215: Soft Tissue Augmentation Flashcards
What are the primary uses of soft tissue fillers?
Soft tissue fillers are used for multiple cosmetic and therapeutic indications.
What are some examples of biodegradable products used as soft tissue fillers?
Examples of biodegradable products include hyaluronic acid, collagen, calcium hydroxylapatite, and poly-L-lactic acid.
What are superficial rhytides and what causes them?
Superficial rhytides are wrinkles caused by solar damage, characterized by loss of collagen at the dermal-epidermal junction (DEJ) and increased elastosis in the reticular dermis.
What is the threading technique in soft tissue augmentation?
The threading technique involves the deposition of filler in a linear fashion along the track of the needle as it is being withdrawn.
What is a significant complication associated with soft tissue fillers?
A significant complication is vascular occlusion, which can lead to local necrosis, CNS infarction, or blindness, especially with collagen and hyaluronic acid fillers.
What is the advantage of the push-ahead technique in injection?
The push-ahead technique allows injectable material to flow from the tip of the needle, hydrodissecting the tissues as it flows, which is advantageous in areas prone to bruising (e.g., upper lid, brow).
What are some other complications that can arise from soft tissue augmentation?
Other complications include ecchymosis, edema, extrusion, foreign body reactions, pigmentary alterations, injection site scarring, overcorrection, undercorrection, misplacement, and infection.
What technique would you use to inject a filler in an area prone to bruising, such as the upper lid or brow?
The push-ahead technique is ideal for areas prone to bruising. It involves anterograde injection, where the material flows from the needle tip and hydrodissects tissues as it flows.
What is the most devastating complication of soft tissue filler injections, and how can it be minimized?
Vascular occlusion is the most devastating complication, potentially causing local necrosis, CNS infarction, or blindness. It can be minimized by exerting minimal pressure, using blunt cannulas, and keeping the needle or cannula moving.
What is the recommended technique for diffuse coverage of a large area during filler injection?
The crosshatching technique is recommended. It involves layering linear threads in succession, followed by a second series of rows at right angles to the first.
What is the recommended technique for injecting fillers in areas with deep folds or near the bone?
The depot technique is recommended, where small ‘pearls’ of filler are deposited serially along a fold or deep by the bone.
What is the purpose of using a blunt cannula for fat transfer during filler procedures?
A blunt cannula minimizes the risk of vascular occlusion and tissue trauma during fat transfer.
What is the recommended technique for injecting fillers in areas with bruising?
The push-ahead technique is recommended for areas with bruising, as it hydrodissects tissues and minimizes trauma.
A patient experiences ecchymosis after filler injection. What is the likely cause, and how can it be minimized?
Ecchymosis is likely due to vascular trauma during injection. It can be minimized by using a blunt cannula and applying gentle pressure.
What are the primary uses of soft tissue fillers in cosmetic and therapeutic applications?
Soft tissue fillers are used for multiple cosmetic and therapeutic indications, including facial rejuvenation and correction of superficial rhytides.
What is the advantage of using subcutaneous volumizers in facial rejuvenation?
Subcutaneous volumizers provide long-lasting results, making them effective for facial rejuvenation.
Describe the threading technique in soft tissue augmentation.
Threading involves the deposition of filler in a linear fashion along the track of the needle as it is being withdrawn, allowing for controlled placement of the filler.
What is the fanning technique in soft tissue filler injection?
Fanning is a type of threading where the needle is withdrawn to create a new track radially adjacent to the last, rather than inserting the needle into a new area each time.
How does the push-ahead technique work in soft tissue augmentation?
In the push-ahead technique, injection is made in an anterograde fashion, allowing the injectable material to flow from the tip of the needle and hydrodissect the tissues as it flows.
What is the depot technique in soft tissue filler application?
The depot technique involves depositing small ‘pearls’ of filler serially along a fold or deep by bone, allowing for targeted augmentation.
What is crosshatching in the context of soft tissue fillers?
Crosshatching is a technique where linear threads are lined up in succession, with a second series of rows layered at right angles to the first, allowing for diffuse coverage of an area.
What is the proposed mechanism behind central occlusive events during filler injections?
Central occlusive events are theorized to occur due to high pressure injections that cause retrograde flow into arterioles connecting with the internal carotid system.
What are some strategies to minimize the risk of vascular occlusion during filler injections?
