Operative Technique in Plastic Surgery – Kevin C.Chung

FIG 1 • Demonstration of vasculature location and
pathways relative to the nasolabial fold.
NATURAL HISTORY
■ In the aging face, bony recession in the anterior maxilla and pyriform aperture
coupled with deflation and descent of the midface soft tissue leads to
deepening of the nasolabial fold.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Physical findings often include midfacial soft tissue descent, shadowing in the
pyriform region adjacent to the lateral nasal base, deepening of the nasolabial
fold, and evidence of associated perioral aging.
IMAGING
■ We recommend obtaining standardized 2D or 3D photography for preinjection
planning and to assess postinjection results.
MANAGEMENT
Nonoperative management of the nasolabial fold is performed through volume
augmentation with various fillers and in some cases autologous fat. The most
common material used is hyaluronic acid filler through needle or blunt cannula
injection technique.

FIG 2 • The depth relationship between the angular
artery and the targeted depth for needle placement in
nasolabial fold injection.

FIG 3 • The deep pyriform space and surrounding
adjacent structures.
Preoperative Planning
■ Preprocedure photographs should be obtained.
■ Complete history and physical exam along with documentation of drug
allergies and current medications should be recorded.
■ Written informed consent should be obtained to document discussing the
indications, risks, and benefits of the injection. Most importantly, patients
should be educated on the risk of intravascular injections and counseled on the
potential sequelae and treatment following vascular compromise during filler
injection.
■ The skin involved in the area of injection should be cleaned with an alcohol
wipe or antiseptic prep swab.
■ Topical anesthetic can be applied to the nasolabial fold skin and allowed to sit
for 15 to 20 minutes for the anesthetic to take effect.
■ We do not routinely perform infraorbital nerve blocks in our patients.

However, it is certainly a reasonable option in select cases if the injector deems
necessary.
Positioning
■ The patient should be marked sitting up in the chair at 90 degrees.
■ For the injection procedure, we recommend reclining the chair to 45 degrees at
a height comfortable for the injector.
Approach
■ For needle injection, specific entry points along the nasolabial fold are
selected. Typically, we use three needle insertion sites for our linear injections.
The distance between each insertion point often depends on the length of the
needle being used. When using a cross-hatching method, additional needle sites
may be required.
■ For blunt cannula injection, one or two port sites are selected for skin
insertion. The distance between the ports often depends on the length of
cannula being used (FIG 4).
FIG 4 • Needle and blunt cannula insertions sites for
nasolabial fold enhancement.
T E C H N I Q U E S

■ Traditional Needle Injection
Video p1-c012
■ Needle insertion sites at the upper one-third, middle one-third, and inferior
one-third are selected.
■ Once the needle is inserted into the skin at the desired location, the injector
can elevate the needle against the overlying tissues and should see a gentle
“white” blanching of the skin (TECH FIG 1A). If the gray color of the
needle is visible through the skin, then the needle is too superficial and the
injector is at risk of creating a Tyndall effect if the filler is deposited at this
level.
■ The injector will perform a gentle subcision release with the needle and then
perform retrograde injection with the bevel facing down (TECH FIG 1B).
■ Sequential linear injections in the reticular dermis or immediate subcutis are
performed in a cranial to caudal direction (TECH FIG 1C).
■ Once the liner injections are completed, the injector can perform cross-
hatching injections horizontally across the fold to smooth out any contour
irregularities. These are performed in a cranial to caudal direction (TECH
FIG 1D).
■ To guide proper depth placement with the needle during the cross-hatching
injections, the injector can use their noninjecting hand to spread the cheek
tissue. This provides tension and creates a taut fold.
00:00 / 00:00

TECH FIG 1 • A. Needle injection into the nasolabial
fold. Note the gentle blanching of the skin underneath
the needle during subcision. The injector wants to see
a slight white blanching of the skin but does not want
to see the gray color of the needle, which would
indicate a too superficial of a plane. B. The injector’s
assistant can clean blood spotting with a cotton tip
applicator. C. Demonstration of preferred location of
filler placement during nasolabial fold enhancement
with needle injection. D. Demonstration of cross-
hatching technique for nasolabial fold enhancement.
■ Blunt Cannula Injection

■ A common alternative to the traditional needle injection technique is to thread
a blunt cannula immediately subcutaneous in the nasolabial crease.
■ Insertion ports are created with a needle stick, then the blunt cannula is
inserted and passed deep to the reticular dermis in line with desired area of
volume augmentation.
■ Retrograde injection is performed with the blunt cannula until desired result is
achieved.
■ Adding Volume to the Peripyriform Region
■ Recession of the bony pyriform coupled with changes in peripyriform soft
tissues results in a deep pyriform shadow at the superior apex of the nasolabial
fold. A augmentation bolus on the bone within the deep pyriform space re-
establishes support to the peripyriform region and can soften the skin
shadowing.
■ Upon completion of deep pyriform volume augmentation, the injector can
inject intradermal in the peripyriform shadow. We recommend injecting either
intradermally or on the deep bone as the angular artery will travel in a tissue
plane between the dermis and the sub-SMAS (TECH FIG 2).
TECH FIG 2 • A. Demonstration of deep injection into
the deep pyriform space for re-establishing support of
the peripyriform region. B. Demonstration of superficial
injection into the peripyriform shadow for softening the
pyriform shadow.

■ Threading Subcision of the Nasolabial Fold
■ Various methods have been described to perform a threading subcision of the
fold attachments using a wire scalpel or suture threading technique (TECH
FIG 3).
TECH FIG 3 • Medical illustration of the suture
threading technique for nasolabial fold treatment.
■ Additional Methods of Nasolabial Fold Treatment
■ Some surgeons advocate for botulinum toxin injections into the nasolabial fold
as alternative means for fold effacement.
■ Release of the dermal attachments of the mimetic muscles in the nasolabial
fold is also a well-established tenant in rhytidectomy.

