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Faria GEDL, Nassif AD, Medina RIS, Espicalsky S, Zattar L, Boggio RF. Precise Needle and Cannula Placement in the Forehead During Aesthetic Procedures: Can Device and Angulation Influence Accuracy? A Fresh Frozen Specimen Study. Aesthetic Plast Surg 2024:10.1007/s00266-024-04350-1. [PMID: 39227473 DOI: 10.1007/s00266-024-04350-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 08/23/2024] [Indexed: 09/05/2024]
Abstract
INTRODUCTION Myomodulation is a technique aimed at enhancing the dynamics of muscle contraction and relaxation through methods like hyaluronic acid (HA) injection. Achieving optimal outcomes depends on the precise placement of the injected product within the targeted anatomical plane. This is particularly important in the forehead, an area with elevated vascular risk. The selected treatment techniques must ensure both efficacy and safety. This study aims to assess the anatomical precision of HA injections in the forehead using different techniques and devices. METHODS Four fresh frozen specimens were injected with HA by five experienced board-certified plastic surgeons using three different techniques/devices: (1) a 50 mm, 22G microcannula; (2) a 13 mm, 27G needle with the bevel down at a 45-degree angle; and (3) the same needle positioned at a 90-degree angle. Ultrasound analysis was used to evaluate the precision of each approach. RESULTS Both the cannula technique and the needle technique with the bevel down at a 45-degree angle consistently delivered the filler to the supraperiosteal layer in 100% of cases without spreading. However, the 90-degree needle technique, despite correct placement on the periosteum, resulted in filler dispersion across multiple layers. CONCLUSION The accuracy of filler placement in the forehead is influenced by the choice of device and its angulation. It is recommended to use a cannula with the entry point at the frontalis crest or a needle angled at 45 degrees to the skin. The use of a needle at a 90-degree angle should be avoided to ensure precise placement and avoid filler migration. NO LEVEL ASSIGNED This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
| | - Alexander D Nassif
- Instituto Boggio - Medicina, ensino e pesquisa, Rua Cincinato Braga, 37, 8°Andar, Bela Vista, SP, 04004-030, Brazil
| | | | - Sheila Espicalsky
- Instituto Boggio - Medicina, ensino e pesquisa, Rua Cincinato Braga, 37, 8°Andar, Bela Vista, SP, 04004-030, Brazil
| | - Luciana Zattar
- Instituto Boggio - Medicina, ensino e pesquisa, Rua Cincinato Braga, 37, 8°Andar, Bela Vista, SP, 04004-030, Brazil
| | - Ricardo Frota Boggio
- Instituto Boggio - Medicina, ensino e pesquisa, Rua Cincinato Braga, 37, 8°Andar, Bela Vista, SP, 04004-030, Brazil
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Bone Formation on Murine Cranial Bone by Injectable Cross-Linked Hyaluronic Acid Containing Nano-Hydroxyapatite and Bone Morphogenetic Protein. Polymers (Basel) 2022; 14:polym14245368. [PMID: 36559734 PMCID: PMC9783206 DOI: 10.3390/polym14245368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 11/20/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022] Open
Abstract
New injection-type bone-forming materials are desired in dental implantology. In this study, we added nano-hydroxyapatite (nHAp) and bone morphogenetic protein (BMP) to cross-linkable thiol-modified hyaluronic acid (tHyA) and evaluated its usefulness as an osteoinductive injectable material using an animal model. The sol (ux-tHyA) was changed to a gel (x-tHyA) by mixing with a cross-linker. We prepared two sol−gel (SG) material series, that is, x-tHyA + BMP with and without nHAp (SG I) and x-tHyA + nHAp with and without BMP (SG II). SG I materials in the sol stage were injected into the cranial subcutaneous connective tissues of mice, followed by in vivo gelation, while SG II materials gelled in Teflon rings were surgically placed directly on the cranial bones of rats. The animals were sacrificed 8 weeks after implantation, followed by X-ray analysis and histological examination. The results revealed that bone formation occurred at a high rate (>70%), mainly as ectopic bone in the SG I tests in mouse cranial connective tissues, and largely as bone augmentation in rat cranial bones in the SG II experiments when x-tHyA contained both nHAp and BMP. The prepared x-tHyA + nHAp + BMP SG material can be used as an injection-type osteoinductive bone-forming material. Sub-periosteum injection was expected.
