OF INJECTABLE FILLERS

153. Butterwick K, Lowe NJ. Injectable poly-L-lactic acid for cosmetic enhancement: learning from the European experience. J Am Acad Dermatol 2009; 61: 281–93. 154. Beer K. Clinicopathologic correlation of delayed-onset periorbital poly-L-lactic acid nodules. Dermatol Surg 2009; 35: 399–402. 155. Apikian M, Roberts S, Goodman GJ. Adverse reactions to polylactic acid injections in the periorbital area. J Cosmet Dermatol 2007; 6: 95–101. 156. Palm MD, Woodhall KE, Butterwick KJ, Goldman MP. Cosmetic use of poly-L-lactic acid: a retrospective study of 130 patients. Dermatol Surg 2010; 36: 161–70. 157. Burgess CM, Quiroga RM. Assessment of the safety and efficacy of poly-L-lactic acid for the treatment of HIV-associated facial lipoatrophy. J Am Acad Dermatol 2005; 52: 233–9. 158. Lowe NJ, Maxwell CA, Patnaik R. Adverse reactions to dermal fillers: review. Dermatol Surg 2005; 31: 1616–25. 159. Vleggaar D. Soft-tissue augmentation and the role of poly-L-lactic acid. Plast Reconstr Surg 2006; 118: 46S–54S. 160. Borelli C, Kunte C, Weisenseel P, et al. Deep subcutaneous application of poly-L-lactic acid as a filler for facial lipoatrophy in HIV-infected patients. Skin Pharmacol Physiol 2005; 18: 273–8. 161. Salles AG, Lotierzo PH, Gimenez R, et al. Evaluation of the poly-L-lactic acid implant for treatment of the nasolabial fold: 3-year follow-up evaluation. Aesthetic Plast Surg 2008; 32: 753–6. 162. Redaelli A, Forte R. Cosmetic use of polylactic acid: report of 568 patients. J Cosmet Dermatol 2009; 8: 239–48. 163. Rossner F, Rossner M, Hartmann V, et al. Decrease of reported adverse events to injectable polylactic acid after recommending an increased dilution: 8-year results from the Injectable Filler Safety Study. J Cosmet Dermatol 2009; 8: 14–18. 164. Alijotas-Reig J, Garcia-Gimenez V, Vilardell-Tarres M. Late-onset immune-mediated adverse effects after poly-L-lactic acid injection in non-HIV patients: clinical findings and long-term follow-up. Dermatology 2009; 219: 303–8. 165. Lizzul PF, Narurkar VA. The role of calcium hydroxylapatite (Radiesse) in nonsurgical aesthetic rejuvenation. J Drugs Dermatol 2010; 9: 446–50. 166. Tzikas TL. A 52-month summary of results using calcium hydroxylapatite for facial soft tissue augmentation. Dermatol Surg 2008; 34: S9–S15. 167. Holzapfel AM, Mangat DS, Barron DS. Soft-tissue augmentation with calcium hydroxylapatite: histological analysis. Arch Facial Plast Surg 2008; 10: 335–8. 168. Alcalay J, Alkalay R, Gat A, Yorav S. Late-onset granulomatous reaction to Artecoll. Dermatol Surg 2003; 29: 859–62. 169. Kim KJ, Lee HW, Lee MW, et al. Artecoll granuloma: a rare adverse reaction induced by microimplant in the treatment of neck wrinkles. Dermatol Surg 2004; 30: 545–7.

13 Postliposuction defects Misbah H. Khan, Theodore Diktaban, and Neil S. Sadick

INTRODUCTION

Adipose tissue is deposited in human subcutaneous tissue as an energy reservoir and serves to provide the body with temperature and vibratory insulation. It is deposited and reabsorbed as part of normal homeostasis and its sites of deposition are in large part genetically predetermined. Two body shapes are known to exist: gynecoid, seen more commonly in females, and android generally seen in males. There are certainly exceptions to both, as well as substantial crossover in fat distribution patterns between men and women. However, an individual may be near his or her ideal body weight, yet have disproportionate, localized adipose deposition. It is for such a patient that liposuction is an ideal procedure. Liposuction is an aesthetic removal of undesirable localized collections of subcutaneous adipose tissues (1). Liposuction is the most common advanced cosmetic procedure in the world. Dermatologic surgeons have played a major role in advancing its safety and reducing the complications associated with this surgery overall. Long-term experience has shown that complications are very low with tumescent liposuction performed only with local anesthesia or with added intravenous or general anesthesia. Nevertheless, complications do occur. Most postoperative complications associated with tumescent liposuction are minor and resolve on their own. These include bruising, swelling, soreness, inflamed incision sites, and fatigue. Rather serious complications such as large seromas, skin necrosis, infection, and even death have been reported from general anesthesia (2). This chapter will focus on treatment of surface irregularities that can be seen after tumescent liposuction and how certain fillers can be utilized to correct these. The goal of liposuction is to improve the shape, proportion, and size of the body and to produce a smooth and pleasing appearance. The outcome of the surgery is influenced by many variables. These variables include the skin condition, age of the patient, extractability of fat, equipment used (e.g., traditional liposuction, ultrasound-assisted lipoplasty, and power-assisted device), infiltration of wetting solution, anesthetic technique, artistic planning, surgical execution, and postoperative care. The impact and interaction of these variables may result in a certain degree of unpredictability in the outcome of the operation (3). 167

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PREVENTION OF POSTLIPOSUCTION SURFACE IRREGULARITIES

In order to avoid or reduce these complications during liposuction, there are three phases that need to be considered: the preoperative, intraoperative, and postoperative periods. Preoperative Patient Evaluation