PEARLS AND PITFALLS
Needle
placement
■ Needle placement should be within the reticular dermis or immediate
subcutis.
■ The injector can perform a linear retrograde injection technique along
the vertical axis of the fold or “cross-hatch” with small horizontal
injections across the fold.
■ Blunt cannula injection should occur in the subcutaneous plane just
beneath the reticular dermis.
Depth of
injection
■ Be cognizant of the depth of the angular artery (approximately 5 mm
deep to the skin).
■ Be aware of the level at which the angular artery crosses underneath
the nasolabial fold (junction of the proximal third) in a medial to lateral
direction.
■ To confirm depth, the injector should see the white color of blanching
skin but not the gray color of the needle when placing the needle in the
skin. If the injector sees the gray of the needle, the needle location is
too superficial and should be readjusted.
■ We recommend a gentle needle subcision of the fold followed by
retrograde injection of medium-sized hyaluronic acid filler.
POSTOPERATIVE CARE
■ We recommend placing a ice pack on the injected areas following injection
and monitoring the patient in the clinic for 10 to 15 minutes to ensure that there
is no evidence of vascular injury.
■ If performing perioral injections in conjunction with nasolabial fold filler, we
recommend a short course of postinjection antiherpetic prophylaxis.
OUTCOMES
■ The primary goal is softening of the nasolabial fold to improve the shadows
and contour reflections along the fold. The objective is not to completely efface
the fold because this will distort the natural transition between the cheek and
perioral aperture (FIG 5).

FIG 5 • A. Preprocedure photograph in nasolabial fold
enhancement with needle injection technique. B.
Postprocedure photograph in nasolabial fold
enhancement with needle injection technique. The
patient also underwent injections of the marionette
lines.
COMPLICATIONS
■ Postinjection bruising is not an uncommon occurrence. Anecdotally we have
found adjuncts such as Arnica and ice packs help expedite the resolution of the
bruising. Most bruising should resolve within 3 to 5 days.
■ Tyndall effect is a bluish hue within dermis following an injection that was too
superficial. This is the result of light reflection off the deposited hyaluronic
acid filler. The injector can attempt massage to soften the area or dissolve the
filler with a hyaluronidase injection.
■ If you suspect vascular compromise following injection, immediate
hyaluronidase injection is recommended. Doses ranging from 40 to 200 units
are recommended depending on the amount of filler injected and the particle
size of the filler. Inject immediately and repeat as many times as needed until
manifested skin changes improve. Watch the patient very carefully and monitor
them in your office until you feel the problem is resolved.
REFERENCES
1. Arlette JP, Trotter MJ. Anatomic location of hyaluronic acid filler material
injected into nasolabial fold: a histologic study. Dermatol Surg. 2008;34:S56-
S63.

2. Braz A, Humphrey S, Weinkle S, et al. Lower face: clinical anatomy and
regional approaches with injectable fillers. Plast Reconstr Surg. 2015;136:235-
257.
3. Cohen JL, Biesman BS, Dayan SH, et al. Treatment of hyaluronic acid filler–
induced impending necrosis with hyaluronidase: consensus recommendations.
Aesthet Surg J. 2015;35:844-849.
4. Costa CR, Kordestani R, Small KH, Rohrich RJ. Advances and refinement in
hyaluronic acid facial fillers. Plast Reconstr Surg. 2016;138:233-236.
5. Goodier M, Elm K, Wallander I, et al. A randomized comparison of the
efficacy of low volume deep placement cheek injection vs. mid- to deep
dermal nasolabial fold injection technique for the correction of nasolabial
folds. J Cosmet Dermatol. 2014;13:91-98.
6. Lee S, Sung K. Subcision using a spinal needle cannula and a thread for
prominent nasolabial fold correction. Arch Plast Surg. 2013;40(3):256-258.
7. Lupo MP, Smith SR, Thomas JA, et al. Effectiveness of juvéderm ultra plus
dermal filler in the treatment of severe nasolabial folds. Plast Reconstr Surg.
2008;121:289-297.
8. Nguyen AT, Ahmad J, Fagien S, Rohrich RJ. Cosmetic medicine: facial
resurfacing and injectables. Plast Reconstr Surg. 2012;129:142-153.
9. Ozturk CN, Li Y, Tung R, et al. Complications following injection of soft-
tissue fillers. Aesthet Surg J. 2013;33:862-877.
10. Pinsky MA, Thomas JA, Murphy DK, Walker PS. Juvéderm injectable gel: a
multicenter, double-blind, randomized study of safety and effectiveness.
Aesthet Surg J. 2008;28:17-23.
11. Prager W, Wissmueller E, Havermann E, et al. A prospective, split-face,
randomized, comparative study of safety and 12-month longevity of three
formulations of hyaluronic acid dermal filler for treatment of nasolabial folds.
Dermatol Surg. 2012;38(7):1143-1150.
12. Rzany B, DeLorenzi C. Understanding, avoiding, and managing severe filler
complications. Plast Reconstr Surg. 2015;136:196-203.
13. Rubin MG. Treatment of nasolabial folds with fillers. Aesthet Surg J.
2004;24:489-493.
14. Scheuer JF, Sieber DA, Pezeshk RA, et al. Anatomy of the facial danger
zones: maximizing safety during soft-tissue filler injections. Plast Reconstr
Surg. 2017;139:50-58.
15. Sun ZS, Zhu GZ, Wang HB, et al. Clinical outcomes of impending nasal skin
necrosis related to nose and nasolabial fold augmentation with hyaluronic acid

fillers. Plast Reconstr Surg. 2015;136:434-441.
16. Wilson AJ, Taglienti AJ, Chang CS, et al. Current applications of facial
volumization with fillers. Plast Reconstr Surg. 2016;137:872-889.
17. Yang HM, Lee JG, Hu KS, et al. New anatomical insights on the course and
branching patterns of the facial artery: clinical implications of injectable
treatments to the nasolabial fold and nasojugal groove. Plast Reconstr Surg.
2014;133:1077-1082.