To minimize the risk of vascular occlusion, it is recommended to exert as little pressure as possible, use blunt cannulas for fat transfer, and keep the needle or cannula moving during injection.
List some common complications associated with soft tissue filler injections.
Common complications include ecchymosis, edema, extrusion or drifting of the filling substance, foreign body reactions, pigmentary alterations, injection site scarring, overcorrection, undercorrection, misplacement, and infection.
What is the clinical significance of using biodegradable products in soft tissue augmentation?
Biodegradable products are significant as they provide temporary results that can be metabolized by the body, reducing long-term complications associated with permanent fillers.
What factors contribute to the appearance of superficial rhytides in patients?
Factors contributing to superficial rhytides include solar damage, loss of collagen at the DEJ, and increased elastosis in the reticular dermis, leading to deeper appearance in nasolabial and melolabial creases.
What is the optimal patient demographic for dermal fillers?
Dermal fillers are considered optimum for younger patients who may benefit from volume restoration and enhancement of facial contours.
How does the choice of filler impact the outcome of facial rejuvenation procedures?
The choice of filler impacts the outcome by determining the longevity, texture, and volume of the augmentation, influencing patient satisfaction and aesthetic results.
What are the advantages of using the push-ahead technique in areas prone to bruising?
The push-ahead technique is advantageous in areas prone to bruising, such as the upper lid and brow, as it allows for smoother distribution of the filler and minimizes trauma to surrounding tissues.
What is the role of autologous fat in soft tissue augmentation?
Autologous fat serves as a viable filler option that can provide natural volume restoration and contouring, with the added benefit of being biocompatible and reducing the risk of allergic reactions.
How can the risk of infection be minimized during soft tissue filler procedures?
To minimize the risk of infection, proper aseptic techniques should be employed, including sterilization of instruments, use of clean techniques, and appropriate patient selection and preparation.
What are the implications of using non-biodegradable products in soft tissue augmentation?
Non-biodegradable products can provide long-lasting results but may carry higher risks of complications such as granuloma formation, migration, and the need for surgical removal if adverse effects occur.
What is the significance of understanding the anatomy of the face in soft tissue augmentation?
Understanding facial anatomy is crucial for safe and effective soft tissue augmentation, as it helps in avoiding vascular structures and achieving optimal aesthetic outcomes.
What are the potential long-term effects of using permanent fillers in soft tissue augmentation?
Potential long-term effects of using permanent fillers include chronic inflammation, formation of granulomas, and the possibility of needing corrective procedures if complications arise.
How does the technique of crosshatching improve the results of filler injections?
Crosshatching improves results by allowing for a more even distribution of filler, enhancing volume and contour while minimizing the risk of lumpiness or unevenness in the treated area.
What considerations should be taken into account when selecting a filler for a specific patient?
Considerations include the patient’s age, skin type, desired outcomes, area of treatment, and any previous reactions to fillers or allergies.
What is the importance of patient education prior to soft tissue filler procedures?
Patient education is important to set realistic expectations, inform about potential risks and complications, and ensure informed consent for the procedure.
What are the key differences between subcutaneous volumizers and dermal fillers?
Subcutaneous volumizers are typically used for deeper volume restoration and provide long-lasting results, while dermal fillers are often used for surface-level corrections and are optimal for younger patients.
What is the role of hydrodissection in the push-ahead technique?
Hydrodissection in the push-ahead technique allows the injectable material to separate tissues, facilitating smoother placement and reducing trauma to surrounding structures.
What are the clinical implications of vascular occlusion during filler injections?
Vascular occlusion can lead to serious complications such as tissue necrosis, vision loss, or stroke, highlighting the need for careful technique and anatomical knowledge during injections.
What are the uses of Collagen as a dermal filler?
- Treatment of medium-to-deep rhytides and folds (nasolabial creases)
- Augmentation of the lips
- Used in bone cement and intraocular lenses
- PMMA microspheres (Artefill, Bellafill) are nonbiodegradable and semipermanent.
What is the recommended placement technique for Poly-L-lactic acid (PLLA)?
- Superficial subcutis (subdermal)
- Technique: Diffuse crosshatching and threading
- NEVER DEPOT!!!
What are the complications associated with Hyaluronic acid fillers?
