Soft tissue augmentation - Fillers Flashcards
Fillers can restore symmetry and volume and recreate a smooth surface
T
Radiesse and Sculptra are considered stimulatory fillers
T
Sculptra is composed of calcium hydroxylapatite microspheres suspended in polysaccharide gel
F
Calcium hydroxylapatite = Radiesse/Radiance is composed of calcium hydroxylapatite microspheres suspended in polysaccharide gel (not Sculptra)
Radiesse is composed of poly-L-lactic acid
F
PLLA = Sculptra/New-Fill (not Radiesse)
Poly-L-lactic acid was initially used for the correction of facial lipoatrophy in patients with HIV
T
Filling the lower third of the face is more challenging due to concurrent dynamic creases in this region
F Upper third (not lower third)
Fillers under the lateral eyebrow can be used as a substitute for surgical brow lift
T
The types of acne scars not amenable to treatment with fillers include atrophic or rolling scars
F
They are most amenable to treatment.
The thinness of nasal skin is associated with a higher rate of complications or unsatisfactory results with fillers
T
Nasolabial folds and marionette lines have the least prolonged results with fillers
F
‘smile lines’
Most prolonged and most popular treatment
Animal derived fillers include bovine and porcine types.
T
The bluish discolouration that is a potential complication of soft tissue augmentation is known as the Tyndall effect
T
There are very few absolute contraindications to prepackaged injectable fillers
T
Robust local infiltration of anaesthesia should be used prior to fillers to decrease pain
F
This makes it difficult to assess the endpoint of treatment. Nerve blocks should be used where possible.
Patients should be lying flat for injectable fillers
F
Patients should be seated either upright or at an angle of no more than 45 degrees - this allows doc to see the effects of gravity on soft tissue
The results of bovine collagen last 6-8 months typically
F
3-4 months.
The risk of hypersensitivity with bovine collagen is 10%.
F
1-3%
Bovine collagen only requires pretesting for hypersensitivity reactions if indicated by patient history.
F
All patients require pretesting.
For bovine collagen, 2 skin tests (performed at 2-4 weeks) is the standard assessment recommended for testing hypersensitivity
T
For bovine collagen hypersensitivity testing, a positive skin test is defined as erythema, tenderness or swelling persisting more than 6 hours after implantation
T
For bovine collagen hypersensitivity testing, a delayed reaction typically arises 2-3 days after implantation
T
Contraindications to injectable bovine collagen include anaphylactic event of any cause
T
Contraindications to injectable bovine collagen include lignocaine sensitivity
T
Pregnancy and lactation are not contraindications to injectable bovine collagen
F
They are
Contraindications to injectable bovine collagen include any signs of infection at the injection site
T
Zyderm I is a superficial dermal filler
T
Injected into upper papillary dermis
Overcorrection by 50% is required for Zyderm I and 100% is required for Zyderm II
F
100% for Zyderm I, 50% for Zyderm II
Zyderm II is injected deeper than Zyderm I
T
Zyderm II injected into upper reticular dermis.
Zyderm I is composed of 3.5% bovine dermal collagen suspended in NaCl with 0.3% lignocaine
T
Zyderm II is composed of 6.5% bovine colleen suspended in NaCl with 0.3% lignocaine
T
Zyderm I is more viscous than Zyderm II
F
Zyderm II more viscous
Zyplast has the same composition as Zyderm I but is cross-liked with glutaraldehyde to form a lattice work
T
Zyplast is less immunogenic than either Zyderm I or II
T
Zyplast is less viscous than Zyderm I or II
F
Zyplast more viscous.
Overcorrection by 25% is required for Zyplast.
