Essentials of Aesthetic Surgery

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Part V Noninvasive and Minimally Invasive Therapy
Bruising
Eyelid or brow ptosis
Headache
Allergic reaction
Nausea
Facial asymmetry
Dysphagia
Respiratory compromise
PREPARATION AND EQUIPMENT
RECONSTITUTION
The powder is usually reconstituted gently with 0.9% sterile saline solution.
When reconstituted, the solution should be clear, colorless, and free from particulate
matter.
SENIOR AUTHOR TIP: Studies have shown that injection site discomfort is less when
using preserved saline.14,15
STORAGE
Before reconstitution, unopened vials should be stored at
• Xeomin can be stored on the shelf at
The manufacturer recommends using the toxin within 4 hours of reconstitution and
storing it at 2°-8° C.

SYRINGE AND NEEDLES
allow injection of a precise volume of solution.
• Tuberculin or insulin syringes are most frequently used.
or needles

penetration.
SENIOR AUTHOR TIP: When performing multiple injections, changing needles after

ANESTHESIA
Use of ice or cold packs, topical local anesthetic combinations, and other modalities can
limit procedural discomfort.
This is not required, and use varies by physician and patient.
IMMUNOGENICITY11
Neurotoxins are macromolecular protein complexes with molecular weights of 300-
900 kDa comprising a 150 kDa neurotoxin protein and varying amounts of nontoxin
proteins.

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Chapter 21 Botulinum Toxin
The immune system may recognize any component of the protein complex and initiate


in a less immunosuppressant response compared with Botox and Dysport.
TECHNIQUE
Treatment must be individualized based on muscle strength, skin thickness, degree of
rhytids, choice of neurotoxin, and previous treatments.

Recommended ratio of 1:2 or 1:2.5 pertains to Dysport.
GLABELLAR COMPLEX
Vertical frown lines are the result of contraction of the muscles within the glabellar
complex.

The and (medial orbicularis
oculi) are the muscles responsible for brow depression.
are composed of a (larger) and an
head.
Frontal bone at the superomedial orbital rim
Dermis at the middle third of the eyebrow, interdigitating with

Depresses and adducts the eyebrows
Vertical glabellar lines
• The
Inferior aspect of the nasal bone and upper lateral nasal cartilages
Dermis overlying the nasal root
Depresses the medial brow
Transverse lines on the nasal dorsum
• The muscle is a portion of the medial orbicularis oculi, just
inferior to the medial brow.

orbital rim
Brow depression
Contributes to both vertical and transverse glabellar lines and
a lower static medial brow position

Five to seven injection sites are
recommended (Fig. 21-1).
Starting doses are approximately 20-30 U
for women and 30-40 U for men.
Midline injection should be at the nasal
root to treat the procerus muscle.
Injection of the depressor supercilii can
raise the static position of the medial brow
if desired.
Injection points for glabellar
complex and vertical forehead lines.

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Part V Noninvasive and Minimally Invasive Therapy
TIP:
SENIOR AUTHOR TIP: Injection only above the orbital rim to prevent diffusion
resulting in eyelid ptosis requires caution.
NASAL REGION
Bunny lines are downward-radiating lines along the nasal sidewalls.

The transverse portion of the nasalis muscle arises from the maxilla and expands into a
thin aponeurosis over the nasal dorsum and interdigitates with the caudal edge of the
procerus.
Contraction compresses the nasal bridge,
depresses the nasal tip, and elevates the lateral
alae.
Bunny lines result from contraction.


Three injections sites are usually chosen (Fig.
21-2).

FOREHEAD
Dynamic transverse forehead lines result from contraction of the

The frontalis is a large, paired muscle that is the continuation of the galea aponeurotica
inferior to the coronal suture.
Variable decussation and interdigitation of the muscle in the midline are responsible for
the diversity of shape of transverse forehead rhytids.

Galea aponeurosis
Dermis at the level of the supraorbital rim
Brow elevation
Transverse forehead lines

Injection varies depending on gender.
• Men generally require large doses because they have thicker muscles.
• The brow is whereas the brow is usually more

Complete paralysis should be prevented because it leads to brow ptosis and

• This is best prevented by injecting

lateral brow.
Starting doses are approximately 10-20 U for women and 20-30 U for men.
Injection points for bunny
lines.

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Chapter 21 Botulinum Toxin
TIP: Brow asymmetry and lateral elevation can be improved with injection of the
superior lateral orbicularis oculi immediately below the eyebrow—sometimes called a

LATERAL PERIORBITAL REGION
are radial, lateral periorbital rhytids that result from orbicularis oculi contraction
and photoaging.

The muscle is a thin, sphincterlike muscle that encircles the eyes.
• Composed of and portions
• Functions to close the eyelids, but also acts as a brow depressor and weak elevator
of the malar region
in this region
Redundant skin laterally bunches over the contracting muscle, leading to lateral rhytids

Injections are given near the lateral
orbital rim with the needle pointing
away from the globe.
subcutaneous
injections are given.

chosen, and starting doses are 8-16 U
per side (Fig. 21-3).
In patients with lower lid laxity
or laxity of the lateral canthal tendon, caution is necessary in this area to prevent
postinjection scleral show and lower lid retraction.
TIP: To prevent injection of the zygomaticus major muscle, injections should not be
given below the zygomatic arch.
TIP:
and additonal injection 2 weeks after the initial procedure.
PERIORAL REGION
Vertical perioral rhytids result from contraction of
the

The orbicularis oris is a layered sphincter
muscle that encircles the mouth.
• Functions to close the mouth and pucker
the lips

Injections are and of
the vermilion border (Fig. 21-4).
Injection points for crow’s-feet.
Injection points for perioral
rhytids.

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Part V Noninvasive and Minimally Invasive Therapy
Injection sites should be symmetrical, and inexperienced injectors should avoid the
lower lip.

injection sites.
CAUTION:
SENIOR AUTHOR TIP: Injections in patients who use their lips for their professions,
such as musicians or public speakers, are not recommended.
• Perioral region is often
this location.
TIP:

CHIN
A dimpled chin results from loss of subcutaneous fat and contraction of the


The mentalis muscles are paired muscles that originate from the mandible, course
downward, and insert into the skin of the chin.
• Functions to raise the chin and protrude the lower lip


It can be given as a midline injection just inferior to the tip of the chin or as paired
lateral injections.
Needle should be angled superiorly, as the muscle originates cephalad to its site of
insertion.
NECK
The cause of plastymal banding is multifactorial and is historically most frequently treated
surgically. Botulinum toxin is an alternative treatment in selected patients.
14
The
16

“banding” with muscular contraction.
Pectoralis major muscle fascia
Contralateral plastyma, mandible, risorius muscle
Depresses the jaw, lower lip, oral commissures

Treatment with botulinum toxin is indicated in patients with preserved skin elasticity
and a paucity of submental fat.

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Chapter 21 Botulinum Toxin
Band should be grasped with the nondominant hand and injected in three to six sites
along its length.
Starting doses are variable and usually are within a range of

injection sites.
TIP: Can also be used in postrhytidectomy patients with residual bands.
MASSETER
Masseter hypertrophy can lead to a wide contour of the lower face. In 1994 Moore and
Wood18 19 later used the toxin
for aesthetic wrinkle reduction.



arises from the anterior zygomatic arch and passes posteriorly and
inferiorly, inserting onto the masseter tuberosity.
• The thinner, arises from the posterior arch and travels downward to
the front and inserts into the masseter tuberosity.
• The arises from the posterior arch as well and passes back and downward
to insert on the masseter tuberosity.
• These three layers fuse together in the lower third of the muscle.


• Type I: Minimal bulging, no obvious bulge
• Type II: Mono, local single longitudinal bulge
• Type III: Double, two separate longitudinal bulges
• Type IV: Triple, three longitudinal bulges
• Type V: Excessive, massive single bulge
Injection is adapted to static
thickness, because thickness correlates with force of muscle.

