Cosmetic Injectables in Practice-Dermal Fillers and Botulinum Toxin Rashmi Sarkar, Vivek Nair
INDEX
Page numbers followed by f refer to figure, b refer to box and t refer to table
A
Ablation, mid dermis depth of 173
Ablative fractional laser 174
concept of 171
Abobotulinum toxin type A 179, 267
Abscess
aseptic 156
formation 146
Abundant blood supply 141
Accelerate hyaluronic acid absorption 124
Acetonide 262f
Acne 262
scars 78, 262
Acyclovir 68
Alar-facial groove 119f
Allergan infraorbital hollows scale descriptors 100t
Allergic reaction 146
history of 263
Allograft 6
Alveolar artery, inferior 48
Aminoglycosides 242, 245
antibiotics 264
Aminoquinolones 245
Anaerobic 267
Anesthesia 72
topical 72, 73
types of 72
Angle's classification 129
Angular artery 46f, 47, 47f, 110
Apraclonidine 248
Arteplast 5
Aspirin 136
Autograft 6
Autoimmune diseases 67
Avascular necrosis 146
Average caucasian face 137
B
Bacterium, rod-shaped 267
Basic filler injection techniques 76f
Basic injection technique 75, 119f
Biofilm reaction 156, 157
Biscarbodiimide 11
Bleeding disorders 67
Blunt tipped metal cannula 76f
Bolus injection 135
technique 144
Bone 161
Bony prominence 153
Bony skeleton 253
Bony volume, loss of 107
Botox
injection of 188, 229f
lip treatments 250
sign 202f, 204
Botulinum injection 243f
Botulinum toxin 132f, 147f, 160, 171, 184, 186, 187, 197, 202, 218, 221f, 225, 226f, 234, 238f, 241, 248f, 253, 260f
antibodies 268, 269t
applications of 191
brow lift 187
combination of 165
conventional 263f
dilution of 265
effects of 239
injection 131, 184f, 195, 205, 234, 235f, 236
safety of 242
technique of 220, 204f
microdosing in 259
resistance 267, 270
serotypes of 267, 270
structure 267
traditional dilutions of 259
treatment 249f
type A 179, 180t
indication use of 229
use of 208, 237, 253, 267
Broad muscle 237
Broad muscular layer 171
Brow 23, 198f
arching, joker face type of 249f
asymmetry 247
injection, unilateral 269
lift 77, 197
malposition 247, 249
position 197
ptosis 189, 189f, 197, 247
region, injections in 27
tail of 262
Bruising 146, 157, 246
mild 246
Buccal fat 44
pad 39f, 82
Bunny lines 202, 202f, 205f, 208f, 209
injections 211
points for 210f
Butanediol diglycidyl ether 10, 16
C
Cadaver dissection 33f
Calcium hydroxylapatite 5
Canine fossa 160
Cannula 75, 125
depth of 96f
entry point 102f
technique 96
type 131
Central retinal artery occlusion 122
Cervical complications 247, 250
Cervicomental angle 59
Cheek 51, 77
anteromedial 103
volume, assessment of 62f
Chemical
peels with fillers 162
structure 9
Chin 20, 21, 42, 51, 58
area 135
augmentation 128
correlation of 63f, 131
dimpled 229, 230
elongation of 131
fat compartments 45
projecting aspect of 128
sagittal section of 129f
size of 136
superficial fat compartments 45f
with toxins, combination treatment of 131
Chloroquine 245
Clostridial proteases 267
Clostridium botulinum 267
Columellar artery 46, 46f
Complex modulus G 17
Compressor naris 209
Concentration 11
Congenital small ear lobes 149
Congestion, venous 156
Contact cooling device 74f
Core neurotoxin 268270
Coronoid process 133
Corrugator supercilii 24, 30f, 197
muscle 24f, 197
Cosmetic
deterioration 160
injectables
procedure 68b
use of 67b
intervention 182
procedures 143f
Crosshatching 75
Cross-linking 16
types of 11f
Crow's feet 166, 191
lines 193f
injection pattern 191, 192f, 193f
treatment of 191
Crown length 218
Cupid's bow 43f, 144
enhancement, technique for 145f
Cyclosporine 245
D
da Vinci's golden ratio 137
Deep dermis 172f
Deep fat pads 161
Deep fatty layer running 116
Deep temporal
arteries 48
fascia 80
deep layer of 82
superficial layer of 82
fat pad 82
Deformity, severe 104
Deltoid fascia 234
Deoxycholate 164
injections 165
Depressor
anguli oris 36, 45, 46, 46f, 123, 134, 140, 147, 226f, 227, 229, 264f
botulinum toxin injection of 147f
function of 237
muscle 225
topography of 226
treatment of 231f
labii inferioris 36, 45, 46, 128, 140
septi 36, 203, 209, 219
supercilii 25
Dermal atrophy 153
Dermal fillers 1, 4, 10, 150f, 154, 154t
augmentation 131
classification of 3, 4t, 6t
facial anatomy for 23
injections 75
rank 154
Dermal graft 6