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Minelli L, Richa J, Mendelson BC. Aesthetic Enhancement of the Brow using Hydroxyapatite. Aesthetic Plast Surg 2022; 46:1201-1210. [PMID: 35288761 PMCID: PMC9411237 DOI: 10.1007/s00266-022-02793-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 01/16/2022] [Indexed: 11/24/2022]
Abstract
Background An aesthetically pleasing appearance of the ‘eyes’ usually includes good projection of the outer brow. Weak bony projection of the superolateral periorbital region tends to be not only less attractive, but also predisposes to hooding over the temporal part of the upper lid. Congenital lack of skeletal volume is exacerbated by ageing due to lipoatrophy and soft tissue laxity. The rationale and technique for performing skeletal augmentation of the superolateral orbital rim is described, along with long-term results from a series of cases. Material and Methods A series of patients having augmentation of the superolateral orbital rim, using the technique described, were evaluated. A forehead crease incision was used, then a precise subperiosteal pocket developed in the lateral brow region between the supraorbital foramen and the superior temporal septum. The hydroxyapatite granule mixture was incrementally placed using modified syringes. The patients were followed to assess the long-term results. Results Two hundred and fifty patients, 80% women, mean age = 53 years [range 23–78] underwent supraorbital rim augmentation using subperiosteal hydroxyapatite granules, during a 12-year period, commencing in 2007. The mean follow-up was 41 months (range 1–12 years). The mean volume used for augmentation was 1.0 mL per side (range 0.4–2.3 mL). Projection of the upper lateral periorbital prominence was effectively increased, resulting in enhancement of the brow position and shape. Twenty-seven patients (11%) had an undercorrection, requiring additional volume augmentation, all during the first three years of the experience. Twelve patients (5%)
required correction of contour irregularities. There were no infections and no long-term complications. Resorption of the hydroxyapatite volume over time was not noted. Conclusion The aesthetic significance of superolateral orbital rim projection is introduced. Patients who have a degree of skeletal deficiency of the zygomatic process of the frontal bone should be considered for hydroxyapatite augmentation of the bone as a complement to upper lid blepharoplasty and brow elevation. This procedure should be considered in the spectrum of upper periorbital aesthetic procedures. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. Supplementary Information The online version contains supplementary material available at 10.1007/s00266-022-02793-y.
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Affiliation(s)
- Lennert Minelli
- Melbourne Advanced Facial Anatomy Course (MAFAC), 109 Mathoura Road Toorak, Melbourne, VIC, 3142, Australia
| | - Jacqueline Richa
- The Panama Clinic, Calle Ramón H Jurado, Centro Pacific Center Torre B, Panama, Panama
| | - Bryan C Mendelson
- The Centre for Facial Plastic Surgery, 109 Mathoura Road Toorak, Melbourne, VIC, 3142, Australia.
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Abstract
ABSTRACT With the sudden emergence of new medical aesthetic fillers, the number of fillers injected worldwide has exploded, but there are also worrying risks in the pursuit of beauty. At present, many cases of blindness caused by injection of aesthetic fillers have been reported. Most of the cases are caused by irreversible vascular embolism. This is a rare yet greatly feared complication of using facial cosmetic fillers. This article reviewed and analyzed the literature and summarized the changes in the anatomical structure of facial blood vessels related to blindness during facial injection.