- Allergic reaction or inflammation
- Blue discoloration (Tyndall effect)
- Misplacement
- Lumps
- Painful due to high viscosity
What is the duration of effect for Hyaluronic acid fillers?
- 6-12 months
- Longevity is directly proportional to the degree of crosslinking.
What are the advantages of using Poly-L-lactic acid (PLLA) as a filler?
- FDA-approved treatment of HIV lipoatrophy
- No downtime
- Biostimulatory agent that activates fibroblast and collagen deposition over time.
A patient with HIV lipoatrophy seeks a filler for facial rejuvenation. Which filler is FDA-approved for this condition, and what is its mechanism?
Poly-L-lactic acid (PLLA) (Sculptra) is FDA-approved for HIV lipoatrophy. It works as a biostimulatory agent, activating fibroblasts and promoting collagen deposition over months.
A patient desires subtle, gradual facial changes with minimal downtime. Which filler would you recommend, and what is the post-procedure care?
Poly-L-lactic acid (PLLA) (Sculptra) is ideal for subtle, gradual changes. Post-procedure care includes massaging the treated areas for 5 minutes, 5 times a day, for 5 days.
Which filler is contraindicated for use in the lips and periorbital area, and why?
Poly-L-lactic acid (PLLA) (Sculptra) is contraindicated for the lips and periorbital area because it can cause visible and palpable papules.
A patient presents with pitted acne scars and desires a semipermanent solution. Which filler would you recommend?
PMMA microspheres (polymethylmethacrylate) (Artefill, Bellafill) are recommended for pitted acne scars as they are semipermanent and suitable for medium-to-deep rhytides.
What is the purpose of reconstituting Poly-L-lactic acid (PLLA) at least 2-8 hours before injection?
Reconstituting PLLA ensures proper hydration and dispersion of the filler, reducing the risk of nodule formation.
What is the primary disadvantage of Poly-L-lactic acid (PLLA) as a filler?
The primary disadvantage of PLLA is the potential for nodule formation, especially if not properly reconstituted or injected.
A patient desires a filler for periorbital hollows. Which filler is suitable, and what technique should be used?
Hyaluronic acid fillers are suitable for periorbital hollows. The threading or fanning technique is recommended for precise placement.
What is the primary advantage of using PMMA microspheres as a filler?
The primary advantage of PMMA microspheres is their semipermanent nature, making them suitable for long-lasting correction of medium-to-deep rhytides.
A patient desires a filler for acne scars with minimal downtime. Which filler would you recommend?
Poly-L-lactic acid (PLLA) (Sculptra) is recommended for acne scars as it has minimal downtime and promotes collagen deposition over time.
What is the purpose of massaging the treated area after Poly-L-lactic acid (PLLA) injection?
Massaging the area helps evenly distribute the filler and reduces the risk of nodule formation.
What are the primary uses of Collagen as a dermal filler?
Collagen is primarily used for treating medium-to-deep rhytides and folds (nasolabial creases), pitted scars, and augmenting the lips. It is also used in bone cement and intraocular lenses.
What is the recommended placement technique for Poly-L-lactic acid (PLLA) injections?
The recommended placement technique for PLLA injections is superficial subcutis (subdermal) using diffuse crosshatching and threading. It is crucial to NEVER depot the product.
What are the complications associated with Hyaluronic acid fillers?
Complications associated with Hyaluronic acid fillers include allergic reactions or inflammation, blue discoloration (Tyndall effect), misplacement, lumps, and pain due to high viscosity.
How long does the effect of Poly-L-lactic acid (PLLA) typically last, and what is its primary advantage?
The effect of PLLA typically lasts for 2 years or longer, and its primary advantage is that it requires no downtime due to its biostimulatory properties that activate fibroblast and collagen deposition.
What is the significance of crosslinking in Hyaluronic acid fillers?
The significance of crosslinking in Hyaluronic acid fillers is that as the proportion and degree of crosslinking increases, the gel becomes more resistant to degradation, enhancing its longevity and effectiveness.
What are the contraindications for using Poly-L-lactic acid (PLLA) in patients?
Poly-L-lactic acid (PLLA) is contraindicated in patients taking immunosuppressives and anti-inflammatory drugs, and it should not be used for the lips and periorbital area.
What is the recommended postoperative care for patients receiving PLLA injections?