13
CHAPTER
Injection of Fillers to the
Lips, Oral Commissures,
Marionette Lines, Prejowl
Area, and Temporal Region
David A. Sieber and Jeffrey M. Kenkel
DEFINITION
■ Hyaluronic acid is a naturally found glycosaminoglycan polymer found in
human tissue that is reversible with hyaluronidase.
ANATOMY
■ The takeoff of the superior labial artery (SLA) from the facial artery is
approximately 1 to 1.2 cm lateral to the superior corner of the mouth (FIG
1A).1,2
■ The SLA then runs superior to the vermilion border, coursing inferiorly
across the border just before reaching the Cupid’s bow.
■ In the upper lip, the SLA is 3 to 8 mm deep to the skin, running in a plane
between the oral mucosa and the orbicularis oris at the junction between the
dry and wet vermilion.
■ The course and location of the inferior labial artery (ILA) are more varied
than those of the SLA; however, the depth of the ILA remains greater than 3
mm beneath the skin.3,4
■ The mental foramen is most commonly situated inferior to the second
premolar and gives way to the mental nerve and artery (FIG 1B).5
■ The frontal branch of the superficial temporal artery (STA) runs within the
temporoparietal fascia (TPF) 2 cm above the zygomatic arch, transitioning to a
completely subcutaneous plane just superior to the brow and lateral to the
lateral border of the frontalis (FIG 1C).6,7

■ The middle temporal vein runs 2 cm above and parallel to the zygomatic arch
within the superficial temporal fat pad.8
PATIENT HISTORY AND PHYSICAL FINDINGS
■ There are three components that define attractive and youthful lip aesthetics9:
■ Shape and definition of the white roll
■ Shape and projection of vermilion
■ Shape and volume of red roll
■ Younger patients typically present desiring enhancement (volume and/or
projection) of their existing lip shape.
■ Older patients often have lost definition of their white roll and Cupid’s bow as
they age. There is also significant volume loss in the lips, contributing to the
appearance of perioral rhytids.
■ Patients also present complaining of down-turned commissures saying they
have a “sad” or “angry” appearance to their mouth.

FIG 1 • A. Location of the facial, superficial labial, and
inferior labial arteries as they relate to anatomical
landmarks. B. Location of the mental foramen along the
mandibular border. C. Location of the superficial
temporal artery, transverse branch of superficial
temporal artery, and middle temporal vein.
■ Other common patient complaints are jowling or excess skin and soft tissue
hanging from their mandibular border and temporal hollowing with aging.
NONOPERATIVE MANAGEMENT
■ The senior author’s preference is to use hyaluronic acid fillers owing to their
temporary nature and ability to be reversed through the use of hyaluronidase.
■ A topical anesthetic may be used along with ice prior to injection to make the
patient more comfortable.
■ The skin is always prepped using a swab containing 4% chlorhexidine
gluconate prior to injection.
■ Injections can be performed with a 30-gauge needle, 27-gauge needle, 25-

gauge cannula, or 27-gauge cannula.
■ The patient should be comfortably seated in an upright position.
■ Injections are made from a standing position beside the patient.
T E C H N I Q U E S
■ Injection of Filler Into the Lips, Oral
Commissures, or Marionette Lines
Preparation
■ For most hyaluronic acid products, the authors add 0.2 cc of 0.5% lidocaine
with epinephrine using a Luer-lok-to-Luer-Lok connector to constrict local
blood vessels, reducing the incidence of postprocedural ecchymosis.
■ The authors’ preference is to use a 30-gauge needle for injections of the lips
and marionette lines, which allows for better control in their hands.
Lips
■ If the patient needs further enhancement of the white roll, injections are
typically started at the lateral border of the lip.
■ The needle is advanced into a precise location beneath the white roll,
filling the area using an antegrade or retrograde linear threading technique.
■ Serial injections are continued until the midline portion of the white roll
has been treated, reestablishing an aesthetically pleasing lip shape.
■ Very small amounts are needed and seldom greater than 0.2 mL per side.
■ Next, lip volume and projection are addressed again using a linear threading
technique.
■ For lip volume, the product is placed at or just posterior to the red line.
■ For lip projection, the product is placed 2 mm beneath the white roll, at the
dry vermilion.
■ A single vertical injection is done in the center of Cupid’s bow for better
definition of the tubercle.
■ Dermal injections along the lateral borders of Cupid’s bow may help better
delineate the lateral borders of Cupid’s bow.
Oral Commissures

■ A triangle-shaped injection is performed at the inferior commissure to help
lift the corners of the mouth and refill areas of soft tissue deflation.
■ Cross-hatching of the product is often necessary and may be more
efficacious when placed in the deeper dermis.
■ A retrograde serial puncture technique is used to place a small amount of
product within the fine radial, vertical lines around the lips in an intradermal
plane.
■ Care is taken to manually massage product in the lips, and the commissures
as this area can be palpable to the patient.
■ Overly aggressive massage in the perioral region may lead to exaggerated
and prolonged lip edema.
Marionette Lines
■ Marionette lines are approached starting near the oral commissure.
■ Using a linear technique, the needle is inserted into the deep dermis or
subdermal location parallel to the marionette line, and filler is placed fairly
superficially until the desire result is achieved.
■ Additional cross-hatching may be necessary depending on the degree of
reinflation required.
■ The deformity may extend down to the mandibular border in some patients
requiring more volume.
■ Some areas may need to be gently massaged to ensure there are no palpable
nodules.
■ Injection of Fillers in the Prejowl Area
■ For most hyaluronic acid injections in the prejowl region, the authors add 0.2
cc of 0.5% lidocaine with epinephrine using a Luer-Lok-to-Luer-Lok
connector to constrict local blood vessels, reducing the incidence of
postprocedural ecchymosis.
■ A serial puncture technique may be done with a needle, but it is the authors’
preference to treat the prejowl area with a cannula.
■ A filler with a higher G′ is preferred for use in this area
■ The index finger or thumb of the nondominant hand is placed below the
inferior border of the mandible to ensure no product is placed below this
point, which would give the illusion of lengthening the mandible in the

vertical plane.
■ A common portal is created using a needle just lateral to the jowl area
needing correction.
■ The cannula is then used to place product in a subcutaneous plane along the
mandible.
■ At all times, the index finger or thumb of the nondominant hand is checking
to ensure the cannula remains superior to the inferior border of the mandible.
■ After correction, product is very gently massaged to ensure there are no
palpable areas.
■ Injection of Fillers in the Temporal Region
■ For temporal injections, the hyaluronic acid being injected is diluted with 0.5
cc of 0.5% lidocaine with epinephrine 1:100 000 using a Luer-Lok-to-Luer-
Lok connector.
■ The addition of epinephrine to the filler helps to constrict local blood vessels
and prevent postprocedural ecchymosis.
■ Injections can be performed with a 27-gauge needle, 25-gauge cannula, or
27-gauge cannula. The authors’ preference is to use a 27-gauge needle for
injection of the temporal area.
■ A superficial or deep injection may be used in this area. It is the authors’
preferred approach to perform a deep injection for correction.
■ The needle should be inserted 1 cm above and 1 cm lateral to the temporal
crest.
■ The needle is inserted directly down to the bone, and product is injected onto
the periosteum until desired correction is achieved.
■ Slight compression at the hairline may help keep the product more anterior,
where its impact is seen.
■ The product can be gently massaged to create an even appearance.
PEARLS AND PITFALLS
Lips, oral
commissures,
■ Knowledge of the location of the labial artery between the oral
mucosa and orbicularis oris helps to prevent ecchymosis and

