Lower Third - Dermal Filler Flashcards
Juvederm
Volift (body)
Volbella (border)
Teoxane
RHA 3 or RHA kiss (volume)
RHA 2 (Hydration)
Filler longevity
3-8 months
Rickett’s line
Lateral profile
Nasal tip to chin
Upper lip 4mm from line
Lower lip 2mm from line
Natural lip symmetry
Upper lip 70-80% of lower lip volume
GK point
Peaks of the cupids bow
The Glogau-Klein points, coincide with the philtral columns
White lip
Philtral dimple
Philtrum columns/ridges
Melolabial/nasolabial folds, Cupid’s bow
Vermilion border
Da Vinci’s golden ratio
1:1.618
White roll
White roll is the white line that borders the top of the upper lip - caucasian
Arterial supply
Superior labial artery - First 1-2cm run superficially before penetrating deep
inferior labial artery
Layer 4 deep to muscle
Lip tubercules
Subcutaneous fat pads within the lip
3 top
2 bottom
Layer 3 in the lip
Orbicularis oris
Prognathic mandible
jaw protusion
Retrognathic jaw
jaw recession
Layer of labial arteries
78% submucosal - layer 4
17.5% intramuscular
2% subcutaneous
Vermillion border treatment
Generally avoid in young patients
Risk of migration and ledge formation
Superficial retrograde linear threads 0.025ml with needle
Body of lip treatment
Width of nose - medial
Tubercule treatment
Layer 2
Bolus, fan and linear threads
Post procedure swelling
up to 10 days
Anatomy of the nasolabial fold
Begins at nose ala
extends through inferior cheek and the upper lip
straight, convex or concave shape
ends below lateral corner of the mouth
How to assess the nasolabial fold
Upright position
assess for volume loss in the midface
is skin fibrosed in the crease
Technique for nasolabial fold filler
Linear threads along fold
Fanning in alar-facial groove
Medial fanning with significant volume lost
As much as 0.8-1ml filler
Type of filler for nasolabial fold
Mid- to high viscosity
Juvederm Vollure or Voluma
Features that are inappropriate for NF filler alone
thick fibrosed skin
severe deficit in the mid midface
Relation of facial artery to nasolabial fold
43% of cases within 5mm of NLF
34% of cases artery crosses NLF
then transitions into angular artery
Which layer is the facial artery found in the lower face
subcutaneous layer
How does filler cause blindness
central retinal artery occlusion
embolisation of filler through arterial anastamosis
Areas for filler in the lower face
Nasolabial folds
Piriform fossa
Lips
Marionette lines
Prejowl sulcus
What are marionette lines
downturning of the angle of the mouth
crease from oral commisure extending to mandible
Cannula entry point for nasolabial fold
Base of nasolabial fold
Lip and peri-oral targets of treatment
Smokers lines
Vermillion Border
Philtrum
Lip volume
Lip differences between men and women
Women - fullness concentrated within width of nose
Men - within width of chin
Cannula technique for lip
entry point .5cm lateral to oral commisure
Cannula remains in layer 2
Natural lip symmetry
upper lip 70-80% volume of lower lip
Nerve supply to lips
maxillary and mandibular branches of trigeminal nerve
Muscle which contributes towards marionette lines
Depressor anguli oris
Aging in the lower third
atrophy of the submandibular fat compartments,
dehiscence of the
mandibular septum
leads to descent of
the fat compartments toward the neck.
Treatment of marionette lines
oral comissure bolus to support lip corners
Cannula in subcutaneous layer
Fanning and retrograde linear threads
Volume of filler for marionette folds
0.5-1ml per side
Mental crease filler
Medium g prime, soft filler
Corrects volume loss in depression beteen body of mentalis and lower lip
Needle
Layers of the gonial angle
- Skin
- Subcutaneous fat
- SMAS
- Parotidomasseteric fascia
- Parotid gland
- Masseter
- Mandible
Jowl fat pad framing ligaments
mandibular ligament anteriorly
masseteri ligament posteriorly
gonial angle
wider in females
Order of treatment in lower third
chin - supraperiosteal bolus
gonial angle - supraperiosteal bolus
pre jowl sulcus - supraperiosteal bolus
then subcutaneous treatments
gonial angle volume & injection point
0.2 - 0.5ml - 1cm into angle
chin volume and injection
0.2 - 0.3ml
either side of midline
pre jowl sulcus volume
0.1-0.3 ml
labiomental crease cannule entry point
tail of crease
Where to avoid adding volume in the lower face
subcutaneous layer
jowl fat pad - buccal area of the mandible
Mental zone - How to treat belnd chin and jowl
Chin to mandibular ligament
subcutaneous
cannula insertion point at chin
cannula reaches resistance at mandibular ligament
retrograde linear threads
Masseteric zone - Masseteric ligament to gonial angle treatment
subcutaneous
insertion at masseteric ligament - posterior border of the jowl
cannula passes across mandibular line to mandible
Masseteric zone - Ascending ramus of mandible treatment
subcutaneous
insert cannula at gonial angle
injecting upwards
avoiding parotid gland
Treatments to define jaw
3 - bone
3 - subcutaneous
Chin, pre jowl sulcus , gonial angle
mental zone, masseteric zone (ascending ramus and masseter to gonial angle)
How does mental crease form
loss of bondy support to mentalis
causing upwards rotation
Causes of temple howllowing
HIV lipoatrophy
Skeletonisation of the orbital rim
Temple needle technique
8mm needle
supraperiosteal
45 degree angle, entry behind fronto-zygomatic process
do not aim for full correction to avoid venous congestion
soft filler
Temple important structures
Superficial temporal artery and vein in the superficial fascia
temporal branch of facial nerve
Facial muscles affected my temporal nerve
frontalis
orbicularis oculi
corrugator supercilli
Temple cannula technique
superficial fascia
medium G prime product
hand palpates lateral orbital rim and superior temporal crest to avoid spread of product
massage
temple injection after care
expect jaw pain - muscle of mastication
temporalis exits beneath SMAS
periosteal is an intramuscular injection
Dangers of treating galeal area
Should be done with cannula
risk to supraorbital and supratrochlear arteries
supraorbital foramen - inject atleast 1.5cm away
Tear trough product selection
Teosyal puresense redensity
mixed crosslinked and noncrosslinked
Tear trough treatment technique (deep)
infraorbital sulcus and area medial to nasojugal groove treated together
25G cannula, entry point 1cm away from end of tear trough
zygomatic space deepto SOOF to restore volume
The tear trough
ligament (TTL)
a osteocutaneous
ligament
from the maxilla and inserting
into the skin, along the location of tear trough
Infraoribital fat anatomy
Seperated by oribularis oculi
superficial malar fat pad
deep suborbicularis oculi fat (SOOF)
Tear trough treatment technique superficial
27G cannula
subcutaneous
entry point - intersection of verticle lateral canthus line to horizontal nasal ala line
Filler brow lift
Restore volume to retroorbicularis fat pad and sub brow fat pads
inject deep to orbicular occuli
avoiding structures exiting supraorbital foramen
linear thread deposots
