filler Flashcards
what are the 10 wrinkles, folds, and contour irregularities of the face
- frown lines
- cheek flattening
- nasolabial folds
- lip lines
- lip thinning
- downturned corners of mouth
- marionette lines
- chin line or mental crease
- extended mental crease
- chin flattening
frown line
glabellar rhytides
cheek flattening
malar atrophy
nasolabial folds
melolabial folds
lip lines
perioral rhytides
lip thinning
lip atrophy
downturned corners of mouth
depressed oral commissures
marionette lines
melomental folds
chin line or mental crease
labiomental crease
extended mental crease
extended labiomental crease
chin flattening
mentum atrophy
facial landmarks
glabella
nasion
alar groove (nasal ala)
tip of nose
subnasale (base of nose)
philtral columns
cupids bow
oral commissure (corners of lips)
vermillion border
menton (bottom of chin)
as we age what do we see diminish
dermal collagen, hyaluronic acid, and elastin
how is the intrinsic aging process accelerated
sun damage and other extrinsic factors like smoking, causing facial lines and wrinkles, habitual muscle contraction of facial expression.
what is mainly seen in the upper 1/3 of face
dynamic lines from contraction and frequent movement of muscles, tox injections are main treatment
what is more evident in lower 2/3rds of face
volume loss and laxity and dermal fillers are more commonly used in these areas
facial volume loss, also referred to as biometric reduction, results from
resorption of facial bones, degradation of subcutaneous tissue, and descent of the fat pads.
how do facial contours change as we age
from high cheek bones and small chin to a bottom heavy appearance with flattened cheeks and prominent jowls
hyaluronic injectables can be degraded using
hyalurondidase for correction if necessary
what shape is used for facial aging progression from youthful to aged contours
youthful: upside down triangle, cheekbones are high and face is slimmer from cheeks to chin
aged: triangle, gravity made everything droop and bottom heavy
what is the expectation that dermal fillers wil do
softne lines and wrinkles as opposed to erase them, and that subtle improvements in contours can be achieved but fillers do not offer surgery like results
restylene agent, component and duration
long acting, hyaluronic acid without/with lidocaine, 6-12 months
sculptra agent, component, and duration
semipermanent, poly-L-lactic- acid, 1-2 years
what component in the filler is naturally in our body
hyaluronic acid, that provides structural support and nutrients and, through its hydrophilic capacity, adds volume and fullness to the skin
what is the mechanism of sculptra
Once injected, Sculptra incorporates into the tissues and stimulates your body’s natural production of collagen.
what are HA fillers mechanism
dermal fillers are made of Hyaluronic acid, clear colorless gel, designed to hold its shape in the form of a gel-like substance.
fillers mechanism of action
correct wrinkles and augment facial contours by filling a volume deficit either in the dermis or in deeper tissue spaces,
what are the space occupying fillers
collagen and HA replace lost volume without effecting significant change in adjacent tissues
what are the biostimulant fillers
calcium hydroxitate (radiesse) and poly-L-lactic acid (sculptra) stimulate fibroblasts to synthesize new collagen
what areas require a more thinner, more supple filler
lips, scars, frown lines
what areas require a more structured filler
chin and malars
what alternative therapies are we going to try first before fillers
other treatments for facial lines and wrinkles include tox, for dynamic wrinkles, skin resurfacing procedures (microdermabrasion, chemical peels morpheus8) and nonablative or ablative laser of static lines (co2 laser)
contraindications of fillers
pregnancy or breastfeeding
infection in area
keloidal scar hx
bleeding abnormality
skin atrophy
impaired wound healing
derm issues in area
immunocompromised
unrealistic expectations
advantage of dermal fillers
instant gratification except sculptra will take time to see results due to body having to reform collagen
disadvantages of filler
temporary swelling and bruising
repeat treatments are necessary to maintain results
what should be in emergency vascular occlusion kit
hot packs, hyaluronidase (150u/mL)
1.0mL syringe
18g, 1 1/2 need (drawing up hylenex)
30g, 1/2 needle for injecting
asprin 325mg, chewable
nitroglycerine ointment 2%
plastic wrap (for occluding ointment)
linear thread technique
placing derma filler in tissue in the retroguide linear thread. insert the needle at the desired tissue depth and depress plunger firmly as the needle is smoothly withdrawn. release plunge pressure just before pulling the needle out of skin.
