Injectable Fillers E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 329

Veröffentlichungsjahr: 2019

Beschreibung

In the innovative field of cosmetic dermatology, the range of products and methods available to patients is expanding all the time. Prominent among these are facial fillers, which, when injected into and beneath the skin, help alleviate wrinkles and improve smoothness. However, the many fillers on offer have varying characteristics and effects, and practitioners must be properly trained in order to administer them safely and successfully.

Injectable Fillers offers those performing these popular procedures an in-depth and far-reaching survey of current best practices, with a strong emphasis on safety. Covering everything from the science behind facial fillers to their appropriate means of application, the book places each product in context, demonstrating the pros and cons of the expanding range of hyaluronic acids and calcium hydroxylapatite microspheres, and exploring injectable submental fat reduction with sodium deoxycholate. This second edition broadens the scope of discussion to also include chin, mandible, temple, nose, brow, and forehead injections, as well as the use of cannulas as an alternative to needles.

Leseprobe

Injectable Fillers:

Facial Shaping and Contouring

Second Edition

EDITED BY

Derek H. Jones, MD

Medical Director

Skin Care and Laser Physicians of Beverly Hills

Los Angeles, CA

USA

Arthur Swift, MD

Plastic Surgeon

The Westmount Institute of Plastic Surgery

Montreal, QC

Canada

This edition first published 2019 © 2019 by John Wiley & Sons LtdEdition History [1e, 2010]

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.

The rights of Derek H. Jones and Arthur Swift to be identified as the authors of editorial in this work has been asserted in accordance with law.

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Limit of Liability/Disclaimer of WarrantyThe contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may provide or recommendations it may make. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.

Library of Congress Cataloging‐in‐Publication Data

Names: Jones, Derek H., 1965– editor. | Swift, Arthur, editor.Title: Injectable fillers : facial shaping and contouring / edited by Derek H. Jones, Arthur Swift.Description: Second edition. | Hoboken, NJ : Wiley‐Blackwell, 2019. | Includes bibliographical references and index. |Identifiers: LCCN 2018048131 (print) | LCCN 2018049205 (ebook) | ISBN 9781119046967 (Adobe PDF) | ISBN 9781119046950 (ePub) | ISBN 9781119046943 (hardcover)Subjects: | MESH: Face–surgery | Cosmetic Techniques | Injections–methodsClassification: LCC RD119.5.F33 (ebook) | LCC RD119.5.F33 (print) | NLM WE 705 | DDC 617.5/2059–dc23LC record available at https://lccn.loc.gov/2018048131

Cover Design: WileyCover Image: ©RomoloTavani/iStockphoto

List of Contributors

Frederick C. Beddingfield, III MD, PhDSienna Biopharmaceuticals, Westlake Village, CA, USA

Katie Beleznay MD, FRCPC, FAADCarruthers & Humphrey Cosmetic Dermatology and University of British Columbia, Vancouver, British Columbia, Canada

Jeanette M. Black MDSkin Care and Laser Physicians of Beverly Hills, Los Angeles, CA, USA

Sebastian Cotofana MDSkin Care and Laser Physicians of Beverly Hills, Los Angeles, CA, USAandDepartment of Medical Education, Albany Medical College, Albany, NY, USA

Claudio DeLorenzi MDThe DeLorenzi Clinic, Kitchener, Ontario, Canada

Shannon Humphrey MD, FRCPC, FAADCarruthers & Humphrey Cosmetic Dermatology and University of British Columbia, Vancouver, British Columbia, Canada

Derek H. Jones MDSkin Care and Laser Physicians of Beverly Hills, Los Angeles, CA, USA

Krishnan M. Kapoor MDFortis Hospital, Mohali, Punjab, IndiaandAnticlock Clinic, Chandigarh, India

B. Kent Remington MDRemington Laser Dermatology Centre, Calgary, Canada

Paul F. Lizzul MD, PhD, MPH, MBASienna Biopharmaceuticals, Westlake Village, CA, USA

Ardalan Minokadeh MD, PhDSkin Care and Laser Physicians of Beverly Hills, Los Angeles, CA, USA

Amir Moradi MDMoradi M.D., Vista, CA, USA

Tatjana Pavicic MDPrivate Practice for Dermatology and Aesthetics, Munich, Germany

