Springer
Clinical Epidemiologist, Division of Evidence Based Medicine dEBM Charit - Universit tsmedizin Berlin Faculty of Medicine of the University of S o Paulo Av. Ibirapuera, 2907 - cj. 1202 Moema - S o Paulo - SP CEP 04029-200, Brazil Library of Congress Control Number 2005933790 ISBN-10 3-540-23941-3 Springer Berlin Heidelberg New York ISBN-13 978-3-540-23941-3 Springer Berlin Heidelberg New York This work is subject to copyright. All rights are reserved, whether the whole or part of the material...
Complications 1
Fig. 5.19 Both the left cheek and the upper lip were filled. Symmetry and balance were obtained after the filling procedure General complications such as redness, pain, and swelling may occur. Ecchymosis and nodule formation are more likely to happen when treating tear-trough deformities. Fig. 5.19 Both the left cheek and the upper lip were filled. Symmetry and balance were obtained after the filling procedure
Cheek
Cheek augmentation follows the same initial steps as that of the cheekbones. Topical anesthesia is usually sufficient for this area. Visual analysis is important to establish the markings, which should be done with the patient in an upright position. Pinching the skin at this level may also indicate the area where the skin and underlying tissues are atrophic. A triangle is usually drawn to limit the area to be treated Fig. 5.18 . Retrograde injections are undertaken beneath the lines. Placing...
List of Contributors
Professor of Dermatology Clinical Epidemiologist E-mail berthold.rzany charite.de Division of Evidence Based Medicine dEBM Charit - Universit tsmedizin Berlin Berthold Rzany is a dermatologist and clinical epidemiologist who has held the position of C3-Professor of Evidence Based Medicine in Dermatology at the Department of Dermatology and Venerology of the Charit Universit tsmedizin in Berlin since 2002. He studied medicine in Freiburg, Germany, Vienna, Austria, and Harvard Medical School,...
Facial Plastic Surgery and Fillers
As BoNT-A has changed the approach to remodeling of the upper face, fillers have revolutionized the surgical approach to the face. Minimal facial surgery with a quicker recovery time and combined with fillers is the treatment of choice for cosmetic facial improvement. In addition to treating wrinkles, fillers may be used to promote Fig. 7.4 a Patient before treatment. b This patient submitted to minimum invasive surgery and full-face filling for volumetric improvement Fig. 7.4 a Patient before...
Anatomy and Territory
The infraorbital nerve exits the infraorbital foramen in the midpupillary line about 1 cm inferior to the infraorbital ridge. It supplies the lower eyelid, nasolabial fold, upper lip, and part of the medial cheek and nose. Fig. 4.4 Blocking of the supratrochlear nerve Fig. 4.4 Blocking of the supratrochlear nerve Fig. 4.5 Blocking of the infraorbital nerve 1 de Maio 2004 Fig. 4.5 Blocking of the infraorbital nerve 1 de Maio 2004
Nonbiodegradable Fillers
Several nonbiodegradable fillers are available Table 1.2 . As well as being expensive, frequent injections can be quite tiresome for both the patient and the physician, and so the application of a nonbiodegradable or permanent filler holds a certain attraction. Conversely, there are certain disadvantages that should be taken into account. First, patients of all ages can be treated in aesthetic medicine. It may therefore be quite uncertain how a permanent depot will appear after 3 or even 4...
Polyacrylamide 1
Adverse reactions to nonbiodegradable fillers and combinations between biodegradable and nonbiodegradable fillers are usually more severe and more difficult to treat. Publications regarding injectable silicones date back to the 1960s. Several silicone preparations are known. Despite being touted by many authors as the ideal augmentation material, sili-cone injected in large volumes has led to some disastrous local and systemic effects. In general, the inflammatory reaction surrounding injected...
Silicone
Injectable silicone is one of the oldest injectable filler materials used. Medical-grade silicon is a clear, oily, colorless liquid composed of long chains of polymerized dimethylsiloxane. There are several methods of injection for this product. One of the recommended techniques is the mi-crodroplet technique Orentreich 2000 Webster et al. 1986 . Fluid silicone is injected into the dermis as 0.01 ml microdroplets. Each mircodroplet is separated by 1 mm. Undercorrection is recommended as the...