fanning technique
a single needle insertion point is used to inject a series of adjacent linear threads placing dermal filler product in a triangular area. insert the needle at the desired tissue depth, advance the needle to the hub and inject filler in a linear thread as the needle is slowly withdrawn; without fuly withdrawing the needle from the skin, redirect the needle using small angulations, advance needle to the hub again and repeat until desired correction is achieved
cross hatching technique
multiple insertion points are used to form a grid pattern of linear threads placing dermal filler product in a square area. insert the needle at the desired tissue depth, advance the needle to the hub, inject filler in a linear thread as the needle is fully withdrawn. reinsert the needle in a adjacent area and place another linear thread parallel to the first thread. repeat at 90 degrees to the first filler threads until desired correction achieved
layering technique
dermal filler product with more structural support (CaHA) is injected first in the mid to deep dermis to treat areas of deep volume loss, using one of the above techniques. a thinner more malleable dermal filler (HA) is then injected in the superficial to mid dermis overlying the first product to treat superficial wrinkles
depot technique
a single insertion point is used to place a collection of product in tissue. often used at the superperiosteal level. a 28g 3/4 in needle is inserted through the skin and muscle and advanced until a gentle tap is felt against bone. the needle is then withdrawn 1mm and a bolus of dermal filler is administered just above the bone
filler aftercare
apply wrapped icepack for 10-15 min every 1-2 hours for the next 1-3 days to reduce swelling and bruising
avoid exercising, heat applications, alcohol consumption, and tanning until swelling subsides
what medication can be used post filler treatment
acetaminophen for discomfort
what factors need to be considered in relation to longevity of filler
patients metabolism, degree of motion int the treatment area due to facial expressivity
how long does HA fillers last
4-12 months
how long does CaHA fillers last
12-18 months
when should the patient come back for more filler
come back when they start to notice the product visibly diminishing but is still palpable, before the area returns to its pre pretreatment appearance. by doing so this this usually requires less dermal filler product as residual volume from the previous treatment is still present
if further filler correction is necessary when should the patient come back
conservative filler volume is recommended initially as additional volumes may be injected at follow up 4weeks after treatment
what is expected after filler treatment
erythema
swelling
tenderness
bruising
what over the counter remedies may help support healing and reduce bruising and swelling after filler injection
arnica montana, vitamin k, bromelain, copper, vitamin c, and zinc
how can the combination of dermal fillers and botulinum toxin offer an advantage
when used together it could offer longer filler duration and improve filler smoothness in highly mobile areas such as the lips and frown
the upper lip is innervated by the
distal portion of the inferior branch of the infraorbital nerve
what nerve innervates the lower eyelid, lateral nose, and medial cheek
superior branches of the infraorbital nerve
the lower lip is innervated by the
mental nerve
the corners of the lip are innervated by the
distal portion of the buccal nerve
where does the infraorbital and mental nerves lie
along a vertical line that extends from the supraorbital notch to the mandible
where does the supraorbital notch lie
along the upper border of the orbit and can be felt approx 2.5cm lateral to the midline of face
where is the infraorbital foramen
can be felt approx 1cm inferior to to the infraorbital boney margin
where is the mental foramen
can be felt 1cm above the margin of the mandible
when performing lip ring block what needle should be used and medication
