Aesthetics: Dermal Filler Flashcards by Emma Wilson

When did the FDA first approve HA fillers?

2003

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What are the different types of biodegradable filler products? (HINT: 8 answers)

Bovine collagen
Human derived bioengineered collagen
Hyaluronic acid
Poly Lactic Acid
Calcium hydroxyapetite or Radiesse
Polycaprolactone based filler
Cross-linked carboxymethyl cellulose
Autologous fat

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What is the half life of endogenous HA vs manufactured HA?

endogenous = 2 days
manufactured = 3-24 months

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Can radiesse (calcium hydroxyapatite) be used in the lips?

No - high incidence of nodules

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What are examples of permanent fillers? (HINT: there’s 7)

Paraffin
PMMA (polymethylmethacrylate)
Silicone
Aquamid
Polyvinylpyrrolidone-silicone suspension
Polyalkylimide gel
Polyvinylhydroxide microspheres suspended in polyacrylamide gel

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Why are stimulatory fillers only to be used by experienced practitioners?

Cause longer acting results than passive volumisers by stimulating endogenous neocollagenesis but are not easily dissolved

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What is the risk associated with higher cross-linked HA?

Higher risk for inflammation & nodule formation
Balance needs to be achieved

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What factors contribute to immunogenicity to HA?

Manufacturing uses cross-linking agents + bacterial endotoxins
Change in structure of HA/degree of cross-linking + by-products
HA may act as a potential bacterial nidus, attracting a bio-film

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What is the G-prime of HA?

the elastic component of the gel which defines its capacity to return to its original/close to original shape

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What does high cohesivity mean?

More vertical projection, can resist compression + maintain initial shape
Capacity of material not to dissociate due to affinity of its molecules for each other

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What are the 5 layers of the face?

Skin
Superficial fat
Muscle/SMAS
Deep fat + space
Periosteum/bone

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What are the superficial fat pads in the face?

From medial to lateral:
- nasolabial fat
- superior middle cheek (inferior orbital fat lies above)
- middle cheek fat
- lateral temporal cheek fat
malar fat pad = NLF + SMC + IOF

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What are the main deep fat pads?

SOOF
medial and lateral deep cheek fat

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What branches come off internal carotid artery?

supraorbital and supratrochlear arteries
- branches of the ophthalmic

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What arteries branch from the external carotid?

Facial
Maxillary
Mental
Superficial temporal

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Where is the facial artery layer wise at the root of the nose?

above maxilla but deep to zygomaticus minor + levator labii superioris

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What does the facial artery become? Where is this and why is it the danger zone?

Angular artery when it crosses the superior aspect of the nose
Seen as danger zone as it gives small branches with anastomose with small branches of internal carotid

What vessels does that maxillary artery give off?

infraorbital
deep temporal
inferior alveolar

What is the significance of the line of ligaments in the midface?

Oblique arrangement in medial midface
Injections medial to line of ligaments results in projection of overlying tissues
Injections lateral to this line lead to a lifting effect in more inferiorly located regions due to contrasting parallel arrangement of lateral midface

What happens to the bony skeleton in ageing?

Resorption maxilla (as early as 20 yrs age)
Reduction in maxilla length causes bony orbits to increase
mandible also resorbs (causes lower face to shorten in length and appear wider)

What superficial fat pads hypertrophy in ageing?

superficial medial cheek and nasolabial fat
- causes increased depth of nasolabial fold
middle cheek fat

What is the difference in atrophy of deep vs superficial fat pads?

Deep happens earlier
- volumise deep first
Deep deflation can effect support of superficial layers

What factors affect bone resorption?

genetic abnormalities
nutritional deficiencies
hormonal changes
lifestyle factors e.g. smoking, low exercise levels

What is (i) Hinderers lines (ii) wilkinsons lines?

(i) Hinderers = one line between nasal alar and upper tragus. Second line from oral commisure to 1cm out from lateral canthus
(ii) Wilkinsons = vertical line from lateral canthus to mandibular edge, with malar prominence at 1/3rd the distance

What is the frankfurt horizontal plane?

used for chin projection assessed by orienting head horizontally between inferior orbital rim and tragus of ear Patient in profile, line from nasion (top of nose) to pogonion (end of chin)

What is Ricketts line?

Lip projection Line from tip of nose to tip of chin - should be 4mm away from upper lip - 2mm away from lower lip

What are the golden ratios for lips?

Caucasians = 1:1.6 Afro-carribean = 1:1

What are the treatment principles for dermal filler?

Superior to inferior Deep to superficial Lateral to medial

What images should be taken (i) pre (ii) post dermal filler treatment?

(i) static views portrait, oblique and profile as minimum dynamic if appropriate (ii) static views, dynamic is appropriate to demonstrate treatment outcome

Do you need written consent for images?

Yes patients must give written consent to images being taken and stored

What advice should be given to patients following lip filler treatment?

1. Avoid strenuous exercise/massage for 24h 2. Avoid alcohol/aspirin/ibuprofen for 24h 3. Avoid touching area/makeup for 12h 4. Avoid sun exposure and extremes of temp for 1-week 5. Topical arnica/tablets may help bruising 6. Avoid facials/microdermabrasion, peels, laser, sunbeds for 2-weeks 7. Signs of allergic reaction seek urgent medical help 8. Avoid flying for 24-48h 9. Contact urgently if signs of VO (worsening pain/pallor)

How long do you need to apply LMX on for?

30-60 mins

What is the toxic dose for lignocaine?

3mg/kg

How do you manage a needlestick injury?

- if mouth or eyes involved wash with water - if skin punctured, encourage free bleeding, wash with soap or chlorhexidine and water - if any risk of HIV exposure urgent advice regarding PEP - participate in post-incident debriefing and reflective practice (duty to report to employers/public health)

What properties does clinisept have?

viricidal, bactericidal, sporicidal and fungicidal actions

Can patients with psoriasis have dermal filler?

Relative contraindication (koebner's phenomenon)

What is the timeline with dental procedures and dermal filler?

Should be at least 2-weeks gap

What drugs should you be wary of with regards to aesthetic treatments? (HINT: there's 4)

1. Anticoagulants/antiplatelets - simple bruise could become haematoma 2. Calcium antagonists - decrease effect of botox 3. Aminoglycosides - can potentiate effects of botox 4. Immunosuppressants - increased risk infection

What are the anterior and posterior borders of the jowls?

Anterior = mandibular ligament (bone to skin Posterior = masseteric ligament (muscle to skin)

In what layer would you perform nasal dermal filler and why?

Deep onto bone in midline (less vasculature here)