Herve Raspaldo MDPrivate Practice Facial Surgeon, Geneva, Switzerland

Arthur Swift MDThe Westmount Institute of Plastic Surgery, Montreal, QC, Canada

Jeff Watson MDMoradi M.D., Vista, CA, USA

Woffles T.L. Wu MBBS, FRCS(Edin), FAMS (Plastic Surg)Woffles Wu Aesthetic Surgery and Laser Centre, Singapore

Foreword

It gives us great pleasure to introduce Injectable Fillers: Facial Contouring and Shaping, edited by our esteemed colleagues, Drs. Jones and Swift. To say this book is timely would be understating the significance of its content. The last decade has deepened our understanding of anatomy and the effects of ageing in the face. We know, for example, that volume loss within the soft tissues combines with bony remodelling to effect significant changes, and we recognize the way that these changes are intricately linked. In turn, this knowledge has refined our techniques and the products we use to produce optimal results – a paradigm shift from the two‐dimensional filling of lines and folds to a full‐face approach in which augmentation begins with the restoration of the underlying structure and support that has been lost over time. It is no longer possible to treat one area in isolation without considering the picture as a whole. We have become artists with a deep appreciation of the human face in all its symmetry and harmony.

With so many advances in so few years, keeping up to date has never been more important. Injectable Fillers: Facial Contouring and Shaping synthesizes the most current information and state‐of‐the‐art injection practices from skilled clinicians across the globe. The authors represent a broad cross‐section of acknowledged experts within the fields of cosmetic dermatology and plastic surgery.

Dr. Jones is a world‐renowned leader in the field of minimally invasive facial aesthetics. With numerous peer‐reviewed publications and book chapters, he knows everything there is to know about injectable fillers and has participated as a key investigator for some of today's leading products in facial rejuvenation. Dr. Swift is an eminent plastic surgeon with over 30 years' experience in shaping and contouring the face and body. He has been recognized for his contributions for the advancement of aesthetic medicine and rewarded for his innovations in teaching and clinical practice.

As editors of Injectable Fillers: Facial Contouring and Shaping, Drs. Jones and Swift have created an indispensable book for the busy cosmetic practitioner who wishes to refine his or her techniques in the art of creating beautiful faces.

Jean CarruthersAlastair CarruthersVancouver, 2018

About the Companion Website

This book is accompanied by a companion website:

www.wiley.com/go/jones/injectable_fillers

The website includes:

Videos

Scan this QR code to visit the companion website:

CHAPTER 1Injection Anatomy: Avoiding the Disastrous Complication

Arthur Swift1, Claudio DeLorenzi2, and Krishnan M. Kapoor3,4

1 The Westmount Institute of Plastic Surgery, Montreal, QC, Canada

2 The DeLorenzi Clinic, Kitchener, Ontario, Canada

3 Fortis Hospital, Mohali, Punjab, India

4 Anticlock Clinic, Chandigarh, India

Over the past two decades, neuromodulators and ‘dermal’ fillers have provided cosmetic physicians with the tools necessary to enhance facial features non‐surgically and usually with minimal discomfort. Having a profound impact on beauty is no longer limited to a surgeon's knife wielded by an experienced specialist proficient in facial anatomy and aesthetics. Originally intended for the safer location of intradermal deposition, synthetic filler therapy has been extended beyond the eradication of unwanted wrinkles and folds into the realm of facial contouring and volume restoration. The transition of more robust fillers into deeper treatment planes by practitioners unfamiliar with the attendant vital anatomy has resulted in the appearance of devastating intravascular complications.

Complications have arisen from the use of various dermal fillers since their inception. Historically, paraffin, Vaseline, and many other materials were used that could not only cause many of the same types of devastating vascular complications, but also result in serious adverse events that were long lasting due to tissue incompatibility and immune‐mediated issues [1]. Fat may be considered the archetype of ‘deep’ fillers, and embolic phenomena have been reported from many sites over the decades since it was first developed as a technique for volume replacement (including blindness, stroke, and tissue necrosis) [2]. Since the development of the hypodermic needle, many different drugs that were either partially insoluble or that had serious inflammatory effects on the linings of blood vessels (particularly arterial wall linings), were implicated in many serious adverse events resulting from the ensuing ischemia when accidental intra‐arterial injection caused inflammatory desquamation of the arterial lining tissue. From this historical perspective, then, the present state of filler complications does not present anything new, but rather mirrors experiences with other filler materials. The most successful modern fillers (the class of hyaluronic acid derivatives) now mainly show improved results for tissue integration and also lack inflammatory effects [3].