One can predict who will develop surface imperfections after liposuction. Patients seeking liposuction of rather larger body surface areas and with poor skin elasticity, aged older than 60 generally do not benefit to a great extent from this procedure. Preexisting scars, abdominal hernias, poor muscle tone, and significant muscle atrophy as seen on extremities, deep indentations, and the presence of coexisting cellulite predict poorer outcome (4). A detailed cardiovascular and pertinent medical history is also of paramount importance and should be obtained at length especially in patients greater than 60 years of age. Special attention should be directed at medications that the patient consumes, particularly nonprescription over-the-counter and holistic medications, as some of these medications can cause significant intraoperative and postoperative bleeding, which makes it very difficult for the surgeon to perform adequate liposuction. Patients who are at risk of getting postoperative surface irregularities should be warned ahead of time especially in areas of poor skin elasticity; they will be more accepting of the end result. Informed consent should be reviewed with emphasis that liposuction is, foremost, a body contouring procedure, with the goal to achieve better lines, both in and out of clothing. Intraoperative Considerations

A set of preoperative photographs should be taken from at least two different angles of the areas being treated. Marking of the areas being treated should be done with special attention to the areas with greater versus lesser protuberance. This is especially true for areas that have a higher incidence of surface irregularities such as posterolateral and medial thighs. Adequate tumescent anesthesia should be employed. For patients seeking correction for larger body surface areas, liposuction should be performed in more than one setting in order to avoid over and/or undercorrection of the treated site. The choice of liposuction equipment, traditional versus powered largely depends on the surgeon’s choice. However, the use of internal ultrasonic cannulas can lead to an increased incidence of seromas, skin necrosis, and necrotizing fasciitis (5). Choice of an appropriate cannula is very essential in achieving better cosmetic outcomes (Table 13.1). As a general rule, large-bore cannulas are mostly used for larger and deeper adiposities and if used for superficial liposuction for too long can cause significant adverse effects such as skin necrosis, track marks, skin dimpling and atrophy, and reticulated mottling. Cannulas with smaller diameter and fewer holes are preferred for rather superficial liposuction and for fine tuning (Fig. 13.1). Newer technologies such as the powered reciprocating instruments and laser-like devices seem to be associated with much lower rates of complications. It remains controversial whether they significantly improve the final aesthetic result. Postoperative Considerations

Compression garments worn after liposuction will enhance even skin contraction. Endermologie, external ultrasound, and/or lymphatic drainage massage may assist in rapid

POSTLIPOSUCTION DEFECTS

Table 13.1

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Commonly used Cannulas for Traditional Liposuction

Aggressive: large diameter numerous holes, holes at the tip of cannula Keel Cobra 3–3.7 mm Capistriano 10–12 gauge Mercedes 10–12 gauge Pinto 10–12 gauge Toledo 10–12 gauge Intermediate: medium diameter, distal holes oriented away from dermis Accelerator/Triport 3 mm 3-port radial or Standard 3 mm Pyramid 3 mm Klein (dual port) 12 gauge Capistriano 14 gauge Keel Cobra 2.5 mm Texas 2.5 mm Dual port Standard 2.5 mm Fourneir 2.5 mm Sattler 2 mm Least aggressive: small diameter, distal holes away from the dermis Capistriano 16 gauge Klein (dual port) 14–16 gauge Spatula 2–3 mm 1-Hole Standard 2 mm

Figure 13.1 Orientation and placement of liposuction cannula tunnels. Smaller cannula diameters are often used to remove superficial fat after deeper fat is suctioned with larger-diameter cannulas.

removal of swelling and fluid accumulation and enhance skin elasticity. Minor irregularities usually improve as the edema improves. Reassurance and reevaluation of the treated areas in three months is advised. Skin dimpling can be caused by damage to the reticular dermis, overzealous suctioning of the deep fat, or poor skin tone.

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ANALYSIS OF POSTLIPOSUCTION SURFACE IRREGULARITIES

Postprocedure surface irregularities can vary from relatively smaller areas of localized lipoatrophy to significant larger contour and bodyline asymmetry. It is important to have a close follow-up with the patient and to examine the treated areas three to six months postprocedure and compare the preoperative and postoperative pictures of the treated areas. Approximately 5% to 10% of the cases require touch-ups. The degree and extent of the surface contour change must be discussed with the patient in-depth. The location of surface irregularities is also important as a small area of surface dimpling on the anterior neck might be more noticeable and concerning to the patient as opposed to the dimpling on lower abdomen or thighs. Postoperative surface irregularities can be largely subdivided into the following categories: (i) isolated smaller areas with approximately 1 to 2 mL of volume loss; (ii) single cosmetic unit with multiple smaller areas of surface irregularities such as neck; (iii) larger cosmetic units with areas of dimpling and/or track marks, or lumpiness such as lower or upper abdomen; larger cosmetic units with well-defined contour irregularities as seen on posterolateral thighs. Of note is the fact that most of these aforementioned surface irregularities can coexist in the same patient and at times within the same cosmetic unit. Although there is a significant degree of overlap in the presentation of these post-procedure complications, management of each of these complications will be discussed separately in this chapter. CORRECTION OF POSTLIPOSUCTION DEFECTS WITH FILLERS Isolated Well-defined Smaller Areas

Isolated and rather smaller postliposuction defects with well-defined borders can be corrected with temporary or semipermanent injectable fillers. Dermal fillers are increasingly being used for multiple cosmetic dermatologic indications (6). The rapid worldwide expansion of injectable filling materials for facial rejuvenation has given rise to long-lasting and permanent fillers. Two principal and different gel fillers are used today. The most common type is a homogenous polymer, called a volumizer, because of its filling effects, such as hyaluronic acid gel (Juvederm, Allergan Inc., Irvine, CA, U.S.) (7). The other gel type is a combination of microparticles dissolved in a transient degradable polymer gel, also called a stimulator as the filling effect partly or completely relies on the host foreign body response to the microparticles. Belonging to this group are poly-L-lactic acid (PLLA) microparticles suspended in sodium carboxymethylcellulose, mannitol, and water (NewFill, Sculptra, Sanofi-Aventis, Paris, France) and calcium hydroxyapatite microspheres suspended in glycerin and carboxymethylcellulose (Radiesse, Bioform Medical Inc., San Mateo, CA, U.S.). Augmentation of the surface dimpling or depressions can be performed to enhance the entire volume loss and to achieve a rather smoother surface contour (8) (Fig. 13.2). The microparticles are slowly degraded and some disappear with time. Others are nondegradable. They stay in the tissue forever and contribute to the permanent filling effect (9). Although there is limited data available regarding the use of gel fillers for correction of postliposuction defects, the authors have used these fillers to correct smaller well-defined depressions. The advantage to the use of fillers is their safety profile and minimal down time. Long-term efficacy of the fillers remains to be investigated.

