The Art and Science of Filler Injection: Based on Clinical Anatomy and the Pinch Technique

By Giwoong Hong, Seungmin Oh, Bongcheol Kim and Yongwoo Lee

This highly illustrated book describes how to perform dermal filler procedures in a way that simultaneously takes into account esthetic and safety aspects in order to achieve optimal outcomes in individual patients. After discussion of filler materials and design considerations, the relevant basic and clinical anatomy is described, drawing on cadaveric examinations and imaging in living subjects. Step-by-step instruction is then provided on how to identify a safe injection plane and on injection using the pinch technique. The coverage includes guidance on injection procedures specific to different sites. A thorough and systemic description of potential side effects of filler injection, and the management of complications is also presented. The Art and Science of Filler Injection equips the reader with a sound knowledge of all aspects relevant to the achievement of pleasing esthetic results without side effects and will be of value for practitioners at all levels of experience.

• Language: English
• Publisher: Springer
• Release date: Feb 27, 2020
• ISBN: 9789811306112

Book preview

Giwoong Hong, Seungmin Oh, Bongcheol Kim and Yongwoo Lee

The Art and Science of Filler Injection

Based on Clinical Anatomy and the Pinch Technique

../images/466406_1_En_BookFrontmatter_Figa_HTML.png

Giwoong Hong

SAMSKIN Plastic Surgery, Seoul, Korea (Republic of)

Seungmin Oh

ON Clinic, Seoul, Korea (Republic of)

Bongcheol Kim

Lamar Clinic Isu Branch, Seoul, Korea (Republic of)

Yongwoo Lee

LIKE Plastic Surgery, Seoul, Korea (Republic of)

ISBN 978-981-13-0610-5e-ISBN 978-981-13-0611-2

https://doi.org/10.1007/978-981-13-0611-2

© Springer Nature Singapore Pte Ltd. 2020

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Preface

The pursuit of beauty has been a universal desire that transcends age, culture, and time. There are diverse approaches to beautification and the outcomes vary according to these approaches.

Soft tissue filler injections are one of the most commonly performed aesthetic procedures that have shown tremendous progress in the last 10 years. However, along with this progress, the indications for filler procedures have also broadened and the efficacy of filler procedures has also advanced extensively. Fillers account for a significant portion of the medical aesthetics market but filler procedures performed indiscriminately by physicians who lack adequate medical knowledge of clinical anatomy, accurate injection techniques, and the potential complications have led to reports of many adverse events. To ensure optimal outcomes without complications, in-depth studies and discussions regarding the most appropriate procedural methods is paramount. In addition, the authors believe that the physician must assess the patient’s psychosocial, philosophical, and cultural perspectives on beauty during the initial consultation and take these factors into consideration when coming up with a treatment plan.

The recent trend in filler procedures has shifted from addressing wrinkles or the appearance of the face when it is in an expressionless, static state to practical treatments that consider the dynamic nature of the facial soft tissues and wrinkle formations when making diverse facial expressions like smiling.

Therefore, this book has been written for filler procedures which go beyond regional volumization or sunken wrinkle treatments; to creating a three dimensional, aesthetically pleasing face with a good impression (Fig.  1 ).

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Fig. 1

PINCH technique for filler procedure

The authors hope this book will help doctors who want to specialize in filler procedures. Even those who have previous experience in this procedure should compare and review their methods with the clinical anatomy-based treatments in this book to find any benefits they can apply to their practice. We sincerely hope this book will help you to perform more safe and effective filler procedures .