and marionette
lines
intravascular injections.
■ The superior labial artery commonly crosses the white roll at
the lateral third of the upper lip. Injections should be very
superficial at this location to avoid injury.
■ Proper product placement can effectively improve projection,
volume, and definition of the lips.
■ Volume loss at the commissures is common and benefits from
correction with product.
■ The patients should be reassured that the product may be
palpable for up to 7–10 days.
Prejowl area
■ This area can be fibrous and difficult to pass a cannula. If
serial puncture is performed, the product must be massaged so
a homogenous result may be achieved.
■ Care must be taken to avoid inadvertent injury to the mental
nerve, which lies in this area.
Temporal region
■ Be cautious of any superficial veins while injecting as these
may lead to unnecessary bleeding and bruising.
POSTOPERATIVE CARE
■ Patients are sent home with small packs of ice and may apply as needed for
swelling and/or bruising.
■ Patients should keep their heads elevated for a few hours after injection and
should abstain from exercise for 24 hours.
OUTCOMES
■ Excellent outcomes are achievable through replacement of lost lip volume,
enhancement of lip shape, improvement in the appearance of radial perioral
rhytids, restoration of lost volume around the oral commissures, and correction
of the prejowl area and temporal hallowing (FIGS 2 to 5).
■ Restoration of lost lip/perioral volume also reduces the prominence of the
nasolabial folds and marionette lines (see FIG 3).
COMPLICATIONS
■ Patients should be counseled on possible risks of procedure, including
bleeding, bruising, facial asymmetry, and intravascular injection leading to skin
necrosis and/or blindness.

FIG 2 • A 34-year-old woman before (A) and after (B)
injection of 1 cc Juvaderm Ultra Plus into her perioral lip
lines.
FIG 3 • A 50-year-old woman before (A) and after (B)
treatment with a total of 2 cc Restylane Silk placed into
her lips, nasolabial folds, and marionette lines.

FIG 4 • A 62-year-old woman before (A) and after (B)
treatment with 0.5 cc Restylane placed into each
prejowl region.

FIG 5 • A 66-year-old woman before (A) and after (B)
injection of 0.5 cc Restylane Lyft into each temporal
region/lateral brow, 1 cc total of Restylane Silk into the
lips/perioral region, and 0.4 cc Restylane Lyft into each
prejowl region.
REFERENCES
1. Magden O, Edizer M, Atabey A, et al. Cadaveric study of the arterial anatomy
of the upper lip. Plast Reconstr Surg. 2004;114:355-359.
2. Tansatit T, Apinuntrum P, Phetudom T. A typical pattern of the labial arteries
with implication for lip augmentation with injectable fillers. Aesthetic Plast
Surg. 2014;38:1083-1089.
3. Al-Hoqail RA, Meguid EM. Anatomic dissection of the arterial supply of the
lips: an anatomical and analytical approach. J Craniofac Surg. 2008;19:785-
794.
4. Pinar YA, Bilge O, Govsa F. Anatomic study of the blood supply of perioral
region. Clin Anat. 2005;18:330-339.
5. von Arx T, Friedli M, Sendi P, et al. Location and dimensions of the mental
foramen: a radiographic analysis by using cone-beam computed tomography. J
Endod. 2013;39:1522-1528.
6. Lee JG, Yang HM, Hu KS, et al. Frontal branch of the superficial temporal
artery: anatomical study and clinical implications regarding injectable
treatments. Surg Radiol Anat. 2015;37:61-68.
7. Trussler AP, Stephan P, Hatef D, et al. The frontal branch of the facial nerve
across the zygomatic arch: anatomical relevance of the high-SMAS technique.
Plast Reconstr Surg. 2010;125:1221-1229.
8. Jung W, Youn KH, Won SY, et al. Clinical implications of the middle temporal
vein with regard to temporal fossa augmentation. Dermatol Surg. 2014;40:618-
623.
9. Surek CC, Guisantes E, Schnarr K, et al. “No-touch” technique for lip
enhancement. Plast Reconstr Surg. 2016;138:603e-613e.

14
CHAPTERInjection of Filler to the Nose
T. Jonathan Kurkjian, Jamil Ahmad, and Rod J. Rohrich
DEFINITION
■ Volume deficiencies of the nose including both congenital and postoperative
deformities
■ Contour irregularities of the postoperative nose
ANATOMY
■ The nose is constituted of multiple layers. From deep to superficial, these
layers consist of the mucosal lining, osteocartilaginous framework,
musculoaponeurotic tissue, subcutaneous fat, and skin.
■ The aesthetic subunits of the external nose include the nasal tip, dorsum,
sidewalls, columella, soft tissue triangles, and paired alae (FIG 1).1
■ The vasculature of the nose has contributions from both the internal and
external carotid systems by way of the ophthalmic and facial artery,
respectively. The arterial arcades are located superficial to the
musculoaponeurotic layer. The subdermal plexus is located in a more
superficial location deep to the dermis.

FIG 1 • Aesthetic subunits of the nose include the nasal
dorsum, sidewall, tip, soft tissue triangle, ala, and
columella.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The patient history and physical findings are fundamental components to
determine if soft tissue filler injection to the nose is an appropriate option.
■ Careful understanding of the patient’s aesthetic complaints is critical to
formulating the treatment plan.
■ Physical examination must include a detailed nasal aesthetic analysis to
determine the specific nasal deformities. An internal nasal examination should
always be a part of the complete nasal examination.
■ The patient’s history of previous nasal trauma, surgery, and soft tissue filler
injections should be documented. Careful examination for surgical scars is also
warranted to confirm the provided history.
■ Assessment of skin thickness and cicatrix is absolutely critical to planning safe
soft tissue filler injections.

