This page contains a Flash digital edition of a book.
| VOLUMISING TECHNIQUES | ARTICLE Where and how to inject into mid-face?


Restoring volume to the mid-face will target the loss of fat, as well as insufficiency in the two fat compartments7


. As


there is a fixed static fat compartment (the deep) and a mobile superficial fat pad, it is important to analyse the movements of the soft compartments during expression to determine whether to fill the fixed part (i.e. the deep malar fat or superficial malar fat) 7, 17


.


Bolus or fanning techniques It is advised that physicians use the technique most comfortable for them — either fan or bolus. However, the authors’ preference is to use a bolus technique at the level of the deep malar fat, and the fanning technique at the level of the superficial malar fat. Highly cross-linked hyaluronic acids, such as


Juvéderm VOLUMA®, are ideal for deep injection, either in the deep malar fat or deep part of the superficial malar fat (Figure 6). The comfort of treatment has been further improved by the addition of an anaesthetic in the product — Juvéderm VOLUMA with lidocaine. The initial introduction of either needle or cannula is associated with some pain; however, the addition of the local anaesthetic lidocaine to the product diminishes the pain response following injection. The authors suggest that waiting for 2 minutes for the lidocaine to take effect before continuing with volumisation improves the level of comfort for the patient. To further ameliorate the pain response, it is recommended to inject slowly and gently, especially into the more fibrous and dense deep malar fat. As an added benefit, the more comfortable patient will be more relaxed. This will aid the ease of administration for the physician. In the authors’ opinion, it makes sense to complement


the hyaluronic acid injections into the deep malar fat with injections into the superficial part of the superficial malar fat. Less cross-linked hyaluronic acids such as Juvederm Ultra® 2, 3 or 4, which are better able to be injected superficially, are ideal for this purpose. These further injections will give volume, but additionally, will improve the skin’s surface with regard to texture, brightness, hydration and radiance.


Cannula or needle? Again, this is generally based on the personal preference of the physician, depending on the technique he/she is most comfortable using. The authors’ preference lies with the use of: ■ Needle with bolus technique at the level of the deep malar fat


■ Needle or cannula when the injection is more superficial (i.e. into the superficial malar fat).


Using a needle is certainly easier — it causes no extra


bruising if the physician knows how to avoid the trunk of the facial artery and vein (i.e. medially) (Figure 4). In the authors’ opinion, the relative risk of trauma on the very small vessels and capillaries, both small branches of the facial artery and facial vein, is the same when using either device. However, the impact on larger vessels, such as the trunks of the facial artery and the facial vein, is riskier still


prime-journal.com | January/February 2012 More than


70 brands of hyaluronic acid exist on the medical market in Europe alone. The quality is improving — the future of the injection will be optimised by research to develop the ideal product.


as the needle can pierce these large vessels, whereas the cannula will avoid them. Despite this, using a cannula requires a greater amount


of force, giving less control, especially in the denser and more fibrous deep malar fat. Physicians should be wary of using flexible cannulae because of their ability to bend, making it more difficult to control its route and end needle position.


Effect of tissue response There is a dermal tissue response secondary to either the trauma itself or the injected product. Elastin, collagen, proteoglycans, and structural glycoproteins are produced in the dermis by fibroblasts8


. It is known that any local


reaction, inflammatory phenomenon or scarring caused by stimulation, whether surgical or by an injected product, induces signs of proliferation and stimulation of fibroblasts8


. From this it can be deduced that a





39


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48  |  Page 49  |  Page 50  |  Page 51  |  Page 52  |  Page 53  |  Page 54  |  Page 55  |  Page 56  |  Page 57  |  Page 58  |  Page 59  |  Page 60  |  Page 61  |  Page 62  |  Page 63  |  Page 64  |  Page 65  |  Page 66  |  Page 67  |  Page 68  |  Page 69  |  Page 70  |  Page 71  |  Page 72  |  Page 73  |  Page 74  |  Page 75  |  Page 76  |  Page 77  |  Page 78  |  Page 79  |  Page 80  |  Page 81  |  Page 82  |  Page 83  |  Page 84  |  Page 85  |  Page 86  |  Page 87  |  Page 88  |  Page 89  |  Page 90  |  Page 91  |  Page 92
Produced with Yudu - www.yudu.com