F
No overcorrection required
Zyplast is not recommended for the glabellar region
T
Due to possibility of intravascular injection causing local tissue necrosis + rarely blindness
Cosmoplast and Cosmoderm are types of human-derived collagen products
T
Skin pretesting is needed with human-derived collagen products
F
There is no potential for immunologic reactions to hyaluronan in humans
T
Hyaluronic acid fillers have a long duration of action, there no retreatment is necessary
F
The efficacy of the filler declines as it is naturally resorbed by the body
The particle size of Perlane is much larger than that of Restylane
T
Some products, such as Juvederm Ultra PlusXC, Restylane-L and Perlane-L contain local anaesthetic
T
Robust local infiltration with anaesthetic is recommended
F
It causes tissue swelling which makes it difficult to assess end-point treatment
Hyluronic acid is a naturally occurring glycosaminoglycan biopolymer which is a component of all connective tissues
T
Hyaluronic acid exhibits significant tissue specificity because the chemical structure of the polysaccharide is uniform throughout nature
F
It exhibits no species or tissue specificity for the same reason
There is no potential for immunologic reactions to hyalurnon in humans
T
Hyaluronic fillers are infrequently used
F
They are the most commonly sued injectable filler
Significantly greater duration of correction of glabellar rhytides can be achieved through cominbation treatments with botox and hyaluronic acid relative to hyaluronic acid alone
T
Linear threading technique can be used for hyaluronic acid fillers
T
Hyaluronic acid fillers should never by layered on top or beneath other types of fillers
F
Fillers more appropriate for superficial correction can be layered above hyaluronic acid derivatives and deeper fillers can be used below.
For lip enhancement, the technique for hyaluronic acid filler injection should first include defining the lip margin by gentle injection along the vermillion border
T
For hyaluronic acid fillers, perioral injections, injections of the lip and injections of the periocular skin are the least painful
F
Most painful due to increased sensory innervation at these sites
For hyaluronic acid fillers, redness persists for a few hours overnight but swelling can least up to 1 week
F
Swelling lasts up to 1-2 days
The mean total injection volume required of hyaluronic acid to achieve optimal results was 1ml of Restylane compated with 1.6mls of Zyplast
T
Zyplast offers signicantly longer-lasting aesthetic improvement than Perlane
F
Perlane is longer lasting than Zyplast
Thicker needles injure more tissue upon injection, thus cause greater injection discomfort
T
Mechanisms to decrease injection pain are pre-injection application of ice, vibration devices, topical anaesthetics, local anaesthetic infiltration and nerve blocks.
T
In patients who take aspirin and other platelet disaggregating agents, bruising may be delayed after filler injection
T
Common locations for bruises are perioral rhytides, lower eyelids, upper third of nasolabial fold, upper lip, and lateral edge of lower lip
T
Significant overcorrection is necessary with injectable hyaluronic acid derivatives
F
Not necessary – should be avoided.
Overcorrection is preferred to undercorrection when injecting fillers
F
unercorrection - can top up later if necessary
Injection-site necrosis is a common side effect of fillers
F
Uncommon
Inadvertent filler injection of the angular artery (nasolabial fold area) or supratrochlear artery (glabellar area) can induce an ischaemic response with violaceous bluish-grey discolouration, pain, erosion and ulceration
T
Large-volume inadvertent intra-artery injections with resultant full-thickness necrosis tend to resolve without significant scarring
F
Scarring common
Treatment with immediate application of nitroglycerin paste may help to reduce the size of the area affected by ischaemia following inadvertent intra-artery injections with filler
T
Nodule formations after hyaluronic acid injections manifests as a blanched, bluish or white papule, or as a palpable lump of visible injectant.
T
Nodule formation after hyaluronic acid injection is not due to superficial or excessive injections
F
Is due to superficial or excessive injection
Post-injection nodules from hyaluronic acid cannot be treated other than by surgery
F
Can inject hyaluronidase, use massage
Local hypersensitivity does not occur with hyaluronic acid injections
F
Has been reported.
For injections into the lip or perioral region, antiviral prophylaxis prior to and immediately following injections are recommended if indicated
T
Radiesse is composed of calcium hydroxylapatite microspheres
T
Calcium hydroxylapatite microspheres remain in place to act as a scaffold that promotes soft tissue ingrowth
T
The implant palpability of calcium hydroxylapatite does not diminish over time
F
Does diminish over time.
