Centrofacial Rejuvenation

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice
Upper Injection Adverse-Event Zone
In the upper m alar region the location of the infraorbital artery is consistent
and includes the ascending palpebral branch of the infraorbital artery (PIOA).9
The traditional location of the PIOA is approximately half the eye width from the

injections, because intravascular injection can cause skin comprom ise in this
region (Figs. 8-14 and 8-15).
To complete the analysis, the level of canthal support and canthal tilt should be
documented. The patient should be asked to gaze upward for evaluation of the
amount of orbital fat protrusion.
Fig. 8-14 Potential adverse-event zones (AEZ) in m idface injections. Filler can m igrate into the
buccal recess (lower zone), or intravascular injection into the palpebral branch of the infraorbital
artery can occur (upper zone). (From Surek CC, Beut J, Stephens R, et al. Pertinent anatomy and
analysis for midface volumizing procedures. Plast Reconstr Surg 135:818e-829e, 2015.)

• Midface Volume Rejuvenation With Fillers

Local anesthetic with epinephrine should be injected into blunt-cannula inser-
tion sites to reduce pain and minimize the risk of embolism from vasoconstric-

Marking
Various methods can be used for preprocedure markings. We recommend out-
lining target areas and potential caution zones before performing injections.

We recom m end perform ing analysis and m arking with the patient in a sitting
position with the chair at 90 degrees. For injection we recommend reclining the
examination chair to 45 degrees at an appropriate height for the injector.
Fig. 8-15 The topographic facial analysis
m arkings are displayed: the m alar equa-
tor (blue line), the lateral vertical reference
(LVR; pink line), the m edial vertical reference
(MVR; green line), the upper m alar partition
(UMP; orange line), the lower m alar parti-
tion (LMP; yellow line), the upper m alar
adverse-event zone (black square), the lower
m alar adverse-event zone (AEZ), the m edial
m alar target area (MED), the m iddle m alar
target area (MID), and the lateral m alar target
area (LAT). (From Surek CC, Beut J, Stephens
R, et al. Pertinent anatomy and analysis for
m idface volum izing procedures. Plast Recon-
str Surg 135:818e-829e, 2015.)

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice

The following techniques can be performed through three insertion ports. The
lateral cheek insertion port is approxim ately 1.5 cm inferolateral to the lateral
canthus. The nasojugal insertion port is horizontally level with the alar crease
w ithin the nasojugal groove. The nasolabial insertion port is approxim ately
1.5 cm inferolateral to the ipsilateral alar base within the midpoint of the nasola-
bial fold (Fig. 8-16). A 23-gauge needle is used for all injections to penetrate the
subcutaneous tissue, and a 25-gauge blunt cannula is inserted to pass through
the remaining tissues. These techniques are designed for cannulas, because nee-

in targeted spaces and compartments.
Fig. 8-16 Insertion points for medial and lateral midface viaducts. The nasolabial port is 1.5 cm
inferolateral to the alar base within the nasolabial fold. The nasojugal port is horizontally level
with the alar crease within the nasojugal groove. The lateral cheek port is 1.5 cm inferolateral to
the lateral canthus. (From Surek C, Beut J, Stephens R, et al. Volum izing viaducts of the m idface.
Aesthet Surg J 35:121-134, 2015.)

• Midface Volume Rejuvenation With Fillers
A

B
Fig. 8-17 Layered dissection of the midface of an elderly male fresh cadaver after percutaneous
injection of red-dyed hyaluronic acid with blunt cannulas through two insertion ports. A, The ar-
cus marginalis has been released to unveil the prezygomatic space (PZS). The retroseptal fat (RS)
(MS) are labeled for orientation. The prezygom atic space capsule
(PZC) is dyed with methylene blue. The deep medial cheek fat compartment (DMC) is noted in the
deeper compartment layer. B, The MS and DMC are labeled for orientation. The PZC is dyed with
methylene blue. A cavernous connection in the buccal recess (BR) is noted.
TECHNIQUES

The medial midface viaduct (Beut type 1) is used when the aesthetic goal is res-
toration of anterior cheek projection and softening of the tear trough (Video 8-3).
The m edial m idface viaduct has a superior and inferior quadrant. The inferior
quadrant contains the deep m edial cheek fat (DMCF), the prem axillary space,
and the deep piriform space10 (Fig. 8-17, A and B; see also Fig. 8-10).

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice
Volum ization in the inferior region is targeted at restoration of anterior cheek
projection and the point of m axim um support in the m edial m idface. The su-
perior quadrant contains the superior portion of the nasolabial fat (NL) and the
m edial aspect of the prezygom atic space (Fig. 8-17, C). Volum e deposits at this

Fig. 8-17, cont’d Layered dissection of the midface of an elderly male fresh cadaver after percu-
taneous injection of red-dyed hyaluronic acid w ith blunt cannulas through two insertion ports.
C, The nasolabial fat compartm ent (NL) (MS) are indicated. The
prezygom atic space (PZS) is dyed with m ethylene blue. (From Surek C, Beut J, Stephens R, et al.
Volumizing viaducts of the midface. Aesthet Surg J 35:121-134, 2015.)
C