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(A)

(B)

Figure 13.2 Localized, well-defined 2.5 × 3 cm sized defect on the lateral knee seen before (A) and three weeks after (B) 1.5 mL of hyaluronic acid gel filler injection with significant improvement in surface contour.

Single Cosmetic Unit with Multiple Surface Irregularities

Multiple surface irregularities in a single cosmetic unit are commonly seen after liposuction especially in areas with rather superficial distribution of fat such as neck, or after aggressive superficial liposuction on rounder surface areas such as lower abdomen and buttocks. Minor contour irregularities can be treated by limited additional liposuction, often performed in the office under local anesthesia. Other invasive treatment modalities include laser-assisted lipolysis (10) that has been successfully employed for corrections of localized adiposities. Fillers have recently gained popularity as one of the minimally invasive procedures that can be used to correct postliposuction surface irregularities. Fillers commonly employed for this purpose include longer-lasting fillers such as PLLA. PLLA is a biodegradable, nontoxic, synthetic, inactive material derived from corn starch. It has been used in suture material, stents, and other biomedical implants (11). The Food and Drug Administration (FDA) approved Sculptra (Sanofi-Aventis, Bridgewater, NJ, U.S.) in 2004 for Human Immunodeficiency Virus (HIV)-related lipoatrophy. PLLA is metabolized to carbon dioxide and glucose after injection. Growth of type I collagen into the areas of accumulated PLLA microspheres causes soft tissue augmentation. The clinical effects can be seen for up to two years (12). Although there is limited experience of treating postliposuction defects with semipermanent fillers such as PLLA, the authors would like to present the case of a 43-year-old female who underwent liposuction of buttocks and love handles. The patient developed significantly noticeable dimpling and contour irregularities of the medial buttocks, which were unresponsive to several noninvasive treatments with SmoothShapes device. The patient was subsequently treated with three sessions of PLLA over a period of five months resulting in a substantial improvement (Fig. 13.3). The longevity of the effects as seen in our patient can be attributed to the host foreign-body response that ends up as a permanent de novo fibrous scar tissue, which might contribute to a rather smooth contour of the surface irregularity. It is postulated that some microparticles slowly degrade over years by disintegration. Since PLLA particles continuously evoke a foreign-body response,

172

(A)

ILLUSTRATED MANUAL OF INJECTABLE FILLERS

(B)

Figure 13.3 Multiple surface irregularities on a single cosmetic unit (buttock) as seen before (A) and after three serial injections of PLLA over five months (B).

they also carry a higher risk of granuloma formation (13). Although this adverse effect was not seen in our patient, long-term follow-up is necessary in order to better identify and manage the formation of granulomas. Larger Cosmetic Units with Well-defined Contour Irregularities

The central premise in treating challenging areas such as lateral and medial thighs and lower abdomen is conservative fat removal. If the surgeon undertreats slightly, then it is possible to go back for a touch-up procedure and remove additional fat to enhance the results. If the surgeon overtreats, then there is a need to either replace fat with fat transplantation, or elevate the skin and improve contours with alternate methods. Clearly, the method of removing more fat is preferable if a touch-up is to be performed. This point cannot be emphasized enough. If the area of concern is largely volume deficient fat transplantation or filler injections are good options. Fat transplantation is the gold standard for these conditions. Fat offers several advantages with minimal complications. First of all, it is nonantigenic, does not require pretesting, readily available, and provides secondary gain to the patient by contouring a protuberant or fuller donor site. The technique, however, is tedious and rather technically challenging. Various steps are involved in the process of fat harvesting and injection.

POSTLIPOSUCTION DEFECTS

173

Donor Site and Fat Preparation

The patient must be assessed for suitable donor sites. Visual inspection is usually sufficient in choosing areas for fat harvesting. The potential donor site should also be palpated to determine the amount of fat that can be obtained. There is not one particular donor site associated with greater cell viability for transfer. The area(s) is marked out and anesthetized. Different types of fat harvesting cannulas are chosen and connected to a hand syringe. Klein and Coleman cannulas are quite popular for this purpose. Cannula size may vary from 14 to 18 gauge or 2 to 3 mm. The authors utilize a 12-gauge Klein cannula to harvest and implant the fat from a 10-mL syringe. It is important to realize that fat will be less likely to maintain permanence in areas of high mobility, such as lateral thighs. Also, some fat is likely to be absorbed during the healing phase, so it is advisable to harvest more fat than is needed and freeze some in the event a fat transplantation touch-up is indicated (3,14). The syringe instrumentation is used most commonly because the negative pressure created is less traumatizing to the fat than using standard liposuction aspirators. Once the fat is harvested then there is one of three ways in which to handle it prior to injection. Some physicians will prepare the fat with serial saline rinses. Others will centrifuge it at 3000 rpm in order to separate the aspirate into three layers. The superficial oily and the deepest saline/bloody layers are discarded. This leaves the remaining middle fatty layer for grafting. Recipient Site Preparation

The recipient site needs to be assessed in terms of the site’s condition. Assessment of the volume that needs to be replaced is essential when performing fat transplantation. Some patients have limited loss of 10 to 20 mL. Others might have a significant volume loss in the order of 100 mL. They cannot be corrected in one session unless they are willing to endure weeks to months of edema and downtime. In general, the degree of edema is proportional to the volume injected. If one injects more than 40 mL the swelling can persist for two weeks or even longer. The volume restoration should preferably be performed in multiple sessions (15,16). The amount of soft tissue adherence to the deeper fascial layers will determine whether or not a release of this adherence is necessary to create space for the fat grafts. A V-shaped notch at the tip of a cannula can be used for release over a broad arc. For smaller areas that require a release, a Nokor needle works quite well. Small amounts of local anesthesia are used so as to not distort the recipient site. Various blunt tip infiltration cannulas are used to inject the fat. Cannula diameters (14–18 gauge), lengths and curves will be determined by the bodily site, the volume needed, and surgeon preference. The fat is injected as the cannula is withdrawn. Fat is placed in different planes with multiple threading passes. Crisscrossing the fat placement will lend itself to a smoother meshed effect. The endpoint varies from full correction to overcorrection depending on the amount of scarring and the anatomical area. Fat grafting should be performed using sterile technique in order to avoid infections and other related complications. Postprocedure care although very simple is essential for survival of the transferred fat. Compression and relative immobilization of the treated area to prevent fat displacement and to decrease edema can be helpful tips. Additionally, patients are often placed in fitted elastic garments that will be worn for two to four weeks. Antibiotics and analgesics can be prescribed as needed or indicated.