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Affiliation(s)
- Dan Li
- From the Department of Plastic and Burn Surgery, the First Affiliated Hospital Chongqing Medical University, Chongqing, China
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Papadopoulos T. Commentary on: Injectable Filler Technique for Face Lifting Based on Dissection of True Facial Ligaments. Aesthet Surg J 2021; 41:NP1584-NP1588. [PMID: 33782682 DOI: 10.1093/asj/sjab151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Tim Papadopoulos
- Department of Plastic and Reconstructive Surgery, Westmead Private Hospital, Westmead NSW, Australia
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Radiographic Features of Facial Cosmetic Material: Report of Two Cases. Case Rep Dent 2021; 2021:7308636. [PMID: 34631177 PMCID: PMC8497133 DOI: 10.1155/2021/7308636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 09/02/2021] [Indexed: 11/18/2022] Open
Abstract
Recently, the use of noninvasive facial cosmetic procedures has been widely disseminated. In the face, cosmetic fillers, threads, and implants are used to reduce or delay the effects of aging or adjust facial defects caused by trauma or disease. The dentist or dental specialist may encounter these materials in the radiographic images of their patients. There are few reports in the dental literature describing the radiographic appearance of some materials along with the diseases they mimic. As the procedures and materials advance and evolve, dentists and dental specialists must be aware of their radiographic appearance to avoid errors in diagnosis. This is a report of two cases that include panoramic radiography and CBCT scan. Among these cases, there is an unusual appearance of a cosmetic filler due to a subperiosteal injection method. Moreover, it will discuss common types of cosmetic materials used in the face and their imaginological appearance. This is the key to dentists and dental specialists due to increasing use of facial cosmetic materials and a parallel increase in the use of cone beam CT and chances to encounter such findings.
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Tseng FW, Bommareddy K, Frank K, DeLorenzi C, Green JB, Sadick N, Fitzgerald R, Onishi EC, Swift A, Cotofana S. Descriptive Analysis of 213 Positive Blood Aspiration Cases When Injecting Facial Soft Tissue Fillers. Aesthet Surg J 2021; 41:616-624. [PMID: 32504468 DOI: 10.1093/asj/sjaa075] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Pre-injection aspiration procedures could increase safety during soft tissue filler injections. However, various influencing factors have been detected in vitro that could result in false negative aspiration results. OBJECTIVE A case series was retrospectively investigated to identify factors contributing to positive blood aspiration procedures in vivo. METHODS This study evaluated 213 clinical cases positive for blood aspiration documented in an Asian population: 208 females (43.8 ± 7.2 years old) and 5 males (46.8 ± 7.8 years old) during soft tissue filler injections. Injection location, layer (depth) of injection, product injected, size of utilized needle (gauge), length of needle (inch), priming of needle (yes/no), injection angle (degree), and time until blood was visible in the needle hub (seconds) were evaluated. RESULTS The most frequent location where a positive aspiration was observed was the pyriform fossa (n = 56; 26.3%), the most frequent plane was the supra-periosteal plane (n = 195; 91.5%), and the most frequent needle utilized was a 27G needle (n = 125; 58.7%). Statistically significantly more positive cases were identified when the needle was primed compared with an unprimed needle (P < 0.001, which was independent of the product). The estimated incidence rate was 0.04% to 0.9% for having positive aspiration procedures per total performed injection procedures. CONCLUSIONS Pre-injection aspiration could be a valuable tool to prevent accidental intravascular injection of soft tissue filler. The results of the present investigation show that aspiration can be performed with an acceptable aspiration time, that is, less than 2 seconds, if a suitable product/needle combination is chosen. LEVEL OF EVIDENCE: 4
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Abstract
Purpose of the present study is to objectively evaluate the number of severe vascular complications, represented by skin necrosis and vision loss or impairment, following facial filler injection. The investigators implemented a review of the literature including articles published on PubMed database without limitation about year of publication, including all reports concerning skin necrosis and vision loss or impairment related to the injection of fillers for cosmetic uses. The search highlighted 45 articles and a total of 164 cases of skin necrosis and vision loss or impairment after injection of different substances. The injection site most frequently associated with complications was the nose (44.5%), followed by glabella (21%), nasolabial fold (15%), and forehead (10%). Results of the present study suggest that injectable filler can cause severe complications even in expertized hands. Treatments in the new defined "Dangerous triangle" must be carefully carried out. Despite our expectations, the highest rates of sever adverse events have been associated with autologous fat transfer practice.