Dermis 161
Dermosubcutaneous junction 172f, 173
Diamond-shaped technique 230, 231f
Diepoxyoctane 16
Dilator naris muscle 211f
Dilution and injection technique 260
Divinyl sulfone 11
Dorsal nasal artery 33f, 100
Dorsum, surface of 150
D-penicillamine 245
Drug molecules, size of 175
Dry
skin 246, 247
vermillion 43f
Dynamic forehead lines 262
Dynamism 253
Dysphagia 247, 264
risk of 235
E
Earlobe
and décolletage 149
repair, technique for 151
Eaton Lambert syndrome 264
Ecchymosis 157
Ectropion 247, 248
Edema 156
Elastic and collagen fibers, loss of 213
Elastic modulus 17
Enzyme-linked immunosorbent assays 269
Epidermis 160, 161
Esthetic
balance 197
consultation 68
enhancement 3
procedures 166
combination of 168
sequence of 166
rejuvenation 85
utility, report of 186
Euclid's elements 52
Extensor digitorum brevis assay 269
Extracellular polymeric substance 157
Eyebrow 50, 92, 92f, 95, 95f, 182, 197
asymmetrical 200
center 96
downward, pulls medial end of 209
fat pad, anatomy of 91f
head 96
injection of 96t
reshaping of 186
tail 96
unit, assessment of 94
Eyelids 30
check position of 187
ptosis 194, 248f
F
Face
anatomy of 133f
arteries of 45, 48
cosmetic enhancement of 160
different zones of 63f
esthetic unit of 208
fat compartments of 32f
layers of 161t
ligaments of 40, 41f
lower third of 133
middle third of 51
muscles of 25f, 129f
muscular anatomy of 204f
proportions 138f
regions of 35f
upper one-third of 50
Facial
aging 133
analysis 138
animation, lack of 250
artery 45, 46f, 47f, 122, 134
anatomical location of 135f
branches of 215
course of 46f
assessment 50, 59, 61
highlights of 50
esthetic industry 253
expressions, muscles of 161
massage 122
muscles, superficial fibers of 259
nerve 39, 40f
buccal branches of 242
frontal branch of 29
temporal branch of 28f
profiles, types of 130f
proportions and angles 57
rhytides, quantification of 254
shapes 50f
skin 173, 253
vasculature 253
zone 20
Famciclovir 68
Fanning 75
Fascial anatomy 80t, 82t
Fat 6
pads, loss of 213
Fibers, arrangement of 43f
Fibrous retinacular cutis ligaments 161
Fillers 160, 165, 221
Belotero range of 19
classification of 3
clumping of 156
combination of threads of 164
complications 154
classification of 154, 156t
desirable feature of 20
for lower face
chin 128
jawline 133
lip augmentation 137
marionette lines 123
for midface
areas and scars 149
cheeks 107
nasolabial folds 118
tear trough and infraorbital areas 98
tear-trough and nose 112
for upper face
eyebrow 90
forehead and temporal region 79
temples 85
upper eyelid 94
inappropriate placement of 156
injection 26
around 116
techniques 75
tower technique of 124f
juvéderm range of 110f
migration of 156
procedures 154
selection 16, 19
guidelines for 20t
treatment, pre-requisites for 70
use of 16
Filling temple region, cannula approach for 87f
Fine lines 19, 20
Firm pressure 206
Fitzpatrick wrinkle scale, modified 118
Fluctuant mass 156
Food and Drug Administration 3, 10
Foraminae 133
Forehead 23, 50, 78, 79, 81, 82, 261
and eyebrow
positions 198
region, muscles of 24
and face, superficial fat compartments of 38f
botulinum toxin, effect of 189t
central 262
depressors of 186
height 54, 186
injection techniques for 187t
lines 186
correction of 188
nerves of 26
treatment of 186
vessels nerves of 26
Fractional carbon dioxide laser 173, 173f
Fractional CO2 laser 175
Fractional laser
assisted botulinum toxin delivery 171
channels 172
Frankfurt plane 57, 58f
Frontalis 186
antibody test 269
muscle 23f, 24, 24f, 26f, 30f, 197
paralysis of 249
Frown lines 182
Frozen forehead 259
FxCO2 treatment, pass of 173
G
Gels
hardness 12
physical properties of 16
Gentamycin 245
Gingival display, excessive 218
Gingival exposure, amount of 218
Ginkgo 246
Glabella 78, 186
dermis of 209
Glabellar arterial branches 26
Glabellar complex 166
Glabellar frown lines 255, 257
treatment of 256f
Glabellar rhytides 182
Glycosaminoglycans 6
Golden ratio, concept of 51, 51f
Goldstein classification 218
Golf ball 230
Granuloma 146
bilateral 155f
formation 156, 185
Greater facial movement 253
Gum tissue display, amount of 218
Gummy smile 218, 219
botulinum toxin injection for 148f