Results have shown a decrease in masseter thickness and improved contour of the
lower face.
POSTOPERATIVE CARE
Postinjection instructions vary widely by physician and are frequently unwarranted.

activity.

edema.
Onset is generally within 3-4 days and plateaus at 14 days after injection.
At 14 days, results are assessed and touchups performed if needed.
Treatment is repeated every 3-6 months.

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Part V Noninvasive and Minimally Invasive Therapy
COMPLICATIONS

• Very rare; possible allergic reaction to human albumin, which is also present within
the vial

• Also uncommon, and very unlikely after cosmetic use
• Seen rarely after treatment for cervical dystonia


• Prevented by following previously mentioned suggestions
Headache, nausea, malaise, vasovagal response, bruising, pain at injection site are
probably related to the injection itself rather than the toxin.
TOP TAKEAWAYS

There are three FDA-approved neurotoxins generally used for treatment of
dynamic facial rhytids.

The toxin works by preventing acetylcholine release at the neuromuscular
junction.

Intramuscular injection is facilitated by knowledge of anatomic location and
depth.



Complete paralysis is avoided, and attention is given instead to aesthetic facial
shaping and softening of dynamic rhytids.
REFERENCES

ed 23. Philadelphia: Saunders Elsevier, 2008.
2. Botox® Cosmetic Package Insert. Allergan, Inc., Irvine, CA. Available at

3. Rohrich RJ, Janis JE, Fagien S, et al. The cosmetic use of botulinum toxin. Plast Reconstr Surg
112(5 Suppl):S117, 2003.
-
ment of hyperkinetic facial lines. Plast Reconstr Surg 112(5 Suppl):S88, 2003.
5. Carruthers JD, Carruthers JA. Treatment of glabellar frown lines with C. botulinum-A exotoxin.
J Dermatol Surg Oncol 18:17, 1992.

33(1 Suppl):S9, 2013.
7. Yielding RH, Fezza JP. A prospective, split-face, randomized, double-blind study comparing
OnabotulinumtoxinA to IncobotulinumtoxinA for upper face wrinkles. Plast Reconstr Surg
135:1328, 2015.

J 33(1 Suppl):S13, 2013.
9. Matarasso A, Shafer D. Botulinum toxin neurotoxin type A-ABO (Dysport): clinical indications
and practice guide. Aesthet Surg J 29(6 Suppl):S72, 2009.

279
Chapter 21 Botulinum Toxin
10. Maas C, Kane MA, Bucay VW, et al. Current aesethic use of abobotulinumtoxin a in clinical
practice: an evidence-based consensus review. Aesthet Surg J 32(1 Suppl):S8, 2009.
11. Klein AW, Carruthers A, Fagien S, et al. Comparisons among botulinum toxins: an evidence-
based review. Plast Reconstr Surg 121:413e, 2008.
12. Nguyen AT, Ahmad J, Fagien S, et al. Cosmetic medicine: facial resurfacing and injectables.
Plast Reconstr Surg 129:142e, 2012.

on the use of botulinum toxin type a in facial aesthetics. Plast Reconstr Surg 114(Suppl 6):S1,
2004.
14. Kwiat DM, Bersani TA, Bersani A. Increased patient comfort utilizing botulinum toxin type a
reconstituted with preserved versus nonpreserved saline. Ophthal Plast Reconstr Surg 20:186,
2004.
15. Alam M, Dover JS, Arndt KA. Pain associated with injection of botulinum A exotoxin reconsti-
tuted using isotonic sodium chloride with and without preservative: a double-blind, random-
ized controlled trial. Arch Dermatol 138:510, 2002.

of the anterior neck. Clin Plast Surg 10:441, 1983.

type a treatment. Plast Reconstr Surg 134:209e, 2014.
18. Moore AP, Wood GD. The medical management of masseteric hypertrophy with botulinum
toxin type A. Br J Oral Maxillofac Surg 32:26, 1994.

disturbing masseteric hypertrophy. Ned Tijdschr Geneeskd 142:529, 1998.

280
RELEVANT ANATOMY AND GENERAL CONCEPTS1,2
NOTE:



FOREHEAD


with muscle chemodenervation alone.

Volume is as much an issue here as in other areas.
PERIORBITA

Deep upper sulcus, either congenital or from aggressive fat removal through


chemodenervation of lateral orbicularis.

Medial groove from region of medial canthus to orbital rim
• Multifactorial in severity, relates to: Position of orbital rim, thickness of skin,
pigment of skin, amount of medial fat in lower lid, characteristic of orbicularis

orbital portions), and insertion of orbital septum


• Severity varies.
• Depth of presentation varies from the tear trough/nasojugal fold toward the lateral
orbital thickening.

• Position is relatively stable throughout facial aging.
3

MIDFACE

Fullness in malar region from lateral zygomaticomaxilllary junction to the nasomaxillary
region below the tear trough is very important in overall facial rejuvenation.

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Chapter 22 Soft Tissue Fillers

• Various depths require
Cheek fold, when present, should be corrected for balance.
This is an excellent indication for

Cause not fully known: Severity may be related to dermal insertions of deeper fascial

lip region.
4
Depth and location vary.
can be useful.
Some upper-segment depth is natural and desired.
Overcorrection should be avoided.
LOWER FACE

Formed mostly during animation

Usually lateral to lowest point of nasolabial fold
May require


(perpendicular) to vermilion
border.
Skin resurfacing (laser versus
peeling) and botulinum toxin,
along with volume restoration

gives most optimal correction
when lines are severe.
Vermilion-cutaneous junction
and upper lip augmentation are
usually required.

Youthful characteristics
• Upper lip/lower lip height ratio

• Cupid’s bow is sharp and well-

• Full philtral columns
• Gentle concave sloping from
nasal base and labiomental
groove
• Oral commissures slightly
upward in orientation
• Full medial tubercle
• Sharp white rolls (vermilion-cutaneous junction)
1/3
2/3
Youthful lip
characteristics.

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Part V Noninvasive and Minimally Invasive Therapy

Depth should be harmonious relative to nose-lip-chin projection.



Often only botulinum toxin required, however


OTHER LOCATIONS

Cephalad and/or caudal to a dorsal hump to blend and balance overall nasal appearance
Postrhinoplasty correction
• Nostril and alar imbalances

Acne, posttraumatic, chicken pox

is best treatment.
Once the skin is severely aged or thinned and separated from the underlying orbicularis

when skin is thick and well adherent to the underlying orbicularis.
TIP: Consider the facial fat compartments5 and recognize/perform other complemen-
tary procedures that will blend facial zones and create overall facial youth and harmony
through proper volume restoration.
INDICATIONS AND CONTRAINDICATIONS
FOLDS AND CREASES


is usually required, which can lead to vascular complications, ulcerations, and visible
product.

would be optimal.
is important.

conservative placement with a small-particle hydroxyapatite.
CAUTION: NOT

• Nasolabial fold has thicker skin and multilevel injection technique with mutiple types

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Chapter 22 Soft Tissue Fillers
VOLUME RESTORATION
Recent literature has helped our understanding of facial aging with respect to volume
and position of soft tissue compartments.
Thorough knowledge of the fat compartments of the face and proper balance between
fullness of these facial zones is essential.
: Malar fullness with submalar hollowing is a desirable aesthetic relation and a
strong visual indication of youth.
Overcorrection can lead to an awkward “overdone” appearance.
ENHANCEMENT
Lips
An unnatural appearance should be avoided.
Adherance to the desired aesthetic proportions is vital.
NOTE:

TIP: The lips are a vital and central portion of the face. It is a primary location that
is subconsciously and consciously evaluated during social interactions. The lips evoke
emotion, sensuality, youth, and vitality. Overcorrection in this region is commonly seen

used, with reevaluation from multiple views during injection.
CHIN PROJECTION
The appearance of minimal chin projection and fullness at the pogonion can be

PREINJECTION EVALUATION
HISTORY
Presence of a collagen-vascular disease process may interfere with healing at the
injection site and compromise skin blood supply.

subside before injections.
Smoking may delay or interfere with healing and longevity of the product, especially if
a collagen response is necessary for results.
Any immunocompromise indicates the need for extra caution.