Calcium hydroxylapatite fillers are not recommended for correction of facial soft tissue loss resulting from HIV-related lipoatrophy
F
FDA approved for this
Radiesse lasts up to 1 year or more in most patients
T
Radiesse is identical in composition to bone material, therefore it is visible on routine x-rays
F
It is invisible on routine x-rays, but can be easily detected on MRI
Longevity of correction with calcium hydroxylapatite is attributed to the slow rate of dissolution, rapid rate of tissue ingrowth, and slow rate of particle dissolution
T
Calcium hydroxylapatite filler is associated with an increased risk of tissue necrosis given the viscosity of the material
T
There are no side effects associated with injection of calcium hydroxylapatite filler into lips
F
Lumpiness, nodularity and granulomas are reported
Calcium hydroxylapatite fillers are most successfully used in deep dermis or subcutis, where it is less likely to be visible or to extrude
F
Note recommended in dermis
CaHA can be utilized in the subcutaneous fat or supraperiosteal plane - latter has fewer AEs
Calcium hydroxylapatite fillers are also recommended for superficial fine lines and very fine depressions
F
For calcium hydroxylapatite fillers, deposition should not extend above the inferior orbital rim in order to avoid clumping of the material by the orbicularis oculi muscle
T
Not recommended for lips, or lower eyelid skin
It is not possible to easily massage or mould calcium hydroxylapatite fillers after injection to eliminate any palpable filler material
F
Typical volumes of calcium hydroxylapatite filler required for facial contouring of the malar and zygomatic regions range from 2mL -3mL per malar area
F
0.7mL to 1.0mL per malar area.
Calcium hydroxylapatite fillers are indicated for lip or nasojugal groove augmentation
F
This is contraindicated – the activity of orbicularis oris can clump the material making it visible at the mucosa or vermillion sides
Calcium hydroxylapatite fillers can still be used if there are pre-existing permanent fillers at the site to be treated.
F
This is a contraindication
Sculptra is a stimulatory filler designed to be injected into the deeper dermis or dermal-subcutaneous junction
F
can be used in the subcutaneous fat or supraperiosteal plane
dermal injection results in higher risk of nodules
Sculptra can be used to treat lipoatrophy of the face and hands, HIV lipodystrophy and liposuction contour deformities
T
Poly-L-lactic (PLLA) acid fillers are distributed freeze-dried and can be stored at room temperature and reconstituted 2-24 hours prior to injection with sterile water
T
Poly-L-lactic acid is intended for direct injection of rhytides
F
It is intended to recontour the face
Injection of Poly-L-lactic acid fillers into the subcutis results in subcutaneous volume restoration
T
Results of Poly-L-lactic acid recontouring lasts for up to 2-3 months
F
2-3 years
Poly-L-lactic acid resorption occurs with breakdown to lactic acid, found naturally in the body
T
Poly-L-lactic acid (once reconstituted) needs to be vigorously shaken to obtain a uniform translucent suspension
T
use a vortex
Treatment with Poly-L-lactic acid filler is followed by 10 minutes of firm massage to the treated areas
T
Vigorous post-treatment massage also may reduce formation of nodules by optimizing distribution of materia
The use of blood thinners is not a relative contraindication for Poly-L-lactic acid filler injection
F
Poly-L-lactic acid filler injection should be avoided with active skin infections or inflammation in the treatment area
T
Skin testing is required prior to using Poly-L-lactic acid fillers
F
The most common side effects of Poly-L-lactic acid fillers are bruising , erythema, swelling and haemtoma formation at the sites of injection
T
Injectable Polymethylmethacrylate (PMMA) is composed of a suspension of 20% bovine collagen and 80% non-resorbable Polymethylmethacrylate
F
80% bovine collagen solution and 20% non-resorbable Polymethylmethacrylate
Skin tests of bovine collagen gel only are provided in syringes containing 0.6ml fill volumes for allergy prescreening
F
0.3ml
Polymethylmethacrylate fillers are extremely long-lasting to permanent
T
Patients with sebaceous skin and large pore size, or those with extremely thin and loose skin, are poor candidates for Polymethylmethacrylate fillers
T
For Polymethylmethacrylate fillers, if there is an area of excessive fullness or inflammation, low-concentration triamcinolone acetonide cannot be used
F
should be used