treatment of 223, 223f
H
Hand fillers, technique for 149
Hand weakness 247, 251
Headache 246
transient 247
Hemagglutinin 267
Hematoma 157
formation 242
Herbal remedies like ginseng 246
Herpes simplex virus 67, 156
Heterograft 6
High-intensity focused ultrasound 164
High-volume injections/improper technique 233
Hinderer's lines 55, 559, 108f
Hirmand's classification 100t
Horizontal facial thirds 52, 53f
Horizontal forehead lines 256, 257
Horizontal neck bands, causes of 234
Human papilloma virus 67
Hyalase 147
Hyaluron 9
Hyaluronic acid 3, 9, 11, 14, 16, 20, 92f, 154, 160
chemical structure of 10f
consisting of 141
dermal fillers 132
properties of 10
distribution of 9
fillers 14, 16, 92f, 103f, 138f, 150f
properties of 9
use of 101
functions of 9
molecule 9
properties of 10
Hyaluronidase 126, 147
Hydroxychloroquine 245
Hyperactive lip muscles 219
Hyperhidrosis 262
indication 174
injections complications 247
Hyperkinetic activity 237
Hyperkinetic depressor angulis oris 230f
Hyperkinetic mentalis 232
Hypertrophic scarring 185
Hypoesthesia 246
temporary 247
Hypoplastic maxilla 119f
I
Iatrogenic blindness 88
Ideal brow 90
Ideal lip
filler 141
proportions 138f
Inanimate lower eyelid 265
Incobotulinum toxin type A 179
Infections 146, 156, 157
cutaneous 246, 247
Inferior alveolar branches 133
Inferior labial artery 45
Inflammatory nodule 155f
Inflammatory skin diseases 67
Infraorbital artery 48
Infraorbital fat 30
pads, pseudoherniation of 247, 249
Infraorbital foramen 110
Infraorbital margin 114
Infraorbital nerve 73f
Infraorbital region 98
Infratrochlear artery 47f
Injectable anesthetics 72
Injected muscles, electromyographic tests of 269
Injection
lipolysis 164, 165
method of 132
procedure of 132
site pain 247
techniques 76, 81, 87, 90, 186
Insulin syringe 182, 265
Intense pulsed light 163
Internal maxillary artery 47, 48
Intra-arterial injection 119
Intradermal injection 126
Intralesional triamcinolone 158, 262f
Intraorbital fat, herniation of 99
Intravascular complication 83f, 114f
Intravascular injection 96, 114f, 116
In-vitro assays 269
Iodine starch test 174f
results of 174f
J
Jaw, angle of 234
Jawline 42, 51, 77, 136, 166
contour 169f
in females 134
in males 134
Jowl and submandibular fat compartments 44f
Jowling 237
correction of 45
Juvéderm ultra 18, 104
Juvederm ultraplus 18, 104
Juvéderm voluma 18, 120
K
Keloids 262
predisposition 67
Koebner response 67
L
Labiomental fold 58
Lacrimal portion 191
Lactation 67, 263
Laser-assisted drug delivery 171
Lasers 163
Lateral brow
elevation 247
lift 199
Lateral canthal lines 191, 255, 257, 262
Lateral corrugators 183
Lateral nasal artery 46
Lemperle scale 118
Lethal dose 245
Levator anguli oris 36
Levator labii superioris 30, 36, 140, 203, 219
alaeque nasi 36, 99, 147, 203, 209
Levator palpebra superioris 186
muscle 248f
role of 186
Lid
laxity 194
ptosis 200, 247, 248
Linear retrograde technique 92f
Linear threading 75
Lips 20, 42, 51, 77, 137, 147, 213
anatomy of 139f
assessment 137
augmentation 62, 148
procedures 137
chin relationship 59
contouring 145
correlation of 63f
drooping corners of 227f, 227t
lines 213
marionette lines 166
moving 138
muscles of 36, 139
vertical height of 221f
weakness 247
Lipstick lines 213
Local anesthesia, eutectic mixture of 141
Loose areolar tissue layer 80
Lower buccal branch 40
Lower eyelid 191, 195
injection techniques for 195
Lower face 20, 21, 42, 61, 62f, 166, 262
aging curves of 44f
and neck 263
treatment of 237
central 123
fat compartments in 43
muscles of 36, 42
sequence of treatments in 167
treatment plan for 167
Lower jaw
position of 130f
zones in 134f
Lower lip 137
droop and weakness 250f
ptosis 247
Lower temporal
compartment 86f
region, structures of 82t
Low-viscosity 152
Luer lock syringe 265
Lumpiness 126, 146
Lumps 138
formation 126
M
Main arterial blood supply 116
Major histocompatibility genes 268
Malar body 56f
Malar projection 112
Malar septum, structure of 33f
Mandible 214
angle of 133
bone 133
ramus of 133
Mandibular border 237
Mandibular branch 40
Mandibular ligament 41, 130, 160
Mandibular prognathism 129
Marginal mandibular nerve 46f
