| fACiAlAeSTHeTiCS | ArtiCle
canthus inferior laterally, and runs parallel to the nasolabial fold. injection above the alar–tragal line should never be carried out medial to this line, as the angular artery is found here. Care should also be taken not to load the adjacent areas with excess product as arterial compression may cause ischaemia to local tissues. The infraorbital foramen should be identified, marked and avoided. A cotton-tipped applicator can be used to find this subtle depression under the tissue, with the patient identifying the foramen by reporting the consequent nerve irritation. The alar–tragal line running from the peri-alar triangle
to the tragus delineates the border between supraperisoteal injections and injections at the subdermal level.
in general, above this line,
supraperisoteal implants along the zygoma can be very effective in producing smooth confluent volumisation. Product placed supraperiosteally will lift from below without weighing down the tissues. Below the alar tragal line, product should be placed subdermally. An exception is onlay implantation on the mandible. The final lines on Figure 2 outline the zygomatic arch. Care should be taken to avoid facial nerve damage when injecting lateral to this point. The midpoint of this arch should be used as the insertion point of the cannula, which will then be advanced medially.
Identifying and marking vectors Careful examination and diagnosis of a patient’s unique
ageing characteristics is essential. This ensures that as volume is used to lift the face, the natural facial balance is preserved. The next step is to identify and mark out the negative vectors that can then be counterbalanced by careful placement of volume to create positive vectors to lift and rejuvenate the face. examine the mid and lower face. identify a problem area and the associated negative vector. Then further examine the tissue and mark out a positive vector to correct the problem.
Zygomatic/malar region for most patients, providing general lift along the zygomatic arch and malar region is an essential component of a full face vectoring approach. Successful treatment of the zygomatic/malar region reduces the requirement for product to be placed in the mid and lower face. Treatment of this area should only be carried out if adding volume will not disturb the natural look of the face. The initial insertion point for the cannula should be midway along the zygomatic arch and should be marked with a single point. Next, identify the length of cannula to be used. if this is 1.5-inch, for example, mark out a single insertion point with three 1.5-inch strands radiating out in a neat fan. A
Patients with scarred fibrotic skin, and some men
with no specific skin problem but who may have thicker skin, are often more easily treated with 25 gauge or lower subdermally.
Figure 3 Identifying and marking vectors. (A) Identify tissue to be lifted; (B) confirm direction of positive vector; (C) mark out insertion point, and pattern of cannula insertion, here 1.5-inch; (D) pattern of calcium hydroxylapatite (CaHA) placement following lines of vector
further insertion point inferiorly and medially may be marked for malar augmentation if there is an area not reached by the initial zygomatic insertion point. The reach of the cannula inserted at the mid-zygomatic arch may be extended by bunching up the tissue to allow the tip of the cannula to move further along the periosteum.
Mid/lower face The correct vector can be identified by gently pulling the skin at a superior, lateral point in sector 3, which is perpendicular to the identified section of the jowls to be corrected (Figure 3a). This pulling action should result in lifting of the specific area of the jowl. By doing this, the correct vector has been identified. Mark this as a single straight line (Figure 3b). identify the length of cannula to be used. if this is 1.5-inch, for example, mark out a single insertion point with three 1.5 inch strands radiating out in a fan shape. As a guide, the middle strand of product may run along the vector line and the further two strands may be placed on either side. Maintain a small angle between the
prime-journal.com | September 2011 ❚ 29
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