IMAGING
■ High-resolution digital photography should be used to obtain standard nasal
views. These views include frontal, lateral (left and right), oblique (left and
right), and basal views.
■ Preinjection computer imaging can be used to simulate results prior to
injection.
■ Preinjection imaging is particularly useful for the patient who has a
preconceived treatment plan.
■ Although computer imaging enables involvement of the patient in the
planning process, great care should be taken to communicate that there is no
implied guarantee of results.
SURGICAL MANAGEMENT
Preoperative Planning
■ Review of the patient’s history is important to ensure that patients do not take
any medications that may make them more prone to bleeding as this may
increase the propensity for postinjection bruising.
■ Photographs should be available for preinjection planning and reassessment
during treatment.
■ Only hyaluronic acid gel fillers are used (ie, Restylane [Medicis, Scottsdale,
AZ], Juvederm [Allergan, Irvine, CA]). Particulate-based fillers (ie, Sculptra
[Valeant, Bridgewater, NJ], Radiesse [Merz, San Mateo, CA), are not used to
avoid long-term palpability.2
■ Soft tissue filler choice is determined by the aesthetic subunit that is to be
injected.
■ Restylane has a higher level of cross-linking and lower hydrophilicity; thus,
it is used for the nasal dorsum and sidewalls.
■ Juvederm Ultra or Juvederm Ultra Plus tends to be more malleable several
days after injection. This ability to mold Juvederm proves to be helpful for the
aesthetically sensitive nasal tip and ala.2
Positioning
■ The patient should be positioned in an exam chair so that he or she is
comfortable and thus less likely to require a change of position during the
procedure. Typically, the patient is positioned with the feet slightly elevated
and the chair back slightly reclined.

Approach
■ Transcutaneous syringe injection approach is preferred as a more sterile route
than a transmucosal injection.
T E C H N I Q U E S
■ Some patients may require the skin to be anesthetized with topical
anesthetic. The injector may also use 1% lidocaine with epinephrine to
perform a nerve block to bilateral maxillary divisions of the trigeminal nerve.
The resulting vasoconstriction can theoretically help minimize the risk for
intravascular injection. However, vasoconstriction may prevent recognition
of vascular compromise of the skin.
■ Proper cleansing of the skin prior to injection can help avoid infectious
complications. All makeup should be removed, and the skin should be
cleansed with chlorhexidine.
■ Aspiration prior to each injection is critical to help prevent intravascular
injection and associated sequelae including tissue necrosis and blindness.
■ All injections should be completed with small volumes and with minimal
pressure to avoid contour deformities and intravascular injection. It is critical
that all injections are deep to avoid palpability and intravascular injection.
■ Gentle massage of the hyaluronic acid can assist with even distribution of
the product.
■ The injector should allow 15 minutes to pass prior to assessing the final
contour. This gives sufficient time for the product to diffuse fully.
■ Skin color and turgor should be assessed continuously throughout the
procedure as an indication of proper soft tissue perfusion.
■ Injection volumes must be monitored closely to help avoid pressure necrosis.
■ The technique of nasal injection depends significantly on the aesthetic
subunit that is being injected.
■ Injection of the Nasal Dorsum

Video p1-c014_01
■ The threading injection technique is preferred to maintain the linear
conformation of the dorsum. The needle is inserted along the long axis of the
nose, thus respecting the dorsal aesthetic lines while pursuing a more
pleasing profile. Careful injection deep along the nasal bone and midvault
cartilages will help prevent visibility and palpability of product (TECH FIG
1).2
TECH FIG 1 • Linear threading injection technique.
The needle is inserted to its full length along a
distance and the filler is then injected uniformly with
removal of the needle.
■ Injection of the Nasal Sidewall
■ Injection of the nasal sidewall should be avoided due to the inherent risk of
intravascular injection. If sidewall injection is necessary, a cross-hatching
00:00 / 00:00

technique is the preferred method of injection to assist with uniform volume
augmentation of the relatively flat nasal sidewall. The needle is inserted
parallel to the sidewall thus maintaining a deep supraperiosteal plane during
injection (TECH FIG 2).1,2
TECH FIG 2 • Cross-hatching injection technique. The
needle is inserted in a grid pattern to achieve a
smooth contour over a flat plane.
■ Injection of the Nasal Tip/ala

Video p1-c001_02
Video p1-c001_03
■ The nasal tip and ala are injected with a serial injection technique using
small aliquots of hyaluronic acid. It is particularly important to continuously
monitor the skin of the nasal tip during injection for any blanching, which
may indicate hypoperfusion due to excessive pressure (TECH FIG 3).2
■ Soft tissue filler should never be injected along the alar groove to avoid
intravascular injection into the lateral nasal artery.
■ In order to avoid contour deformities, the filler should be injected deep and
never along the alar rim.
00:00 / 00:00
00:00 / 00:00

TECH FIG 3 • Serial puncture injection technique. The
needle is inserted to a shallow depth, and a small
aliquot of filler is injected to maximize accuracy and
precision.
PEARLS AND PITFALLS
Clinical
assessment
■ Accurate clinical assessment is absolutely necessary to achieve
optimal aesthetic results.
Filler
choice
■ Hyaluronic acids are the safest and most forgiving products to use
for soft tissue filler injection of the nose.
■ Restylane is the preferred soft tissue filler for the nasal dorsum and
sidewalls.
■ Juvederm is preferred for the nasal tip and ala.
Technique
■ Each anatomic subunit of the nose is best treated with a specific
injection technique, thus enabling accurate and reproducible volume
augmentation.
■ Aspiration is recommended prior to each injection to minimize the
risk for intravascular injection.
Necrosis
■ The skin should be continuously monitored for any signs of
hypoperfusion that may occur as a result of intravascular injection or
pressure necrosis.
■ Injection into the previously operated nose should be performed by
those with significant injection experience and understanding of the
altered blood supply.

POSTOPERATIVE CARE
■ Patients are advised to avoid pressure to the injected areas for 2 weeks because
it may impact the aesthetic outcome.
■ For 24 hours after injection, patients are instructed to avoid exercise, alcohol,
and aspirin to minimize the risk of bruising.
OUTCOMES
■ The aesthetic outcomes depend greatly on the clinical analysis of the nose
prior to injection.
■ Clinical experience indicates that Juvederm Ultra/Ultra Plus or Restylane can
persist in the nose for 2 to 3 years as opposed to the shorter durations seen with
injection to other locations in the face (FIGS 2 and 3).3

FIG 2 • Low radix and inadequate dorsal and tip
projection. Preprocedure (left) and postprocedure (right)
views of a 19-year-old woman with a low radix and
inadequate dorsal projection. She was treated with 0.8
mL of Restylane to the dorsum and radix and 0.1 mL of
Juvederm to the nasal tip.