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Lipko-Godlewska S, Bolanča Ž, Kalinová L, Kermen I, Onisak B, Papp I, Rebrov M, Valančienė G. Whole-Face Approach with Hyaluronic Acid Fillers. Clin Cosmet Investig Dermatol 2021; 14:169-178. [PMID: 33633459 PMCID: PMC7901566 DOI: 10.2147/ccid.s292501] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 01/29/2021] [Indexed: 11/23/2022]
Abstract
The use of hyaluronic acid fillers in aesthetic medicine has changed over the years and the procedure became one of the most common in the world. Understanding the ageing process of the face and the anatomical interrelationships in the face have dramatically influenced the use of the hyaluronic acid fillers and the assessment of the patient. It was supported by a new technology of products and by the delivery of tools (eg, blunt cannulas), face imaging, and innovative injection techniques. The whole-face approach challenges the practitioner to look at the face as a whole, and the patient to trust and rely on the treatment plan. Over the years, we have understood, that the most important outcome of aesthetic procedures is what does the whole face look like not static but in motion, and how do people read emotions from it. Nowadays, the result changes "the face information" and makes aesthetic procedures more satisfactory. In this manuscript, we reviewed essentials of the current treatment approach including patient's consultations, product selection and injection techniques used in different parts of the face. One size fits none; thus, we provided a general overview of hyaluronic acid fillers used in different indications and presented several treatment approaches to each region of the face.
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Affiliation(s)
| | - Željana Bolanča
- University Clinical Hospital Center "Sestre Milosrdnice", Zagreb, Croatia.,Private Clinic Milojević, Zagreb, Croatia
| | | | | | | | - Ildikó Papp
- Koruti Orvosesztetikai Centrum, Budapest, Hungary
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Davidovic K, Melnikov DV, Frank K, Gavril D, Green JB, Freytag DL, Heisinger S, Pavicic T, Gold MH, Cotofana S. To click or not to click - The importance of understanding the layers of the forehead when injecting neuromodulators - A clinical, prospective, interventional, split-face study. J Cosmet Dermatol 2020; 20:1385-1392. [PMID: 33251687 DOI: 10.1111/jocd.13875] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/25/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Differences in the effectiveness of neuromodulator treatments for horizontal forehead lines dependent on depth of product administration have been described. However, knowledge in respect to the fascial anatomy of the forehead still remains elusive. AIMS To relate the fascial anatomy of the forehead to the effectiveness of neuromodulator treatments by conducting a clinical, prospective, interventional split-face study in which injections for the treatment of horizontal forehead lines are performed differently between facial sides. METHODS This study included a total of n = 14 patients with a mean age of 35.71 (7.8) years and mean body mass index of 21.9 (3.0) kg/m2 . One side of the forehead was injected superficially by positioning the product in the superficial fatty layer, whereas the contralateral side was injected deep targeting the supraperiosteal plane (random selection). The treatment outcome was rated by the physician and by two independent observers according to a forehead line severity scale (0-4) at 14 and at 30 days. RESULTS All three observers agreed in their ratings (ICC: 0.942) that the deep injection technique resulted in a superior outcome: D14 (superficial vs deep) 0.17 (0.4) vs 0.14 (0.4; P = .583) at rest and 1.26 (0.6) vs 0.43 (0.5; P < .001) for frontalis contraction; D30 0.17 (0.4) vs 0.14 (0.3) at rest (P = .583) and 1.21 (0.6) vs 0.43 (0.5; P < .001) for frontalis contraction. CONCLUSION The results of this study underscore how detailed anatomic knowledge can enhance results of aesthetic interventions, in this case horizontal forehead line treatment with neuromodulators.