• Midface Volume Rejuvenation With Fillers
As the nasolabial insertion port is entered, the injector should maintain a vertical
and deep course to avoid the descending infraorbital artery that runs along the
undersurface of the SMAS 2 to 4 mm medial to the midpupillary line. Once the
injector reaches bone, the cannula is retracted a few millimeters, at which time
the deep medial cheek compartment or the more medial deep piriform space is
entered. A bolus is placed in the compartment or space depending on the injec-
tor’s intended target (Fig. 8-18). The topographic change in the nasolabial fold
and piriform aperture can be monitored for desired results.
To approach the superior quadrant, cephalic passage of the cannula is best ac-
complished in a rotating or screw motion. Attempts at “pushing” with the can-
nula are not recommended. Resistance will be met at the orbital retaining liga-
ment.8 Injections are deposited as parallel vertical passes.
Fig. 8-18 A, Entry into the nasolabial insertion port. B, Once the injector reaches bone, the can-
nula is retracted a few millimeters, at which time the deep medial cheek fat compartment or deep
piriform space can be entered and volumized. (From Surek C, Beut J, Stephens R, et al. Volumizing
viaducts of the m idface. Aesthet Surg J 35:121-134, 2015.)
A
B
Deep piriform
space
Deep medial
cheek fat

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice
The material is placed in a triangular “stalagmite” fashion, tapering from larger
to smaller aliquots as the cannula is retracted inferiorly (Fig. 8-19). The medial
injection should extend 5 mm lateral to the medial canthus. This maneuver will
prevent angular vein restriction, which may result in a venous prominence in the
-
ing. These parallel stalagm ite injections perpendicular to the orbital rim are
made medial to lateral, softening the tear trough. The cannula can be advanced
laterally, and obliquely oriented injections can soften the orbitom alar groove.
The patient should use an upward gaze during this treatm ent to enhance the
visibility of the lower eyelid components, making the associated malar aesthetic
defect easier to visualize.

Large particles should be used with caution in the superior quadrant, because
they can block lymphatics. A 25- to 27-gauge cannula with a sm all to m edium
particle size and cohesivity is recommended. The small linear thread lipostruc-
ture technique for autologous fat can be considered if properly placed.
B
A
Fig. 8-19 A, Filler location in the Beut type 1 technique for tear trough softening and volumiza-

B,
in the suborbicularis oculi plane. (From Surek C, Beut J, Stephens R, et al. Volum izing viaducts of
the m idface. Aesthet Surg J 35:121-134, 2015.)

• Midface Volume Rejuvenation With Fillers

The m edial m idface viaduct (Beut type 2) is used when the aesthetic goal is to
blend the lateral lid-cheek junction (Video 8-4).
The reduction of the increased vertical height of the lower lid softens the lid-
cheek junction. The lateral cheek or nasojugal insertion ports facilitate cannula
insertion deep to the inferior orbital rim. Filler is placed in a parallel “stalagmite”
fashion over the concave curvature of the inferomedial orbital rim (Fig. 8-20). The


when the patient smiles, causing a less natural look with movement and heavi-

higher G-prime values is suggested.
Fig. 8-20 -
tion follows an oblique vector. (From Surek C, Beut J, Stephens R, et al. Volum izing viaducts of the
midface. Aesthet Surg J 35:121-134, 2015.)

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice

The lateral m idface viaduct (Beut type 3) is used when the aesthetic goal is to
attain harmony of the ogee curve and restore the oval-shaped orbit (Video 8-5).
Creation of anterolateral projection and restoration of orbicularis oculi support
blends the eyelid and cheek. Accurate patient analysis is important, because
som e patients need volum ization and shape, which is achieved w ith m idsize
particles, and others need projection and support, attained with larger particles
-

(Fig. 8-21). Analysis consists of performing the previously described algorithm
m arkings in addition to standing behind the patient w ith a bird’s-eye view to
assess anteroposterior dim ensions in the area of m axim um cheek projection.
Projection (Beut 3a) and volume (Beut 3b) techniques are performed in the same

A
Volume
B
Projection
Fig. 8-21 The vector goals used for the Beut types 3a (A) and 3b (B) techniques. (From Surek C,
Beut J, Stephens R, et al. Volumizing viaducts of the midface. Aesthet Surg J 35:121-134, 2015.)

• Midface Volume Rejuvenation With Fillers
Beut Type 3a: Projection
Injectors should insert a 21-gauge cannula through the lateral cheek insertion
port (1.5 cm from the lateral canthus). The cannula is inserted in a steep down-
ward m otion w hile perform ing a “pinch and pull” upward of the orbicularis
oculi muscle (Fig. 8-22). The cannula is advanced caudal and deep until the in-
jector m eets resistance at the prezygom atic space capsule. Injection proceeds
past the “pop,” and the cannula is oriented transversely to glide into the space.
The cannula then passes over the periosteum, where the texture of bone can be

and 8-24).
Fig. 8-22 The pinch and pull technique for penetration of a blunt cannula in a suborbicularis plane
into the prezygom atic space. (From Surek C, Beut J, Stephens R, et al. Volum izing viaducts of the
midface. Aesthet Surg J 35:121-134, 2015.)

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice
Fig. 8-23 The pinch and pull technique (A) and suborbicularis oculi depth of the cannula (B).
(From Surek C, Beut J, Stephens R, et al. Volumizing viaducts of the midface. Aesthet Surg J 35:121-
134, 2015.)
B
A
Fig. 8-24
(From Surek C, Beut J, Stephens R, et al. Volumizing viaducts of the midface. Aesthet Surg J 35:121-
134, 2015.)