It is imperative that all injection specialists have an intimate understanding of facial anatomy and its relationship with injection therapy so that serious adverse events are minimized. A 100% foolproof method of facial injection therapy is impossible because of the variability in facial anatomy. Anatomy textbooks only give an average depiction of what exists in vivo, with numerous classifications and variations of vascular patterns reported (with their intendant percentages) for every facial region [4]. It is therefore crucial that treating physicians familiarizes themselves with the different techniques available to limit intravascular compromise (Table 1.1).

Table 1.1 Techniques to limit intravascular injection.

Know your injection anatomy – avoid danger areas and depths.

Aspiration before injection in higher risk areas

[5]

. This is not a guarantee of extravascular location as false negatives are high. Nonetheless, it is still the authors' recommendation, especially in higher risk areas.

Slow injections with the least amount of pressure

[6]

(definitely advantageous). Adverse events will commonly occur when the injector is rushing to complete a treatment.

Move the tip of the needle slightly with delivery of the product

[7]

. Although theoretically this will limit the amount of possible embolic material, it is controversial as the tip can move in or move out of a vessel.

Incremental injections of 0.1–0.2 cm

3

of product

[8]

. Severe adverse events have been associated with a significant deposition of product.

Small syringe to deliver precise aliquots

[9]

. The amount of product deposited over time is a significant factor in embolic events.

Small needles to slow the injection speed

[10]

. This is controversial in that the higher gauge can conversely access the smaller diameter vessels inaccessible to larger bore needles.

Blunt flexible microcannulae

[11]

. Intravascular transgression is still possible and has been reported. A cavalier approach is not warranted.

Addition of a small amount of vasoconstrictor in the product or as a preparatory step may effect some vasoconstriction without the long lasting block nor blanching of the skin

[12]

.

Patient selection (e.g. previous surgery with scarred beds portends an increased risk of a vascular event).

The injector should always observe the skin at the area of injection and not the syringe in his/her hand, just as a driver watches the road and not the steering wheel. Drivers have rear view mirrors into which they glance to prevent accidents – so too does the injector whose rear view mirror is the glabellar region. Glabellar blanching can be the first indication of intravascular injection in the face regardless of the injection location. Therefore occasional glancing into the ‘rear view mirror’ of the glabellar region for signs of blanching,

regardless of the site of facial injection

, is advisable.

The occurrence of patient pain distant to the site of injection, in spite of lidocaine with the commercially available products

[13]

. (N.B. This is not noted in every case)

The possibility of delayed onset (several hours later) of symptoms and signs that require emergent care

[14]

.

In principle, all the facial areas currently considered for treatment can be divided into higher risk or lower risk areas, but as we shall see, there are no ‘zero risk’ areas. This is an important detail that is often glossed over by manufacturers, who are keen to promote fillers as safe and effective. As the numbers of practitioners (who often learn the techniques in a weekend course) increase, certain trends in complications have been identified. One important issue is that many new practitioners have no recent experience with the vascular anatomy of the face, and worse, are completely unfamiliar with the previous reports of serious complications with the use of fillers. The combination of exuberance for a new technique, its seemingly easy implementation, and the lack of knowledge of the consequences of severe complications, has resulted in many unrecognized adverse events with high morbidity. Although serious adverse events can happen even in the hands of the most experienced injectors, when these are properly recognized and treated appropriately, the outcome can be good, but when they are not, the outcome can be seriously debilitating or mutilating. The purpose of this chapter is to familiarize the injector with the ‘injection anatomy’ of the face, so that practitioners can properly gauge the level of risk for the intended treatment.

1.1 Injection Anatomy Defined

Many different categories of human anatomy have been described, most of which relate to the instrument being used and the ensuing treatment or therapy (e.g. surgical anatomy, radiological anatomy, etc.).

Injection anatomy, not previously described, is centred on the use of a syringe and needle rather than a scalpel. Where the tip of the needle resides (the point from which the product will flow) once under the skin is crucial. Injecting under the skin involves encountering vital structures. Knowledge of injection anatomy therefore pertains to the depth of injection as it relates to the location of the tip of the needle.

Injection anatomy can be defined as the study of regional anatomy as it relates to surface landmarks and the underlying depth of targeted tissue and vital structures. Although a myriad of vascular patterns exist in two dimensions, there is relative consistency in the depth (third dimension) at which vessels pass through the tissues in specific geographical regions of the face. Appreciating the depth location of the tip of the needle, although not infallible, should guide treatment into ‘safer’ lower risk zones for specific facial regions. The clinician's ability to delineate these facial anatomical zones at the time of treatment is limited to visual and palpable topographical assessment. To this end, five bony and three soft tissue landmarks must be discerned, which divide the face into specific treatment regions according to depth (Figure 1.1).