AESTHETIC EVALUATION
Lips
Proper proportions should be understood, and all portions relating to improving lip
aesthetics should be treated to optimize results.
Philtral columns, downturned oral commissures, and vermilion-cutaneous junction
should not be ignored.
Volume and contour require treatment.

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Part V Noninvasive and Minimally Invasive Therapy

Evaluate depth and skin type.
Evaluate height of lower lid.

Often, malar augmentation is also necessary.

Facial fat compartment locations should be assessed and understood.
Asymmetry should be documented. (One side is always wider than other.)

This region is complementary with lower lid injections.
Multiple syringes are often required.

The contribution of dynamic muscle motion, if any, is determined.

modalities.
Small static lines (periorbital and perioral) are a good indication for small-particle
collagen.
INFORMED CONSENT
Should include, but not be limited, to the following:
Edema: Patients need to know timeline, because returning to their work and other

others.
SENIOR AUTHOR TIP: Radiesse (Merz Aesthetics) injections deep in the malar
region may allow return to work the same day whereas injections in the nasolabial fold

vascularity.
Ecchymosis: Patients should not take aspirin, NSAIDs, and other blood-thinning
medication for at least 1 week before injection.
As with any cosmetic procedure, the possibility of a poor cosmetic
outcome or asymmetry should be discussed with patients.

• Contour irregularity
• Overcorrection or undercorrection
Rare hypersensitivity has been reported

localized hypersensitivity and 1%-5% of negative skin test patients can produce an
allergic reaction to facial injection.
6
contraindication to repeat treatment.
• Cystic and granulomatous reactions are possible.
• Cystic abscesses have been reported.

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Chapter 22 Soft Tissue Fillers
Rare, but should be mentioned; more likely in poorly
selected patients (e.g., cocaine abusers and those with autoimmune disease or
collagen-vascular disorders); upper third of nasolabial fold near base of nose, and

increases risk (e.g., glabella).
Very temporary and easily minimized with proper technique; reduced
by anesthetic block and icing. Prolonged discomfort or reaction at injection site may
require corticosteroid treatment (injection or oral).
Recent laser or chemical peel treatment may increase the risk of


coexists at injection site(s). Delaying treatment may be needed.


several days with oral antiviral therapy.
bluish
discoloration will result (particulate bolus scattering shorter wavelength blue light).
EQUIPMENT
NECESSARY MATERIALS

Often provided in packaging
A 1¼-inch 27-gauge needle helpful for long, linear threading and for large areas such as
the malar and nasolabial fold.
Otherwise, a ½-inch 27-gauge needle often used


Custom-compounded triple-anesthetic combinations can be special ordered from most
pharmacies.
Requires application 15 minutes before procedure
Useful adjunct that should be placed before or at same time as local anesthetic blocking
techniques

Agent: 1% lidocaine with or without epinephrine versus Septocaine
SENIOR AUTHOR TIP: Septocaine causes less discomfort.

• Posterior superior alveolar nerve (PSA)
• Infraorbital nerve (ION)
• Mental nerve
• Inferior alveolar nerve (IAN)
• Superior alveolar nerve branches
• Buccal branches (intraoral/mucosal)

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Part V Noninvasive and Minimally Invasive Therapy
Ice
Useful before and during injection
• Apply with pressure immediately before needle entry and between injections to
prevent or minimize bruising and swelling.
May use ready-made iced rollers
Icing with pressure if bruise noted can minimize ecchymotic progression.
IDEAL SOFT TISSUE FILLER CHARACTERISTICS1
FDA approved
Biocompatible
Nonantigenic
Nontoxic


does not fail easily)

NOTE:


• Predictable outcome (“What you see is what you get.”)
• Potentially reversible
• Nonpalpable and soft where necessary
• Readily available
• Minimal downtime
• No migration
• Reproducible
• Durable
HYALURONIC ACID FILLERS
NONANIMAL STABILIZED HYALURONIC ACID ACKGROUND
Not animal based
NASHA products such as Restylane (Galderma) and Perlane (Galderma) are
manufactured with blocks of gel passing through sizing screens (sieving) and
dispersed within a lubricant. This creates a less homogeneous particle size, which is the
characteristic of the Hylacross HAs such as Juvéderm products (Allergan).
Normal component of ground substance of many tissues (skin, cartilage, bone, and


Glycosaminoglycan biopolymer of repeating disaccharide units of N-acetylglucosamine
and glucuronic acid

Hydrophilic (accounts for initial swollen/overcorrected appearance)

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Chapter 22 Soft Tissue Fillers
NASHA AND OTHER HA PRODUCTS THAT ARE FDA APPROVED
: First FDA-approved NASHA (December 2003)
is a larger-particle HA indicated for deeper folds and used often for malar
augmentation.

A very-low-molecular-weight HA
Restylane with lidocaine
Perlane with lidocaine

• All above
denotes lidocaine in the product.
• Particle size increases from Ultra to Ultra Plus and Voluma

Plus (larger-particle HA)
Highest viscosity and particle size; indicated for deep
folds and malar augmentation







• Various Belotero products from Merz Aesthetics available in United States include:


marionette lines, oral commissures
Deeper areas such as nasolabial folds and lines, lips
Malar and other areas requiring volume

volume restoration of face, hands, neck
INDICATIONS AND TECHNIQUE FOR HYALURONIC ACID FILLERS
NOTE:

NOTE:


lumpiness is seen or felt, then massage immediately to smooth the product.

white roll of the vermilion necessitates linear threading, whereas commissures may be
best treated with cross-radial injections (Fig. 22-2).

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Part V Noninvasive and Minimally Invasive Therapy
TIP:
volume restoration and overlying wrinkle correction are required, then consider a


thickness, and look for veins and scar tissue, which can cause bruising or unexpected

amount and type and appreciating the “feel” of the product, which comes with time
and experience.
Serial puncture. B, C, Fanning technique. D, Cross-radial technique
or cross-hatching.
A
B
1
2
3
4
5
6
7
8
9
C
D

• Overcorrection is not required with HAs, in general
CALCIUM HYDROXYAPATITE FILLER
RADIESSE ERZ AESTHETICS
FDA-approved
Composed of synthetic microspheres (30%) suspended in an
aqueous carrier gel (70%)
• Microspheres: 25-45 µm
• Similar to mineral portion of bone and teeth
Packaged as 1.3 cc or 0.6 cc syringes
Biocompatible, nontoxic, nonirritating, and nonantigenic13
When placed into soft tissue, immediate correction noted
• Over time: Carrier gel absorbed and a collagen response surrounds microspheres

noted at 1 and 6 months
13

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Chapter 22 Soft Tissue Fillers

Over time: Broken down into calcium and phosphate ions

Results clinically seen up to
Varies by location


Ideal sites are generally in regions with overlying thicker skin.
• Nasolabial folds
• Malar augmentation
• Submalar augmentation
• Oral commissures
• Marionette lines

• Jawline

• Chin augmentation
NOTE:

TIP:





extraoral).
Radiesse is ideally injected with a 27-gauge needle, most commonly one with 1¼-inch
length.
Injection should be in
The needle is preloaded with product.
Deposition of product is best performed

.
is most useful, because product is placed during needle withdrawal.
Postinjection massage
• Handheld vibration is also useful to evenly distribute product.
NOTE:

Fanning technique useful
Multiple injection points along fold
Can use cross-radial technique for certain, stubborn locations along fold

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Part V Noninvasive and Minimally Invasive Therapy


• Requires as many syringes as needed for desired shape

Can start deep in subcutaneous or preperiosteal level and layer
Fanning technique from lateral submalar point and/or medially at upper nasolabial fold
• Cross-hatching and overlapping passes important to prevent linear-appearing
deposition of product
Augment entire malar region.
Can extend inferiorly along medial zygoma
Malar augmentation is important and complementary to lower lid–tear trough
treatments with HA agents.
• Allows comprehensive and natural blending of the periorbital with malar
subcutaneous compartments
DO NOT inject in region of lower eyelid.