• Midface Volume Rejuvenation With Fillers
The injector should adjust to a position behind the patient to obtain a bird’s-
eye view and locate the point of maximum cheek projection for the patient (Fig.
8-25). A bolus injection is placed while watching for tenting of the skin and topo-
graphic anterior excursion of the malar tissue until the desired cheek projection
is achieved. This injection consists of a bolus on the bone with minimal tunnel-

contour. Before the cannula is extracted, the syringe should be rem oved and

exteriorization of product. Large particles are safe in this technique when used at


Fig. 8-25 The bird’s-eye view is used to assess the point of maximal cheek projection. (From Surek
C, Beut J, Stephens R, et al. Volum izing viaducts of the midface. Aesthet Surg J 35:121-134, 2015.)
Fig. 8-26
(From Surek C, Beut J, Stephens R, et al. Volumizing viaducts of the midface. Aesthet Surg J 35:121-
134, 2015.)

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice
Beut Type 3b: Volume
-
geted between the m idpupillary line and lateral orbital rim . The cannula is in-
serted through the nasolabial insertion port, and the cannula tip is pointed at
the lateral canthus (Fig. 8-27). A pinch and pull of cheek tissue ensures cannula
passage into the suborbicularis plane.

medial access viaduct by the Beut type 1 method. Once the desired volumization
has been placed in the inferior central prezygom atic space, inferolateral volu-
mization and pure lateral volumization can be achieved without removal of the
cannula by changing the angulation and directing the cannula over the antero-
lateral zygoma, staying caudal to the lateral canthal mechanism.
The need for this particular technique can be determined during preprocedure
facial analysis. For most patients this can result in a greater radius of the cheek.
We use an occlusive dressing (such as Tegaderm) on the area for 24 hours to re-
duce edema.

on cannula depth. Projection in the suborbicularis plane requires large-particle

B
A
Fig. 8-27 A, The nasolabial insertion port is entered, and the cannula tip is aim ed at the lateral
canthus. B, Volum e is added in the prezygom atic space and can be lateral to the space if needed.
(From Surek C, Beut J, Stephens R, et al. Volumizing viaducts of the midface. Aesthet Surg J 35:121-
134, 2015.)

• Midface Volume Rejuvenation With Fillers

Once replenishment of the deep midface viaducts is achieved, augmentation and
-
venation process (Video 8-6). Concavities form clefts such as the nasojugal fold.
All folds are the expression of lymphatics that are responsible for m alar folds
and rhytids.11-12

-

ultim ately obtaining a sm ooth transition with dynam ic action and m ovem ent.

umization has been achieved.
The injector inserts a blunt cannula through the nasolabial insertion port, main-


the appropriate vector to prevent malposition of material. The cannula is aimed
at the lateral canthus with appropriate fanning m edial and lateral to blend the
adjacent fat compartments (Fig. 8-28). The injector must take care to avoid ex-
cessive manipulation of the malar infraorbital fat pad.
Fig. 8-28

C, Beut J, Stephens R, et al. Volum izing viaducts of the midface. Aesthet Surg J 35:121-134, 2015.)

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice
The Langer lines are collagen elastin bundles where expansion occurs perpen-
dicular to their direction of travel. The injection path should be perpendicular to
the cheek sulcus and perpendicular to the Langer lines. Correction of prominent

can be drawn on the face to assist if needed (Fig. 8-29).

m aterial is not recom m ended, because it can result in less natural m ovem ent
during dynamic phases of animation.
Fig. 8-29 Injections placed in a vector perpendicular to the Langer lines (red m arks) increase
cheek radius and expansion. (From Surek C, Beut J, Stephens R, et al. Volum izing viaducts of the
midface. Aesthet Surg J 35:121-134, 2015.)

A comprehensive facial rejuvenation plan including skin care and neurotoxin in-


Prophylactic medications such as antiherpetics, medications to decrease bruis-
ing, and a short course of postprocedure antibiotics should be considered on a

• Midface Volume Rejuvenation With Fillers
Fig. 8-30 Before (left) and 12 m onths after (right) treatm ent with Beut type 1 through 4 tech-


-
matic sweep. She also has an improved upward midface vector.
RESULTS AND OUTCOMES
The patient in Fig. 8-30 received large-particle hyaluronic acid injection through
the m edial m idface viaduct using the Beut t ype 1 technique to volum ize
the deep m edial cheek fat compartm ent and tear trough. She also had sm all-
particle hyaluronic acid injection using the Beut type 2 technique through the
m edial m idface viaduct. For cheek projection and shape, the patient received
Beut type 3a and 3b techniques through the lateral midface viaduct.

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice



(TCA) peel, and neurotoxin injections in the glabella, crow’s-feet, orbicularis oris

particle hyaluronic acid, 2 cc with large-particle hyaluronic acid).
Fig. 8-30, cont’d Before (left) and 12 months after (right) treatments.

• Midface Volume Rejuvenation With Fillers
Fig. 8-30, cont’d Before (left) and 12 months after (right) treatments.

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice
The patient in Fig. 8-31 received hyaluronic acid injection through the m edial
midface viaduct using the Beut type 1 method to volumize the deep medial cheek
fat and tear trough. She underwent hyaluronic acid injection using the Beut type
2 technique through the medial midface viaduct. For cheek shape, the patient re-

cheek blending was perform ed using the Beut type 4 m ethod with hyaluronic


neurotoxin injections in the glabella, crow’s-feet, orbicularis oris m uscle, and
-
aluronic acid, 2 cc with large-particle hyaluronic acid).
Fig. 8-31 Before (left) and 12 months after (right) treatment with hyaluronic acid injections with

acid peel, and neurotoxin injections in the glabella, crow’s-feet, orbicularis oris, and platysm a.
triangle marking demonstrates the conversion of facial
shape after volum e augm entation. The three-dim ensional surface rendering elucidates the im-
proved cheek projection and contour.