FIG 3 • Asymmetric dorsal aesthetic lines and low radix.
Preprocedure (left) and postprocedure (right) views of a
26-year-old woman with asymmetric dorsal aesthetic
lines, narrow midvault, and low radix. She was treated
with 0.3 mL of Restylane to the left nasal sidewall and
0.2 mL of Restylane to the right nasal sidewall and 0.5
mL of Restylane to the radix and nasal dorsum.

COMPLICATIONS
■ Intravascular injection of hyaluronic acid may cause local tissue necrosis and
even blindness. To avoid this complication, aspiration should always be
attempted prior to each injection. Small needles (27 g or smaller) are preferred
with careful attention to minimize pressure of injection.
■ Pressure necrosis can result from volume injected in excess to the compliance
of the overlying soft tissue and skin. This complication is more common in the
previously operated nose where cicatrix can greatly reduce the pliability of the
skin.
■ If skin blanching is observed, the injection should be stopped immediately. If
the blanching does not improve, hyaluronidase should be injected into the area.
If the skin still appears to be hypoperfused, the patient should be started on
oral aspirin and topical nitropaste. If a wound results, hyperbaric oxygen may
assist with wound healing (FIG 4).2
FIG 4 • Management of tissue necrosis. A.
Preprocedure view of a 36-year-old woman with
asymmetry of the nasal tip including an irregularity of
right tip-alar junction and an over-reduced nasal tip after
eight previous rhinoplasty surgeries. She was injected
with 0.1 mL of Juvederm Voluma to the right tip-alar
junction and 0.2 mL to the supratip and left tip-alar

junction. B. At 6 days postprocedure, she began to
show signs of tissue necrosis. Three separate injections
at 10-minute intervals delivering a total of 30 units of
hyaluronidase in 1.5 mL of 2% lidocaine were injected
to the nasal tip, alae, dorsum, and sidewalls. The
patient was started on 81 mg aspirin daily, and
nitropaste was applied topically every 8 hours.
Hyperbaric oxygen treatment was started and she had
a total of 12 sessions. C. At 8 days postprocedure with
the maximum amount of tissue necrosis that she
experienced. D. At 6 months after the initial injection. E.
After injection of 0.1 mL of Juvederm Refine to the right
tip-alar junction and 0.05 mL to the left tip-alar junction
over two treatment sessions at 4-week intervals. Both
the type of product and the volume injected during the
session may have contributed to this complication.
(From Kurkjian TJ, Ahmad J, Rohrich RJ. Soft-tissue
fillers in rhinoplasty. Plast Reconstr Surg.
2014;133:121e-126e, with permission.)
REFERENCES
1. Millard DR Jr. Aesthetic reconstructive rhinoplasty. Clin Plast Surg.
1981;8(2):169-175.
2. Kurkjian TJ, Ahmad J, Rohrich RJ. Soft tissue fillers in rhinoplasty. Plast
Reconstr Surg. 2014;133(2):121e.
3. Rohrich RJ, Ghavami A, Crosby MA. The role of hyaluronic acid fillers
(Restylane) in facial cosmetic surgery: review and technical considerations.
Plast Reconstr Surg. 2007;120(Suppl 6):41S-54S.

15
CHAPTER
Section III: Fat Grafting of
the Face
Fat Grafting at the Time of
Facelifting
Sammy Sinno and James M. Stuzin
DEFINITION
■ The aging face is characterized by complex problems that evolve over time.
■ Fat descent, deflation, and radial expansion of fat away from the central face
contribute to some of the changes seen with aging.
■ The goal of a facelift is to surgically reposition fat to create a more youthful
facial contour. Surgery alone, however, cannot treat deflation of fat that occurs
with age.
■ Autologous fat grafting has become a common technique utilized by most
surgeons today performing facial rejuvenation.1 In addition to treating volume
deflation, fat can make smooth the noticeable demarcations between aesthetic
regions in the face that occur with aging.
ANATOMY
■ Studies have identified precise anatomic compartments of the face where fat
should ideally be placed.2,3
■ The anatomy of the deep malar compartment has only been recently
elucidated, clarifying that there is deep volumetric support that exists in the
plane deep to the mimetic muscles and superficial to the periosteum of the orbit
and anterior cheek.4 This deep fat system provides volumetric support between
the lower eyelid and anterior cheek in youth.
■ The medial deep malar compartment is situated along the pyriform aperture

and blends the anterior cheek with the perioral region in youth. Similarly, the
central aspect of the deep malar fat pad abuts the buccal extension of the
buccal fat pad, allowing for a smooth blending of contour between the lateral
cheek and the anterior cheek. Augmenting this compartment is critical to
correct the deep deflation that occurs with aging.1
PATIENT HISTORY AND PHYSICAL FINDINGS
■ In aging, typically both deep and superficial malar compartment deflation
develops, leading to demarcation lines between aesthetic subunits of the
midface. Visually, the lower lid sinks into the cheek, developing the infraorbital
V deformity.
■ Similarly, the nasolabial fold deepens, and, in many patients, an abrupt
transition is noted between the lateral cheek and the anterior cheek over time.
All of these characteristics are hallmarks of deep malar deflation.1
■ Other areas that should be assessed for potential volume augmentation include
the perioral region, temples, tear trough, and prejowl sulcus.
IMAGING
■ No imaging is needed for this procedure other than routine preoperative
testing.
SURGICAL MANAGEMENT
Preoperative Planning
■ Patients are asked to bring pictures from their youth. Patients who have
sustained volume loss with age in various compartments of the face are
candidates for fat grafting.
■ Particular attention is paid to patients who have deep compartment deflation.
■ The amount of fat needed for facial fat grafting is estimated.
■ A donor site (abdomen, thighs, or hips) is selected with adequate fat for
harvesting.
■ Importantly, patients should be counseled that not all fat survives, and repeat
fat grafting procedures may be necessary 6 to 12 months postoperatively to
adequately augment the areas of interest.
Positioning
■ The patient is in a supine position for this procedure.