Injection technique. Injection of the nasolabial folds and malar mounds with Radiesse.


• Important to stay deep
• Start from lateral to medial and use fanning.


• Fanning and/or cross-hatching technique

• Fanning/cross-hatching
• Do not overcorrect.

• Fanning with cross-hatching and deep serial threading is most useful.
• Approach chin bilaterally with a central entry site when necessary.

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Chapter 22 Soft Tissue Fillers


rhinoplasty”
• Injected cephalad to a dorsal hump and sometimes caudal to it to balance the
sagittal appearance of the nose
L
SCULPTRA ALDERMA
for HIV lipoatrophy of the face
Injectable poly-L

Synthetic polymer
• Biodegradable, biocompatible, immunologically inert
• No skin test required
Delivered as microparticles that are broken down by nonenzymatic hydrolysis into lactic
acid monomers
2 or glucose.



NOTE:

• Patients should be informed that the results will diminish and return at
approximately 8-12 weeks as collagen replacement is under way.

May last up to 15-17
May require

Approved for
Typically, this involves the malar and submalar areas and parts of the zygomatic process
and arch.
Has been used for temporal wasting as well
Must be injected in deepest dermis and/or subcutaneous tissue
• Can also be multilayered starting with preperiosteal deposition

reconstituted with 3-5 ml of sterile water

• After reconstitution, can be stored at room temperature for
• Vial must be agitated or rolled (preferred).

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Part V Noninvasive and Minimally Invasive Therapy
(26-gauge is the smallest possible)

• Multiple injection entries with cross-radial and/or fanning overlaps allow smooth
product placement.


manipulation.

• Average is three to six treatment sessions

Bovine collagen–coated PMMA beads
• Collagen serves only as a transport vehicle and is absorbed over 4-6 weeks.
Synthetic and biologically active

Volume of soft tissue augmented is from connective tissue increase around beads.
Considered a PERMANENT

• Initial results may not be seen for 6-8 weeks.
INDICATIONS
Useful for deep acne scars and lines
• Nasolabial fold and deep marionette lines
• Can be used in malar augmentation
Permanency makes product very unforgiving.
TIP: As soft tissue and skin atrophies with age, the product will become more visible
with time. It should be placed very carefully and conservatively. It is NOT safe for

TECHNICAL CONSIDERATIONS


Use a 26-gauge needle.
Product is injected during withdrawal.

Massage is needed to make sure no lumpiness is present.
For depressed scars


Postinjection irregularities should be treated with dilute doses of Kenalog (0.2 mg/ml).
• In refractory cases, direct incision may be required.
• Granulomas have been reported.
19,20

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Chapter 22 Soft Tissue Fillers
POSTINJECTION CARE
TIP: Injectables are known as or treatments by the lay public,
which is a misperception. Ask patients about their plans for the next several days to
weeks after treatment. Some may be planning to attend a wedding in 24 hours and
expect to have no bruising or swelling!


injection.
• Massaging at home is only rarely helpful and may be detrimental if done incorrectly.




• Initial ice application may help to reduce facial edema.

12-24 hours

• Patients are instructed to limit activity that increases heart rate for 3-7 days.
• Head of bed is up (45 degrees) for 3-5 days if possible.

excess/additive edema

• Usually not needed if no active infection and proper skin preparation with alcohol or
chlorhexidine
• Continued orally for 3-5 days every 8 hours

• Oral steroids

augmentation, nasolabial fold, lips, and tear trough) then a 5- or 6-day oral
steroid regimen may be useful.
• Injectable diluted Kenalog (Kenalog 10)


NOTE:


• Patients can resume previous diet as tolerated.
• As with any cosmetic procedure, limiting salt intake may to help decrease edema
slightly.

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Part V Noninvasive and Minimally Invasive Therapy


before and/or after injection for several days.

• Bromelain, a high-dose pineapple extract helpful for ecchymosis and edema, can be

COMPLICATIONS
SENIOR AUTHOR TIP: Use light source and possibly loupes to see small- to medium-
sized veins. This is useful in areas such as the lateral periorbita.
Edema
• Initial edema may last up to 3-5 days.
• Bruising can last as long as 1-2 weeks and depends on individual.

discoloration.

• More likely with less malleable products or semipermanent to fully permanent
products


when seen, with massage to smooth out


Hylenex (Halozyme Therapeutics)—ovine 200 USP units/ml

dissolution.


• Inject more adjacent to site to help balance area out; e.g., if upper lip is too full,
consider injecting more to lower lip to achieve proper lip balance.
• Excess HA can be treated with hyaluronidase in extreme cases.
• Reassurance is sometimes best, because appearance will improve in most cases in
several weeks.
• Injection of appropriate volume of hyaluronidase is essential.

• Most commonly seen with lips
• Vital to be aware of preinjection lip anatomy and inherent asymmetries
NOTE:

• Corrected by touchup injection, immediately or at subsequent session

end of injection session) or from a bruise or internal venous puncture on only
one side.

295
Chapter 22 Soft Tissue Fillers

• Usually venous, from rupture of a medium- to large-sized vein
• Treat immediately with pressure and cooling to minimize progression.
• Prevent with careful attention to venous architecture during injection.
• May be more common at vascular crosspoints (lateral orbit, oral commissure, base
of nose/upper nasolabial fold, mid–lid-cheek junction)
• A true hematoma is rare.

• Rare

product
• Can treat with oral antihistamine

• Self-limiting over several weeks




• Treat with steroid injection or surgical excision if refractory.
TOP TAKEAWAYS

Calcium hydroxyapatite should be injected in the lower lid–cheek junction
and tear trough area.

The appearance of minimal chin projection and fullness at the pogonion can be


Presence of a collagen-vascular disease process may interfere with healing at the
injection site and compromise skin blood supply.


example, the white roll of the vermilion necessitates linear threading, whereas
commissures may be best treated with cross-radial injections.
REFERENCES
-


and limitations. Plast Reconstr Surg 120(6 Suppl):S8, 2007.

2007.
4. Yousif NJ, Gosain A, Sanger JR, et al. The nasolabial fold: a photogrammetric analysis. Plast
Reconstr Surg 36:239, 1994
5. Rohrich RJ, Pessa J. The fat compartments of the face: anatomy and clinical implications for
cosmetic surgery. Plast Reconstr Surg 119:2219, 2007.
6. Somerville P, Wray RC Jr. Asymmetrical hypersensitivity to bovine collagen. Ann Plast Surg
30:449, 1993.

296
Part V Noninvasive and Minimally Invasive Therapy

considerations. Plast Reconstr Surg 120(6 Suppl):S33, 2007.
-
metic surgery: review and technical considerations. Plast Reconstr Surg 120(6 Suppl):S41,
2007.

their relevance to aesthetic applications. Plast Reconstr Surg 132(4 Suppl):S5, 2013.

Plast Reconstr Surg 132(4 Suppl):S33, 2013.
12. Flynn TC, Thompson DH, Hyun SH. Molecular weight analysis and enzymatic degradation

Surg 132(4 Suppl):S22, 2013.



mid- and lower face: consensus recommendations. Plast Reconstr Surg 120(6 Suppl):S55, 2007.
-
tion. J Drugs Dermatol 3:385, 2004.




indications, techniques, and complications. Dermatol Surg 29:573, 2003.

29:859, 2003.

Histopathological and clinical study of 11 cases. J Oral Pathol Med 33:115, 2004.
21. Alam M, Dover JS. Management of complications and sequelae with temporary injectable

297
PREOPERATIVE EVALUATION1
Consultation with the patient to establish realistic goals and expectations (see Chapter 4)
Comprehensive medical and surgical history and physical examination
• Surgical implants are at risk for rupture or puncture with fat grafting techniques.
• Bleeding complications/risks are possible from prescription and herbal medicine.
• History of cold sores requires herpes simplex prophylaxis.
• Patients planning weight loss should wait until weight goal is achieved.
Standard preoperative photographs for surgical planning (see Chapter 3)
• Patients being evaluated for facial rejuvenation are asked to provide photographs of
their younger selves in repose.
• Preoperative and postoperative photographs are helpful for patients who had prior
surgery on their face.