Introduction Baa
Although most injectable fillers are usually considered to be safe, adverse reactions do occur. These reactions might vary from persistent erythema and edema to granulomatous reactions or even ulcerations Table 6.1 . Although these reactions are rare, patients should be made aware of the possibility of an adverse outcome. It is the responsibility of the doctor to communicate these risks to the patient without exaggerating the potential harm. Table 6.1 Possible adverse reactions to fillers Table...
Laser Resurfacing and Fillers
Both of these methods are indicated for the treatment of static wrinkles. The depth of the wrinkle, skin type, and recovery time after the procedure may influence the choice of either method. Usually, patients with a fair complexion benefit from laser resurfacing. Patients with a dark complexion may present hyper- and or hypopigmenta-tion. Due to skin quality, it is more common that patients with fair and sun-damaged skin may present full-face wrinkling and should be treated first with a skin...
Nose Reshaping
The surgical approach to the nose may be seen as a quite invasive procedure, especially when surgery is based on fracturing the nasal bone. Reshaping the nose with injectable fillers, however, is a minimally invasive technique with a quick recovery time that will help to evolutionize this aesthetic area. Specifically reshaping the dorsum and lifting the tip can be achieved with fillers. The knowledge of anatomy and gold standards of the nose are important tools for those who are willing to...
Technique Gay
As the nose is quite a sensitive area, topical anesthesia might not be sufficient. Therefore a block of the fibers of the ophthalmic and maxillary nerve branches is recommended. Tissue expansion is easier on the bone dorsum and more difficult in the lower third. Care should be taken with the vessels that pass within the subcutaneous tissue above the muscles. The injection of any substance into patients with oily skin and large pores may be followed by extrusion and loss of the product, so...
Technique
Inject 1 ml of lidocaine through the inferior labial sulcus, inserting the needle between the sec- Fig. 4.6 The mucosal approach for infraorbital nerve blocking Fig. 4.6 The mucosal approach for infraorbital nerve blocking Fig. 4.7 The mental nerve may be blocked either trans-cutaneously a or through the mucosa b Fig. 4.7 The mental nerve may be blocked either trans-cutaneously a or through the mucosa b ond and third inferior premolars aiming at the foramen mentalis Fig. 4.7 .
Introduction Tvw
The chin is a symbol of masculinity for men and sensuality for women. Any negative marks such as wrinkles, folds, or a deep oral commissure may impair the sense of beauty. Women must have a more delicate chin, with less fullness concentrated at the central part. Men, on the other hand, may have heavier features and should have a stronger chin. In all cases, a youthful and clean jawline is desired. Reshaping the mandible area promotes chin and jawline contours. Despite the scientific studies...
Polymethylmethacrylate and Collagen
The combination of PMMA and collagen was the first combination therapy to become available. Granulomatous reactions are a well known complication of this combination treatment, as reported in a large case series Lemperle et al. 1998, 2003 and in various case reports Alcalay et al. 2003 Hoffmann et al. 1999 Lombardi et al 2004 Reisberger et al. 2003 Requena et al. 2001 Rudolph et al. 1999 . The retrospective case series, published in 1998 by Lemperle, is based on 515 questionnaires from 290...
of Bacterial Origin
Crosslinked hyaluronic acid of avian origin became the first noncollagen filler to be widely used. The Hylaform product family is based on hyaluronic acid derived from processed rooster combs. Several products with different viscosities allow the treatment of different dermal levels. The Hylaform product family, with an average content of hyaluronic acid of 5.5 mg ml, is easy to inject due to its superior rheological properties and is less palpable than some products of bacterial origin Manna...
Polyalkylamide
Polyalkylamide is available as Bio-alcamid. It consists of alkyl-imide group networks approximately 4 and water approximately 96 . The product is available at two different viscosities for lip and facial augmentation and is used for folds, skin sculpting including the lips , and facial atrophy, but not for the treatment of fine lines. The material must be injected subdermally and, according to the manufacturer's information, is supposed to be easily removable when injected in larger volumes...