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Affiliation(s)
- Kristina Davidovic
- Department of Radiology & Medical School, University of Belgrade, Belgrade, Serbia
| | - Dmitry V Melnikov
- Plastic Surgery Department, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Konstantin Frank
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig - Maximilian University Munich, Germany
| | | | - Jeremy B Green
- Skin Associates of South Florida, Skin Research Institute, Coral Gables, FL, USA
| | - David L Freytag
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig - Maximilian University Munich, Germany
| | - Stephan Heisinger
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Michael H Gold
- Gold Skin Care Center, Tennessee Clinical Research Center, Nashville, TN, USA
| | - Sebastian Cotofana
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
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Cotofana S, Alfertshofer M, Frank K, Bertucci V, Beleznay K, Nikolis A, Sykes J, Swift A, Lachman N, Schenck TL. Relationship Between Vertical Glabellar Lines and the Supratrochlear and Supraorbital Arteries. Aesthet Surg J 2020; 40:1341-1348. [PMID: 32469392 DOI: 10.1093/asj/sjaa138] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Glabellar soft tissue filler injections have been shown to be associated with a high risk of causing injection-related visual compromise. OBJECTIVES The aim of this study was to identify the course of the superficial branch of the supratrochlear and of the deep branch of the supraorbital artery in relation to the ipsilateral vertical glabellar line and to test whether an artery is located deep to this line. METHODS Forty-one healthy volunteers with a mean age of 26.17 [9.6] years and a mean BMI of 23.09 [2.3] kg/m2 were analyzed. Ultrasound imaging was applied to measure the diameters, distance from skin surface, distance between the midline, distance between vertical glabella lines, and the cutaneous projection of the supratrochlear/supraorbital arteries at rest and upon frowning. RESULTS The mean distance between the superficial branch of the supratrochlear artery and the ipsilateral vertical glabellar line was 10.59 [4.0] mm in males and 8.21 [4.0] mm in females, whereas it was 22.38 [5.5] mm for the supraorbital artery in males and 20.73 [5.6] mm in females. Upon frowning, a medial shift in supratrochlear arterial position of 1.63 mm in males and 1.84 mm in females and of 3.9 mm in supraorbital arterial position for both genders was observed. The mean depth of the supratrochlear artery was 3.34 [0.6] mm at rest, whereas the depth of the supraorbital artery was 3.54 [0.8] mm. CONCLUSIONS The hypothesis that injecting soft tissue fillers next to the vertical glabellar line is safe because the supratrochlear artery courses deep to the crease should be rejected. Additionally, the glabella and the supraorbital region should be considered as an area of mobile, rather than static, soft tissues.
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Affiliation(s)
- Sebastian Cotofana
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Michael Alfertshofer
- Department for Hand, Plastic, and Aesthetic Surgery, Ludwig- Maximilians University Munich, Munich, Germany
| | - Konstantin Frank
- Department for Hand, Plastic, and Aesthetic Surgery, Ludwig- Maximilians University Munich, Munich, Germany
| | - Vince Bertucci
- Division of Dermatology, University of Toronto, Toronto, Ontario, Canada
| | - Katie Beleznay
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, Canada
| | - Andreas Nikolis
- Erevna Innovations Inc, Clinical Research Unit, Montreal, Quebec, Canada
- Division of Plastic Surgery, McGill University, Montreal, Quebec, Canada
| | - Jonathan Sykes
- Facial Plastic and Reconstructive Surgery, UC Davis Medical Centre, Sacramento, CA, USA
| | | | - Nirusha Lachman
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Thilo L Schenck
- Department for Hand, Plastic, and Aesthetic Surgery, Ludwig- Maximilians University Munich, Munich, Germany
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Rosamilia G, Hamade H, Freytag DL, Frank K, Green JB, Devineni A, Gavril DL, Hernandez CA, Pavicic T, Cotofana S. Soft tissue distribution pattern of facial soft tissue fillers with different viscoelastic properties. J Cosmet Dermatol 2020; 19:312-320. [DOI: 10.1111/jocd.13246] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 09/20/2019] [Indexed: 01/20/2023]
Affiliation(s)
- Gianna Rosamilia
- Division of Anatomy Department of Medical Education Albany Medical College Albany NY USA
| | - Hassan Hamade
- Division of Anatomy Department of Medical Education Albany Medical College Albany NY USA
| | - David L. Freytag
- Department for Hand, Plastic and Aesthetic Surgery Ludwig–Maximilians University Munich Munich Germany
| | - Konstantin Frank
- Department for Hand, Plastic and Aesthetic Surgery Ludwig–Maximilians University Munich Munich Germany
| | | | - Aditya Devineni
- Division of Anatomy Department of Medical Education Albany Medical College Albany NY USA
| | | | | | | | - Sebastian Cotofana
- Division of Anatomy Department of Medical Education Albany Medical College Albany NY USA
- Division of Plastic Surgery Department of Surgery Albany Medical Center Albany NY USA
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