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filler Flashcards

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USMLE® Step 1 flashcards
1
Q

what are the 10 wrinkles, folds, and contour irregularities of the face

A
  1. frown lines
  2. cheek flattening
  3. nasolabial folds
  4. lip lines
  5. lip thinning
  6. downturned corners of mouth
  7. marionette lines
  8. chin line or mental crease
  9. extended mental crease
  10. chin flattening
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2
Q

frown line

A

glabellar rhytides

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3
Q

cheek flattening

A

malar atrophy

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4
Q

nasolabial folds

A

melolabial folds

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5
Q

lip lines

A

perioral rhytides

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6
Q

lip thinning

A

lip atrophy

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7
Q

downturned corners of mouth

A

depressed oral commissures

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8
Q

marionette lines

A

melomental folds

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9
Q

chin line or mental crease

A

labiomental crease

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10
Q

extended mental crease

A

extended labiomental crease

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11
Q

chin flattening

A

mentum atrophy

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12
Q

facial landmarks

A

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)

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13
Q

as we age what do we see diminish

A

dermal collagen, hyaluronic acid, and elastin

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14
Q

how is the intrinsic aging process accelerated

A

sun damage and other extrinsic factors like smoking, causing facial lines and wrinkles, habitual muscle contraction of facial expression.

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15
Q

what is mainly seen in the upper 1/3 of face

A

dynamic lines from contraction and frequent movement of muscles, tox injections are main treatment

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16
Q

what is more evident in lower 2/3rds of face

A

volume loss and laxity and dermal fillers are more commonly used in these areas

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17
Q

facial volume loss, also referred to as biometric reduction, results from

A

resorption of facial bones, degradation of subcutaneous tissue, and descent of the fat pads.

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18
Q

how do facial contours change as we age

A

from high cheek bones and small chin to a bottom heavy appearance with flattened cheeks and prominent jowls

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19
Q

hyaluronic injectables can be degraded using

A

hyalurondidase for correction if necessary

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20
Q

what shape is used for facial aging progression from youthful to aged contours

A

youthful: upside down triangle, cheekbones are high and face is slimmer from cheeks to chin
aged: triangle, gravity made everything droop and bottom heavy

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21
Q

what is the expectation that dermal fillers wil do

A

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

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22
Q

restylene agent, component and duration

A

long acting, hyaluronic acid without/with lidocaine, 6-12 months

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23
Q

sculptra agent, component, and duration

A

semipermanent, poly-L-lactic- acid, 1-2 years

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24
Q

what component in the filler is naturally in our body

A

hyaluronic acid, that provides structural support and nutrients and, through its hydrophilic capacity, adds volume and fullness to the skin

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25
Q

what is the mechanism of sculptra

A

Once injected, Sculptra incorporates into the tissues and stimulates your body’s natural production of collagen.

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26
Q

what are HA fillers mechanism

A

dermal fillers are made of Hyaluronic acid, clear colorless gel, designed to hold its shape in the form of a gel-like substance.

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27
Q

fillers mechanism of action

A

correct wrinkles and augment facial contours by filling a volume deficit either in the dermis or in deeper tissue spaces,

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28
Q

what are the space occupying fillers

A

collagen and HA replace lost volume without effecting significant change in adjacent tissues

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29
Q

what are the biostimulant fillers

A

calcium hydroxitate (radiesse) and poly-L-lactic acid (sculptra) stimulate fibroblasts to synthesize new collagen

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30
Q

what areas require a more thinner, more supple filler

A

lips, scars, frown lines

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31
Q

what areas require a more structured filler

A

chin and malars

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32
Q

what alternative therapies are we going to try first before fillers

A

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)

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33
Q

contraindications of fillers

A

pregnancy or breastfeeding
infection in area
keloidal scar hx
bleeding abnormality
skin atrophy
impaired wound healing
derm issues in area
immunocompromised
unrealistic expectations

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34
Q

advantage of dermal fillers

A

instant gratification except sculptra will take time to see results due to body having to reform collagen

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35
Q

disadvantages of filler

A

temporary swelling and bruising
repeat treatments are necessary to maintain results

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36
Q

what should be in emergency vascular occlusion kit

A

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)

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37
Q

linear thread technique

A

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.