• Midface Volume Rejuvenation With Fillers
Fig. 8-31, cont’d Effacem ent of the tear trough is outlined by the black square. The three-
dim ensional volum e comparison dem onstrates the change in volum e after the procedure. Fo-
cused augmentation is obvious in the tear trough and upper midface after the Beut type 1 through
3 procedures.

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice
The three-dim ensional surface renderings in Fig. 8-32 are of a patient who re-
ceived hyaluronic acid injections using the Beut type 1 m ethod for augm enta-
tion of the deep medial cheek fat compartment and tear trough. The patient also
received hyaluronic acid injections using the Beut type 3 technique to improve
cheek projection and a Beut type 4 procedure to soften the nasolabial fold and

m idsize-particle size hyaluronic acid, 2 cc w ith large-particle size hyaluronic
acid).

PROBLEMS AND COMPLICATIONS
The overall complication rate in midface volumization is low. Allergic reaction,
hypersensitivity, infection, and granuloma formation are potential complications
in midface volumization.13 Asymmetry and contour irregularities are potential

depth of injection and skin thickness, can help prevent palpable clumps and
contour irregularities. As previously discussed, the practitioner must be aware
of the anatomic architecture of the midface to prevent inadvertent puddling in
the lower cheek, iatrogenic malar mounds, and prominent angular veins. Ecchy-


be injected immediately. Standard doses ranging from 60 to 200 units should be

w ith saline to help w ith dispersion or m ixed w ith lidocaine to improve vaso-
dilation. Aggressive m assage should be perform ed, and a warm compress can
be applied to assist in vasodilation. If clinical improvem ent is not observed in
60 minutes, the injection of hyaluronidase should be repeated. Topical nitroglyc-
erin paste may also be useful.
To prevent clot propagation, patients can take oral aspirin.14 Blindness has been

injection port cannulas and inject during cannula withdrawal to help prevent
this dreaded complication. If blindness occurs, im m ediate ophthalm ologic in-
tervention is recommended.

• Midface Volume Rejuvenation With Fillers
Fig. 8-32 Three-dimensional surface renderings of before (left) and 12 months after (right) a pa-
tient underwent 3 cc of hyaluronic acid injections with the Beut type 1, 3, and 4 techniques. The
improved cheek projection and dim inished presence of the tear trough are evident.

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice
Technical Pearls
• With a cannula approach, the prezygomatic space
can be entered percutaneously by perform ing a pinch and pull technique
over the lateral cheek region. The cannula will make a readily apparent pop
through the prezygomatic space capsule to enter the space. The sensation
-
rived in the prezygomatic space.
• Entry into the deep piriform space is reliably per-
formed through a port in the nasolabial crease approximately 1.5 cm infe-
rior and lateral to the alar base. The cannula is passed with a steep angle
down onto bone. A free space, devoid of ligamentous structures, is entered

accomplished through the sam e portal with a shallower angle of cannula
approach. Once in the space, the cannula is aim ed m ore cephalic and can
traverse in a gliding space to the level of the tear trough ligament.
• After the completion of deep volumiza-

a blunt-cannula fanning technique.
ACKNOWLEDGMENT
The authors would like to extend a special thank you to The Department of Plastic Surgery at
the University of Kansas Medical Center, Departm ent of Anatomy at Kansas City University
of Medicine and Biosciences, 3D Tech Omega Zeta, University of Barcelona and University of

REFERENCES
1. Lambros V. Observations on periorbital and midface aging. Plast Reconstr Surg 120:1367-
1376, 2007.
2. Kahn DM, Shaw RB Jr. Aging of the bony orbit: a three-dimensional computed study. Aes-
thet Surg J 28:258-264, 2008.
3. Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg 83:11-16, 1989.
4. Pessa J, Rohrich R. Facial Topography: Clinical Anatomy of the Face. St Louis: Quality Med-
ical Publishing, 2012.
-

2014.
6. Mendelson B, Wong C. Anatomy of the aging face. In Neligan P, ed. Plastic Surgery, vol 2,
ed 3. Philadelphia: Elsevier Saunders, 2012.
7. Surek CC, Beut J, Stephens R, et al. Pertinent anatomy and analysis for midface volumizing
procedures. Plast Reconstr Surg 135:818e-829e, 2015.

• Midface Volume Rejuvenation With Fillers

trough deformity. Plast Reconstr Surg 129:1392-1402, 2012.

artery relating to midface lift. J Craniofac Surg 22:1489-1490, 2011.
10. Surek C, Beut J, Stephens R, et al. Volum izing viaducts of the m idface. Aesthet Surg J
35:121-134, 2015.
11. Guisantes E, Beut J. Linfáticos faciales: cómo prevenir el linfedema en los rellenos del
surco de la ojera. Eur Aesth Plast Surg J 5:36-43, 2015.

234, 2014.

Plastic Surgery, vol 2, ed 3. Philadelphia: Elsevier Saunders, 2012.

necrosis with hyaluronidase: consensus recommendations. Aesthet Surg J 35:844-849,
2015.

(Trang không có chữ)

Chapter
5
The MACS-Lift
Short-Scar Face Lift
Technical and Strategic
Considerations
Mark Laurence Jewell • Mark Laurence Jewell
Chapter
9
Filling Temples


Fillers
Val Lambros

The eyes say nothing


but a cyclone of m eaning



sw irls all around them
VAL LAMBROS

Chapter Videos
9-1 Temple Filling
9-2 Immediate Result
Additional procedural video and author discussion of technique can be
found on Media Center.

