The Art and Science of Filler Injection (Based on Clinical Anatomy and the Pinch Technique) ||

This highly illustrated book describes how to perform dermal filler procedures in a way that simultaneously takes into account esthetic and safety aspects in order to achieve optimal outcomes in individual patients. After discussion of filler materials and design considerations, the relevant basic and clinical anatomy is described, drawing on cadaveric examinations and imaging in living subjects. Step-by-step instruction is then provided on how to identify a safe injection plane and on injection using the pinch technique. The coverage includes guidance on injection procedures specific to different sites. A thorough and systemic description of potential side effects of filler injection, and the management of complications is also presented. The Art and Science of Filler Injection equips the reader with a sound knowledge of all aspects relevant to the achievement of pleasing esthetic results without side effects and will be of value for practitioners at all levels of experience. Preface 5 Contents 7 About the Authors 10 1 The Art and Science of Filler Procedures for a More Attractive Face 14 1.1 Natural Beauty and Human Attractiveness 14 1.2 Differences Between Asian and Western Beauty Concepts 18 1.3 Medical Reference Values to Create an Attractive Face 21 Bibliography 26 2 Filler Types and Characteristics 28 2.1 Type of Filler 28 2.1.1 Number of Various Fillers Used Recently 28 2.2 Characteristics of Hyaluronic Acid Filler 29 2.2.1 Hyaluronic Acid as a High Molecular Compound 29 2.2.2 Hyaluronic Acid Filler Manufacturing Process 29 2.2.2.1 Preparation of Raw Materials of Hyaluronic Acid 29 2.2.2.2 Dissolution with Strong Base (NaOH) 29 2.2.2.3 Cross-Linking Process 29 2.2.2.4 Dialysis or Washing 30 2.2.2.5 Cutting 32 2.2.2.6 Filling 33 2.2.2.7 Sterilization Process 33 2.2.3 Rheology of Hyaluronic Acid Filler 33 2.2.4 Selection of Hyaluronic Acid Filler 38 2.3 Calcium Filler 45 2.4 Polycaprolactone Filler 47 2.5 Filler Selection 49 Bibliography 49 3 Anatomical Considerations for Filler Procedures 51 3.1 Vessels and Nerves 51 3.2 Fat Compartments and Muscles 54 3.3 Retaining Ligaments 56 3.4 Layer and Space 59 3.5 Identification of SubSMAS Space for Filler Injection: Cadaver Study Using Stained Gelatin 60 3.6 SSRT (Skin and SMAS Layer Remodeling Technique) for Volumization and Lifting Effect 74 Bibliography 80 4 Basic Technique for Filler Procedure 83 4.1 Design (Method) 83 4.1.1 Frontal View-Horizontal/ Vertical Ratio of the Face 83 4.1.2 Frontal View—Heart-Shaped Midface 84 4.1.3 Oblique View—S-Line/Inverted S-Line/Ogee Curve 86 4.1.4 Lateral View-Ricketts Line 86 4.1.5 Design for Safe Filler Injection—Mark of Dangerous Area 87 4.1.5.1 Design Examples for Safe Procedures 87 4.2 Anesthesia—Nerve Block 88 4.2.1 Supratrochlear/Supraorbital Nerve 88 4.2.2 Zygomaticotemporal Nerve (Fig. 4.14) 89 4.2.3 Zygomaticofacial Nerve (Fig. 4.15) 90 4.2.4 External Nasal Branch of Anterior Ethmoidal Nerve (Fig. 4.16) 91 4.2.5 Infraorbital Nerve (Fig. 4.17) 91 4.2.6 Mental Nerve (Fig. 4.18) 91 4.2.7 Greater Auricular Nerve (Fig. 4.19) 91 4.3 Selection of Cannula or Needle 92 4.3.1 Cannula 92 4.3.2 Characteristics of Needles 93 4.4 Injection Technique 94 4.4.1 Types of Injection Techniques 96 4.4.1.1 Retrograde Injection and Anterograde Injection (Fig. 4.26) 96 4.4.1.2 Fanning (Fig. 4.27a) 96 4.4.1.3 Cross Hatching (Fig. 4.27b) 96 4.4.1.4 Bolus (Fig. 4.28) 96 4.4.1.5 Linear/Serial Threading (Fig. 4.29a, b) 98 4.4.1.6 Serial Puncture (Fig. 4.29c) 98 4.4.1.7 Micropuncture/Droplet (Fig. 4.29d) 98 4.4.1.8 Mantoux Test Injection Technique 98 4.4.1.9 Sandwich Technique 98 4.4.1.10 Tower Technique (Fig. 4.30) 98 4.4.1.11 DPS Technique: Deep Puncture and Separation (Fig. 4.31) 98 4.4.2 Injection Techniques for Each Area 98 4.5 Basic Techniques by Region 100 4.6 Filler Molding and Filler Degradation Test 106 4.6.1 Filler Molding 106 4.6.2 Filler Degradation Test 109 Bibliography 113 5 Filler Procedures Based on the Facial Area 114 5.1 Upper Face 114 5.1.1 Forehead and Glabella 114 5.1.2 Temple 117 5.2 Midface 122 5.2.1 Supraorbital Hollowness (Sunken Eyelid) and Flat Eyebrow 122 5.2.2 Pre-tarsal Roll (=Lower Eyelid Charming Roll, Pre-tarsal Fullness) 129 5.2.3 Infraorbital Groove and Hollowness 132 5.2.3.1 Definition and Classification of Terms 133 5.2.3.2 Tear Trough and Nasojugal Groove 136 5.2.3.3 Palpebromalar Groove and Orbital Retaining Ligament (ORL) 137 5.2.3.4 Midcheek Furrow (Groove) and Zygomatico-Cutaneous Ligament 138 5.2.3.5 Orbital Fat and SOOF (Suborbicularis Oculi Fat) and Malar Fat 139 5.2.4 Dark Circle (Tear Trough and Palpebromalar Groove) 139 5.2.4.1 Design 140 5.2.4.2 Anesthesia 140 5.2.4.3 Choice of Filler 140 5.2.4.4 Injection Technique 140 5.2.4.5 Side Effect/Precaution 142 5.2.5 Midcheek Groove 144 5.2.5.1 Causes and Anatomy 144 5.2.5.2 Treatment 144 5.2.6 Anteromedial, Buccal, and Lateral Cheek Hollow 146 5.2.7 Nose 152 5.2.7.1 Design and Anatomy 154 5.2.7.2 Choice of Filler 156 5.2.7.3 Injection Technique 157 5.2.7.4 Side Effect 160 5.2.8 Nasolabial Fold 160 5.3 Lower Face 168 5.3.1 Lip and Philtrum 168 5.3.2 Marionette Line (Static Labiomandibular Fold) 172 5.3.3 Perioral Wrinkles (Smoker’s Line) 177 5.3.3.1 Definition of Perioral Wrinkles 177 5.3.3.2 Injection Technique 177 5.3.3.3 Precaution/Side Effect 179 5.3.4 Chin Augmentation and Jaw Line Contouring 179 5.3.4.1 Design 179 5.3.4.2 Anatomy 180 5.3.4.3 Choice of Filler 180 5.3.4.4 Injection Technique for Chin Augmentation 181 5.3.4.5 Injection Technique for Jawline Contouring 182 5.3.4.6 Precaution/Side Effect 183 Bibliography 184 6 Complication of Filler Procedures 187 6.1 Type and Treatment of Complication 187 6.1.1 Bruising and Hematoma 187 6.1.2 Edema 188 6.1.3 Neovascularization and Erythema 189 6.1.4 PIH (Post-inflammatory Hyperpigmentation) 189 6.1.5 Nodule and Granuloma 189 6.1.6 Infection 190 6.2 Treatment and Prevention of Vascular Complication 191 6.2.1 Mechanism and Classification of Vascular Complications 191 6.2.1.1 Extravascular Compression 191 6.2.1.2 Intravascular Emboli 191 6.2.1.3 Commonly Affected Areas 191 6.2.2 Skin Necrosis 191 6.2.2.1 Predisposing Factors of Skin Necrosis 191 6.2.2.2 Influencing Factors with Prognosis of Skin Necrosis 192 6.2.2.3 Symptoms of Skin Necrosis 192 6.2.2.4 Treatment of Skin Necrosis (Table 6.3) 193 6.2.2.5 Tips for Early Detection and Immediate Treatment 195 6.2.3 Vascular Complication—Blindness 195 6.2.4 Vascular Complication—Pulmonary Embolism 196 6.2.5 Prevention of Vascular Complication 196 6.2.5.1 Procedural Tips to Reduce Vascular Complications 196 6.2.5.2 Prevention of Vascular Complications—Aspiration Test (Fig. 6.1) 198 6.2.5.3 Prevention of Vascular Complications—Needle Versus Cannula 199 6.2.5.4 Prevention of Vascular Complications—Diameter of Injection Tool 200 6.3 Hyaluronidase Usage 200 6.3.1 Hyaluronic Acid Turnover 200 6.3.2 Use of Hyaluronidase 201 6.4 Retrobulbar Injection Technique 211 Bibliography 213