Giwoong Hong

Seungmin Oh

Bongcheol Kim

Yongwoo Lee

Seoul, Korea (Republic of)

Contents

1 The Art and Science of Filler Procedures for a More Attractive Face 1

1.​1 Natural Beauty and Human Attractiveness 1

1.​2 Differences Between Asian and Western Beauty Concepts 5

1.​3 Medical Reference Values to Create an Attractive Face 8

Bibliography 13

2 Filler Types and Characteristics 15

2.​1 Type of Filler 15

2.​1.​1 Number of Various Fillers Used Recently 15

2.​2 Characteristics of Hyaluronic Acid Filler 16

2.​2.​1 Hyaluronic Acid as a High Molecular Compound 16

2.​2.​2 Hyaluronic Acid Filler Manufacturing Process 16

2.​2.​3 Rheology of Hyaluronic Acid Filler 20

2.​2.​4 Selection of Hyaluronic Acid Filler 25

2.​3 Calcium Filler 32

2.​4 Polycaprolactone​ Filler 34

2.​5 Filler Selection 36

Bibliography 36

3 Anatomical Considerations for Filler Procedures 39

3.​1 Vessels and Nerves 39

3.​2 Fat Compartments and Muscles 42

3.​3 Retaining Ligaments 44

3.​4 Layer and Space 47

3.​5 Identification of SubSMAS Space for Filler Injection:​ Cadaver Study Using Stained Gelatin 48

3.​6 SSRT (Skin and SMAS Layer Remodeling Technique) for Volumization and Lifting Effect 62