• Filling Temples With Highly Diluted Hyaluronic Acid Fillers
Many of the changes of aging can be understood by observing changes of fa-
cial weight. Some faces gain weight, albeit unevenly, from bottom to top. Other
faces thin, and the cheeks, orbits, and temples all hollow with age. As the temples

but as the tails of the brow fall into the temple hollow they seem to shorten and
descend. Temple wasting, like the prejowl sulcus, can be an early sign of aging;
som e younger people who otherw ise look reasonable for their age can exhibit
this phenomenon.
Problem s involving the temple are both technical and aesthetic. The norm al

concave temple becomes an aged-looking hollow temple is a matter of judgment.
What a temple emphatically should not be is very convex. This appearance can
vary from alien to hydrocephalic and is not desirable in any case.

temporal bone isn’t thick enough to explain the collapse of shape. An older tem -
ple can be quite thin with no subcutaneous padding and have visible vasculature.
Certain concepts of facial injections are not at all intuitive. Patients simply don’t

photographs do not express the anticipated changes to a particular individual in
the examination room.
The concept of trying on clothes to see how they look is a traditional and uni-
versal way to choose between options; it is no surprise that computer-assisted
patient imaging has become a powerful tool to demonstrate possible outcomes
of surgery. I rely heavily on a simple form of injection imaging, which is simply


-
ple hollow and then massage it into place.
Although injecting the brow this way requires some practice, temple and ante-
rior jawline previews are easy. This simple m aneuver is im m ensely helpful for
a number of reasons: The patient will have seen the result beforehand, which is

decision on whether to do a procedure; here the balance of power shifts to the
patient: If they don’t like the preview, the saline simply resorbs. If they like the

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice
-

As a byproduct, the area is now numb and vasoconstricted and ready to inject. The
deep subcutaneous tissue of the temples is less sensitive than most areas of the
face, and local anesthetic can be foregone; however quite large vessels are present
in the vicinity and vasoconstriction is a good idea for all injections. The presence






injectors typically have an extremely low incidence of complications.
PATIENT EVALUATION AND SELECTION
-
ily seen as a shadow behind the superior lateral orbit. Patients who have an im -
balance in the size of the face below the arch and above it (“my head looks like a
peanut”) should also be considered. Ultimately, because this is a cosmetic pro-
cedure, the best determinant of patient happiness is whether the patient looks

TECHNIQUE


necessarily have textbook borders. The temples are marked; one side is almost
always deeper than the other. The apex of the temple hollow is at the temporal
fusion line and is m arked. The hollow is oblong and is com m only deepest im-
m ediately lateral to the orbit and above the arch. The injection site is planned
just inferior to this area over the arch; using this site automatically places more
-


cannula (usually a 2-inch No. 22 or 1.5-inch No. 25) should reach from the in-
jection site to the upper border of the defect; otherwise the temple deform ity
will not be fully corrected.

at present. One is particulate and the other is m ore highly crosslinked. I have
found that the long-term results (2 years and longer) are slightly more smooth

because of their much higher viscosity.

• Filling Temples With Highly Diluted Hyaluronic Acid Fillers
Dilution
One of the keys to this procedure is a high dilution of the product with saline.

is true with liposuction). Dilution m akes it easier to m aintain evenness of the
product placem ent, because each pass of the cannula puts in a relatively sm all
-

The injection site is blocked with a small amount of 0.5% lidocaine with epineph-



that m en require 0.5 to 1 cc m ore, depending on their anatomy and the depth
and size of the hollow.
The product is diluted, using a Luer-Lock transfer hub. More dilution results in a
safer and smoother result;
-
nephrine, and 3 cc normal saline to make a total of 6 cc (when 1% plain lidocaine
was used in the diluent, the incidence of lower lid bruising was higher). Once
the injection point is blocked, the rest of the injection is surprisingly painless.
Injection
The other key to the technique is the depth of injection. After the cannula is in-
troduced into the chosen site of injection, it is guided into the deep subcutaneous
tissue of the temple (Video 9-1). Ideally, for the body of the temple, the plane of
-

the hollow, up the lateral orbit and tail of the brow to the apex. Injecting slowly,

passes are then repeated more posteriorly. The goal is to expand the temple hol-
low as evenly as possible with about four to six radial passes.
The most visually important part of the temple hollow is adjacent to the lateral

in the tail of the brow and the lateral orbit in the subcutaneous plane. These
passes are the most important in creating the extended “lifted” brow.
Because about 6 cc of volum e are initially placed into the temple, the area can

and dart from the cannula into unintended places from the body of the injection,
especially in patients who have had scarring from prior surgery, adding to the
impression of irregularity. Inexperienced clinicians may believe that the patient

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice
area. This temptation should be resisted. Forceful m assage only causes bruising
and discomfort and does not assist in dispersing the product. The patient should

-
m al. The saline component absorbs rem arkably quickly, m ost w ithin m inutes

a liability; the full volum e should be used even if the m ass in the temple looks
disturbing. With som e experience the injecting tim e for each temple is about

There is no appearance downtime (Video 9-2).

evenly dispersed in 4 cc of saline. More saline leads to m ore even distribution
of product; however, because only so much volume can be placed into the tem-
ple, the dilution described is a reasonable compromise. The product cannot be
injected in one spot and then m assaged into position; this will lead to a m ajor

This procedure results in a high degree of satisfaction. Although in general pa-
tients forget very quickly how they looked before the procedure, they rem em-
ber the result of this change. The advantage of the procedure is the remarkable
sm oothness of the result. I have not had any patient complaints about irregu-
larities, although I have noticed a few m inor ones when looking in tangential


using sharp needles and when epinephrine is not used in the dilution. Since
changing to cannulas and including epinephrine I have seen bruising only rarely.




with 0.5 to 1 cc more required for men.


hand for a few minutes several times the evening of the procedure. Although the
appearance is good soon after the injection, the temple changes subtly for about
a week before stabilizing. Some patients complain of headache, and the area can

-
ways recede to normal projection soon after.