Marionette lines 77, 225
grading of 225t
grading scale 124t
severity of 225
treatment of 225
Masseter
deep layer of 82
hypertrophy 62
injection complications 247, 250
muscle 43
originates, superficial portion of 241
superficial layer of 82
Masseteric hypertrophy 241, 243, 244
etiology of 241
Maxilla 214, 219
frontal process of 209
part of 218
skeletal resorption of 213
soft tissue protrusion of 59f
Medial brow lift 198
Medial mentalis muscle injections 250f
Medial platysmal fibers 238
Melomental fold 126, 225
Mental crease, dermal fillers in 132
Mental nerve 73f
Mentalis 140
moderate rhytides of 229
muscle 37, 128, 131, 229, 229f, 231f, 250f
anatomy of 229
hypertrophy of 129
injection of 233
treatment of 231f
Mesobotox 259
Microbotox 262
action of 259
acts on superficial muscle fibers 259
objective of 260
solution 264f
technique 263, 265
postadministration of 264f
volume of 263
Microgenia 128
Microneedling radiofrequency 263
Midcheek groove 34f
Midface 21, 35, 107f, 166
assessment 61f
augmentation 109f, 113f
concerns 167
fat compartments of 37
filler 125
injections 126f
muscles of 36
planes 55
rejuvenation 61
sequence of treatments in 167
volumization 126
Mid-pupillary line 99, 114, 183
Minimally invasive esthetic procedures 253
Minors’ iodine starch test 173
Modiolus, anterior portion of 214
Moisturizers, topical 246
Motor nerve innervation 139
Mouse hemidiaphragm assay 268, 269
Mouse protection assay 268, 269
Mouth
left angle of 155f
retraction of 236
Mueller's muscles 248
Multiple microablative columns 171
Muscle
anatomy of 209t
deeper fibers of 260f
functions of 209t
main 203, 214
masticatory 241
paralysis-related complications 247
tone, loss of 213, 237
Myasthenia gravis 264
N
Naphazoline 248
Nasal
bone 209
cartilage 209
dorsum hyperhidrosis 211
flutter 211, 212
hyperhidrosis 212
septum, cartilaginous 209
tip
elevation of 210, 211f
injection 212
projection 57, 57f, 57t
Nasalis 203
muscle 36
Nasofrontal angle 58f
Nasoglabellar lines 202, 206, 208f, 209
causes of 203
Nasojugal groove 34f, 98, 99, 101, 104f
Nasolabial angle 57, 57f, 116
Nasolabial filler, complications of 155f
Nasolabial fold 20, 77, 113f,118
junction of 236
Nasomaxillary angles 59f
Natural lip symmetry 138
Neck
and jawline 261
angle 237
lines 262
movement 239
rejuvenation 171
weakness 247
Needle 75
type 131
Neural structures 110
Neuromuscular disease, history of 67
Neurotoxin
diffusion of 232
injections, classical 264
preparations 179
resistance 267
Neutralizing antibodies 270
development of 268
role of 271
Ninhydrin sweat test 269
Nodulation 126
Nodules 156
Nonanimal stabilized hyaluronic acid, evolution of 10
Nonbarbed threads and barbed threads, types of 164t
Nonhemagglutinin proteins 267
Nonsteroidal anti-inflammatory drug 82, 111, 136
Nonsurgical skin tightening devices 163
Nontoxic accessory proteins 267
Normal smile preinjection 232f
Nose 20, 21, 51, 56, 77, 115, 208
augmentation 115f
chin evaluation 59
correlation of 63f
dorsum of 116
lifting upper lip and wing of 209
lip-chin line 60f
muscles of 209f
part of 203
width 55
O
Omega-3 fatty acid 136
Omohyoid 236
Onabotulinum toxin 173, 180, 223, 257t, 264f
type A 179, 259
Ophthalmic artery 100
branch of 26, 47f
Optical coherent tomography imaging 173f
Oral commissure 43f, 250
Oral muscles, adjacent 237
Oral pain killers 246
Orange peel 230
Orbicularis
muscle 30
oculi 31, 198
muscle 30, 30f, 32f, 98
oris 37, 140, 147, 214t
muscle 43f, 139, 213
retaining
element 40
ligament 25, 31, 31f, 99, 113
Orbit 30
Orbital rim 99
Orbital septum 99, 200
Orbital zone 247, 248
Overeruption, anterior 218
P
Pain 156, 246
Palatal necrosis 88
Palmar hyperhidrosis 173, 174
severe bilateral 174f
Palmar sweating, severe 174f
Palmoplantar skin, anatomical section of 172
Palpable nodules 115, 116
Palpeabromalar groove 99, 102, 103f
Papulopustular lesions 157
Paradoxical bulging 247
Parotid
duct 39f
gland hypertrophy 62
Parotidomasseteric ligament 42
Peau D'orange 230
Penicillamine 264
Pentavalent vaccine 268
Perform stretch test 187
Periocular rejuvenation 61, 61f
Perioral area 213
blood supply of 215f
muscles of 214f
Perioral blood vasculature 140f