Analysis and operative planning based on patient desires, clinical examination, and
photographs
INFORMED CONSENT1
RECOMMENDED ITEMS TO BE INCLUDED IN THE INFORMED CONSENT

A statement that reads,


No warranties, guarantees, or special contracts about the success and longevity of the
procedure
Possible need for additional surgeries/procedures
Complications (including donor site complications)
EQUIPMENT AND PREPARATION
CHOICE OF HARVEST SITE
There is on grafted fat longevity based on donor site.
Fat should be harvested from sites that will enhance body contour and are easily
accessible in the supine position.
Most common sites used are the abdomen and Other sites include the
knees, and lateral and anterior thigh.
Incisions should be placed in creases, previous scars, stretch marks, and hirsute areas.
The pubic region is the most useful site—it allows access to the abdomen, medial thigh,
and anterior thigh.

298
Part V Noninvasive and Minimally Invasive Therapy
Incisions are closed with a single stitch of nylon or plain gut.
Recommended incision sites are shown in Fig. 23-1.
Recommended incision sites for fat harvest.
HARVEST CANNULAS
A two-holed cannula with a blunt tip and dull distal openings at the end is used for
harvesting (Fig. 23-2). Cannula lengths are 23 and 15 cm. The advantageous greater

resulting from the greater torque generated by the longer cannula.

Harvest cannulas.

Right oblique view

Back view

299
Chapter 23 Fat Grafting
TECHNIQUE
The harvest areas are surgically prepared.

using a 25-gauge needle.
A stab incision is made with a No. 11 blade just large enough for the harvesting cannula
(2-3 mm).

every cubic centimeter of fat harvested. For larger volumes or multiple sites, a solution
of lactated Ringer with a 1:400,000 epinephrine is used instead. Wait 7 minutes before
harvesting.
SENIOR AUTHOR TIP: Superwet or tumescent techniques are not used during the

tissue into smaller components of tissues and cells. This will decrease the survival of the
injected fat. The extra volume of liquid aspirated with the harvested fat will decrease
the yield of fat for each syringe and increase operative time.
The plunger is manipulated on a 10 cc syringe to generate 1 to 2 cc of negative pressure
space.
TIP:
down to allow the fat and liquid to separate. Express the excess liquid out of the syringe
and continue to use it to collect more fat.
TIP: The oil separated from the fat can be used to lubricate the cannula to minimize


is used to cap the syringe (Fig. 23-3). With the syringe tightly capped, the plunger is
removed and the syringe placed in a centrifuge for .
NO
A
Yes
B
Separating the fat. A, The plugs that
accompany the syringe should not be used,
because they frequently allow the aqueous
portion of the contents to leak. B, The preferred

is twisted on to create a seal that will prevent
spillage during the centrifuging process.

300
Part V Noninvasive and Minimally Invasive Therapy
SEPARATION OF COMPONENTS
After centrifugation, the harvested fat will separate into (Fig. 23-4).

layer into a medicine cup and save it for lubricating the cannulas.


the aqueous layer from draining, the syringe should be gently tapped or pulled out.

down) and a Codman neuropad is placed into the syringe to wick the fat. The wick should
be replaced every 4 minutes, and this should be done at least twice (Fig. 23-5, ).
NOTE:
B
Upper level
• Least dense layer
• Oil from ruptured fat cells
Middle level (30% to 70%)
• Potentially viable parcels of tissue
Lowest level
• Most dense layer
• Blood, water, lidocaine

A
B
Wicking. A, The wick should
be replaced every 4 minutes, and this
should be done at least twice. B, Fat is seen
sticking to the Codman neuropad. This is
an indication that the fat has been exposed
to the air too long. This syringe of fat
should be discarded.

301
Chapter 23 Fat Grafting
The plunger is replaced and the excess air
carefully expressed out of the syringe.


into the back of the plungerless 1 cc syringe.
(The syringes must be vertical and nothing
should block the tip of the 1 cc syringe, to allow
air to escape). The plunger to the 1 cc syringe is

Alternatively, a double-sided female connector
can be used to join both syringes together (and
their plungers), and fat from the 10 cc syringe
is passed into the 1 cc syringe. (The plunger on
the 1 cc syringe should be fully mobile before
the transfer so it can slide to accommodate the
transferred fat).
FAT PLACEMENT
The recipient site is surgically prepped and
draped.

lactated Ringer solution) to minimize bruising, hematoma, and the possibility of arterial
embolization.
Incisions should be placed in wrinkle lines, folds, or hair-bearing areas.

• To strengthen soft tissue projection over bony prominences, fat should be injected
deep against bone or cartilage.
• To support skin for an aesthetic appearance, fat should be layered immediately
under the skin.

skin and the appropriate underlying tissue.


fat to be injected will be diluted with blood, lidocaine, and oil. It will be displaced by
postoperative muscle contraction and lost to necrosis/absorption.

There are three types of blunt cannulas, and the recipient site determines which one is
best.
Transfer of fat into a 1 cc

302
Part V Noninvasive and Minimally Invasive Therapy
(Fig. 23-7)
• The is used for correction of scars.
• Type I: Completely capped on the tip, it minimizes injury to nerves, vessels, glands.
It lays out the most stable placement of fat.
• Type II: Similar to type I, but not completely capped at the tip
• Type III: Flat on the end, it allows dissection through tissue. Useful for scars or

eyelid or the white roll of the lip.
TYPE I (GREEN)
A

B
TYPE III (RED)
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U

V
W
X
Cannula types.

303
Chapter 23 Fat Grafting
POSTOPERATIVE CARE1
EDEMA
is the most common problem.

SENIOR AUTHOR TIP: The following is a timetable “of what to expect”:
Week 1, “Monster”: Patients are not recognizably human—swelling at worst on day 3.
Week 2, “Human”: Patients begin to look like a younger, “beat-up version” of
themselves. The bruising is resolving but swelling remains.
Week 3, “Recognizable”: Patients begin to recognize themselves.
Weeks 3-5, “Acceptance”: Patients begin to understand and like their new look.
Up to 16 weeks: Some swelling is present in varying degrees.
TREATMENT AND PREVENTION OF EDEMA1
Elevation and cold therapy should be used immediately for up to 48 hours
postoperatively.
Microfoam tape is placed immediately over the treated areas and left in place for 3 to
4 days. The tape helps to keep the transplanted fat in place and minimizes edema.
Patients are counseled against placing any pressure on their treated areas, especially
while they sleep.
Patients are encouraged to massage their donor site as soon as tenderness in the area
will permit.

CAUTION:
TREATMENT OF SELECTED AREAS
NASOLABIAL FOLDS AND MARIONETTE GROOVES 1,2
Midmalar
Commissure
Lateral chin or
mandibular border
Preoperative markings of nasolabial folds and marionette grooves for location to transfer
fat and location of stab wounds to introduce the fat grafting cannulas.

304
Part V Noninvasive and Minimally Invasive Therapy

• 0.5% lidocaine with 1:200,000 epinephrine

• A lower midmalar incision is used for perpendicular placement of fat to the
nasolabial fold, and a lateral chin or mandibular border for parallel placement.

placement. An alternative location is an incision at the most cephalad portion of the
nasolabial fold, just lateral to the alar groove.

• A Coleman type II is most commonly used for the nasolabial fold. A Coleman type III


• The primary level is at the

• For the nasolabial fold, 2-11 cc is needed depending on the depth. For marionette
grooves, usually 1-3 cc is needed.

• Fat is placed into the deepest part of the fold without feathering into the
surrounding area. This can lead to reformation of wrinkles in the areas adjacent to


1-inch Microfoam tape
Massaging the nasolabial area IS NOT recommended.
Quick. Bruising is minimal, and patients look acceptable within a few days.