0.05–0.1 mL per treatment session of 10 mg/mL triamcinolone acetonide directly into the area of excess fullness or inflammation using an insulin syringe with 31g needle
- repeated every 3–4 wks until desired result is achieved
Treatment of the lips with Polymethylmethacrylate is not contraindicated
F
Is contraindicated – undesired fullness
Skin testing does not need to be performed prior to Polymethylmethacrylate fillers
F
0.1 mL intradermal injection of collagen into the volar forearm
4 weeks before Rx
Pt should notify Dr if any possible response occurs
A positive response consists of erythema of any degree, induration, tenderness, and swelling, with or without pruritus – do not procede w/ Rx
rpt on other arm if equivocal
Injectable Polymethylmethacrylate contains 0.3% lignocaine
T
Polymethylmethacrylate is injected into the dermal-subcutaneous junction utilising the ‘tunneling’ or ‘linear threading’ technique
T
Harvested autologous fat is processed by mixing with sterile distilled water and frozen, leading to rupture of adipocytes
T
Solid fraction of frozen autologous fat, representing lipocyte cell walls and connective tissue, is utilised for soft tissue injection
T
The injected material in autologous collagen injection is not viscous, therefore small needles can be used.
F Highly viscous – requires large needles more pain more trauma and bruising more visible needle marks
Local anaesthesia is not needed prior to injection with autologous collagen
F
extensive local anesthesia is required prior to injection
It is difficult to place precisely autologous collagen at the required dermal level
T
Injectables can be used to counter the effects of gravity
F
Injectables are not effective in treating ‘jowls’ or other problems associated with excessive skin laxity
T
Deep dynamic rhytides will not be improved better with concomitant use of filler with botulinum toxin
F
Deeper lines and folds may require subcutaneous fillers or hyaluronic acid-based fillers
T
Layering of soft tissue augmentation materials of varying viscosity allows for slow, natural, smooth augmentation, which minimises clumping and asymmetry
T
use of a filler can remove the “double bubble” between the lower eyelid and the upper cheek as well as camouflage the nasojugal groove
T
nasojugal groove = groove between lower eyelid and nasal sidewall and lower eyelid and cheek
glabellar frown lines cannot be diminished with fillers
F
A secondary effect of filling the nasolabial fold and marionette lines is to increase the prominence of the lateral cheeks in profile view
F
increase medial cheeks prominence
Marionette or “drool” lines are a combination of expression, aging, and genetics
T
in older individuals or those with advanced actinic damage and sagging, filling the marionette lines may create ripples lateral to the injection area.
T
unevenness of the jawline is asign of aging in the lower face
T
Due to loss of skin elasticity and gravity and resorption of the mandible
the physician should advise the patient of the strengths and potential pitfalls of various products and advise adverse reactions, post injection side effects, and duration of correction
T
Patient and physician should come to a mutual agreement regarding which product would best suit the patient’s needs, downtime, and risk tolerance
Patients can continue NSAIDs, aspirin, high-dose vitamin E, and most herbal medications prior to injection
F
should discontinue if possible to reduce risk of ecchymosis
particularly important prior to injection of the thin skin of the eyelids and lips
aspirin should be stopped 8 days before filler injected
T
at least
stop NSAIDs for at least 5 days
INR less than 3 is preferred for pts on warfarin undergoing filler injection
F
INR/PT 2 or under
These herbal medicines predispose to bleeding
ginkgo biloba, St John’s wort, vitamin E, garlic, ginseng, fish oil
T
no anaesthetic is needed when using fillers which come mixed with local anaesthetic
F
usually still need LA
there is no need to clean the site prior to injecting filler
F
All make-up should be removed
Areas to be treated should be prepared with an antiseptic such as isopropyl alcohol, chlorhexidine, or benzalkonium chloride solution
The following fillers are available in Australia; Juvederm Restylane Sculptra Radiesse
F Juvederm Restylane Sculptra But not Radiesse
Juvéderm Ultra lasts more than 12 months
F
Juvéderm Ultra lasts more than 9 months
Juvéderm Ultra Plus lasts for a year or more
HA is usually injected into the deep dermis
F