30g short 1/2in needle and 2% lido wit epi 1:100
when performing upper lip ring block how many injection sites, location, amount of med
2 injections (on both sides of frenum) 0.1ml in each
2 injections above canine teeth above gums 0.5mL
total of 1.2mL
place needle superiorly toward pupil staying parallel to the maxilla. advance needle almost full length and inject
corners of lip block
1 injection of 0.1mL at each corner just under mucosa
when performing lower lip ring block how many injection points, sites, and amount
2 injections ( on both side of frenum) 0.1mL each
2 injections below 3rd tooth from medial 0.5mL
total of 1.2mL place needle superiorly toward pupil staying parallel to the maxilla. advance needle almost half length and inject
lip numbing cream
LTP
facial numbing cream
BLT
when should topical numbing be removed
15-30 min
if patient has a history of cold sores what should be prescribed
acyclovir 500mg prophylactic
1 tab 2x daily
taken 2 days prior to treatment and 3 days following treatment
what are the 5 arteries that run parallel with needle
- superior and inferior labial arteries
- dorsal nasal artery
- facial artery
- supratrochlear artery
- submental artery
what artery runs parallel with the lips
superior and inferior labial artery in the vermillian border
what artery runs parallel with the lateral portions of the nose
dorsal nasal artery
what artery runs parallel with the nasolabial folds
facial artery (be aware that chinese people tend to have their facial artery running in the exact spot of nasolabial folds
what artery runs parallel with the frown lines
supratrochlear artery (the entry of this artery is very deep and gets superficial as it goes up the forehead)
what artery runs parallel to the jawline
submental artery
6 deep danger points to not inject filler deep
- supratrochlear
- supraorbital notch (both are medial supraorbital ridge)
- infraorbital foramen (opening into the floor of the eye socket)
- mental foramen ( anterior surface of the mandible below oral commissures)
- mandibular groove (also know as mandibular foramen is located in the ramus below the mandibular notch)
- deep temple vessels
what are the layers of the skin
epidermis
papillary dermis
reticular dermis
hypodermis
smas
deep fat
muscle
periosteum
what is the depth check for superficial injections
once needle is in skin lift needle up and skin should blanch along surface and when resting needle with force, there should be no blanching
what does blanching at rest while needle is inserted mean
above papillary dermis, too superficial and filler will be seen
when treating nasolabial folds what options are there to inject besides parallel (facial artery runs parallel to nasolabial folds)
many will opt for deep perisosteum injection, unlikely to inject in artery this way because you are out of the fatty tissue where artery is located
other option is to treat superficially if there is not volume loss and its the actual crease trying to treat. in this case morpheus8 and co2 laser are recommended for creases
when treating the jawlines what is the best way to avoid the submental artery
the submental artery runs along jawline inferiorly on mandible. even when cannulating you can still occlude the vessel since it is parallel. when cannulating always keep it moving
how would you know if you are in a vessel when cannulating
the cannula feels tethered, if you are in the fat (where you want to be) it should move easily
what is one way to choose depth of filler
crease=superficial
contour=deeper
movements of the face changes how the filler interacts over time. when you try to emulate a bone like the angle of the jaw but are superficial what happens to the filler
as the mouth opens the filler doesnt move with the bone, creating an odd look
if you are emulating bone where should injection be
injected deep onto periosteum
what level are lines and wrinkles most noticeable
dermis; mid labial folds, marrionette lines, nasolabial folds, if there is a crease you will treat superficially
if you are treating a shadow or contour can you treat superficially?