• Folds medial or distal to the older folds recur, because fat was not feathered around
the fold.
SENIOR AUTHOR TIP: If multiple sites are addressed on the face, the nasolabial folds
and marionette grooves should be approached before the cheek or lower eyelid.
Placement of structural fat into the nasolabial fold and marionette grooves requires a

Feathering should always be done, except in fuller areas.

and feathered over at least to that area.
Surgeons should not create too much of a mound lateral to the fold, because it can
accentuate an already existing fold.
Perforation of the mucosa should be carefully avoided; this is a primary cause of
infection.

injections of collagen, hyaluronic acid, and other materials.
TIP: To minimize the risk of postoperative infection, patients should be instructed to
gargle with Peridex a few days preoperatively.

305
Chapter 23 Fat Grafting
LIPS 1,2
Midmalar
Commissure
Lateral chin
Preoperative marking of lips and chin for location to transfer fat and location of stab
wounds to introduce the fat grafting cannulas.

• 1% lidocaine with 1:100,000 epinephrine is used for an infraorbital and mental
block. A solution of 0.5% lidocaine with 1:200,000 epinephrine is used in the dermis

lip. (A Coleman type III cannula is recommended.)

• Incisions are placed at the commissures; occasionally, an incision is made in a wrinkle
radiating from the lip or a midmalar incision
is used to approach the cutaneous lip.




• Fat needs to be placed with precise
accuracy in the plane immediately deep
to the mucosa or vermilion. Placement
within the muscle only creates a fat lip (Fig.
23-10).

• 0.75-1.25 cc to restructure the white roll
and the same volume for the lower lip rim.
In the body of the upper lip, volumes range
from 0.75-4 cc; the volume used for the
body of the lower lip is twice that used for
the upper lip.

• Placing fat under the skin above the white
roll (and not directly under it) or placing fat under the skin of the upper and lower
lip, creating a “cutaneous lip.”

None. To prevent chapping, tell patients to keep their lips moist with lip
balms or ointments.
Gentle massage of the lips after 1 or 2 weeks on the skin but not on the

encourage lymphatic drainage.
Correct superficial fat placement
Fat used for lip augmenta-
tion should be placed with precise ac-
curacy in the plane immediately deep
to the mucosa or vermilion and should

306
Part V Noninvasive and Minimally Invasive Therapy

the swelling is usually resolved. Cold therapy helps to decrease the swelling time.
Some patients report still being able to feel changes in texture and size of their lips
for up to 8 months.

• Splitting of the lip. Splitting of the lower lip has been seen when the volume

chromic sutures.
SENIOR AUTHOR TIP: If multiple sites are addressed on the face, the lip should be
treated last to prevent contaminating the other areas of the face or body.
To augment the lip with increased vermilion show, fat should not be placed deep to the
cutaneous portion of the lip. This can expand the lip and actually decrease the amount
of vermilion show.
Small lumps are amazingly well tolerated in the lip; large lumps are not.
Flipping the lip outward can shorten the upper lip in two ways:
– By shortening the distance from the columellar base to the height of the Cupid’s
bow—the action of turning up the lip.
– By increasing the amount of vermilion visible—the relative proportion of the
cutaneous lip to the vermilion lip is adjusted.


patients, maxillary incisor show may be less because of a slight descent of the upper lip.
Mandibular incisor show can also be changed during lip augmentation. The aging lip
descends to increase visibility of the lower incisors; raise the entire lip slightly, by placing
more fat into the submucosal plane of the lower lip and sometimes into the orbicularis
oris muscle itself.
The philtrum is approached in one of two ways:
– By simply running a type III cannula up into the philtral columns while placing fat
below the white roll. Although the 90-degree angle may appear sharp, it is usually
easy to navigate.
– By making a central incision in the vermilion about half a centimeter inferior to
the Cupid’s bow and passing a type III cannula up through the base of the philtral
column to the columella. This begins by placing the fat deep using 5-8 passes to
deposit less than 1/30 cc each time.
Augmentation of the muscle will initially evert the lip vermilion and mucosa from edema
overlying the muscle. As the swelling subsides, so does the eversion of the vermilion
and the apparent augmentation.

307
Chapter 23 Fat Grafting
TROUBLESHOOTING1: PATIENTS WHO HAVE HAD PERMANENT FILLERS
PLACED IN THEIR LIPS



Gore-Tex, solid silicone, dermal fat grafts, or fascia grafts. If these substances can be
removed from the lip, they should be removed.
SENIOR AUTHOR TIP: In patients in whom the substance was left in place, the lip
retained an unnatural feel.



is impossible to remove these substances, surgeons who choose to operate on these
patients must devise a careful plan that will NOT make the lips worse.
TEAR TROUGH AND CHEEK 1,2
Preoperative markings of tear trough and cheek for locations to transfer fat and
location of stab wounds to introduce the fat grafting cannulas.
Commissure
Midmalar
Eyebrow
Low temple
Commissure
Midmalar
Eyebrow
Low temple

• A solution of 0.5% lidocaine with 1:200,000 epinephrine using a blunt cannula (type I)
to prevent injuring infraorbital nerve

• Four primary incisions are used on each side: The lateral eyebrow, lateral inferior
temple at the level of the zygomatic arch, lower midmalar region, and the lateral lip.

• For placement against the periosteum of the anterior and lateral malar region: Type I
cannula
• Deep soft tissue: Type II cannula (A curved cannula is used to follow the curvature of
the maxilla and zygoma.)

308
Part V Noninvasive and Minimally Invasive Therapy

• Immediate subdermal plane: This
provides structural support to
the skin that eliminates wrinkles,
reduces pore size, and can lighten
the eyelid skin.
• Anterior malar fold: Fat is placed at
every level from the periosteum to
the skin (Fig. 23-12). This pattern is
used over the entire malar region.
In the midmalar and lateral malar
cheeks, stay deep to provide
structural support.


Fat is placed in the immediate
subdermal plane or in the
orbicularis oculi muscle.

neurovascular injury.






1-3
Between the anterior malar fold and nose
0.25-1
Infraorbital rim lateral to the anterior malar fold

1-5

0.25-1.5
Anterior malar region

1-5
Midmalar cheek

1-7


1-8
Buccal cheek

1-10

• Not feathering over to the nose and leaving an area of depression between the nose
and anterior malar cheek

lower eyelid or if molding the fat into shape
• Overcorrection, especially in the anterior malar fold
Maxilla
Orbicularis oculi
muscle
Infraorbital
fat
Orbital septum
For the anterior malar fold, fat is
placed at every level from the periosteum to
the skin over the entire malar region. In the
midmalar and lateral malar cheeks, stay deep to
provide structural support.

309
Chapter 23 Fat Grafting

Microfoam tape on the lower
eyelids from below the ciliary margin
beyond the limits of fat placement. A layer
of Microfoam tape is placed over the malar
and buccal cheeks (Fig. 23-13). Dressings
are removed between days 3 and 5, and
patients are instructed to start massaging
the treated areas. Ice compresses can be
used, but cautiously if the fat grafting was

cause contour irregularities.
After dressings are removed,
patients should start massaging the treated
areas. They should start gentle downward rolling massage to encourage lymphatic
drainage four to six times a day for 1 minute on each lower eyelid.
Quick. Swelling is usually minimal. Patients may have black and blue
discoloration for a few weeks.

• Contour irregularities from fat deposited in lumps. The problem is corrected by
aspirating the excess fat using a type I cannula or open removal. Some patients
may have prolonged infraorbital hyperpigmentation (probably from hemosiderin
deposits from resolving hematoma).
SENIOR AUTHOR TIP: Note the aperture direction and removal of grafted fat.
Although the direction of the aperture is not usually a concern, keeping the cannula
facing upward toward the skin and maneuvering the cannula so that the fat is between
the cannula and the skin will allow aspiration of unwanted fat easier.
Special care should be taken during fat grafting in the lower eyelid. Only miniscule
amounts are placed with each withdrawal of the cannula. If a visible lump is noted after

postoperatively). Digital pressure and smoothing the fat can be attempted, but if it is


globe (Fig. 23-14). The thumb can also be used to detect the correct level for placement

input can be helpful, particularly along the entire infraorbital rim, from the medial
commissure to the lateral commissure.

detect the position of the cannula more accurately is sometimes helpful. This can be

Continued
Recommended dressing
following malar fat grafting consists
of using Microfoam tape on the lower
eyelids from below the ciliary margin
beyond the limits of fat placement.