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ILLUSTRATED MANUAL OF INJECTABLE FILLERS

There are several reasons touch-up procedures should be performed. With the use of smaller volumes for fat grafting versus overcorrection, one treatment session may not be adequate to achieve optimal aesthetic outcome. Adequately placed fat can provide a smooth contour for up to six months. Fat transplantation can be combined with touch-up liposuction for better cosmesis (Fig. 13.4). Postliposuction defects can also be corrected by a combination of fat transfer and other treatment modalities such as mesotherapy (Fig. 13.5). An alternative or complimentary solution to fat transplantation is subdermal undermining. This is done with the 12-gauge Klein cannula and can be performed alone or in combination with fat transplantation. The cannula is inserted in a piston-like motion similar to liposuction and is directed to bound-down or fibrous areas that are in need for elevation. Release of the tissue improves the surface contours. The body’s natural response to injury will likely produce a fibrous reaction, which develops into a form of soft tissue augmentation.

(A)

(B)

Figure 13.4 Postliposuction defects seen on lower abdomen before (A) and after 10 mL of fat transfer resulting in significant improvement in surface contour (B) four months after the procedure.

(A)

(B)

Figure 13.5 Postliposuction defect on posterolateral thigh with significant localized dimpling seen before (A) and after two sessions of fat transfer with a total of 30 mL of fat injected into the area followed by mesotherapy treatments (B).

POSTLIPOSUCTION DEFECTS

175

CONCLUSIONS

Liposuction is a challenging surgical procedure that can produce superb aesthetic results when performed properly. Careful suctioning, use of smart hand, triangulation, and fluid management are all important parts of liposuction procedure. Due to ever increasing demand and popularity of liposuction procedures being performed every day, the need to correct some of the undesirable outcomes such as surface irregularities is also increasing. Fillers have revolutionized how volume and body contour is restored or corrected and have certainly found its place in the correction of postliposuction defects. It is a safe, minimally invasive, well-studied aesthetic procedure with rather predictable outcomes. Although not much is published regarding their use in postliposuction surface irregularities, they can be safely used with essentially no downtime. Another exciting development relates to stem cell research. Subcutaneous fat may be the most ideal source for adult stem cells. It is simple, safe, inexpensive to procure, and is present in abundant quantities (17–19). Laser assisted lipoplasty can also be used to correct postprocedure contour irregularities (20). Although there are several ways to correct postliposuction surface defects, it is beyond the scope of this chapter to discuss all of them. Instead the use of fillers and other minimally invasive techniques have been presented in detail. The authors hope that the reader will benefit from their personal experiences, as presented in this chapter and they would like to thank Dr. Karchar for sharing her experience of using fillers to treat postprocedure complications. REFERENCES 1. Coldiron B, Coleman III WP, Cox SE, et al. ASDS Guidelines of care for tumescent liposuction. Dermatol Surg 2006; 32: 709–16. 2. Beeson WH, Slama TG, Beeler RT, et al. Group A Streptoccal fasciitis after submental tumescent liposuction. Archives of Facial Plast Surg 2001; 3: 277–9. 3. Chang KN. Long-term results of surgical correction of postliposuction contour irregularities. Plast Recon Surg 2002; 109(6): 2141–5. 4. Lanzer D. Safety of large volume liposuction. Int J Cos Surg Aesth Dermatol 2002; 4: 173–7. 5. Igra H, Lanzer D. Avoiding complications. In: Hanke W, Sattler G, eds Liposuction. Elsevier Saunders, 2005: 131–40. 6. Cox SE. Clinical experience with filler complications. Dermatol Surg 2009; 35: 1661–6. 7. Taylor SC, Burgess CM, Callender VD. Safety of nonanimal stabilized hyaluronic acid dermal fillers in patients with skin of color: a randomized, evaluator-blinded comparative trial. Dermatol Surg 2009; 35: 1653–60. 8. Distante F, Pagani V, Bonfigli A. Stabilized hyaluronic acid of non-animal origin for rejuvenating the skin of the upper arm. Dermatol Surg 2009; 35: 389–94. 9. Christensen LH. Host tissue interaction, fate and risks of degradable and nondegradable gel fillers. Dermatol Surg 2009; 35: 1612–19. 10. Goldman A, Gotkin RH. Laser assisted liposuction. Clin Plast Surg 2009; 36(2): 241–53. 11. Rohrich JR, Nguyen TA, Kenkel JM. Lexicon for soft tissue implants. Derm Surg 2009; 35: 1605–11. 12. Broder KW, Cohen SR. An overview of permanent and semipermanent fillers. Plast Reconstr Surg 2006; 118: 7S–14S. 13. Valantin MA, Auborn-Olivier C, Ghosn J, et al. Ploy-L-lactic acid implants to correct facial lipoatrophy in HIV infected patients: results of an open label study VEGA, AIDS 2003; 17: 2471–7.

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14. Pereira LH, Sterodimas A. Correction of iatrogenic form of banana fold and sensuous triangle deformity. Aesth Plast Surg 2008; 32: 923–7. 15. Fulton JE, Suarez M, Silverton K et al. Small volume fat transfer. Dermatol Surg 1998; 24: 857–65. 16. Markey AC, Glogau RG. Autologous fat grafting: comparison of techniques. Dermatol Surg 2000; 26: 1135–44. 17. Fodor P, Fraser JK, Hedrick MH. Banking on stem cells. Plast Surg Prod 2002: 16–17. 18. Fodor PB. Initial clinical experience with fat recycling: stem cells and autologous matrix. Presented at the American Society for Aesthetic Plastic Surgery 35th Anniversary Meeting, Las Vegas, NV. May 2002. 19. Fodor PB. Reflections on lipoplasty: history and personal experience. Aesth Surg J 2009; 29(3): 226–31. 20. DiBernardo BE, Reyes J. Evaluation of skin tightening after laser-assisted liposuction. Aesth Surg J 2009; 29(5): 400–7.