Perioral complications 247, 249
Perioral muscles 140f
Perioral region 166
bony structure of 214
Perioral rhytides 213
Periorbital arteries 33f
Periorbital complications 247
Periorbital injections 247f, 250
Periorbital veins 33f
Periosteum 82
Phenylephrine 248
Philtral ridge 43f
Philtrum 43f
columns 145
Phosphatidylcholine 164, 165
Platysma 134
muscle
hyperkinetic activity of 237
tenses 237
originates 234
Platysmal auricular ligament 42
Platysmal bands 234, 239, 262
formation of 237
Plump cheeks 112
Plumping 143
lip, technique for 144f
Polyacrylamide hydrogel 5
Polyalkylimide gel 6
Poly-l-lactic acid 4
Polymethyl methacrylate 5
Polyvinylpyrrolidone-silicone suspension 5
Postdental treatment 223f
Posterior mandibular curve 44f
Postfiller administration, complications of 103
Postinflammatory hyperpigmentation 155f
risk of 174
Postinjection instructions 82, 88, 97, 212
Powell and Humphreys’ esthetic angles 59f
Predental treatment 223f
Pregnancy 67, 263
Prejowl sulcus 77
Preseptal skin 94f
Pretarsal skin 94ff
Prezygomatic space 31, 32f
Primary axillary hyperhidrosis treatment, use of 171
Procerus muscle 25, 203f
Prominent lid-cheek junction 99
Propionibacterium acnes 67
Pterion 29
Q
Quinine 264
R
Radioimmunoprecipitation assay 269
Ramus, processes of 133
Reduce pain 261
Reidel's plane 63
Respiratory impairment 264
Restylane 18, 104
Retaining ligaments 87, 161
Retinal artery embolus 122
Retrognathia 128
Retro-orbicularis oculi fat 91f, 95
Rheological parameters 17
Rheological properties 17, 20
Rheology 17
Rickett's esthetic line 129f, 132, 138f
Riedel line 60f
Risorius muscle 36
Risus sardonicus 37
S
Scar
formation 157
technique for 151
tissue 138
Scrunch lines 202
Sebaceous gland activity 263
Serial puncture 75
Simons ratio 58f
Single-point technique 230, 231f
Six horizontal measurements 54f
Skeleton-like look 112
Skin 23f, 80, 82
atrophy of 99
blanching of 155f, 156
discoloration 156, 158
fascia of 186
flaccidity and poor quality of 237
hydrated 160
necrosis 114f
on chin, cobblestone appearance of 130f
roughness 149
Skull 254f
Small gauge needles, use of 105
Smoker's lines 213, 213f
Smooth glabellar area 182
Snap test 248, 265
Soft tissue
cephalometric points 52, 52f
layers of 23f
ptosis of 62
Speech difficulty 264
Standard post botulinum toxin injection 236
Sterile 180
folliculitis lesions 157
Sternocleidomastoid 250
test 269
Sternohyoid 236
Strabismus 247, 249
Subcutaneous fat 80, 82, 99
Subcutaneous tissue 253
Sublabial veins 126
Submandibular fat compartments, atrophy of 123
Submental artery 47
Submental fat excess 165
Suborbicularis oculi fat 55, 99, 102f
Suborbital area 99
Superficial fat
compartment 161
pads 134
thin layer of 23f
Superficial filler placement 104
Superficial injection 242
Superficial layer 80
Superficial muscle fibers 260f
Superficial musculoaponeurotic system 36, 81, 86, 112, 123, 126, 136
Superficial temporal
artery 28f, 29, 152
frontal branch of 83
fascia 80, 82
fat pad 82
Superior labial artery 46, 46f
Superior temporal septum 27
Supraorbital artery 26, 79, 83f
Supraorbital margin 182
Supraorbital notch 24f
Supraorbital vessels 24f
location of 97f
Supraperiosteal bolus points 88f
Supraperiosteal technique 88
Supratrochlear artery 26, 79
Supratrochlear vessels, location of 97f
Sweat
and sebum production 260
glands 172f
Swelling 110, 146
Swift point 89
Synaptosome inhibition assay 269
Syringe, aspiration of 242
Systemic botox exposure 246
T
Tear
Hirmand's classification of 100t
trough 20, 21, 34f, 76, 101
deformity 99
ligament 30, 31, 98
Teeth 219
shape of 218
size of 218
Temple filler injection 88f
Temple hollowness 166
Temporal adhesion 27
Temporal aging, stages of 87t
Temporal area 80, 81
layers of 80, 82
Temporal bone 80
zygomatic process of 35
Temporal branch 28f, 39
Temporal ligamentous adhesion 27
Temporal muscle
atrophy 86
attaches 133
Temporal region 27
Temporalis fascia 80
Temporalis muscle 28, 80, 82
Temporoparietal fascia 27, 28f
Tenting technique 145
Tissue
integration 13
necrosis 156
Tooth and gum tissue complex 218
Tower technique 75
Toxin 147, 270
higher doses of 236
injection treatment 173
Transverse nasalis 209