Postoperative care for PLLA injections includes massaging the treated areas for 5 minutes, 5 times a day for 5 days to help with the distribution and absorption of the product.
What is Poly-L-lactic acid (PLLA) contraindicated in?
Poly-L-lactic acid (PLLA) is contraindicated in patients taking immunosuppressives and anti-inflammatory drugs, and it should not be used for the lips and periorbital area.
What types of facial areas can Hyaluronic acid fillers be used to treat?
Hyaluronic acid fillers can be used to treat medium-to-deep folds, periorbital hollows, nasolabial folds, midcheeks, lips, labiomental creases, and acne scars.
What is the FDA-approved use of Poly-L-lactic acid (PLLA)?
Poly-L-lactic acid (PLLA) is FDA-approved for the treatment of HIV lipoatrophy, specifically for restoring volume in areas such as nasolabial folds, cheeks, and temples.
What is the primary disadvantage of using Poly-L-lactic acid (PLLA) as a filler?
The primary disadvantage of using Poly-L-lactic acid (PLLA) is the potential for nodule formation at the injection site.
What are the characteristics and benefits of stabilized forms of fillers?
- Persist longer in tissue and may increase de novo collagen synthesis by fibroblast stretching.
- Maintain a constant volume despite degradation due to ability to bind water (mucopolysaccharide).
- Smaller particle size is used for finer wrinkles, while larger particle size is for volumetric filling.
- Indicated for areas like periorbital, nasolabial folds, and labiomental crease.
What is the recommended technique and placement for Calcium Hydroxylapatite (Radiesse)?
- Placement: Deep dermis to superficial subcutis.
- Technique: Threading.
- Uses: Treatment of deep folds, nasolabial folds, labiomental crease, and for age-related atrophy of dorsal hands.
What are the complications associated with Calcium Hydroxylapatite (Radiesse)?
- Nodules in lips and periorbital areas.
- Misplacement with demarcation of product.
- Contraindicated for use in lips and periorbital area.
What are the uses and techniques for Autologous Fat Transfer?
- Uses: To restore youthful architecture to fat compartments, for pan-facial filling, especially in periorbital areas and lips.
- Technique: Threading, depot, crosshatching.
- Goal: Advance tissues forward and elevate them away from the bone, filling in areas of shadow.
What are the complications associated with Autologous Fat Transfer?
- Postoperative edema and ecchymoses lasting about 2 weeks.
- Bumps that may indicate atypical mycobacteria if persistent for more than 1 year.
- Vascular occlusive events due to injudicious placement.
- Not indicated for those with very low body fat, elderly, or HIV-associated conditions.
A patient presents with deep nasolabial folds and desires a long-lasting filler. Which filler would you recommend, and why?
Calcium hydroxylapatite (Radiesse) is recommended because it lasts 6-18 months, is suitable for deep folds, and acts as a biostimulatory agent by forming a scaffold for autologous collagen growth.
A patient with a history of cold sores is scheduled for hyaluronic acid filler injections. What pre-procedure step is necessary?
Prophylactic antiviral medication should be administered to prevent cold sore outbreaks.
A patient desires a filler that maintains a constant volume despite degradation. Which filler would you choose, and why?
Hyaluronic acid fillers are ideal because they bind water (mucopolysaccharide), maintaining a constant volume even as they degrade.
What is the primary advantage of using autologous fat transfer for facial rejuvenation?
Autologous fat transfer provides a dramatic global change in facial appearance and is the filler of choice for patients with collagen vascular disease or allergies to other fillers.
A patient experiences blue discoloration after hyaluronic acid filler injection. What is the likely cause, and how can it be corrected?
The blue discoloration is likely due to the Tyndall effect, caused by superficial placement of the filler. It can be corrected using hyaluronidase to break down the filler.
Which filler is ideal for treating age-related atrophy of the dorsal hands, and what is the maximum volume recommended?
Calcium hydroxylapatite (Radiesse) is ideal for treating age-related atrophy of the dorsal hands, with a maximum recommended volume of 3 ml.
A patient presents with medium-to-deep folds and desires a filler with a natural appearance. Which filler would you recommend?
Hyaluronic acid fillers are recommended as they provide a softer, more natural appearance and are suitable for medium-to-deep folds.
What is the role of calcium hydroxylapatite microspheres in facial rejuvenation?