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38
Q

fanning technique

A

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

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39
Q

cross hatching technique

A

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

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40
Q

layering technique

A

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

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41
Q

depot technique

A

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

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42
Q

filler aftercare

A

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

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43
Q

what medication can be used post filler treatment

A

acetaminophen for discomfort

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44
Q

what factors need to be considered in relation to longevity of filler

A

patients metabolism, degree of motion int the treatment area due to facial expressivity

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45
Q

how long does HA fillers last

A

4-12 months

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46
Q

how long does CaHA fillers last

A

12-18 months

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47
Q

when should the patient come back for more filler

A

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

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48
Q

if further filler correction is necessary when should the patient come back

A

conservative filler volume is recommended initially as additional volumes may be injected at follow up 4weeks after treatment

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49
Q

what is expected after filler treatment

A

erythema
swelling
tenderness
bruising

50
Q

what over the counter remedies may help support healing and reduce bruising and swelling after filler injection

A

arnica montana, vitamin k, bromelain, copper, vitamin c, and zinc

51
Q

how can the combination of dermal fillers and botulinum toxin offer an advantage

A

when used together it could offer longer filler duration and improve filler smoothness in highly mobile areas such as the lips and frown

52
Q

the upper lip is innervated by the

A

distal portion of the inferior branch of the infraorbital nerve

53
Q

what nerve innervates the lower eyelid, lateral nose, and medial cheek

A

superior branches of the infraorbital nerve

54
Q

the lower lip is innervated by the

A

mental nerve

55
Q

the corners of the lip are innervated by the

A

distal portion of the buccal nerve

56
Q

where does the infraorbital and mental nerves lie

A

along a vertical line that extends from the supraorbital notch to the mandible

57
Q

where does the supraorbital notch lie

A

along the upper border of the orbit and can be felt approx 2.5cm lateral to the midline of face

58
Q

where is the infraorbital foramen

A

can be felt approx 1cm inferior to to the infraorbital boney margin

59
Q

where is the mental foramen

A

can be felt 1cm above the margin of the mandible

60
Q

when performing lip ring block what needle should be used and medication

A

30g short 1/2in needle and 2% lido wit epi 1:100

61
Q

when performing upper lip ring block how many injection sites, location, amount of med

A

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

62
Q

corners of lip block

A

1 injection of 0.1mL at each corner just under mucosa

63
Q

when performing lower lip ring block how many injection points, sites, and amount

A

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

64
Q

lip numbing cream

A

LTP

65
Q

facial numbing cream

A

BLT

66
Q

when should topical numbing be removed

A

15-30 min

67
Q

if patient has a history of cold sores what should be prescribed

A

acyclovir 500mg prophylactic
1 tab 2x daily
taken 2 days prior to treatment and 3 days following treatment

68
Q

what are the 5 arteries that run parallel with needle

A
  1. superior and inferior labial arteries
  2. dorsal nasal artery
  3. facial artery
  4. supratrochlear artery
  5. submental artery
69
Q

what artery runs parallel with the lips

A

superior and inferior labial artery in the vermillian border

70
Q

what artery runs parallel with the lateral portions of the nose

A

dorsal nasal artery

71
Q

what artery runs parallel with the nasolabial folds

A

facial artery (be aware that chinese people tend to have their facial artery running in the exact spot of nasolabial folds

72
Q

what artery runs parallel with the frown lines

A

supratrochlear artery (the entry of this artery is very deep and gets superficial as it goes up the forehead)

73
Q

what artery runs parallel to the jawline

A

submental artery

74
Q

6 deep danger points to not inject filler deep

A
  1. supratrochlear
  2. supraorbital notch (both are medial supraorbital ridge)
  3. infraorbital foramen (opening into the floor of the eye socket)
  4. mental foramen ( anterior surface of the mandible below oral commissures)
  5. mandibular groove (also know as mandibular foramen is located in the ramus below the mandibular notch)
  6. deep temple vessels
75
Q

what are the layers of the skin

A

epidermis
papillary dermis
reticular dermis
hypodermis
smas
deep fat
muscle
periosteum

76
Q

what is the depth check for superficial injections

A

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

77
Q

what does blanching at rest while needle is inserted mean

A

above papillary dermis, too superficial and filler will be seen

78
Q

when treating nasolabial folds what options are there to inject besides parallel (facial artery runs parallel to nasolabial folds)

A

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

79
Q

when treating the jawlines what is the best way to avoid the submental artery

A

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

80
Q

how would you know if you are in a vessel when cannulating

A

the cannula feels tethered, if you are in the fat (where you want to be) it should move easily

81
Q

what is one way to choose depth of filler

A

crease=superficial
contour=deeper

82
Q

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

A

as the mouth opens the filler doesnt move with the bone, creating an odd look

83
Q

if you are emulating bone where should injection be

A

injected deep onto periosteum

84
Q

what level are lines and wrinkles most noticeable

A

dermis; mid labial folds, marrionette lines, nasolabial folds, if there is a crease you will treat superficially

85
Q

if you are treating a shadow or contour can you treat superficially?

