Aesthetics: Dermal Filler

Question 1

When did the FDA first approve HA fillers?

Answer 1

2003

Question 2

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

Answer 2

1. Bovine collagen
2. Human derived bioengineered collagen
3. Hyaluronic acid
4. Poly Lactic Acid
5. Calcium hydroxyapetite or Radiesse
6. Polycaprolactone based filler
7. Cross-linked carboxymethyl cellulose
8. Autologous fat

Question 3

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

Answer 3

endogenous = 2 days
manufactured = 3-24 months

Question 4

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

Answer 4

No - high incidence of nodules

Question 5

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

Answer 5

1. Paraffin
2. PMMA (polymethylmethacrylate)
3. Silicone
4. Aquamid
5. Polyvinylpyrrolidone-silicone suspension
6. Polyalkylimide gel
7. Polyvinylhydroxide microspheres suspended in polyacrylamide gel

Question 6

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

Answer 6

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

Question 7

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

Answer 7

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

Question 8

What factors contribute to immunogenicity to HA?

Answer 8

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

Question 9

What is the G-prime of HA?

Answer 9

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

Question 10

What does high cohesivity mean?

Answer 10

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

Question 11

What are the 5 layers of the face?

Answer 11

1. Skin
2. Superficial fat
3. Muscle/SMAS
4. Deep fat + space
5. Periosteum/bone

Question 12

What are the superficial fat pads in the face?

Answer 12

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

Question 13

What are the main deep fat pads?

Answer 13

SOOF
medial and lateral deep cheek fat

Question 14

What branches come off internal carotid artery?

Answer 14

supraorbital and supratrochlear arteries
- branches of the ophthalmic

Question 15

What arteries branch from the external carotid?

Answer 15

Facial
Maxillary
Mental
Superficial temporal

Question 16

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

Answer 16

above maxilla but deep to zygomaticus minor + levator labii superioris

Question 17

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

Answer 17

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

Question 18

What vessels does that maxillary artery give off?

Answer 18

infraorbital
deep temporal
inferior alveolar

Question 19

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

Answer 19

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

Question 20

What happens to the bony skeleton in ageing?

Answer 20

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)

Question 21

What superficial fat pads hypertrophy in ageing?

Answer 21

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

Question 22

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

Answer 22

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

Question 23

What factors affect bone resorption?

Answer 23

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

Question 24

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

Answer 24

(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

Question 25

What is the frankfurt horizontal plane?

Answer 25

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)

Question 26

What is Ricketts line?

Answer 26

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

Question 27

What are the golden ratios for lips?

Answer 27

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

Question 28

What are the treatment principles for dermal filler?

Answer 28

Superior to inferior
Deep to superficial
Lateral to medial

Question 29

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

Answer 29

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

Question 30

Do you need written consent for images?

Answer 30

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

Question 31

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

Answer 31

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)

Question 32

How long do you need to apply LMX on for?

Answer 32

30-60 mins

Question 33

What is the toxic dose for lignocaine?

Answer 33

3mg/kg

Question 34

How do you manage a needlestick injury?

Answer 34

• 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)

Question 35

What properties does clinisept have?

Answer 35

viricidal, bactericidal, sporicidal and fungicidal actions

Question 36

Can patients with psoriasis have dermal filler?

Answer 36

Relative contraindication (koebner’s phenomenon)

Question 37

What is the timeline with dental procedures and dermal filler?

Answer 37

Should be at least 2-weeks gap

Question 38

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

Answer 38

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

Question 39

What are the anterior and posterior borders of the jowls?

Answer 39

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

Question 40

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

Answer 40

Deep onto bone in midline (less vasculature here)