Bibliography 68

4 Basic Technique for Filler Procedure 71

4.​1 Design (Method) 71

4.​1.​1 Frontal View-Horizontal/​Vertical Ratio of the Face 71

4.​1.​2 Frontal View—Heart-Shaped Midface 72

4.​1.​3 Oblique View—S-Line/​Inverted S-Line/​Ogee Curve 74

4.​1.​4 Lateral View-Ricketts Line 74

4.​1.​5 Design for Safe Filler Injection—Mark of Dangerous Area 75

4.​2 Anesthesia—Nerve Block 76

4.​2.​1 Supratrochlear/​Supraorbital Nerve 76

4.​2.​2 Zygomaticotempor​al Nerve (Fig.​ 4.​14) 77

4.​2.​3 Zygomaticofacial​ Nerve (Fig.​ 4.​15) 78

4.​2.​4 External Nasal Branch of Anterior Ethmoidal Nerve (Fig.​ 4.​16) 79

4.​2.​5 Infraorbital Nerve (Fig.​ 4.​17) 79

4.​2.​6 Mental Nerve (Fig.​ 4.​18) 79

4.​2.​7 Greater Auricular Nerve (Fig.​ 4.​19) 79

4.​3 Selection of Cannula or Needle 80

4.​3.​1 Cannula 80

4.​3.​2 Characteristics of Needles 81

4.​4 Injection Technique 82

4.​4.​1 Types of Injection Techniques 84

4.​4.​2 Injection Techniques for Each Area 86

4.​5 Basic Techniques by Region 88

4.​6 Filler Molding and Filler Degradation Test 94

4.​6.​1 Filler Molding 94

4.​6.​2 Filler Degradation Test 97

Bibliography 101

5 Filler Procedures Based on the Facial Area 103

5.​1 Upper Face 103

5.​1.​1 Forehead and Glabella 103

5.​1.​2 Temple 106

5.​2 Midface 111

5.​2.​1 Supraorbital Hollowness (Sunken Eyelid) and Flat Eyebrow 111

5.​2.​2 Pre-tarsal Roll (=​ Lower Eyelid Charming Roll, Pre-tarsal Fullness) 118

5.​2.​3 Infraorbital Groove and Hollowness 121

5.​2.​4 Dark Circle (Tear Trough and Palpebromalar Groove) 128

5.​2.​5 Midcheek Groove 133

5.​2.​6 Anteromedial, Buccal, and Lateral Cheek Hollow 135

5.​2.​7 Nose 141

5.​2.​8 Nasolabial Fold 149

5.​3 Lower Face 157

5.​3.​1 Lip and Philtrum 157

5.​3.​2 Marionette Line (Static Labiomandibular Fold) 161

5.​3.​3 Perioral Wrinkles (Smoker’s Line) 166

5.​3.​4 Chin Augmentation and Jaw Line Contouring 168

Bibliography 173

6 Complication of Filler Procedures 177

6.​1 Type and Treatment of Complication 177

6.​1.​1 Bruising and Hematoma 177

6.​1.​2 Edema 178

6.​1.​3 Neovascularizati​on and Erythema 179

6.​1.​4 PIH (Post-inflammatory Hyperpigmentatio​n) 179

6.​1.​5 Nodule and Granuloma 179

6.​1.​6 Infection 180

6.​2 Treatment and Prevention of Vascular Complication 181

6.​2.​1 Mechanism and Classification of Vascular Complications 181

6.​2.​2 Skin Necrosis 181

6.​2.​3 Vascular Complication—Blindness 185

6.​2.​4 Vascular Complication—Pulmonary Embolism 186

6.​2.​5 Prevention of Vascular Complication 186

6.​3 Hyaluronidase Usage 190

6.​3.​1 Hyaluronic Acid Turnover 190

6.​3.​2 Use of Hyaluronidase 191

6.​4 Retrobulbar Injection Technique 201

Bibliography 203

About the Authors

../images/466406_1_En_BookFrontmatter_Figb_HTML.png

Giwoong Hong, M.D., Ph.D.

Board-certified Plastic Surgeon

President of SAMSKIN Plastic Surgery Clinic

Clinical Professor, Department of Plastic Surgery, Chung-Ang University Medical Center

Member of the Korean Society of Plastic and Reconstructive Surgery

Member of the Korean Society of Aesthetic Plastic Surgery

Member of Korean Cleft Palate-Craniofacial Association

Member of Korean Society for Microsurgery

Member of Korean Association of Stem Cell Therapy

Scientific Committee of Korean Association of Minimally Invasive Plastic Surgery

Advisory Board Member of Galderma Korea

Advisory Board Member of N-FINDERS

Advisory Board Member of Hugel

Advisory Board Member of Chong Kun Dang Pharm

Restylane Filler Global Key Doctor

President of ICALA (International Clinical Aesthetic Leaders Academy)

Published books

Botulinum Toxin Clinical Usage (2019) MDWORLD Medical Publishing Co.

Thread Lifting Clinical Usage (2019) MDWORLD Medical Publishing Co.

Practical Guidelines for Effective and Safe Filler Procedures (2018) KOONJA Publishing Inc.

Clinical Anatomy for Filler & Toxin (2018) MEDICAL Observer

Filler.Toxin Practical Knowhow (2017) MDWORLD Medical Publishing Co.

../images/466406_1_En_BookFrontmatter_Figc_HTML.png

Seungmin Oh, M.D. Medical M.B.A.

Director, ON Clinic

President of OK Medi. Co. Ltd.

Seoul national university college of medicine

Seoul national university hospital internship, Residentship

Seoul national university hospital Clinical Instructor

Executive board member of the Korean Association for Laser, Dermatology and Trichology

Faculty member of IMCAS (International Master Course on Aging Science)

Advisor, Galderma (Restylane filler)

Advisor, JongKunDang (Stylage filler-VIVACY)

Advisor, Medytox. Co. Ltd. (Neuramis filler)

Advisor, Hugel Co. Ltd. (Blue Rose Forte thread)

Advisor, Sthepharm C. Ltd. (QTL, QT cell)

Books

『The Art and Science of Thread Lifting: Based on Pinch Anatomy』 Bongcheol Kim, Seungmin Oh, Wonsug Jung (2019, SPRINGER NATURE)

『English version: Safe Filler Injection Technique Demonstration-using live imaging tools』 Seungmin Oh, Bongcheol Kim (2017)

『Chinese version: The art and science of the Thread lifting (埋线提升术的定石)』/Bongcheol Kim, Seungmin Oh, Wonsug Jung (2017)

『Korean version: The art and science of the Thread lifting』/Bongcheol Kim, Seungmin Oh, Wonsug Jung (2017)

『Chinese version: Safe Filler Injection Technique Demonstration-using live imaging tools (安全地注射玻尿酸以活体影像为工具)』/Seungmin Oh, Bongcheol Kim (2015)

『Safe Filler Injection Technique Demonstration-using live imaging tools』/Seungmin Oh, Bongcheol Kim (2014)

../images/466406_1_En_BookFrontmatter_Figd_HTML.png

Bongcheol Kim, M.D.