310
Part V Noninvasive and Minimally Invasive Therapy

visualization of the skin of the lower eyelid.

proposed height. The attractive malar prominence is usually most protuberant along
a line running from the alar base to the base of the auricular helix. This line is marked
with the patient standing and participating. (I use diamonds to mark this line so there
is no confusion with other marks.) These marks will keep surgeons oriented when

malar prominence is determined, careful attention should be paid to these landmarks
to ensure the prominence will be maintained in an attractive direction and level.


such situations, surgeons can try to force a plane in the tissue with a type I or II cannula.
After a plane is somewhat established, a type III cannula is used for fat placement. This
does not always work, but I have found it helpful many times.
The use of a V-dissector in the periorbital region is not recommended.

the globe. The thumb can also be used to detect the correct level for placement and to guide the

COMPLICATIONS
Inaccurate volume causing undercorrection or overcorrection
Poor preoperative planning, fat necrosis, poor viability of fat caused by excessive
negative pressure during fat harvest, exposure to air, mechanical trauma during
harvesting, or placement

311
Chapter 23 Fat Grafting
FATE OF TRANSPLANTED ADIPOCYTES
In vitro studies showed that transplanted adipocytes are susceptible to an ischemic
death, whereas adipose-derived stromal cells can remain viable for 3 days.
Most adipocytes died on day 1, with only some survivors.
Seven days after grafting, there was an increase in viable adipocytes, suggesting that
repair and regeneration of dead adipocytes was under way.
There are of transplanted fat:
1. A surviving area (adipocytes survived)
2. A regeneration area (adipocytes died and adipose-derived stromal cells survived to
replace dead adipocytes)
3. A necrotic area (where both adipocytes and adipose-derived stromal cells died)



results in central necrosis and depression.
• Fat placement is isolated, without feathering or intradermal placement.

• Muscle motion causes intrinsic pressure and displacement, which occurs most often
around the glabella.
• External pressure can displace recently transplanted fat. Patients should not
manipulate treated areas or wear objects that can cause pressure such as glasses
and hats.

• Proper surgical scrub at the donor and recipient sites
• Perioperative antibiotics
• Antiviral prophylaxis in patients with history of fever sores if fat is grafted around
mouth

from sponges or Telfa used to wick fatty oils.
TIP: Use Codman neuropad to prevent this complication.

• Almost always temporary
• Most likely to occur if sharp needle is used to inject fat; preventable when blunt
cannulas are used
caused by needles or cannulas and is most noticeable in the face
caused by needles or cannulas and may result in parotitis
at harvest/recipient sites causing prolonged erythema and

TIP: Using a patient’s own residual oil left over from the fat harvest can lubricate the
cannula and minimize this problem.

312
Part V Noninvasive and Minimally Invasive Therapy




• Intraarterial injection of fat will result in excruciating pain followed by skin loss.
• Central arterial injection can cause blindness, stroke, and soft tissue necrosis. This

and supraorbital arteries.
SENIOR AUTHOR TIP: There are ways to prevent complications caused by intraarterial
injections.1
Do not use sharp cannulas or needles; instead, use larger, blunt cannulas.
Use epinephrine—a vasoconstricted vessel is much harder to cannulate than a dilated
one.
Inject small volumes (1/10 cc) around danger areas.

syringe than a 10 or 20 cc syringe.
Do not use mechanical assistance devices for injecting fat that can generate high and
destructive pressures in soft tissues.
TOP TAKEAWAYS

There is no

Fat sticking to the Codman neuropad is an indication that the fat has been
exposed to the air too long and should be discarded.

Incisions should be placed in wrinkle lines, folds, or hair-bearing areas.

Postoperative edema is the most common problem.
REFERENCES
1. Coleman SR. Structural Fat Grafting. New York: Thieme Publishers, 2004.
2. Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg 24:347, 1997.

Surg 19:421, 1995.

5. Coleman SR. Hand rejuvenation with structural fat grafting. Plast Reconstr Surg 110:1731;
discussion 1745, 2002.
6. Eto H, Kato H, Suga H, et al. The fate of adipocytes after nonvascularized fat grafting: evidence
of early death and replacement of adipocytes. Plast Reconstr Surg 129:1081, 2012.

313
PROMINENT VEINS1
Can occur in the presence or absence of either symptoms or an underlying functional
venous disorder2
Present in up to of individuals
include:
• Advancing age
• Family history

• Prolonged standing
• Increased BMI
• Smoking
• Sedentary lifestyle
• History of trauma
• History of venous thrombosis
• Arteriovenous shunting
• High estrogen states, including pregnancy in women
often referred to as spider veins, are most common.
3

• Improvement of symptoms (including pain or aching, heaviness, swelling, dry and/
or irritated skin, and tightness)
• Improvement of appearance
TREATMENT OPTIONS
CONSERVATIVE MANAGEMENT
Extremity elevation
Exercise
Compression therapy
SCLEROTHERAPY


Appropriate for the treatment of telangiectasias, reticular veins, and small varicose
veins4

Acute venous thrombosis or phlebitis
Pregnancy
Diabetes mellitus (relative)

314
Part V Noninvasive and Minimally Invasive Therapy
Moderate to severe peripheral artery disease (relative)
Patent foramen ovale (relative)5

For patients who are
distressing, sclerotherapy can be performed after physical examination without further

patients should undergo further evaluation with venous duplex imaging
to identify the presence of

Veins will lighten and become less noticeable but may not completely disappear.

is a relatively common complication.
TIP: Veins are documented photographically before each treatment and reviewed
with the patient periodically.

Common Sclerosing Agents for the Treatment of Prominent Veins


Size





Maxi

Dose


Sodium
tetradecyl
sulfate
0.3-1
1-3
3-5

0.1-0.25
0.25-0.5
0.5-1
1-3
0.25
0.5
0.5-1
1-2
10 ml
of
3%

telangiectatic
matting
Allergy
Hyperpigmentation
at high
concentrations
Ulceration/necrosis
Polidocanol
<0.5
0.5-1
1-3
0.25
0.5
1
0.1-0.3
0.1-0.3
0.1-0.3
2 mg/
kg
Painless
Nontoxic
Rare ulceration
No necrosis
Allergy
Telangiectatic
matting
Hyperpigmentation
Hypertonic
saline
<0.5
0.5-1
1-3
11.7
11.7
23.4
0.25
0.5
0.5-1
None
No allergy
Pain
Muscle cramping
Ulceration/necrosis
Hyperpigmentation
Glycerin8
<1
25-72
0.25
10 ml
of
72%
No matting
No ulceration
No necrosis
Contact sensitivity
Urethral colic
Hematuria (rare)

approved

315
Chapter 24 Treatment of Prominent Veins

Sclerosants may be used in their liquid form or mixed with room air as a foam, to
increase their surface area for the treatment of larger veins.
involves using a three-way stopcock and two syringes, mixing air with
liquid to create a foam.9
After the sclerosant liquid or foam (with or without lidocaine) is mixed into a syringe at
the appropriate concentration, attach the syringe to a 27- or 30-gauge needle.
Place the patient in
Apply alcohol to clean the area, introduce the needle into the vein,

sclerosant.
Withdraw the needle, apply compression, and massage the treated area to prevent

Secure a compressive dressing in place with tape while advancing to other treatment
areas.
SENIOR AUTHOR TIP: The use of 2-way Baxa connectors are an easier, more rapid
way to generate foam.
TIP:
telangiectasias are treated.

