PEER-REVIEW | INJECTABLES |
within specific deep fat compartments that, regaining their lost volume, have a lifting action on the superficial fat compartments. In type 1 and 2 patients, physicians have to first treat the
Figure 6 Patient type 2 (A) before and (B) after treatment with 3 ml of volumizer filler injected with the bolus technique in DMCF, lateral SOOF, and medial SOOF
To facilitate the treatment choice the author uses a
personal classification of the aging types that simplifies the patient’s placement and the treatment planning: the Aging Type Classification of Midface (ATC Midface) (Table 1).
Treatment of deep fat compartments First of all, physicians have to consider that deep fat compartments predominately need an augmentation of volume. For this reason, plan patient treatments with volumizer fillers with a high elastic and viscous moduli (G’ and G’’) that, by definition, can give the volume augmentation required. These fillers can have a lifting action only if injected in specific anatomical regions
Figure 7 (A,B) patient type 3 before treatment and (C,D) after treatment with 2 ml of volumizer filler injected with the bolus technique in lateral SOOF, DMCF, and medial SOOF as well as with low G’ filler in the tear trough
main defects, which are volume reduction of the deep medial cheek fat and lateral SOOF. Therefore, to reduce the adipose hypotrophy, physicians first need to enhance the volume of DMCF. With this first correction, a volume augmentation and an initial lifting action of the soft cheek tissue will be achieved. Next, the physician should treat the lateral SOOF, enhancing the cheekbone projection, and further increasing the lifting action of the soft cheek tissue. In type 2 patients (hypotrophic/ptotic), it will be beneficial to augment the quantity of filler injected in lateral SOOF because they need a greater lifting action than type 1 patients. Lastly, the author would treat the medial SOOF to correct the hollow in the infraorbital region (Figure 5–6). In type 3 patients (ptotic/hypertrophic) the main defects
are ptosis and the downward migration of adipose tissue of the superficial fat compartments. In this case, physicians have to lift the ptotic fat compartments but to do this they have to increase the volume of lateral SOOF. The volume restoration of this compartment will augment the projection of the cheekbone and will give a lifting action to the superficial fat. Only after the assessment of the obtained lifting action, the physician will be able to increase the volume of the DMCF. Attention must be paid not to inject too much filler in the DMCF because the inferior part of the maxillary region is already characterized by hypertrophy and volume excess in this patient type. In type 3 patients it will be necessary to treat the medial SOOF to eliminate the infraorbital hollow (Figure 7). A similar approach was used with type 4 patients in
which it was necessary to augment the volume of lateral SOOF to lift the soft cheek tissue and to balance the excessive volume in the inferior part of the maxillary region. The DMCF is usually not treated if not in its higher location at the border with the lateral SOOF. The main strategies of the treatments are summarized in Table 2.
Treatment of superficial fat compartments Most superficial fat compartments have an aging process characterized by ptosis and hypertrophy. Only lateral temporal-cheek fat is characterized by a hypotrophic aging process. The treatment of superficial fat must be accurate to avoid adding too much volume and increase the ptosis. For these reasons the author recommends use of fillers with intermediate G’ and G’’ in these compartments. Only in lateral temporal-cheek fat does the author suggest using a volumizer fillers with high G’ and G’’. The infraorbital fat has a high tendency for water retention and for this reason the author does not suggest treating with fillers of hyaluronic acid that, due to their hydrophylicity, can increase the oedema. In type 1 patients it will be useful to inject the medial
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cheek fat and the nasolabial fat to complete the volume enhancement that begun from injecting the DMCF. In type 2 patients only treat the medial cheek fat to avoid increasing the initial ptosis of the nasolabial fat. In those
October 2015 |
prime-journal.com
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