Director of Lamar Isu Clinic

College of Medicine, Chonnam National University

Internship—Samsung Medical Center (Seoul)

Residency—Samsung Medical Center (Seoul)

Executive board member of the Korean Association for Laser, Dermatology and Trichology

KOL of Merz Korea (Ulthera ® , Radiesse ® , Belotero ® , Xeomin ® )

KOL of Classys (Shrink ® , Ultraformer ® , Scizer ® , Ulfit ® )

KOL of Sinclair Korea (Silhouette Soft ® lifting)

KOL of Sthepham (QT Lift ® , QT cell ® )

KOL of DNC (Theosyal ® )

Published Books

/Seungmin Oh, Bongcheol Kim (Korean version 2014, Chinese version 2015, English version 2017, Taiwanese version 2018 )

/Bongcheol Kim, Seungmin Oh, Wonsug Jung (Korean version 2017, Chinese version 2017, SPRINGER NATURE 2019 )

../images/466406_1_En_BookFrontmatter_Fige_HTML.png

Yongwoo Lee, M.D., Medical M.B.A.

Board-certified Plastic Surgeon

President of LIKE Plastic Surgery Clinic

Clinical Professor, Department of Plastic Surgery, Han-Yang University Medical Center

Member of the Korean Society of Plastic and Reconstructive Surgery

Member of the Korean Society of Aesthetic Plastic Surgery

Committee of Korean Association of MIPS (Minimally Invasive Plastic Surgery)

Scientific Committee of ICALA (International Clinical Aesthetic Leaders Academy)

Advisory Board Member of Galderma Korea

Advisory Board Member of Hugel

Advisory Board Member of Medytox

Advisory Board Member of N-FINDERS

Published books

Botulinum Toxin Clinical Usage (2019) MDWORLD Medical Publishing Co.

Thread Lifting Clinical Usage (2019) MDWORLD Medical Publishing Co.

Practical Guidelines for Effective and Safe Filler Procedures (2018) KOONJA

Clinical Anatomy for Filler & Toxin (2018) MEDICAL Observer

© Springer Nature Singapore Pte Ltd. 2020

G. Hong et al.The Art and Science of Filler Injectionhttps://doi.org/10.1007/978-981-13-0611-2_1

1. The Art and Science of Filler Procedures for a More Attractive Face

Giwoong Hong¹  , Seungmin Oh²  , Bongcheol Kim³   and Yongwoo Lee⁴  

(1)

SAMSKIN Plastic Surgery, Seoul, Korea (Republic of)

(2)

ON Clinic, Seoul, Korea (Republic of)

(3)

Lamar Clinic Isu Branch, Seoul, Korea (Republic of)

(4)

LIKE Plastic Surgery, Seoul, Korea (Republic of)

Giwoong Hong (Corresponding author)

Email: [e-mail]

Seungmin Oh

Email: [e-mail]

Bongcheol Kim

Email: [e-mail]

Yongwoo Lee

Email: [e-mail]

1.1 Natural Beauty and Human Attractiveness

The current trend and prevailing issue in aesthetic medicine are creating natural beauty. In addition to enhancing natural beauty with cosmetics, hair products, and fashion items, more and more people are fervently striving for healthier lifestyles and well-being. Such social and cultural changes have not only impacted the field of aesthetic medicine but have also changed how people react to facial changes related to aging. People seek to age beautifully but focus has shifted. From deliberately reverting and masking the signs of aging and inadvertently looking awkward, more and more people are pursuing beauty that is natural, graceful, and effortless.

Minimally-invasive cosmetic procedures, including filler procedures, do not require the patient to go under the knife. There is less swelling and there are barely any signs of having undergone a medical aesthetic procedure. Patients can be discreet and are able to return to their daily lives with more convenience. Moreover, because minimally-invasive procedures do not cause significant changes to the facial skin and tissue, they are highly unlikely to cause any permanent side effects. Moreover, additional procedures may be performed at any time.