Trigeminal nerve 133
Trough ligament 41
Two-point technique 230, 231f
Tyndall effect 104, 146
U
United States Food and Drug Administration 171
Upper buccal branch 40
Upper eyelids 173
Upper face 166
concerns 166
treatment 166, 262
recommendations for 166
Upper jaw 219
vertical position of 219
Upper lip 138, 209
length and degree of movement of 219
ptosis 247
Upper temporal
compartment 86f
region, structures of 80t
Upturned mouth corners 145
V
Valaciclovir 68
Vascular complication 105, 158
Vermillion border 43f, 143
enhancement, technique for 143f
Vertical fanning 144
Vertical fifths 53, 53f
Vertical maxillary excess 219, 223f
Vibration 74
Viscosity 12
Viscous modulus g 17
Vision, blurred 156
Visual analog scale 174
Visual loss 83, 83f
Vitamin E 136
supplements 246
Voice, hoarseness of 247
Voluminous lips 137
Volumization 143
V-shaped injection technique 119
W
Western blot assay 269
Wet vermillion 43f
Wrinkle 213
severity rating scale 118
X
Xeomin 179, 267, 270
Xylocaine, injection of 96f
Y
Yonsei point 220
Youthful jawline 133
Yvoire fillers 19
Z
Zig-zag injection pattern 188f
Zygoma, body of 32f
Zygomatic
arch 28f, 29, 35, 43, 56f, 103, 241
branch 39
eminence 35, 103
facial vessels 110
ligament 31, 32f, 41
region, anterior 99
Zygomaticocutaneous ligament 113, 160
Zygomaticofacial
nerve 35
vessels 35
Zygomaticus
major 36, 46f, 140, 219
minor 36, 140, 219
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Chapter Notes

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1
Dermal Fillers
SECTION OUTLINE
  • 1. Classification of Fillers
  • 2. Science and Properties of Hyaluronic Acid Fillers
  • 3. Guide for Selection and Use of Fillers
  • 4. Facial Anatomy for Dermal Fillers
  • 5. Facial Assessment
  • 6. Patient Selection and Esthetic Consult
  • 7. Pre-requisites for Filler Treatment
  • 8. Anesthesia
  • 9. Filler Injection Techniques
  • 10. Fillers for Upper Face—Forehead and Temporal Region
  • 11. Fillers for Upper Face—Temples
  • 12. Fillers for Upper Face—Eyebrow
  • 13. Fillers for Upper Face—Upper Eyelid
  • 14. Fillers for Midface—Tear Trough and Infraorbital Areas
  • 15. Fillers for Midface—Cheeks
  • 16. Fillers for Midface—Tear-Trough and Nose
  • 17. Fillers for Midface—Nasolabial Folds
  • 18. Fillers for Lower Face—Marionette Lines
  • 19. Fillers for Lower Face—Chin
  • 20. Fillers for Lower Face—Jawline
  • 21. Fillers for Lower Face—Lip Augmentation
  • 22. Fillers for Nonfacial Areas and Scars
  • 23. Complications of Fillers and their Treatment
  • 24. Combination Therapies with Fillers
  • 25. Fractional Laser-assisted Botulinum Toxin Delivery2

Classification of FillersCHAPTER 1

Rashmi Sarkar,
Gillian Ruth Britto
 
INTRODUCTION
Esthetic enhancement has been a desire since ancient times of people from various cultures. There are several methods available to improve the facial appearance such as topical and systemic agents, surgical intervention, energy-based devices (like radiofrequency, high intensity focused ultrasound, intense pulse light) and injectables like botulinum toxin and fillers. Fillers by far are the simplest and effective method to get instant results, both for the patient and the treating physician.1 Paraffin was the first injectable substance that was used as dermal filler but its complication of embolization and granuloma formation abandoned its use as dermal filler. However, fillers have been the most popular method since the 1980s when bovine collagen was injected to treat facial lines and creases and to restore volume deficits. It was the first Food and Drug Administration (FDA) approved facial filler and it has been used for almost 30 years.2 It was originally used to treat viral pox scars, acne scars, lipoatrophy, and soft tissue augmentation. Since the augmentation effect lasts only for 6 months and due to its side effects, physicians were on the lookout for more sustainable and effective fillers. An ideal filler has not yet been discovered; however, hyaluronic acid (HA)-based fillers have helped revolutionize the filler market with a number of ideal products available to patients.