Appendix of product names

I HYALURONIC ACID PREPARATIONS

Note: the following list is included as a helpful ready reference. It is not intended to be complete in all aspects; in particular, practitioners should check independently the current status of any product they plan to use and the exact indication that has been FDA-approved. Products should not be assumed to be FDA-approved unless this is specifically noted.

Product name AcHyal® Alayna Hydro Alayna Light Alayna Regular Alayna Repair Alayna Lip Volume Amalian Balance Amalian I Amalian II Amalian III Amalian Lips Beauty Gel (Estherase/ Coilingel) Beauty Sphere (Lastingel) Belotero Basic® Belotero Soft® Belotero Intense® Captique CRM® Soft CRM® Dur CRM® Gel CRM® Dex CRM® DX Cristal 1 Cristal 2 Cristal Soft

Manufacturer

Status CE marked

Beauty Science Center

SBV Technologies

CE marked

Rofil

Merz

CE marked/FDA pending

Inamed/Genzyme BioPolymer GmbH

FDA approved

Parpas Group

(Continued)

177

178

APPENDIX

(Continued) Product name Cristal Lips Cytocare 532 Cytocare 516 Cytocare 502 Emervel® Touch Emervel® Classic Emervel® Lips Emervel® Deep Emervel® Volume Esthélis Fortélis Extra Glytone Hyacell® Hyacorp® Hyacorp® H Hyacorp® L Hyacorp® S Face Hyacorp® S Lips Hyal 2000 Injection Hyal-System® HyalACP Hyaluderm® Hyaluderm Revitalize Hyaluronica® Soft Hyaluronica® Style Hyaluronica® Ultra Hydrafill Grade 1® Hydrafill Grade 2® Hydrafill Grade 3® Hydrafill Softline® Hydrafill Softline Max® Hylaform Fine Lines® Hylaform® Hylaform Plus® ISOGel 1 ISOGel 2 ISOGel 3 Juvederm® 18 Juvederm® 24 Juvederm® 30 Juvederm® 24 HV Juvederm® 30 HV Juvederm® Ultra Juvederm® Ultra 2 Juvederm® Ultra 3 Juvederm® Ultra Plus Juvederm® Ultra Smile Juvederm® Voluma Juvederm® Hydrate

Manufacturer

Status

Revitacare

CE marked

Galderma

CE marked

Anteis S.A. Anteis S.A. Pierre Fabre KuhraVital BioPolymer GmbH

CE marked/FDA pending

CE marked

Merz LCA Pharmaceutical LCA Pharmaceutical Vital Esthetique

CE marked CE marked CE marked

Allergan

CE marked CE marked CE marked CE marked CE marked

Inamed FDA approved FDA approved Euromedical Systems

Allergan

CE marked

FDA approved

FDA approved

(Continued)

179

APPENDIX

(Continued) Product name Juvélift Corneal® Juveni HA Volumizer Juveni Mesolift Juveni HA Volumizer + Lidocaine 2% mixing M-HA 18 MacDermol S® MacDermol R® MacDermol Bio® Macrolane® Matridur® Matridex® NCTF 135 NCTF 135HA® Pluryal® Prevelle Silk Prevelle Plus Perlane Lidocaine Princess® Rich Princess® Filler Princess® Volume Puragen Puragen Plus Radiesse Restylane Perlane® Restylane Lidocaine Restylane® Restylane SubQ® Restylane Touch® Restylane Vital® Restylane Lipp® Revanesse® Revanesse® Pure Revanesse® Ultra ReDexis® ReDexis Ultra Reviderm® Intra Reviderm® Fine Reviderm® Forte Rofilan® Forte Rofilan® Touch Rofilan® Lips Rofilan® Basic SkinFill Silver SkinFill Gold SkinFill Diamond

Manufacturer

Status

Sanofi Feratti Global Brands

Filorga ORGéV

CE marked CE marked

Q-Med BioPolymer GmbH

FDA approved CE marked

Filorga

Mentor/Genzyme

FDA approved

Q-Med Croma-Pharma GmbH

FDA approved CE marked

Mentor/Genzyme

CE marked/FDA pending CE marked/FDA pending FDA approved Worldwide except Japan, United States

BioForm Medical Medicis/Q-Med

Worldwide except Japan Worldwide except Japan

Prollenium

Prollenium Medical Technologies Inc.

CE approved CE marked/Health Canada

CE marked

Rofil

Philoderm Aesthetics

CE approved in Europe, elsewhere

Pharma Marketing & Services

Not FDA approved

(Continued)

180

APPENDIX

(Continued) Product name Succeev® One Succeev® Two Succeev® Three Surgiderm® 18 Surgiderm® 30 Surgiderm® 24XP Surgiderm® 30XP Surgilips® Surgilift® Plus Stylage® S Stylage® M Stylage® L Stylage® XL Stylage® Hydro Teosyal Global action® Teosyal Deep Lines Teosyal Ultra Deep Teosyal Kiss Varioderm Varioderm Plus Varioderm Subdermal Varioderm FineLine Visagel® Viscontour® Voluma Corneal® X-HA X-HA Volume Zetavisc L® Zetaderm ZFill refresh ZFill Deep ZFill Repair

Manufacturer

Status CE marked

Allergan

CE marked

Corneal Group/Allergan Energy Control

Not FDA approved; CE marked CE marked/Not FDA approved

Teoxane

CE marked/FDA pending

Adoderm/Pacific Trading

Marketed in Europe, elsewhere

Surgical-Concepts GmbH Q-Med Corneal Group/Allergan

CE marked

Filorga

Not in United States, Asia Pacific, Canada; CE marked CE marked

Rofil Medical/Philoderm Aesthetics

CE approved in Canada, elsewhere

Zimmer Aesthetic Division

CE marked

181

APPENDIX

II

COLLAGEN PREPARATIONS

Note: the following list is included as a helpful ready reference. It is not intended to be complete in all aspects; in particular, practitioners should check independently the current status of any product they plan to use and the exact indication that has been FDA-approved. Products should not be assumed to be FDA-approved unless this is specifically noted.