Calcium hydroxylapatite microspheres act as a scaffold to support the growth of autologous collagen, providing biostimulatory effects.
A patient experiences lumps after hyaluronic acid filler injection. What is the likely cause, and how can it be managed?
Lumps are likely due to misplacement or high viscosity of the filler. They can be managed by massaging the area or using hyaluronidase to dissolve the filler.
A patient desires a filler for facial contouring with a long duration of effect. Which filler would you recommend?
Hyaluronic acid fillers are recommended for facial contouring, especially those with a high degree of crosslinking for longer durability (6-12 months).
A patient desires a filler for tear trough deformity correction. Which filler is suitable, and what precautions should be taken?
Hyaluronic acid fillers are suitable for tear trough deformity correction. Precautions include using a topical anesthetic and avoiding overcorrection.
A patient desires a filler for nasal reconstruction. Which filler is suitable, and what is its mechanism?
Calcium hydroxylapatite (Radiesse) is suitable for nasal reconstruction. It acts as a biostimulatory agent, forming a scaffold for collagen growth.
A patient desires a filler for lip augmentation with a natural appearance. Which filler would you recommend?
Hyaluronic acid fillers are recommended for lip augmentation as they provide a softer, more natural appearance.
What is the primary advantage of using calcium hydroxylapatite as a filler?
The primary advantage is its biostimulatory effect, promoting autologous collagen growth for long-lasting results.
What is the role of mucopolysaccharides in hyaluronic acid fillers?
Mucopolysaccharides bind water, helping hyaluronic acid fillers maintain a constant volume despite degradation.
What are the advantages of using stabilized forms of fillers in soft tissue augmentation?
- Persist longer in tissue
- May increase de novo collagen synthesis by fibroblast stretching
- Maintain a constant volume despite degradation due to water binding (mucopolysaccharide)
- Smaller particle size is effective for finer wrinkles, while larger particle size is suitable for volumetric filling.
What are the recommended uses for Calcium Hydroxylapatite (Radiesse) in facial aesthetics?
- Treatment of deep folds, nasolabial folds, labiomental crease, and acne scars
- Reconstruction for nasal, malar, jawline, and nipple areas
- Age-related atrophy of dorsal hands (max: 3 ml)
- Treatment of vocal cord insufficiency
- Acts as a biostimulatory agent to support autologous collagen growth.
What are the key preoperative and postoperative considerations for using Calcium Hydroxylapatite?
Preoperative:
- Prophylactic antiviral for cold sores
Postoperative:
- Avoid manipulation of the area for the first 48 hours
- May use hyaluronidase to break down hyaluronic acid products if necessary.
What are the complications associated with Calcium Hydroxylapatite injections?
- Nodules in the lips and periorbital areas
- Misplacement with demarcation of product
- Not recommended for use in lips and periorbital areas.
What is the primary purpose of Autologous Fat Transfer in facial rejuvenation?
- To restore youthful architecture to fat compartments
- Ideal for pan-facial filling, especially in periorbital areas and lips.
What are the preoperative instructions for patients undergoing Autologous Fat Transfer?
- Stop taking all NSAIDs, Vitamin E, and omega-3 fatty acid supplements
- Avoid ginkgo, ginger, or ginseng
- Start prophylactic antistaphylococcal antibiotics.
What are the common complications following Autologous Fat Transfer procedures?
- Postoperative edema and ecchymoses lasting up to 2 weeks
- Formation of bumps
- Risk of atypical mycobacterial infections if symptoms persist for more than 1 year
- Potential for vascular occlusive events due to improper placement.
What is the recommended technique for placing Autologous Fat Transfer?
- Subcutaneous tissue techniques include:
- Threading
- Depot
- Crosshatching
- The goal is to advance tissues forward, elevate them away from the bone, and fill in areas of shadow to restore youthful contours.
What are the ideal fat harvesting sites for Autologous Fat Transfer in women and men?
Gender | Fat Harvesting Site |
|——–|——————–|
| Women | Outer thighs and hips |
| Men | Flanks |
What is the duration of effect for Calcium Hydroxylapatite (Radiesse) after injection?
- The effects typically last between 6 to 18 months, requiring touch-ups or retreatment every 3 months for optimal results.
What is the maximum recommended dose of lidocaine for tumescent fluid in relation to body weight?