 
CLASSIFICATION OF DERMAL FILLERS
Classification of dermal fillers is based on the following (Table 1):3
  • Based on the origin: Natural/synthetic.
  • Based on the source: Autograft/allograft/heterograft.
  • Based on effect: Temporary/semi-permanent/permanent.
  • Content: Collagen/fat/hyaluronic acid/silicone/peptides.
 
Based on the Origin
 
Natural
This group of fillers was the bovine derived collagen products, namely Zyderm® and Zyplast® collagen. The collagen material was derived from a closed herd of cattle and purified for human use. Zyderm® I was first approved by the FDA in 1981 and recommended for injection into the superficial papillary dermis, and was approved for the treatment of superficial lines and wrinkles, as well as shallow acne scars. Zyderm® II, FDA approved in 1983 to treat postacne and traumatic scars on the face, although it worked well for lines and wrinkles. Zyplast® was best injected into the mid-deep dermis and its recommended use was for deep lines and folds.44
Table 1   Classification of dermal fillers.3
Dermal fillers
Examples
Based on origin
Natural
Zyderm, fibrel, restylane, Juvederm
Synthetic
ArteFill® (PMMA), Bellafill (PMMA), Aquamid (Polyacrylamide hydrogel), Alcamid (Polyalkylimide) Silicone (Silikon 1000, Bioplastique, Pro fill), calcium hydroxylapatite (Radiesse), poly-L-lactic acid (PLLA) (Sculptra/New fill)
Based on source
Autograft
Fat, dermal graft, isolagen (Autologous collagen)
Allograft
Fascian (cadaver), cymetra (cadaver)
Xenograft
Zyderm, zyplast, fibroquel, endoplast-50 (Bovine collagen)
Based on effect
Temporary
Zyderm, fibrel, cymetra, fibroquel, endoplast-50 restylane, Juvederm, autologous fat, frozen fat
Semi-permanent
Autologous fat, CaHA (Radiesse), PLLA (Sculptra)
Permanent
Artefill® (PMMA), expanded polytetrafluoroethylene (EPTFE), adatoSil 5000, silicone (Silikon 1000, Biocell ultra vital)
Based on content
Collagen
Zyderm, zyplast, fibroquel, CosmoDerm, CosmoPlast
Fat
Autologous fat, Frozen fat
Hyaluronic acid (HA)
Hylaform, restylane, Juvederm, prevelle, esthelis, belotero, captique, puragen, elevess, teosyal
Silicone
Silikon 1000, biocell ultra vital, bioplastique
Peptides
SYN®
(PMMA: polymethyl methacrylate)
Since Zyderm®/Zyplast® had hypersensitivity concerns, human-derived collagen products were developed, namely CosmoDerm® and CosmoPlast®. These fillers are made from cultured human fibroblasts and were FDA approved in 2003 for facial Esthetic procedures. They do not require intradermal testing, which was a major drawback with bovine collagen.4 These products had longevity of approximately 3 months.
 
Synthetic
Poly-L-lactic acid (PLLA): Injectable PLLA is biocompatible, biodegradable, biostimulatory, synthetic filler that must be injected into the reticular dermis or subcutaneous fat. PLLA, marketed as Sculptra®, was FDA approved in 2009 as soft tissue augmentation filler.5,6 It stimulates neocollagenesis through fibroblast activation.7 Histological studies show increase in type 1 collagen over 8–30 months after the injection.8,9 It is degraded by nonenzymatic hydrolysis into carbon dioxide and water over 9–24 months. However, due to neocollagenesis the augmentation effect lasts for about 24 months.10 Side effects of Sculptra include immediate effects of swelling, bruising, inflammation, and pruritus which lasts for a few days.11 Long-term effects include foreign 5body granuloma formation and extremely rare effect of anaphylactic reaction has been noted.