Product Name

Manufacturer

AlloDerm® Autologen® (processed from own skin)

LifeCell Corporation Collagenesis

CosmoDerm 1, 2® CosmoPlast® Cosmeta Life® Cosmeta Corp Cymetra® Dermalogen® Human Tissue Matrix Endoplast® Evolence® Evolence® Breeze Fascian®

Inamed

Fibroquel Fibrel® Isolagen Koken® Atelocollagen Implant Permacol

Aspid S.A.

Resoplast® Zyderm I® Zyderm II® Zyplast®

Rofil Inamed

Status

Gel-Del® Technologies

FDA approved? FDA-classified as tissue product without limitation on use? FDA approved FDA approved Not yet FDA approved

LifeCell Corporation Collagenesis

FDA approved? Withdrawn?

Filorga Johnson & Johnson

Not FDA approved Withdrawn? CE marked FDA-classified as tissue product without limitation on use? Not FDA approved

Isolagen Inc. Koken Co. Covidien A.G.

Not yet FDA approved? Not yet FDA approved FDA-classified as tissue product without limitation on use? FDA approved CE marked

182

III

APPENDIX

RESORBABLE SYNTHETIC FILLERS

Note: the following list is included as a helpful ready reference. It is not intended to be complete in all aspects; in particular, practitioners should check independently the current status of any product they plan to use and the exact indication that has been FDA-approved. Products should not be assumed to be FDA-approved unless this is specifically noted.

Product name

Manufacturer

Status

Atléan®βTCP (tricalcium phosphate suspended in HA) Bioinblue “deep blue” (polyvinyl alcohol) Bioinblue “lips” (polyvinyl alcohol) Evolution® Hyaldex® Laresse (carboxymethylcellulose + polyethylene) Novabel® (alginate) Profill® Radiesse (calcium hydroxylapatite) Sculptra® (poly-L-lactic acid)

Stiefel

CE marked

Polymekon

CE marked

PolyCytech

CE marked CE marked

FzioMed Inc. Merz Aesthetics

CE marked

Merz Aesthetics Sanofi-Aventis

FDA approved, CE marked FDA approved, CE marked

183

APPENDIX

IV

PERMANENT FILLERS

Note: the following list is included as a helpful ready reference. It is not intended to be complete in all aspects; in particular, practitioners should check independently the current status of any product they plan to use and the exact indication that has been FDA-approved. Products should not be assumed to be FDA-approved unless this is specifically noted. Product name

Manufacturer

AdatoSil-OL 5000 (PDMS)

Bausch & Lomb

Amazing Gel (PAAG)

FuHua High Molecular Matter Company Ltd, China Bioform Medical, Russia Ferrosan SA, Denmark Artes Medical, USA Rofil, The Netherlands Suneva Medical Inc. Canderm Pharma Inc. Polymekon, Italy Biocell Ultravital, Switzerland Polymekon, Italy Uroplasty BV, Netherlands

Argiform® (PAAG) Aquamid (PAAG) ArteFill (PMMA + collagen) Artecoll® (PMMA + collagen) Arteplast® (PMMA + collagen) ArteSense (PMMA + collagen) Bio-Alcamid (polyalkylimide) Biopolymere (PDMS) Bioformacryl® (polyacrylamide) Bioplastique (methylpolysiloxane + polyvinylpyrrolidone) Dermabiol® (PMMA + collagen) Derma Collagen DermaLive® (HEMA + EMA + HA) DermaDeep® (HEMA + EMA + HA) Dermagen (PDMS) Evolution (polyvinyl + polyacrylamide) Formacryl (polyacrylamide) Kopolymer 4E (polioxyethlene + elastin copolymer) Juveni PMMA DX (PMMA + HA) Juveni PMMA Confort (w/Lidocaine) Medical grade polydimethylsiloxane oil MetaCrill (PMMA + carboxygluconatehydrolactic of magnesium) Metrex® (acrylate and methacrylate + polyethylenglycol) Outline® Fine, Original, Ultra(PAAG) Procell (elastine, polyoxyethylene, HA + methacrylate) PMS 350® Rhegecoll® (methacrylate + copolymer 4-G + collagen + 5% stemcells) Silicex 350 Silikon 1000 (PDMS)

Dermabiol Institute of Kuhra Vital GmbH, Switzerland GeriGene Med. Corp., USA Dermatech, France Radiant Skin Sciences, USA ProCytech, France

Status FDA approved (retinal uses only)

CE marked FDA approved CE marked Discontinued?

CE marked

CE marked CE marked CE marked

Bioform, Russia Dermabiol Institute of Kuhra Vital GmbH, Switzerland Feratti Global Brands

Dermabiol Institute of Kuhra Vital GmbH, Switzerland ProCytech, France Dermabiol Institute of Kuhra Vital GmbH, Switzerland Vikomed, Germany Dermabiol Institute of Kuhra Vital GmbH, Switzerland Alcon Laboratories Inc.