• Filling Temples With Highly Diluted Hyaluronic Acid Fillers
RESULTS AND OUTCOMES



1
2,3 Injected fat can provide satisfactory


results in irregularities. After trying for years I gave up on the area, but when I

-
-
ers for the dorsum of the hand.4 Although I developed this particular m ethod
independently, it is a logical extension of such uses.


-
tributes more evenly than I have found possible with traditional injection tech-
niques. Not only is the temple hollow leveled, but the tail of the brow rotates
anteriorly, giving the impression of rising and lengthening (Fig. 9-1). Because
young faces do not typically have temple hollows, leveling the hollows alters
the gestalt of the face in a very powerful way. The pinched upper face now looks
more vertical and the peanut shape disappears. More here is not better. The goal
is to level the temple hollows, not make them convex. Overcorrection is not likely
with the amounts used as described.
Fig. 9-1 A 58-year-old woman seen (A) before and (B) 3 years after injection of the temples. Each

look extended and longer after injection.
B
A

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice
-
cult and thinner parts of the face5 (Figs. 9-2 and 9-3).
-
tients with 4-year longevity (Fig. 9-4).6,7
Fig. 9-2 This is the patient seen in Video 9-1. A, The 49-year-old patient had 1.5 cc diluted cohe-
B, The result at 3 months.
B
A
Fig. 9-3 A 66-year-old man seen (A) before and (B) 1 year after injection of 2 cc diluted Juvéderm

B
A
Fig. 9-4 A 56-year-old wom an seen (A) before and (B)
The tail of the brow on the right side now appears extended and elevated.
B
A

• Filling Temples With Highly Diluted Hyaluronic Acid Fillers
This technique leads to high satisfaction, even in patients w ith a good deal of
temple and skin atrophy in whom irregularities would easily be visible (Fig.
9-5). For patients who have had facelifts or browlifts w ith temple dissection,
the injection is harder to control because of the scarring, and immediately after

alternatives (Fig. 9-6). Many older patients have had several cosmetic surgeries

an improved appearance for even thin, operated faces.8
Fig. 9-5 Left,
side of diluted Restylane as described in the text. Right, At 1 year after the injection, the temples
-
luted product.
Fig. 9-6 A, This 58-year-old woman had 0.5 cc of Restylane injected into each brow. A year later
B, She is shown 4 years after the
brow injection and 3 years after the temple injection with a balanced and more youthful anatomy.
B
A

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice
The main disadvantage of this procedure is cost. Because most cosmetic patients

substantial.
-
perience, and it has a short learning curve, though there are subtleties. It is for-
giving and reliable and can be reversed. With a recognition of temple defects and



PROBLEMS AND COMPLICATIONS

most worrisome complication is an unintended intravascular injection. The tem -
poral artery is a large vessel close to the injection area and can anastomose with
the supraorbital or supratrochlear artery and gain access to the orbit and globe.
Vascular complications are so rare that it is not possible to determ ine ways to
minimize them. Still, a common sense approach is helpful in preventing such a
complication. For example, the surgeon m ust understand the temporal artery
anatomy before undertaking this injection. The artery often can be felt and seen
before the injection. In secondary procedures a Doppler may be used to map the
artery. Cannulas are generally considered safer than needles; they presumably
work by pushing vessels out of the way rather than cutting into the lumen. The
diminished bruising seen with cannulas reinforces that notion. Larger cannulas
should thus be safer than thinner ones, because they are less sharp. The most im-
portant factor is the presence of scarring in the injection plane as with a browlift

or polylactic acid. Im m obilizing the vessel in a layer of scar w ill not let it shift
in response to the cannula; m ore important, if the vessel is perforated and the
cannula is withdrawn, injected product may follow the path of least resistance

arterial injection is very low, estimated at 1 in 900,000 in one study.9
-
uct and site of injection.

• Filling Temples With Highly Diluted Hyaluronic Acid Fillers
REFERENCES
1. Coleman SR. Structural Fat Grafting. St Louis: Quality Medical Publishing, 2004.
-
sium, Miami, FL, Feb 2005.
3. Fagien S. Variable reconstitution of injectable hyaluronic acid with local anaesthesia for
expanded applications in facial aesthetic enhancement. Dermatol Surg 36(Suppl 1):815-
821, 2010.

Reconstr Surg 120(6 Suppl):74S-80S, 2007.

-
ment of the “joker line” and its treatment. Plast Reconstr Surg 122:1543-1552, 2008.
7. Ozturk CN, Yum eng RT, Parker L, et al. Complications following injections of soft tissue


1991.
9. Coleman S, Mazzola R, eds. Fat Injection From Filling to Rejuvenation. St Louis: Quality
Medical Publishing, 2009.