Approach
■ Fat grafting can be performed immediately prior to the facelift or immediately
after. Advantages to fat grafting before the facelift include minimized tissue
trauma and swelling prior to placement. Advantages to fat grafting after facelift
include the ability to visualize the effect of surgical repositioning prior to
grafting and also avoid displacing the grafted fat during surgical dissection.
T E C H N I Q U E S
■ Fat Grafting at the Time of Facelifting
Fat Harvest
■ The goal of fat harvest is to acquire fat as gently as possible.
■ The Coleman technique is utilized for fat grafting procedures.5
■ Possible donor sites include the abdomen, thighs, or hip area.
■ The area is infiltrated with a solution of dilute lidocaine and 1:200 000
epinephrine.
■ Stab incisions are made with an 11-blade scalpel.
■ Fat is collected using a harvesting cannula attached to a 10-cc syringe
(TECH FIG 1).
Fat Processing
■ A Luer Lock plug is attached to the end of the syringe and the syringe spun
in a balanced centrifuge for 3 minutes at 3000 rpm (TECH FIG 2A).
■ The oil layer (ruptured adipocytes) is removed with a neuropad whereas the
aqueous layer (blood and local anesthesia) is evacuated, leaving intact
adipocytes (TECH FIG 2B).
■ Fat is transferred to a 1-cc syringe in preparation for grafting (TECH FIG
2C).
Fat Placement
■ An 18-gauge needle is used for access.
■ Fat is injected using a 1-cc syringe and a 27-gauge Tulip blunt tip side-port
cannula (TECH FIG 3).

■ All fat should be placed in small aliquots in multiple passes with the cannula
in constant motion under low pressure.
TECH FIG 1 • Fat harvest.
Injection by Anatomic Location
■ Deep malar compartment
■ Although facelift techniques can be successful in repositioning superficial
malar facial fat into areas of deflation, it is technically difficult to
reposition fat into the deep compartment.
■ For this reason, deep compartment augmentation requires volumetric
addition for correction. Volumetric addition to the deeper compartments is
technically straightforward,6 and our preference is to approach this
injection via the alar base.
■ Approximately 1 to 3 cc is placed depending on the severity of deflation
deep onto the periosteum (TECH FIG 4).

TECH FIG 2 • A. Luer Lock plugged syringe and
centrifuge carriers. B. Centrifuged syringes with
ruptured adipocytes in the top layer and an aqueous
layer at the bottom; fat to be injected is in the middle
and then (C) transferred to 1-cc syringes.

TECH FIG 3 • Injection cannula.
■ Superficial and lateral malar compartments
■ Though typically addressed with surgical repositioning, 1 to 3 cc of fat can
be injected directly into these compartments to accentuate malar convexity.
■ Nasolabial folds
■ The nasolabial folds are injected directly with 1 to 2 cc of fat depending on
fold depth in the subcutaneous and preperiosteal layers.
■ Care is taken to avoid injection into the angular vessels.
■ Temples
■ Significant temporal hollowing can result with aging.

TECH FIG 4 • Fat injection into the deep malar
compartment.
■ Often a significant amount of fat, 3 to 5 cc or more, injected onto the
periosteum is required for correction.
■ Tear trough and eyelid-cheek junction
■ The tear trough is anatomically a very challenging area to inject.
■ Aesthetic goals in this area are to restore smooth transitions between
topographic compartments in the face, overcoming sharp demarcations that
become evident with aging.
■ If injected, less than 0.5 cc of fat should be injected cautiously directly into
the tear trough with care to avoid causing any irregularities.
■ 1 cc of fat can be injected to blend the eyelid-cheek junction.
■ Prejowl sulcus
■ To create a well-defined mandibular border, 1 to 2 cc of fat can be injected
preperiosteally into the prejowl sulcus (TECH FIG 5).
■ Lips
■ Significant perioral rejuvenation can be achieved with fat injection into the
lips.
■ 1 or 2 cc of fat is injected with access from the commissure.
Completion
■ Following injection, all access sites are closed with a 4-0 plain gut suture.

TECH FIG 5 • Fat injection into the prejowl sulcus.
PEARLS AND PITFALLS
Aesthetic
considerations
■ Surgery alone cannot correct deep compartment deflation that
occurs with age.
■ Fat augmentation at the time of facelifting should be considered
into areas of volume deflation (ie, deep malar compartment) and
into areas where volume will help blend demarcations between
anatomic regions that occur with age.
Harvest
■ Fat can be harvested from the abdomen, thighs, or hip area.
Processing
■ Fat is prepared using the Coleman technique of centrifugation
followed by removal of the oil and aqueous layers.
Injection
■ All fat should be placed in small aliquots in multiple passes with
the cannula in constant motion under low pressure.
■ Avoid superficial injections that can cause contour irregularities.
■ Exercise extreme caution when injecting into the tear trough.
■ Pay close attention to the anatomy of vasculature in the areas of
injection to avoid intravascular complications.
Revisions
■ Typically, 5%–60% of the injected fat is viable at 1 year.
■ Augmentation with additional fat can be performed at 3 months,

but it is advisable to wait 6–12 months if possible.
FIG 1 • A–D. A 54-year-old female seen prior to and
following an extended SMAS facelift. Autologous fat (3
cc) was injected into the central deep malar
compartment, and 2 cc of autologous fat were injected
into the lateral aspect of the deep malar compartment.
Note the blending between the lower eyelid, anterior
cheek, and lateral cheek as superficial fat repositioning
is combined with deep compartment augmentation.
POSTOPERATIVE CARE
■ Head of bed elevation is encouraged to minimize swelling.
■ Patients will also follow instructions for postoperative facelift care.
■ Deep massage is discouraged to avoid displacing injected fat.
OUTCOMES
■ The combination of facial fat repositioning, which alters shape by shifting
volumetric highlights, in conjunction with volume addition, which further
corrects deflation, provides greater aesthetic control in surgical outcome (FIG
1).
■ Additional fat grafting, or supplementation with off the shelf fillers, can be
performed at 3 to 6 months.
■ Additional fat grafting is typically performed under sedation.
COMPLICATIONS
■ Contour deformity (most common)