no you will not get results you want and filler will be seen
what if you see the grey part of needle under skin
too superficial and pushing out the blood supply in the epidermis
what is tyndall effect
filler reflects light different and see blue tint in the area where injected too superficially
what level is it an easier plane to pass a cannula
hypodermis
not possible to inject in the dermis when using a cannula, you will alwasy scoop right under it
where are some of the shadows and curvatures we are trying to treat located
in the hypodermis , good thing about injecting here when using cannula you will be slightly above arteries (but getting closer to them) and easier path with cannula than deeper
what will you see in a depth check of the hypodermis
will see tissue lift but not clear line of blanching
when filling jawline where do you want to be
above facial artery so wont inject deep
if filling zygoma for volume where do you want to be
more in the hypodermis
when injecting cheek for volume what should depth check look like
it shouldnt be clear where needle is, just see shape of needle and maybe slight blanching
what is the important layer for supporting structures, never thinking of injecting directly into it but rather staying above or below
SMAS (superficial musculoaponeurotic system)
what layer is above SMAS
hypodermis
what layer is below SMAS
deep fat pads
what are the advantages of injecting into the deep fat pads
more aesthetically forgiving, wont see blobs of filler, just general lift
for cheek treatments where do you want to inject
under the SMAS (lifting) when supporting ligaments beneath SMAS you get a lifting affect
what layer creates a more stable structure and stability long term
periosteum
what is the advantage of periosteum injection
you know exactly where you are when the needle touched the bone, everything sits on top of it. and lasts longer because it sits on the bone and no other movements
what are used to help our muscles slide more easily across each other
superficial fat pads
as we get older what happens to the fat pads
the fat pads shift and as they deplete you start to see anatomy beneath
fatpads contribute to volume, if we start to lose our lateral fat pads (gravity starts pulling them down) what happens
women start to look more square, wanting to restore fat pads higher up and trying to reduce the fat pad size that are lower down is constant battle as we age
when we restore fat pads higher up and reduce fat pad size lower down what happens
this creates a more feminine/heart shaped face
what 3 key factors are controlled by fat pads
harmony of face structures, shape of face, and proportion of face
what is an holistic treatment when treating face
treating lateral to medial
where are the superficial fat pads located
first thing after skin, before SMAS
what are the 12 superficial fat pads broken down
Forehead (3)
1. central forehead FP (center)
2. middle forehead FP (lateral form central)
3. lateral temporal FP (sides of forehead)
Eye (3)
1. superior orbital FP (above eyelid)
2. inferior orbital FP (below eye)
3. lateral orbital FP (sides)
Anterior Cheek (3)
1. medial FP (below inferior orbital FP)
2. middle cheek FP (lateral to medial)
3. nasolabial FP (against sides of nose)
Lower Face (3)
1. superior/inferior Jowl FP (by oral commissures)
2. premental FP (below bottom lip)
3. Platysmal FP
explanation of reasoning why we lose volume
a fat pad in place shrinks as we age, if we replace it with volume we can make you look younger.
as you lose fat lateral to medial what happens to the tissue
it causes tissue to droop down causing jowls and nasolabial folds because support was lost higher up, allowing the fat pads to descend and slip forward
where are the deep fat pads located
below the SMAS (they lie on muscles)
how does fat pads and beauty correlate to health
when the fat pads are in the correct place and volume it creates what we perceive as beauty and that conveys a sense of a healthy individual
what attach skin to surface and run through fat pads
ligaments (its what holds skin in place to foundational structure)
what do you start to see with lost volume or excess volume combined with ligaments
little dips in the skin where it has held on
what is 70%-80% of what you are seeing in terms of aging
superficial FP, deep FP, and ligaments (shadows on face are mainly ligaments)
what could be considered the other 20% you are seeing in terms of aging
health of skin and collagen, if you can make it tighter it would look younger but also help fat pads stay in position (morpheus great treatment)
as we get older we get more hyperpigment in skin that makes us look older and clear lyft, CO2 laser would help with resurfacing and building collagen
what are the break points where the fat pad is shifting and cause shadow
orbicularis oculi retention ligament (teartrough)
zygomatic ligament (crosses cheek)
nasolabial fold ligament
mandibular retaining ligament
volume and lifting are linked through the ligaments and fat pads, as fat pads decrease what happens
as they decrease in size the ligaments lose support (think of balloon analogy)
when you inflate soemthing it makes the the skin want to
stand up straight (for example, when you fill the cheek, you will notice the jowls improve as well
as volume is lost and tissue descends what do you see
what you see are the shadows caused by the ligaments holding on to the skin
what are the first shadows seen as we age
tear troughs, nasolabial folds, and mediallabial folds