A

no you will not get results you want and filler will be seen

86
Q

what if you see the grey part of needle under skin

A

too superficial and pushing out the blood supply in the epidermis

87
Q

what is tyndall effect

A

filler reflects light different and see blue tint in the area where injected too superficially

88
Q

what level is it an easier plane to pass a cannula

A

hypodermis
not possible to inject in the dermis when using a cannula, you will alwasy scoop right under it

89
Q

where are some of the shadows and curvatures we are trying to treat located

A

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

90
Q

what will you see in a depth check of the hypodermis

A

will see tissue lift but not clear line of blanching

91
Q

when filling jawline where do you want to be

A

above facial artery so wont inject deep

92
Q

if filling zygoma for volume where do you want to be

A

more in the hypodermis

93
Q

when injecting cheek for volume what should depth check look like

A

it shouldnt be clear where needle is, just see shape of needle and maybe slight blanching

94
Q

what is the important layer for supporting structures, never thinking of injecting directly into it but rather staying above or below

A

SMAS (superficial musculoaponeurotic system)

95
Q

what layer is above SMAS

A

hypodermis

96
Q

what layer is below SMAS

A

deep fat pads

97
Q

what are the advantages of injecting into the deep fat pads

A

more aesthetically forgiving, wont see blobs of filler, just general lift

98
Q

for cheek treatments where do you want to inject

A

under the SMAS (lifting) when supporting ligaments beneath SMAS you get a lifting affect

99
Q

what layer creates a more stable structure and stability long term

A

periosteum

100
Q

what is the advantage of periosteum injection

A

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

101
Q

what are used to help our muscles slide more easily across each other

A

superficial fat pads

102
Q

as we get older what happens to the fat pads

A

the fat pads shift and as they deplete you start to see anatomy beneath

103
Q

fatpads contribute to volume, if we start to lose our lateral fat pads (gravity starts pulling them down) what happens

A

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

104
Q

when we restore fat pads higher up and reduce fat pad size lower down what happens

A

this creates a more feminine/heart shaped face

105
Q

what 3 key factors are controlled by fat pads

A

harmony of face structures, shape of face, and proportion of face

106
Q

what is an holistic treatment when treating face

A

treating lateral to medial

107
Q

where are the superficial fat pads located

A

first thing after skin, before SMAS

108
Q

what are the 12 superficial fat pads broken down

A

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

109
Q

explanation of reasoning why we lose volume

A

a fat pad in place shrinks as we age, if we replace it with volume we can make you look younger.

110
Q

as you lose fat lateral to medial what happens to the tissue

A

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

111
Q

where are the deep fat pads located

A

below the SMAS (they lie on muscles)

112
Q

how does fat pads and beauty correlate to health

A

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

113
Q

what attach skin to surface and run through fat pads

A

ligaments (its what holds skin in place to foundational structure)

114
Q

what do you start to see with lost volume or excess volume combined with ligaments

A

little dips in the skin where it has held on

115
Q

what is 70%-80% of what you are seeing in terms of aging

A

superficial FP, deep FP, and ligaments (shadows on face are mainly ligaments)

116
Q

what could be considered the other 20% you are seeing in terms of aging

A

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

117
Q

what are the break points where the fat pad is shifting and cause shadow

A

orbicularis oculi retention ligament (teartrough)
zygomatic ligament (crosses cheek)
nasolabial fold ligament
mandibular retaining ligament

118
Q

volume and lifting are linked through the ligaments and fat pads, as fat pads decrease what happens

A

as they decrease in size the ligaments lose support (think of balloon analogy)

119
Q

when you inflate soemthing it makes the the skin want to

A

stand up straight (for example, when you fill the cheek, you will notice the jowls improve as well

120
Q

as volume is lost and tissue descends what do you see

A

what you see are the shadows caused by the ligaments holding on to the skin

121
Q

what are the first shadows seen as we age

A

tear troughs, nasolabial folds, and mediallabial folds

Medical Aesthetic Treatments (8 decks)

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