into subcut fat or supraperiosteal planes
Morbidity is minimized when HA fillers are placed in the supraperiosteal plane compared with the subcutaneous fat layer
T
Many experts feel that the supraperiosteal plane is the safest area for injection
Blunt cannulas for HA injection maximize bruising and swelling compared with sharp needles
F
Blunt cannulas minimize bruising and swelling compared with sharp needles
Least morbidity in HA injection occurs using sharp needles in the suncutaneous plane
F
The least morbidity occurs when HA fillers are injected in the subcutaneous plane with a blunt-tipped cannula
A limited number of tower injections of HA should be used for each nasolablial fold e.g. 3
T
Bruising is a common side effect of HA injection
F
redness and swelling common
bruising rare; due to needle-associated perforation of vessels and crushing vessels secondary to the pressure of the injected substance
The check to ensure that approximately equal amounts of filler are placed into corresponding structures on each side of the face is the most important procedure to ensure maintenance of symmetry
F
Visual inspection after initial correction is the most important procedure
But should also ensure that approximately equal amounts of filler are placed into corresponding structures on each side of the face unless you are trying to correct assymetry
Injections in the glabella with hyaluronic acid derivatives have been associated with retinal artery thrombosis due to emboli
F
was seen in past with collagen
Incision and drainage can be used to treat local hypersesnitvity reactions to HA injections
T
clear up spontaneously after months
Can speed remission by topical application of tacrolimus ointment, intralesional steroids, or incision and drainage
treatment with oral antibiotics is essential to promote rapid healing, and to prevent scarring in the case of bacterial infections or acne flare ups post HA injection
T
Local hypersensitivty is v rare and presents as red indurated bumps over areas treated with hyaluronic acid derivatives may appear up to 3 months after treatment
T
Post injection nodules that occur immedietely after HA treatment are a result of local inflammatory or granulomatous foreign body reactions
F
immediately after treatment likely a result of superficial injection or excessive injection to a given location
Nodules weeks later as a result of local inflammatory or granulomatous foreign body reactions
CaHA is more effective and longer lasting than hyaluronic acid in maintaining nasolabial augmentation
T
Also requires smaller volumes injected; 2.2mls Vs 2.9-4.8 mls for HA
lignocaine with or without adrenaline cannot be safely added to original CaHA without harmful changes in physical properties
F
safe
E.g. 0.3ml 2% lignocaine added to 1.5ml CaHA
Lip and other nodules due to CaHA can be easily treated by extrusion with a needle or slit incision
T
Pain is significantly reduced when CaHA is used mixed with LA
T
The CaHA used in Radiesse is synthetic in origin. It is inherently biocompatible because it is identical in composition to bone mineral
T
Blunt tipped cannulae are preferred for injection of HA and PLLA
F
not recommended for PLLA
preferred for HA and CaHA
2 sessions are usually needed for PLLA recontouring
F
3-6 sessions required – start to see effect after 2nd Rx
PLLA recontouring is most effective in lower face
T
Clinical results and side-effects of PLLA recontouring are generally technique dependent
T
also depend extensively on the quality of the tissues in which they are injected
with PMMA it is preferable to inject more deeply than too superficially
T
subcut filler is wasted
too superficial causes long-term skin surface texture or colour abnormalities
when injecting PMMA in the correct plane the needle is not seen at all
F
Proper needle placement will result in the needle outline being visible
Further PMMA injections should be performed after 4-6 wks
F
Rw pt at 4-6 wks to assess the need for further additional treatments
But wait until 8-16 wks to repeat Rx
Optimal correction with PMMA usually requires two to three treatments
T
Patients without prior experience with soft-tissue filler should consider a temporary filler, such as hyaluronic acid, before investing physically, emotionally, and financially in more permanent fillers
T
Azifcel-T is an in-vitro culture of autologous fibroblasts in an extracellular matrix
T
prepared from a 3mm punch biopsy of the patients skin
Azifcel-T needs to be injected within 48h of receipt
F
24h