Compressive stockings should be worn continuously for at least 24 hours and then daily
for 2-3 weeks.10
Avoid strenuous exercise and sun exposure for 2-4 weeks.
Repeat injections are not performed for at least 4-6 weeks.
Clearance of of treated telangiectasias, reticular veins, and small varicose
veins can be expected.11
SENIOR AUTHOR TIP: In the sclerotherapy consultation, inform patients that new
spider veins will occur over time and annual maintenance treatments are encouraged.
12

• Pain
•
Reported incidence: 1%-5% of patients treated
Usually small and heal with local wound care in 4-6 weeks
•

Relatively common, occurring in 15%-24% of patients
Usually resolves
13

316
Part V Noninvasive and Minimally Invasive Therapy
Check for the presence of local feeding vessels
Consider treating using sclerotherapy with 72% glycerin
Minimize incidence by using the minimum strength concentration of sclerosant

•
Caused by deposition of hemosiderin in the skin
Occurs in up to 30% of patients
Resolves spontaneously in 80% of patients within 2 years
SENIOR AUTHOR TIP: Minimize incidence of matting and hyperpigmentation by using


•
•
• events
Occur in <1% of patients
Symptoms include visual disturbance (scotoma), migraine-like headache, and

•
LASER THERAPY
14
Patients who do not tolerate or fail sclerotherapy

Needle phobia on the part of the patient

Acute venous thrombosis or phlebitis
Pregnancy
Diabetes mellitus (relative)
Moderate to severe peripheral artery disease (relative)
Fitzpatrick skin types III-VI (relative)
TIP: A test spot should be performed before proceeding with laser therapy on
patients with Fitzpatrick skin types III-VI out of concern for either hyperpigmentation
or hypopigmentation.


a physical examination.

Multiple treatments are typically required.
Alterations in skin pigmentation can occur.

317
Chapter 24 Treatment of Prominent Veins

Common Laser and Light Sources for the Treatment of Prominent Veins









Alexandrite
755

I/II/III
High penetration
depth

Purpura
Telangiectatic
matting
Diode
800, 810,
940, 980
<4
I/II/III/IV
Treats larger veins
Unpredictable
results
KTP
532
0.5-1.5
I-III

Pigmentary
changes
Nd:YAG
1064
0.3-3.0
I-IV
High clearance
rate

changes
Pain

585-595
<1.5
I-III

changes
Purpura

585+
<1 (red)
I-III



Intense pulsed light; KTP, potassium titanyl phosphate; neodymium:yttrium-aluminum-
garnet; PDL, pulsed dye laser.

The U.S. Occupational Safety and Health Administration (OSHA) requires that
protective eyewear be worn when operating class 4 lasers.
Enter the selected treatment parameters into the laser/light control panel.
First, cool the skin, and then activate the laser/light over the target vessel or vessels.
A visible clearing of the vein should be seen, but, if not, the vessel can be treated again
and/or the laser parameters can be adjusted.
CAUTION:


No dressings are needed.
Patients may return to their normal daily activities immediately.
Avoidance of sun exposure to the treated areas is critical.
Repeat therapy may be performed within 4-8 weeks.


• Pain
Usually lasts only seconds to minutes after treatment
Application of topical anesthetic for 30-60 minutes prior may lessen pain
16

318
Part V Noninvasive and Minimally Invasive Therapy

Common in patients with skin types III-VI
Usually develop within 3 weeks after treatment
Hyperpigmentation—usually temporary
Hypopigmentation—may be permanent
• Telangiectatic matting


May take up to 6 weeks to resolve
Rarely has sequelae
ENDOVENOUS LASER ABLATION
Percutaneous technique using
(i.e., great, small, or accessory saphenous veins) are the primary target for
this therapy.
Varicose vein recurrence reported to occur in 7%-14% of patients in the long-term 17

Venous thrombosis or phlebitis
Pregnancy
Moderate to severe peripheral artery disease
Severe tortuosity, which may limit passage of the device



Bruising/hematoma
Skin burns

Deep venous thrombosis (DVT)
Cutaneous nerve injury18
RADIOFREQUENCY ABLATION
Percutaneous technique that uses to ablate incompetent veins
(i.e., great, small, or accessory saphenous veins) are the primary target, but
intersaphenous veins or perforator veins can also be treated with specialized probes

Venous thrombosis or phlebitis
Pregnancy
Diabetes mellitus
Moderate to severe peripheral artery disease
19


DVT
Cutaneous nerve injury

319
Chapter 24 Treatment of Prominent Veins
NONENDOTHERMAL ENDOVENOUS ABLATION
Percutaneous access, with direct injection into saphenous veins
1% Polidocanol microfoam-injected directly into the saphenous veins. FDA approved for
treatment of the great saphenous vein and tributaries
Cyanoacrylate glue: Injected directly into the saphenous veins. FDA approved for
treatment of the great saphenous vein and tibutaries
SURGERY

Remains the standard to which other techniques are compared
Most commonly used to manage
(e.g., varicose vein hemorrhage, recurrent phlebitis)
Surgical techniques involve ligation and/or removal of veins through multiple incisions.

• Saphenous vein inversion and removal
• High ligation of the saphenous vein
• Ambulatory phlebectomy
• Transilluminated phlebectomy
• Conservative venous ligation (CHIVA)
• Perforator ligation
Surgical techniques are associated with 20%-28% varicose vein recurrence rates.20

Venous thrombosis or phlebitis
Diabetes mellitus
Moderate to severe peripheral artery disease


Bruising/hematoma
Infection

DVT
Cutaneous nerve injury

TOP TAKEAWAYS

Sclerosants may be used in their liquid form or as a foam to increase their
surface area for the treatment of larger veins.

Clearance of 60%-80% of treated telangiectasias, reticular veins, and small
varicose veins can be expected.

To prevent burns, no more than three attempts should be made over the same
area.

Never double pulse veins with diode or 1064 Nd:YAG laser.

A test spot should be performed before proceeding with laser therapy on
patients with Fitzpatrick skin types III-VI.

The U.S. Occupational Safety and Health Administration (OSHA) requires that
protective eyewear be worn when operating class 4 lasers.

320
Part V Noninvasive and Minimally Invasive Therapy
REFERENCES
1. Callam MJ. Epidemiology of varicose veins. Br J Surg 81:167, 1994.

signs, symptoms, and presence of functional disease. J Vasc Surg 46:322, 2007.

Med 31:257, 2002.

the San Diego population study. Arch Intern Med 165:1420, 2005.
-
ectatic matting of the lower extremity: a retrospective analysis. J Dermatol Surg Oncol 16:327,
1990.

Rev 18:CD008826, 2011.
7. Tisi PV, Beverley C, Rees A. Injection sclerotherapy for varicose veins. Cochrane Database Syst
Rev CD001732, 2006.

the treatment of telangiectatic leg veins. Dermatol Surg 29:612; discussion 615, 2003.
-
ment of varicose veins. Dermatol Surg 27:58, 2011.
10. Weiss RA, Sadick NS, Goldman MP, et al. Post-sclerotherapy compression: controlled com-

25:105, 1999.
11. Hamahata A, Yamaki T, Sakurai H. Outcomes of ultrasound-guided foam sclerotherapy for
varicose veins of the lower extremities: a single center experience. Dermatol Surg 37:804,
2001.
12. Munavalli GS, Weiss RA. Complications of sclerotherapy. Semin Cutan Med Surg 26:22, 2007.

great and small saphenous veins: a controlled multicentre prospective study including 1,025
patients. Phlebology 24:131, 2009.

Dermatol Surg 37:729, 2011.

and 755 nm alexandrite lasers for treatment of 0.3-3 mm leg veins. Dermatol Surg 28:224,
2002.

controlled studies evaluating the S-Caine Peel for induction of local anesthesia before long-
pulsed Nd:YAG laser therapy for leg veins. Dermatol Surg 29:1012, 2003.
-

period. J Endovasc Ther 16:500, 2009.
18. Desmyttère J, Grard C, Wassmer B, et al. Endovenous 980-nm laser treatment of saphenous
veins in a series of 500 patients. J Vasc Surg 46:1242, 2007.
-

Vasc Surg 42:502; discussion 509, 2005.
20. Michaels JA, Campbell WB, Brazier JE, et al. Randomised clinical trial, observational study and

Technol Assess 10:1, 2006.