Tear Trough
The lower lid should be smooth with no evidence of bagginess beneath the preseptal orbicularis muscle, and no delineation of the inferior orbital rim should be evident. Mild tear-trough deformities e.g., infraorbital rim depression are a good indication for fillers. The presence of fillers along the infraorbital rim may improve the suborbital groove. Topical anesthetics are usually sufficient for treatment of the tear-trough area. A careful approach is recommended as this area may lead to...
Anatomy
The forehead and glabellar areas are characterized by extensive mimic movements of three main muscles occipitofrontal, corrugators, and procerus. Horizontal forehead lines appear when the occipitofrontal muscle is activated. The vertical glabellar folds are the product of the continuous contraction of both corrugator muscles. The horizontal lines in the glabellar area are due to pronounced procerus muscle activity. Fig. 5.2 Immediately after injection of hyaluronic acid relaxed Fig. 5.2...
Botulinum Toxin and Fillers
The use of BoNT-A has changed the way cosmetic procedures are handled. Nonsurgical treatment of wrinkles used to consist of filling or resurfacing methods, both of which were focused on static rhytides. Dynamic wrinkles could at that time only be treated by a surgical approach and only in a few areas, such as the forehead and glabella. Muscle action may affect the duration of biodegradable fillers so that the presence of wrinkles in areas of direct muscular action produces only partial results...
Granulomatous Reactions
Several types of granulomatous reactions exist, and all are treated with injections of steroids. It is hypothesized that a higher initial dosage and or frequent injections might increase the healing time personal communication, G. Lemperle . Initially patients are treated with triamcin-olonacetonid, either 10 mg in 1 ml or 40 mg in 1 ml. Please note that triamcinolonactonid 40 may induce severe atrophy in areas with underlying fatty tissue. Therefore, the steroid should Injection of...
Anatomy Oht
Fig. 5.20 The nose blood supply. a Superficial temporal artery a. , b occipital a., c transverse facial a., d posterior auricular a., e maxillary a., f inferior alveolar a., g external carotid a., h ascending pharyngeal a., i internal carotid a., j common carotid a., k superior thyroid a., l lingual a., m facial a., n submental a., o mental a., p inferior labial a., q superior labial a., r angular a., s infraorbital a. Fig. 5.20 The nose blood supply. a Superficial temporal artery a. , b...
Surgery for Granulomatous Reactions
14. Ficarra G et al. 2002 Silicone granuloma of the facial tissues a report of seven cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 94 1 5-73 15. Fitzpatrick RE 1999 Treatment of inflamed hypertrophic scars using intralesional 5-FU. Dermatol Surg 16. Friedman PM et al. 2002 Safety data of injectable nonanimal stabilized hyaluronic acid gel for soft tissue augmentation. Dermatol Surg 28 6 491-494 17. Hoffmann C et al. 1999 Adverse reactions after cosmetic lip augmentation with permanent...
Polylactic Acid
et al. 2003 . Based on the HIV-lipodystrophy data, granulomatous reactions, described as palpable but invisible subcutaneous micronodules, were observed in 22 out of 50 44 patients. In 6 of these 22 patients the nodules disappeared at week 96. In that particular study, one vial of PLA was diluted in a volume of 3-4 ml. Clinically relevant granulomatous reactions have also been observed in patients treated for aesthetic indications Rzany et al. 2004 . Between January 2000 and April 2003...
Biodegradable Fillers
Biodegradable fillers are defined as having a limited life span usually ranging from a couple to several months, or even to a couple of years. They usually consist of purified dermal components from human, animal, or bacterial sources and can be divided into the following categories xenografts donor and recipient are from different species , autografts donor and recipient are from the same individual , homografts donor and recipient are from the same species , and synthetic materials Table 1.1...