■ Fat necrosis
■ Infection
■ Unnatural growth of fat
■ Tissue necrosis (rare)
■ Intravascular injection
REFERENCES
1. Sinno S, Mehta K, Reavey PL, et al. Current trends in facial rejuvenation: an
assessment of ASPS members’ use of fat grafting during face lifting. Plast
Reconstr Surg. 2015;136(1):20e-30e.
2. Rohrich RJ, Pessa JE. The retaining system of the face: histologic evaluation
of the septal boundaries of the subcutaneous fat compartments. Plast Reconstr
Surg. 2008;121(5):1804-1809.
3. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical
implications for cosmetic surgery. Plast Reconstr Surg. 2007;119(7):2219-
2227.
4. Gierloff M, Stohring C, Buder T, et al. Aging changes of the midfacial fat
compartments: a computed tomographic study. Plast Reconstr Surg.
2012;129(1):263-273.
5. Coleman SR. Structural fat grafting. Aesthetic Surg J. 1998;18(5):386, 388.
6. Rohrich RJ, Arbique GM, Wong C, et al. The anatomy of suborbicularis fat:
implications for periorbital rejuvenation. Plast Reconstr Surg.
2009;124(3):946-951.

16
CHAPTER
Section IV: Laser
Resurfacing of the Face
Techniques for Laser
Resurfacing of the Face
Daniel A. Belkin and Roy G. Geronemus
DEFINITION
■ With age, there is a loss of the supporting frame of the skin: collagen, elastin,
and hyaluronic acid. Skin laxity results, with increased redundancy,
accentuated skin folds, and uneven texture. Skin aging is expedited by
exogenous factors, most importantly chronic sun exposure and cigarette
smoking, resulting in further wrinkling and dyspigmentation.
■ Resurfacing of the skin of the face can be achieved with dermabrasion,
chemical peels, energy devices (radiofrequency and plasma energy), and laser
surgery, which is the focus of this chapter. Laser resurfacing stimulates
collagen synthesis and improves rhytides, dyspigmentation, and the overall
quality of the skin.
ANATOMY
■ The histology of skin treated with laser resurfacing has been well studied and
varies based on the specific laser or device used.
■ Resurfacing lasers are either ablative or nonablative and either fractionated or
nonfractionated.
■ Ablative lasers vaporize treated zones of skin with surrounding heat injury
and coagulation, whereas nonablative lasers produce heat injury without
vaporization.
■ Fractionated lasers create small columns of injury within treated areas,

leaving large zones of unaffected skin between them, rather than injuring the
entire treated area at once (FIG 1).
PATHOGENESIS
■ Resurfacing lasers tend to use wavelengths in the near- and mid-infrared range
and target water as their chromophore. Destruction can therefore be achieved to
any thickness through the skin. The depth and extent of injury are determined
by the wavelength of the laser source (nm) and the power delivered, known as
fluence (J/cm2).
■ Once injury is produced, new collagen is formed via the wound healing
response of dermal fibroblasts, and the epidermis is repopulated from stem
cells found in skin appendages.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patient expectation, skin quality including Fitzpatrick skin type, and relevant
medical history should be assessed before treatment.
■ Patient history
■ An appropriate patient has reasonable expectations for cosmetic outcome,
and the primary concern is related to the indications described above. Patients
should understand the side effect profile and be able to manage the necessary
downtime following treatment (depends on modality—see Table 1).
■ Topical and oral medications and medication allergies should be reviewed.
■ History of herpes simplex virus, connective tissue disease, local
inflammatory skin disease, and other conditions that may affect wound
healing should be elicited.
■ Physical examination
■ For most laser resurfacing techniques, it is best if the patient is Fitzpatrick
skin types I to IV. Caution is advised in patients of skin types V and VI as
they are at risk for dyspigmentation.
■ The aesthetic issue to be addressed will determine the type of resurfacing.
Subtle fine lines, sun damage, mottled pigmentation, and hypopigmented
scars are some conditions that will respond to noninvasive fractional
nonablative resurfacing. Moderate to severe rhytides and atrophic scars will
respond to more invasive fractional ablative resurfacing. Elevated lesions,
such as fibrous papules or papular scars, may require the localized use of a
nonfractionated ablative laser (see Table 1).

FIG 1 • A schematic of fractional treatment. Healing
occurs via stem cells within zones of viable tissue
amidst columns of injury, either coagulation (A) or
ablation (B).
Table 1 Representative Resurfacing Devices and Our Protocols for Their Use
Selected
Representative
Devices
Category
Medium
Wavelength
(nm)
FST
Preoperativ
Preparation
Fraxel dual
(Solta)
Fractional
nonablative
Thulium/erbium
glass
1927/1550
I–
III
1 hour topica
lidocaine/pri
Clear and
Fractional
Diode
1927
I–
1 hour topica

brilliant
Perméa
(Solta)
nonablative
(low energy)
VI
lidocaine/pri
(optional)
Fraxel repair
(Solta)
Halo
profractional
(Sciton)
Fractional
ablative
Carbon dioxide
Erbium-YAG
10 600
2940
I–
III
I–
IV
1 hour topica
lidocaine/pri
nerve blocks
(mental,
infraorbital,
supraorbital)
lidocaine inf
Burane (Alma)
Nonfractional
ablative
Erbium-YAG
2940
I–
VI
Local lidoca
infiltration, n
blocks (men
infraorbital,
supraorbital)
IMAGING
■ No radiologic or diagnostic studies are necessary prior to routine laser
resurfacing.
SURGICAL MANAGEMENT
Preoperative Planning
■ Topical retinoids should generally be stopped a week before treatment and
only restarted after complete healing has occurred.
■ There is controversy over how long to wait to resurface after a course of oral
isotretinoin; to be safe, it is reasonable to wait six months for ablative
procedures until there is further data.
■ Pre- and postoperative medication depends on provider preference, patient
medical history, and device used.
■ Full-face nonablative fractional resurfacing, except for low-energy low-
density treatment, may warrant immediate preoperative and postoperative
treatment with corticosteroids (eg, prednisone 40 mg prior to procedure and
then daily for 2 more days) and antiviral prophylaxis (eg, valacyclovir 500 mg
prior to procedure and then BID for 3 more days).
■ Full-face ablative fractional resurfacing often warrants corticosteroids as
above, antiviral prophylaxis extended to 7 days, and antibiotic prophylaxis for
7 days (eg, dicloxacillin 500 mg prior to procedure and then BID × 7 days).