Lidocaine should not exceed 35 mg per body weight and allow at least 20 minutes for epinephrine (1:200,000) to achieve hemostasis.
What are the four steps essential for the success of collagen or hyaluronic acid treatments?
The success depends on four steps:
- Collecting
- Processing
- Injecting
- Protecting
What are the advantages of using injectable silicone for treatment?
Advantages of injectable silicone include:
- Treatment of HIV lipoatrophy
- Effective for deep folds, lips, plantar defects, and scars
- Only small volumes are injected each visit
- Very little postoperative discomfort, edema, and ecchymoses
What are the contraindications for using injectable silicone?
Injectable silicone is contraindicated in patients with:
- Autoimmune disease
- Chronic or active infections
What is the recommended treatment for delayed granuloma formation after silicone injection?
Treatment options for delayed granuloma formation include:
- Intralesional (IL) or systemic steroids
- Minocycline
- Topical imiquimod
- Surgical excision
A patient with very low body fat seeks facial rejuvenation. Why might autologous fat transfer not be suitable?
Autologous fat transfer is not suitable for patients with very low body fat because there may not be enough fat available for harvesting.
What is the recommended post-procedure care for autologous fat transfer to ensure long-term success?
Post-procedure care includes avoiding submerging the body in water until all incisions are healed (at least 1 week) and undergoing a series of treatments for cumulative augmentation.
A patient desires a filler for lip augmentation with minimal postoperative discomfort. Which filler would you recommend?
Injectable silicone is recommended for lip augmentation as it causes very little postoperative discomfort, edema, or ecchymoses.
A patient with a history of autoimmune disease seeks filler treatment. Which filler is contraindicated, and why?
Injectable silicone is contraindicated in patients with autoimmune disease due to the risk of delayed granuloma formation and migration.
What is the recommended pre-procedure care for patients undergoing autologous fat transfer?
Pre-procedure care includes stopping NSAIDs, Vitamin E, omega-3 fatty acids, ginkgo, ginger, or ginseng, and starting prophylactic antistaphylococcal antibiotics.
What is the primary disadvantage of using injectable silicone as a filler?
The primary disadvantage is the risk of delayed granuloma formation and migration, which may require treatment with steroids or surgical excision.
What is the maximum dosage of lidocaine that should be administered based on body weight for tumescent fluid, and what is the recommended waiting time for epinephrine to achieve hemostasis?
Lidocaine should not exceed 35 mg per kg body weight, and at least 20 minutes should be allowed for epinephrine (1:200,000) to achieve hemostasis in tumescent fluid.
What precautions should be taken post-operatively regarding water exposure and healing time for incisions?
Post-operatively, patients should not submerge their body in water until all incisions are healed, which is recommended to be at least 1 week.
What are the four steps that success in soft tissue augmentation depends on?
Success in soft tissue augmentation depends on the following four steps:
1. Collecting
2. Processing
3. Injecting
4. Protecting
What are the advantages of using injectable silicone for treatment, and what conditions can it address?
Advantages of injectable silicone include very little postoperative discomfort, edema, and ecchymoses. It is used for treating HIV lipoatrophy, deep folds, lips, plantar defects, and scars.
What is the recommended treatment for delayed granuloma formation and migration after silicone injection?
Treatment for delayed granuloma formation and migration includes intralesional (IL) or systemic steroids, minocycline, topical imiquimod, or surgical excision.
What are the contraindications for using injectable silicone in patients?
Injectable silicone is contraindicated in patients with autoimmune disease, chronic conditions, or active infections.
What is the significance of undercorrection in soft tissue augmentation, and what causes it?
Undercorrection in soft tissue augmentation is common due to a decline in edema rather than absorption of fat, which can affect the final aesthetic outcome.
What types of facial lines and disorders can PMS-50 injectable silicone address?
PMS-50 injectable silicone can address glabellar lines, nasolabial folds, perioral lines, lip augmentation, and scarring disorders.
What is the composition of medical grade silicone oil used in injectable procedures?
Medical grade silicone oil contains long polymers of dimethylsiloxanes and is considered noncarcinogenic.
What is the recommended approach for managing lipodystrophy in patients receiving injectable fillers?
Management of lipodystrophy in patients receiving injectable fillers should consider patient health, especially those on concomitant anticoagulant treatment.