CE marked

CE marked

Index

Active fillers, 23 Adatosil 5000, 30 Adipose tissue, 167 in lower face and neck, 87 midface, 55 Aging, 40 extrinsic, 122 intrinsic, 122 lips, 107 lower face, 83 neck, 83 of upper face, 44 Albeit, 126 Allergy testing of skin, 7 Alloplastic implants, 59 chin augmentation, 100 The American College of Chest Physicians (ACCP), 143 The American Society for Aesthetic Plastic Surgery (ASAPS), 139 Aquamid®, 18 Artecoll®, 18 ArteFill, 8, 18 in dermal fillers, 5 in permanent fillers, 4 in synthetic active fillers, 29–30 Arterial occlusion, 154 Autologous fat, 2, 17 Autologous fat transfer technique, 7 hand rejuvenation grafting, 125–126 harvesting, 124–125 lower facial rejuvenation, 103 midfacial rejuvenation, 78 in temporal area treatment, 47 Beauty Sphere®, 17 Belotero®, 16 Biodegradable active filler, 28–29

Biodegradable passive fillers calcium hydroxylapatite, 27–28 collagen, 24–25 hyaluronic acid, 25–27 Bovine collagen, 3, 7, 127 Brow area in upper facial volumetric rejuvenation, 48 volume loss, 45 Bruising, 114–118 Buccinator muscle, 85 Calcium hydroxylapatite (CaH), 4, 8 biodegradable passive fillers, 27–28 cosmetic procedures late postprocedure, 158 during treatment, 150 rejuvenation of hands, 128–130 in temporal area treatment, 47 Cheek augmentation, midfacial rejuvenation, 67–72, 81 Chin augmentation, lower facial rejuvenation, 100–101 Cleft chin, 84 Cohesive polydensified matrix (CPM®), 15–16 Collagens, 3 biodegradable passive fillers, 24–25 product names, 181 rejuvenation of hands, 127 Corrugator, 41 Cosmetic procedures early postprocedures allergic reactions, 154 hypersensitivity reactions, 154 skin necrosis, 154–155 initial treatment local common reactions, 142–144 patient selection and expectations, 140

185

186

Cosmetic procedures (Continued) prevention of infection, 144–146 skin testing, 140–142 late postprocedure calcium hydroxylapatite, 158 granulomatous reactions, 155 HA fillers, 155–156 poly-L-lactic acid, 157–158 polymethylmethacrylate, 159 during treatment calcium hydroxylapatite, 150 high risk areas, 152–153 hyaluronic acid, 148–150 injection patterns and techniques, 151–152 patient expectations, 152 polymethylmethacrylate, 150–151 product placement, 147–148 skin of color, 154 superficial filler placement, 148 CosmoDerm, 5, 7, 25 CosmoPlast, 5, 7, 25 CPM®. See Cohesive polydensified matrix Crow’s feet, 52 Depot injection technique, 10 in temporal area treatment, 45, 47 Depressor anguli oris (DAO), 85 muscles, 100 Depressor labii inferioris, 85 Dermadeep®, 19 Dermal fibroblasts, 25 Dermal fillers, 78 jawline rejuvenation, 93 uses of, 5 Dermalive®, 19 Dermal placement fillers, 24 Dethail Lastingel®, 17 Digastric muscle, 87 Duck lips, 109 Ecchymosis, 77 Edema, 46 Esthélis®, 16 Evolence, 8, 25 Extrinsic aging, 122 Eyebrow aesthetics, 40 depressor, 41 Eyelids, 36 Face, upper third bony anatomy, 40–43 fat pads, 42–43 innervations, 42

INDEX

ligaments, 42–43 muscle function of, 41–42 Facial aging process, 1 Facial expression muscles, 39 Facial nerve branches of, 38 midface, 54–55 Fanning injection technique, 10 Fat pads midface, 55–56 postseptal, 43 preseptal, 42–43 Fat transplantation, 172 Feminine eyebrow, 40 Fillers active, 23 dermal, 78 factors for, 33–34 longevity, 152 passive, 23 permanent, 4–5 resorbable, 23 selection of, 35 semipermanent, 3 soft tissue, 123 Fishbone technique, 82 Food and Drug Administration (FDA), 3, 7, 12, 23, 59, 127, 141, 171 Forehead, 36 depressor muscles, 40 rhytids, 40 Fournier’s technique, 124, 136 Frontal bone, 40–41 Frontalis muscle, 41 Glabella definition, 45 injection necrosis, 154–155 longer-lasting fillers, 50 in upper facial rejuvenation treatment, 48–49 Glycerol, 17 Hairline, anterior, 40 Hands rejuvenation autologous fat transfer grafting, 125–126 harvesting, 124–125 injectable fillers calcium hydroxylapatite, 128–130 collagen, 127 hyaluronic acid, 127–128 poly-L-lactic acid, 130 PLLA injection bolus technique, 131–132

187

INDEX

clinical data, 133–134 linear treading technique, 131 reconstitution, 131 Homogenous orbital matrix (HOM™), 19 Human-derived collagen fillers, 24–25 Hyaluronans, fourth generation, 16 Hyaluronic acid (HA) fillers, 3–4, 8, 112, 113 biodegradable passive fillers, 25–27 chin projection, 101 cosmetic procedures late postprocedure, 155–156 during treatment, 148–150 development of, 16 glabella treatment, 48–49 inferior orbital rim, 62, 66 jawline rejuvenation, 93 labiomental sulcus, 102 lip augmentation products, 15 for lips, 112–114 lower lip vertical rhytids, 102 preparation properties, 15 product names, 177–180 products on market, 13–14 rejuvenation of hands, 127–128 Hyaluronidase, 116 Hypertrophic scarring, 151 Ideal filler, 2 definition, 22 patient selection, 22–23 Inferior orbital rim HA fillers, 62, 66 midfacial volumetric rejuvenation, 61–67 serial puncture technique, 65–66 Injection techniques depot, 10 fanning, 10 linear threading, 10 serial puncture, 9 Intrinsic aging, 122 Isolagen, 25 Jawline rejuvenation, 91–97 Juvederm, 26, 62 Juvederm Ultra, 26 Juvederm Ultra Plus, 26 Labiomandibular folds (LMF), lower facial rejuvenation, 97–100 Labiomental sulcus, lower facial rejuvenation, 102 Laser assisted lipoplasty, 175 Lateral orbital thickening (LOT), 56 Levator labii superioris alaeque nasi, 54