Figure 1.1 Eight topographical landmarks for defining injection zones. The five boney markers are the temporal crest, the orbital rim, the inferior maxillary border, the pyriform fossa, and the gonial angle. The three soft tissue landmarks are the medial iris, the lateral iris, and the anterior border of the masseter.

1.2 Pathogenesis of Vascular Obstruction

Intravascular deposition (either arterial or venous) of filler product, and subsequent embolization is a necessary feature of vascular compromise in the face. Unlike the distal limbs where compartment syndromes may occur from external compression, this is not the case for the facial partitions, especially considering the amount of product being deployed and the extensive collateral vascular arborization.

In terms of general organization, the arterial blood flow is from larger bore to smaller vessels, whereas the reverse is true in the venous system (smaller veins connect to larger diameter veins). Intravenous injection of sclerosing drugs works because the material is rapidly diluted and mixed with blood as the material flows through ever‐larger vessels on the way to the right heart. Any foreign material in the venous system is ultimately filtered out in the pulmonary arterial system. When relatively large amounts of foreign material are injected intravenously, serious pulmonary complications have been reported [15]. However, with the small aliquots of hyaluronic acid (HA) filler typically injected, the resulting pulmonary lesions often go unnoticed or undiagnosed.

Tissue necrosis following a filler treatment is invariably due to inadvertent intra‐arterial embolization of filler material as confirmed by the finding of intraluminal filler material on pathological examination of necrotic skin [16]. The filler may enter the vessel directly, as a result of intra‐arterial needle tip location, or indirectly, through tissue channels created by the passing of a needle or cannula through the vessel (discussed in detail below). The embolism may be anterograde, i.e. distal or downstream from the site of injection, or even retrograde, contrary to the normal direction of blood flow (vide infra). Although filler material has been identified in the lumen of arteries in every case examined histologically [17], there is a common misconception that external pressure on a small artery is sufficient to cause skin necrosis by limiting blood flow. This is incorrect – tissue necrosis is the sine qua non of accidental intra‐arterial injection. Repeated separate laboratory studies in animals have not been able to cause tissue necrosis by external pressure alone, even when very large amounts of filler have been used to significantly increase interstitial pressure [18]. This is analogous to the situation when intravenous fluid has ‘gone interstitial’. There may be tissue blanching from the pressure increase of the injectate, but unless the liquid is toxic (e.g. chemotherapeutic drugs, etc.), the pressure resolves long before any tissue necrosis occurs. Similarly, extensive experience with tissue expanders has demonstrated that skin is extraordinarily resistant to necrosis on the basis of pressure alone, unless extraordinarily severe, and/or the tissues are abnormally scarred. (Tissue manometry studies carried out decades ago on tissue expanders showed that tissues respond rapidly, first by elastic and then by plastic deformation in response to pressure, and indeed, this forms the basis for the technique of tissue expansion.) Although future information may reveal exceptions to this rule, in general, any type of tissue necrosis following a filler injection is due to inadvertent intra‐arterial injection [19]. The filler may travel extraordinary distances depending on the unique vascular anatomy of the area, even crossing the midline in certain situations. Almost 100 years ago, Freudenthal [20] described necrosis of the digits from an injection in the deltoid due to arterial embolism. Understanding this phenomenon explains the dozens of cases of blindness reported due to filler injections in the face [21].

Every injection under the skin violates a vascular entity, regardless of the appearance, or not, of a drop of blood from the injection site. Skewering a vessel with the subsequent deposition of product outside its walls, in a previously non‐violated, non‐scarred bed, should limit any adverse event to possible bruising (once the tamponade effect of the needle is lost upon its withdrawal). Application of immediate pressure over the injection site should limit this untoward aesthetic consequence.

As mentioned earlier, intravascular instillation of product may occur as a result of the tip of the needle being located inside the vessel, or more uncommonly as a result of a side‐cut in the vessel created by the needle in zones of scarring where subsequent flow of product follows the tunnel created back into the vessel. With the tip of the needle inadvertently located within a vessel, once the plunger of the syringe is depressed, the pressure generated at the tip of the needle surpasses the systolic pressure within the vascular system. The flood of product that ensues is indifferent to the actual direction of blood flow, and obeys Poisseuile's law of resistance, which is inversely related to the radius (to the fourth power) of the vessel (Figure 1.2