(Trang không có chữ)

Chapter
5
The MACS-Lift
Short-Scar Face Lift
Technical and Strategic
Considerations
Mark Laurence Jewell • Mark Laurence Jewell
Chapter
10
Aesthetic Contouring
of the Upper
and Central Third
of the Face With Soft
Tissue Fillers

True beauty is mesmerizing—it knocks you out
and leaves you breathless.
W OFFLES T.L. W U

(Trang không có chữ)

• Aesthetic Contouring of the Upper and Central Third of the Face
S -
surgical facial rejuvenation and contouring in the last 2 decades. Originally con-
ceived to sm ooth nasolabial lines and plump up lips, they are now used for a
variety of purposes, including volum etric restoration and sculptural aesthetic
contouring of the face. The brow, upper eyelids, forehead, and temples are im -
portant components of overall facial aesthetics, and volum e improvem ents in

is not part of the upper third of the face, its origins are in this area, and it has
important connections to structures in this facial region. This chapter examines
the aesthetic considerations of the upper third of the face and presents my injec-
tion rationale and techniques. Vascular territories and potential complications
are also discussed.

that has becom e one of the m ost important nonsurgical techniques employed
by doctors who provide aesthetic facial treatm ents.1,2 Any physician who per-
form s this procedure m ust have proper injection technique to correctly assess

treat any complications in a safe and competent manner.
Emphasis has previously been on volumetric restoration of the lower two thirds
of the face, including the infraorbital area, malar eminences, cheek hollows, chin,
nasolabial and m arionette lines, w ith scant attention paid to the nose, upper
eyelids, brows, forehead, and temples.3

of this area for total facial rejuvenation obvious. Volumization of the upper lids
and forehead have only becom e fashionable in the last decade, with the grow-

aging and unaesthetic. Aesthetic contouring of the upper face therefore brings

the rest of the face.
AESTHETIC CONSIDERATIONS OF UPPER FACIAL CONTOURING
Although the nose, supraorbital brow ridge, upper lids, forehead, and temples


other, creating a balanced, harmonious, and aesthetically pleasing upper face. In

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice
the study of faces nothing is more important than the shape of the forehead and
nose, because these convey connotations of that person’s character, morals, and

the sexes, with males having strong nasal bridges that meet low-set, prominent
brow ridges at a more acute angle and a shorter forehead that can be straight or
mildly convex. Invariably men should have a modest suprabrow concavity that
highlights the projection of the brow ridge and gives a more masculine and rug-
ged appearance.
For wom en, the sides of the nose, which should be sm aller and m ore petite,
should obliquely and gently curve into the medial aspect of the eyebrow (naso-
orbital or dorsal aesthetic lines), which then continues smoothly over the supra-
orbital ridge to its lateral aspect without any undulations. The supraorbital brow

is high, wide, and slightly rounded. The forehead in turn should blend in with

of the temples leads to lateral brow ptosis and a sickly appearance. Volume re-
placement of the temples elevates the lateral brow and lends the face a healthy
appearance. Conversely, the temples should not bulge convexly. Absence of a
suprabrow concavity confers a more feminine appearance.
Of course these are m ere generalizations, and m any variations are considered
aesthetically acceptable, but these ideals emphasize the importance of the upper
face as an area for cosmetic contouring and completing the visual perception of a
face.4-8 Furthermore, in all races, sunken upper eyelids with A-frame deformities
give the face an aged and unappealing appearance. The recent trend in facial re-

them with volume replacement.9


surgical techniques were used to aesthetically improve these areas of the upper
face. Fat grafts from the lower lids (by surgical excision) or periumbilical area (by

sulci.10 Silicone and, later, bone substitute implants were used for decades for
elevating the nasal bridge and reshaping the forehead. Periosteal and temporo-

complex craniofacial operations have been used to burr down the supraorbital

• Aesthetic Contouring of the Upper and Central Third of the Face

fat injections have in recent years been used to volumize and contour these ar-
eas successfully, but this rem ains a surgical procedure with a degree of unpre-
dictability and potential risk of vascular occlusive complications. Good results
with fat injections require excellent surgical judgment and skill. Complications

INDICATIONS AND CONTRAINDICATIONS
-
thetic contouring of the nose, brow, and forehead with minimal to no downtime.
Often used in conjunction with botulinum toxins in the glabellar and forehead

the comfort of a nonsurgical setting. The techniques are easy to learn, and with
proper precautions and judgment the results can be very satisfying and compli-

single sitting, with pain relief provided by local nerve blocks or by the lidocaine

-
tic expectations, patients who have had multiple previous surgeries (especially
open rhinoplasties, because the subsequent altered blood supply may result in
tissue necrosis), and patients who have not been m ade aware of the potential
complications.

patients want only the dorsum and tip of the nose to be reshaped, whereas oth-
ers may want to enhance the nasoorbital line and the columella as well. Others

-

should be used so contour irregularity or vascular complications can be poten-
tially reversed.
PREOPERATIVE PLANNING AND PREPARATION


personal preference based on fam iliarity and practice with the chosen instru-
ment. With experience, equally good results can be obtained using either tech-
nique.11 -

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice
used in the face regardless of whether it is the upper, middle or lower third of the

-

directly and accurately to the desired target and in the correct plane, which in
most situations should be directly onto bone. The underlying vascular anatomy
must be considered to minimize the risks of vascular compromise. Occasionally,


cannulas invariably glide in the plane of least resistance, which in the forehead
is subgaleal or intramuscular. This is the plane where the facial vessels, having
emerged through their respective foramina, tend to arborize. The periorbital re-
gion must be injected carefully whether using a needle or cannula.

Vascular occlusion is the m ost serious complication of injecting any substance,

skin and soft tissue necrosis, loss of vision from occlusion of the retinal or oph-
thalm ic arteries, and even brain infarction have all been reported and rem ain
risks that m ust be adequately discussed with every patient receiving these in-
jections.12-22 A thorough knowledge of the vascular supply of the orbits and nose
is essential (Fig. 10-1), noting the course of the facial and angular arteries, their
branches to the nose, the branches of the ophthalm ic artery as they em erge
through the supratrochlear and supraorbital foramen, and in particular the anas-
tomoses between these two systems.23,24
In the face, all arteries emerge from foram ina and arborize in and on the over-
lying muscular layers, never in the interface between the periosteum and peri-
chondrium and the facial and nasal muscles (Fig. 10-2).

is on the bone or periosteum itself, ensuring that the supratrochlear and supra-

point. The needle must not enter any of the facial bony foramina.

