PEER-REVIEW | INJECTABLES | It is recommended not to
exceed 0.5 ml for each main release and for each single point in order not to risk overcorrection.
The injection given using this technique
allows the filler to be placed in the deep fatty tissues which, as we have seen, are the ones that are most attached to the underlying periosteal level. Insertion of filler in these particularly stable compartments, which are not too subject to ptosis, prevents it from migrating due to the effects of gravity. All deep fat compartments are treated with the same
bolus technique. The injection is done by inserting the needle vertically to the underlying bone plane until the tip is touching the periosteum (Figure 8). After withdrawing the needle by a few millimeters and ascertaining, by withdrawing the plunger, that vessels have not been penetrated, the author proceeds with the supraperiosteal release of a bolus of the product. The amount of product injected for each release varies
according to the deficit to be corrected. It is recommended not to exceed 0.5 ml for each main release and for each single point in order not to risk overcorrection. It is possible to integrate it with another injection immediately after the first one following the evaluation of the effect obtained. It’s important to massage the product after injection to equally distribute it inside the fat compartment. The superficial fat compartment is treated using a
microcannula (25G). The microcannula is flexible with rounded ends that can go through the fat compartment in multiple directions without damaging the vessels and nerves. The filler is released through a small hole placed laterally, thereby allowing a uniform and regular outflow. The microcannula is inserted through an entry point made with a needle that has the same or a slightly larger diameter than the one of the microcannula, so as to allow the cannula to penetrate easily. When the cannula is inserted, it is slowly slid above the SMAS plane, releasing
References
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2. Rorich RJ, Pessa JE. The retaining system of the face: histologic evaluation of the septal boundaries of the subcutaneous fat compartments. Plast Reconstr Surg 2008; 121: 1804
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12. Defatta RJ, Williams EF. Evolution of Midface Rejuvenation. Arch Facial Plast
Surg 2009; 11: 6-12
13. Mendelson BC, Muzaffar AR, Adams WP Jr. Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg 2002; 110: 885–911
14. McGregor M. Face Lift Techniques. Presented to the Annual Meeting of theCalifornia Society of Plastic Surgeons. Yosemite, California, 1959.
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17. Owsley JQ, Roberts CL. Some Anatomical Observations on Midface Aging and Long-Term Results of Surgical Treatment. Plast Reconstr Surg 2008; 121: 258
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21. Loukas M, Kapos T, Louis RG Jr, Wartman C, Jones A, Hallner B Gross anatomical, CT and MRI analyses of the buccal fat pad with special emphasis on volumetric variations. Surg Radiol Anat 2006; 28: 254–260
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injectable calcium hydroxylapatite in a carrier gel when mixed with lidocaine and with lidocaine/epinephrine. Dermatol Surg 2008; 34: S16–S24
25. Royo de la Torre J, Moreno-Moraga J, Isarría MJ, Muñoz E, Cruz I, Pérez G, Cornejo P. The evaluation of hyaluronic acid, with and without lidocaine, in the filling of nasolabial folds as measured by ultrastructural changes and pain management. J Drugs Dermatol 2013; 12: 46–52
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the filler by means of an antero- retrograde fan-wise technique (Figure 8). This technique allows for an homogeneous spread of filler within the compartment with a low rate of side-effect thanks to the atraumatic design of the microcannula27
.
The amount of product injected for each superficial compartment varies according to the deficit to be corrected. It is important to avoid the overtreatment of these compartments because their superficiality exposes the risk of unnatural and excessive corrections.
Key points Knowledge of the
anatomy and the aging fat compartments is fundamental in avoiding mediocre treatments and to plan specific solutions based on the characteristics of every single patient
The Anatomologic
approach consists of a good understanding of both the facial anatomy and the anatomy of aging
The injection technique used is also very important and the author uses the bolus technique
In the author’s
experience, the Anatomologic approach has proven to be safe and extremely effective
Conclusion In the author’s experience, the Anatomologic approach has proven to be safe and extremely effective. It has increased the correction capability of the age related defects of the midface. There is a low rate of side-effects and complications. When treating the deep fat compartments with the bolus technique it’s important to remember to make sure not to inject inside vessels, withdrawing the plunger before injecting. The intravascular injection is in fact the main cause of serious complications that can occur in this area (expecially in the infraorbital zone) including skin necrosis and/or ischemic injuries of the retina.
Declaration of interest None Figures 1 & 4-8 © Dr Fundaro; 2 Data @ Dr Fundaro,
recreated by Prime Journal, images © Shutterstock; 3 Data @ Dr Fundaro, recreated by Prime Journal, illustration © Kevin February Tables 1-2 © Dr Fundaro
October 2015 |
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