Ligaments in lower face and neck, 87–88 midface, 55–56 Linear threading injection technique, 10 Lip augmentation aging, 107 complications, 114–118 injection materials, 112–114 injection methods, 107–112 products for, 15 Liposuction complications intraoperative considerations, 168 postoperative considerations, 168–169 preoperative patient evaluation, 168 defects with fillers donor site, 173 fat preparation, 173 isolated well-defined areas, 170–171 multiple surface irregularities, 171–172 recipient site preparation, 173–174 well-defined contour irregularities, 172 definition, 167 goal of, 167 postoperative surface irregularities, 170 traditional, 169 Lipstick lines, 112 Liquid silicone, 7 LMF. See Labiomandibular folds Long-term fillers calcium hydroxylapatite, 4 poly-L-lactic acid, 4 LOT. See Lateral orbital thickening Lower face adipose tissue, 87 definition, 83 innervation of muscles, 86–87 ligaments, 87–88 musculature of, 84–86 superficial musculoaponeurotic system, 87 Lower facial rejuvenation autologous fat transfer, 103 chin, 100–101 complications management, 102–103 jawline rejuvenation, 91–97 labiomandibular folds, 97–100 labiomental sulcus, 102 lower lip vertical rhytids, 102 postinjection care, 102–103 Lower lip vertical rhytids, 102

188

Macrolane (Q-MED), 16–17 Malar implants, 59 Malar mounds, 68–70 Male eyebrow, 40 Mandibular ligament, jawline rejuvenation, 92–93 Mandibular retaining ligament, 87–88 Marionette lines, 88. See also Labiomandibular folds (LMF) Masseter muscle, 85 Matridex®, 17 Medical grade silicone, 17, 30 Mentalis, 85 Microgenia, 100 Midface adipose tissue, 55 aging, 52, 60 facial nerve, 54–55 fat pads, 55–56 ligaments, 55–56 musculature, 53–54 skeletal foundation of, 52–53 superficial musculoaponeurotic system, 55–56 vascular anatomy, 37 youthful, 59–60 Midfacial volumetric rejuvenation alloplastic implants, 59 autologous fat transfer, 78 buccal region, 72–74 cheek, 67–72 goal of, 69 infraorbital rim, 61–67 management complications, 76–78 nasolabial fold, 74–76 postinjection care, 76–78 Muscle fibers, 54 Nasolabial folds (NLFs) Artefill rejuvenation of, 29 midfacial volumetric rejuvenation, 74–76, 81–82 Radiesse, 76 Neck adipose tissue, 87 aging, 83 innervation of muscles, 86–87 ligaments, 87–88 musculature of, 84–86 superficial musculoaponeurotic system, 87 Nerve, orbital region, 38 NewFill®, 18

INDEX

Nonanimal-stabilized hyaluronic acid (NASHA) fillers, 62 Nonpermanent fillers, 3 Novabel®, 19 Orbicularis oculi, 53–54 Orbicularis oculi muscles, 41 Orbicularis oris, 85 Orbicularis retaining ligament (ORT), 56 Orbitomalar ligament, 56 Passive fillers, 23 Perioral rhytids, 85 Perlane, 26 Permanent fillers, 4–5, 23, 183 Pinch technique, 48 Pitanguy’s line, 42 PLA rejuvenation of hands bolus technique, 131–132 clinical data, 133–134 linear treading technique, 131 reconstitution, 131 Platysma, 85–86 PMS 350 (Vikomed), 17 Poly-L-lactic acid (PLLA), 4, 17 biodegradable active filler, 28–29 cosmetic procedures late postprocedure, 157–158 in multiple surface irregularities, 171 rejuvenation of hands, 130 Polymethylmethacrylate (PMMA), 18 cosmetic procedures late postprocedure, 159 during treatment, 150–151 synthetic active filler, 29–30 Porcine collagen, 25. See also Evolence Postinjection massage, 45, 47 Postseptal fat pad, 43 Preseptal fat pad, 42–43 Prevelle, 26–27 Procerus muscle, 41 Pseudoherniated lower lid fat, 62 Puppet lines, 110–111 Push ahead technique, 116 Radiesse™, 4, 18, 27–28 nasolabial fold, 76 Redexis®, 17 Resorbable fillers, 23 Resorbable synthetic fillers, 182 Restylane, 26 Retro-orbicularis oculi fat (ROOF) pad, 42

189

INDEX

Reviderm Intra®, 17 Risorius muscle, 54 Sausage lips, 109–110, 121 Sculptra, 8 biodegradable active filler, 28–29 in dermal fillers, 5 in long-term fillers, 4 Semipermanent fillers, 3. See also Calcium hydroxylapatite (CaH) Semipermanent soft-tissue volumizer, 123 Serial puncture injection technique, 9 inferior orbital rim, 65–66 labiomandibular fold, 98–99 Short-term fillers collagens, 3 hyaluronic acid, 3–4 Short-term volumizers. See Short-term fillers Silicone, synthetic active filler, 30 Silikon 1000, 30 Skin dimpling, 169 Skin necrosis, 154–155 Skin roughness, 122 Skin tenting technique, 129 Skin testing, 140–142 Smile lines, 52 Soft-tissue fillers, 123 Soft-tissue volume augmentation, 78 Structural fat grafting, 125 Subdermal placement fillers, 24 Suborbicularis oculi fat (SOOF) pad, 42 Superciliary arches, 41 Superficial filler placement, 148 Superficial injections, 47 Superficial musculoaponeurotic system (SMAS) in lower face, 87 midface, 55–56 in neck, 87

Superficial temporal artery, 152–153 Superficial temporal nerve, 153 Supraorbital nerve, 42 Supratrochlear artery, 152 Supratrochlear nerve, 42 Synthetic active filler polymethylmethacrylate, 29–30 silicone, 30 Traditional liposuction, 169 Trigeminal nerve, 42 Tubercles, 107 Type I aging hand, 122 Type II aging hand, 122 Type III aging hand, 123 Upper facial volumetric rejuvenation glabella treatment, 48–49 lateral brow area treatment, 48 temporal area treatment autologous fat transfer techniques, 47 depot injection technique, 45, 47 preinjection facial markings, 46 U.S. FDA-approved HA fillers, 3 Vascular occlusion, 154 Volumetric augmentation clinical evaluation, 9 injection techniques, 9–10 multispecialty based approach, 8 Volumetric facial rejuvenation, 2 Volumetric filling, 1 Youthful jawline, 92 Youthful midface, 59–60 Zygomaticus major muscle, 54 Zygomaticus minor muscle, 54 Zygomaticus muscles, 54