• Aesthetic Contouring of the Upper and Central Third of the Face
Fig. 10-1 Vascular anatomy of the upper face showing the possible points of connection between
the facial artery (external carotid system ) and the ophthalm ic artery (internal carotid system ).
(a, Artery; ant, anterior; post, posterior; v, vein.) (Courtesy Jean Carruthers.)
Fig. 10-2 Anatom ic dissection of the nose and its soft
tissue layers. The skin envelope has already been re-

-
tilaginous fram ework. No blood vessels lie beneath the

superior surface.

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice
Over the nose, the arterial supply is paired with an alar, columellar (derived from
the facial artery), and dorsal nasal (a branch of the ophthalmic artery) artery on
each side, with a vascular watershed in the midline of the nose (Fig. 10-3). The
midline of the nose is therefore an anatomically safe place for sharp needle in-
jections, which should be placed directly on the underlying bone or cartilage of
the nose.23
Fig. 10-3 A, The facial artery is seen coursing upward through the nasolabial region to the junc-
tion of the alar lobule w ith the lip, where it splits into a robust colum ellar artery, which runs in
the nostril sill and then along the columella to the tip of the nose, and an alar artery, which curves
around the alar groove and supplies the alar lobule. An attenuated tributary of the alar artery con-
tinues toward the medial canthus of the eye, where it anastomoses with the dorsal nasal artery, a
terminal branch of the ophthalmic artery. B, The paired colum ellar arteries run through the colu-
mella to the tip of the nose, where they anastomose with the alar plexus, which unites branches
from the columellar, alar, and dorsal nasal arteries. (a, Artery.) (A from Wu WTL. The oriental nose:
an anatomical basis for surgery. Ann Acad Med Sing 21:176-189, 1992.)
B
A

• Aesthetic Contouring of the Upper and Central Third of the Face
In the forehead the only anatom ic constants are the supraorbital and supra-

supraorbital and supratrochlear arteries branch out over the central two thirds


Fig. 10-4 Anatom ic dissection of the supraorbital ridge and forehead seen from above. The su-
pratrochlear and supraorbital arteries emerge from their bony foramina and arborize in and above
the galea but not beneath it. This therefore makes the supraperiosteal-subgaleal plane the safest

VOLUMETRIC CONTOURING OF THE NOSE
The bridge, root, and tip of the nose are important areas for aesthetic shaping and
rejuvenation in both Asian patients and patients of European descent. Younger
patients require volume to contour and beautify the nose, correcting any struc-

what has been lost. Ethnic considerations and the physician’s frequency of use

25

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice



-

the place of either the implant or any cartilage grafts. To augment the dorsum,
sharp needle injections should be delivered along the m idline of the nose at

raise the level of the “start point” of the nose and give the illusion of a longer,

nasolabial fold can also displace the alar lobules medially, giving the impression
of a narrower nasal base.
Fig. 10-5 Left, A 28-year-old Asian woman with a low nasal bridge and a bulbous tip with thick,
rounded alar lobules. Right, -
icant elevation and three-dimensional contouring of the nasal bridge.

• Aesthetic Contouring of the Upper and Central Third of the Face

and tip projection but m ay have contour irregularities that can easily be
26-29 Narrow noses can be widened. The
root of the nose becom es thinner and m ore attenuated with aging, and resto-

smooth and continuous orbital-nasal lines of youth. Plunging nasal tips can be el-

crura and into the tip. Patients with vertical glabellar lines or horizontal creases
at the root of the nose indicate excessive muscular activity of the corrugator and
procerus m uscles and consequent volum e loss (Fig. 10-6). Restoring the shape
and volume of the nasal root and medial brow together with appropriate injec-

lines and the appearance of an “old, pinched” nose.
Fig. 10-6 Left, A 49-year-old man with deep glabellar and procerus frown lines and an attenuated
nasal root. Right,
the root of the nose, aesthetic continuity w ith the m edial brow was attained.

• The Place of Toxins and Fillers in the Modern Plastic Surgery Practice

Before injecting in the nose, glabella, or periorbital regions, supraorbital and
infraorbital nerve blocks are useful, using lidocaine 1% to 2% mixed with adren-
aline 1:80,000 to 1:200,000. This not only provides pain relief but also vasocon-
stricts the blood vessels that accompany the nerves and m ay decrease the risk
of vascular embolism. The local blocks are administered 10 to 15 minutes before

Sometimes a blanching of the vascular territories can be seen. Placing an ice pack
over the areas to be injected can also encourage vasoconstriction.

Injection pressure should be slow and steady. The injector must be alert for any
blanching or intense pain felt by the patient. The 30-gauge needle is always in-
troduced in a perpendicular fashion directly down to the nasal bone, starting at

the midline, then, as the needle is withdrawn 1 to 2 mm toward the surface, the

(Fig. 10-7). This has more structural integrity than a mere bolus. By starting the
injection on the bone, there is less likelihood of intravascular embolism, and as


Fig. 10-7
it is w ithdrawn to m ake a broad base, tapering to a point (like an upside-down ice cream cone).
This technique involves injecting big blobs as close to the bone as possible, which displaces the