Cupid S Bow Tubercle
The lips cover more than the area of the red part of the mouth. They also include the skin adjacent to the red part of the mouth. It must be considered as an anatomic unit with extensions superior to the nose and inferior to the chin Salasche and Bernstein 1988 . Perfect lip Fig. 5.35 Frontal a and lateral view b on landmarks of the upper lip Philtrum dimple Philtrum column White Line Tubercle Philtrum dimple Philtrum column White Line Tubercle Philtrum dimple Phillrum col 11111 ti Cupids bow...
Collagen of Bovine Origin
leagues even recommend double skin testing. It is important to note that skin testing does not exclude a hypersensitivity reaction. A few porcine collagen-based fillers have been described in the literature Saray 2003 . However, they have not been widely used. A novel porcine collagen filler, Evolence, was introduced into the European market in 2004. In contrast to other collagens, this product is crosslinked by mimicking the process of collagen glycation using d-ribose as the crosslinking...
Local Anesthesia
Local anesthetics decrease or completely block sensory, autonomic, and motor functions. They act by blocking sodium channels at the cell membrane and interrupting the excitation-conduction process Carvalho and Mathias 1997 . The systemic absorption of the local anesthetics depends upon the vascular flow at the injection site, the chemical and physical characteristics of the agents, and the adjunctive use of vasoconstrictors such as epinephrine. Vasoconstrictors will decrease the absorption and...
Anatomy Nta
Fig. 5.45 Mandible filling may improve the definition of the mandible a and even treat mild saggy skin b Fig. 5.46 Either one or the other demarcation may be chosen depending on the projection desired. a The right-hand side demarcation is for mild projection and the left-hand side is suitable when both mid and lateral augmentations are needed. b After proper demarcation, the injection technique is started Fig. 5.46 Either one or the other demarcation may be chosen depending on the projection...
Nerve Block
Nerve block anesthesia is effected by an injection of a small amount of local anesthetic around a nerve, resulting in anesthesia within the area supplied by that nerve. The volume of anesthetic used in these procedures is small and so there is a low risk of systemic toxicity. In contrast to the infiltrative method, there is almost no imbalance with nerve blocks and it is associated with less discomfort. However, this method requires good technical and anatomical knowledge to obtain optimal...
Cheekbones
Either no anesthetic or only topical anesthesia is usually required for this procedure. Less product will be necessary if there is good bone projection at the malar level. Injecting over the malar eminence may be helpful in these cases. The best route for treating this area is transcutaneously. Outlining the entire area with eyeliner before injection may promote accurate filling and easy removal of the marking Figs. 5.13 and 5.14 . Use of the frame technique will limit the area before the...
Introduction Nwf
The malar projection and full cheeks are important hallmarks of facial beauty and a youthful appearance. Degenerative changes of the skin and The middle third of the face encompasses the area between the eyebrows and the base of the nose, and the inferior third reaches from the nasal base to the menton. The ideal location of Fig. 5.9 The lateral upper part of the orbit roof may be filled, promoting a better tridimensional projection at this level Fig. 5.9 The lateral upper part of the orbit...
The Tip and the Columella
The medial crura should be expanded if the nostrils are flat. It should be teardrop shaped. A retracted columella can also be filled. Depending on the degree of retraction, soft-tissue expansion should be handled in more than one session. Expansion is undertaken with an injection into the membranous septum. Injecting into the Fig. 5.22 Treatment of the nasofrontal angle must be undertaken close to the periosteum, injecting into the muscular and subdermal layers. This filling will make the bone...
Miriam Bollerhoff
Work's of art are continuously restored over time - Isn't a person a work of art, too This reference on injectable dermal fillers is the first comprehensive manual for the practitioner. It is a perfect symbiosis of pragmatism, experience, and wisdom of two well-known scientists and practitioners from both continents Europe and South America. Today, information on aesthetic surgery is not limited to an exclusive group of injectors any more, but finds a broad, multi-disciplinary interest among...
Miriam Bollerhoff
A book like this would not have been possible without the help of many others. First, we would like to thank our patients, and in particular our teaching patients, without whom we would not be able to teach our colleagues all over the world. We would like to thank those who helped us with theirs skills and support during the completion of this book. Furthermore, we would like to take this opportunity to thank Mrs. Ellen Blasig from Springer Heidelberg for her guidance and her continuous...