Calcium hydroxylapatite: Calcium hydroxylapatite (CaHA) is a biocompatible, biodegradable, resorbable, and biostimulatory filler that contains microspheres which can stimulate the endogenous production of collagen.12 Histopathologically, they appear bluish and round or oval in shape and packed together, 25–40 µm and surrounded by fibrin fibers and mild cellular infiltrate. These microspheres are degraded by enzymatic process and disappear clinically by 9–12 months.13 It has been used in cases of lipoatrophy of HIV, hand rejuvenation, and lip augmentation. There are reports of nodule formation after lip injections. Migration to a distant location from the injection site, a foreign body granulomatous reaction, seen as blue-gray microspheres in the extracellular matrix or within multinucleated giant cells has also been reported.14
Polymethyl methacrylate: Polymethyl methacrylate (PMMA) is rigid, transparent and colorless, thermoplastic permanent skin filler with low cost, easy accessibility, and potential to achieve lasting results. It has been used as an injectable filler to treat hollows and reduce rhytids. ArteFill® became the first and only permanent injectable wrinkle filler to receive FDA approval in 2006. ArteFill® is a third-generation polymeric microsphere-based filler, following its predecessor Artecoll®. It has been approved for the treatment of nasolabial folds. ArteFill® consists of PMMA microspheres (20% by volume), 30–50 μm in diameter, suspended in 3.5% bovine collagen solution (80% by volume), and 0.3% lidocaine. The collagen carrier is absorbed within 1 month after injection and completely replaced by the patient's own connective tissue within 3 months.15
First-generation polymerized PMMA microspheres (Arteplast) are purified with diameter greater than 20 μm, which may produce foreign body granulomas, larger microsphere (second generation Artecoll) of 30–50 µm resist phagocytosis; however, it was demonstrated that giant cell reaction still occurs with larger particles.16,17 Complications of PMMA injection were classified as nodular masses, inflammation, allergies, and skin hypopigmentation.18
Polyacrylamide hydrogel: Aquamid is a biocompatible and nonabsorbable hydrogel consisting of 97.5% water and 2.5% cross-linked polyacrylamide gel (PAAG). The gel is manufactured through polymerization of the acrylamide monomers and N,N’-methylenbisacrylamide.19 PAAG is available in more than 40 countries worldwide (Europe, Asia, the Middle East, and Latin America) and awaiting FDA approval. After injection, the implant is encapsulated and surrounded by fibroblasts and microphages, theoretically preventing migration. It is used for treating various rhytides (deep rhytides and folds), facial contouring, and correction of HIV lipoatrophy. It usually lasts for about 1 year after injection.20 There have been reported cases of inflammation, nodule and granuloma formation, and delayed hypersensitivity reactions of Aquamid injections.21
Polyvinylpyrrolidone-silicone suspension: It is a permanent filler comprised of particles of polymerized silicone elastomer, 100–600 μm in size, dispersed in a carrier of polyvinylpyrrolidone. It has been used for lip augmentation and the correction of facial rhytids. It is injected into the subcutaneous plane and this avoids any phagocytosis due 6to its large particle size. Cases of foreign body granuloma formation, swelling, and induration have been reported.22,23
Polyalkylimide gel: Polyalkylimide gel is a permanent hydrophilic translucent gel filler composed of a hydrophilic biopolymer with 96% sterile water and 45% polyalkylimide polymer (Alcamid®), and different from polyacrylamide. It has been used for lipoatrophy of HIV, skeletal deformities such as pectus excavatum. Complications noted with this filler include swelling, bruising, and nodule formation. 24-26
 
Based on the Source
 
Autograft
Fat, dermal graft: Fat grafts are taken from the lower abdomen and inner thigh especially in younger patients. When processed with proper centrifugation they can reliably produce purified fat, concentrated growth factors, and adipose-derived stem cells.27
 
Allograft
Allograft includes fascia (cadaver).
 
Heterograft
Heterografts include fibroquel which is bovine derived.3
 
Based on Effect
Temporary fillers are fillers which last for >12 months, such as HA fillers. Semi-permanent fillers last for 1–2 years and permanent fillers more than 2 years (Table 2).3
Table 2   Classification of dermal fillers based on duration.3
Temporary
(Biodegradable) <1 year
Semi-permanent (Biodegradable) 1–2 years
Permanent
(Nonbiodegradable) >2 years
Collagen
Calcium hydroxyapatite (CaHA) (Radiesse)
Polymethyl methacrylate (PMMA) (ArteFill®, Artecoll, Arteplast)
Collagen-human (Cosmoderm 1,2, Cosmoplast)
Polyacrylamide gel (PAAG) (Aquamid)
Collagen-Bovine (Zyderm 1,2, Zyplast)
Poly-L-lactic acid (PLLA) (Sculptra)
Polyalkylimide (Alcamid)
Hyaluronic acid-avian (Hylaform)
Silicone (Polydimethylsiloxane oil)
Hyaluronic acid-bacterial (Restylane, Juvederm)
Hydroxyethylmethacrylate (HEMA) (Dermaline/Derma deep)
 
Based on Content
Hyaluronic acid based fillers are one of the most popular and widely used materials in esthetic procedures. HA was first discovered by two American scientists, Carl Meyer and John Palmer. This polymer also known as Hyaluronan, is the most abundant glycosaminoglycans found in the human dermis. It is a ubiquitous component of all membrane connected tissue. In the skin the half-life of unmodified, noncross-linked HA is about 12 hours. Therefore to increase longevity when injected into the skin HA is cross-linked. Currently there are a large number of dermal fillers available to the physician based on various cross-linked HA technologies. Some 7of these technologies include VYCROSS (Allergan Inc.), NASHA (Galderma Pharma), CPM (Merz Pharmaceuticals) and OXIFREE technology (Kylane laboratories).6 The main differentiators for HA fillers are: Source of HA; concentration of HA in each syringe being utilized; the particulate size of the HA; whether the HA is cross-linked; the type of cross-linking agent used in the HA; whether the HA is monophasic or biphasic; and whether there is an anesthetic in the HA syringe.4
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