Facial fillers are in widespread use today, and have firmly established their place in the aesthetic armamentarium among the minimally-invasive cosmetic procedures. Unlike in the earlier years, the materials and manufacturing methods used to produce fillers have become much more sophisticated. The indications for filler procedure have broadened and the efficacy of filler procedures has also advanced extensively. Fillers account for a significant portion of the medical aesthetics market and filler procedures performed indiscriminately by professionals who lack adequate medical knowledge regarding clinical anatomy, accurate injection techniques, and the potential complications have led to reports of many adverse events. To ensure optimal outcomes without complications, in-depth studies and discussions regarding the most appropriate procedural methods are paramount. In addition, the physician must assess the patient’s psychosocial, philosophical, and cultural perspectives on beauty during the initial consultation and take these factors into consideration when coming up with a treatment plan.

Filler indications diversified significantly and injection techniques have become more sophisticated. When fillers were first introduced to Korea around 30 years ago, no one could have anticipated the current pervasiveness of filler procedures. Until the mid-1990s, collagen fillers from the United States were the only fillers available and these fillers had a duration period of only 1–2 months. Due to numerous inconveniences associated with collagen fillers, including pretreatment skin testing to check for allergic reactions, there were very few doctors at the time who actually used these products at their clinical practices. Korean doctors encountered hyaluronic acid (HA) fillers for the first time in the late 1990s when Restylane® (Q-Med, Sweden) was launched in Korea.

HA fillers are used currently for facial volumization but before the introduction of HA fillers, fillers were mostly used to efface superficial skin wrinkles or to correct small, regional depressions. Administration of fillers for facial contouring and full face volumization, as in fat grafting, is a practice that has become popular only within the past few years.

As a member of the first generation of plastic surgeons to perform filler procedures in Korea, the author aims to delve into the following; standards of natural beauty for effective patient consultation, differences between Asian and Caucasian facial anatomy, and medical reference values to identify procedural standards and methods most suitable for Asians.

The sociologist Beverley McNamara stated that people all have inner desires to look good for their age, albeit to a different degree. In addition, there are scholars who state that human health today does not simply signify physical health, but also comprises mental, sexual, and aesthetic health. An anecdote about Dr. Ivo Pitanguy, a famous Brazilian plastic surgeon, illustrates this point. In 1961, a fire broke out during a circus performance in Rio de Janeiro, Brazil, causing burns and other injuries to many children. Dr. Pitanguy treated children whose faces had been disfigured by the fire and became a national hero. After this event, he became a philanthropist who offered free cosmetic surgeries to the rich and poor and gained international acclamation. He played a pivotal role in creating a favorable public opinion toward cosmetic surgery in Brazil. Subsequently, Brazil became one of the world leaders in cosmetic surgery. Dr. Pitanguy stated that even poor people have the right to beautiful, suggesting that pursuit of beauty is a universally fundamental human desire and maybe one of the driving factors in people’s lives.

Historically, some Western philosophers emphasized inner beauty or the person’s character as opposed to his or her external appearance when discussing beauty. Likewise, up until the mid-twentieth century, Koreans, strongly influenced by Confucian philosophy, believed that they should not be reckless with the faces and bodies they had inherited from their parents. Even just few decades ago, satirical cartoons and editorials appeared in newspapers, lamenting the fact that women had received cosmetic surgery from doctors who had been trained in Japan. In this context, it is astonishing that Korea has become a leader in cosmetic surgery, surpassing even Japan.

The initial surge in popularity of cosmetic surgery and introduction of Western culture coincided with patients undergoing extreme cosmetic surgeries to attain Caucasian facial characteristics. This led to numerous complications and in the disappearance of traditional Korean beauty. In the early 2000s, there was a shift from the materialistic fast food culture to the slow food movement that encompassed a return to nature. With the slow food movement gaining momentum, there was also a shift from drastic, artificial altering of the face to minimally-invasive cosmetic procedures that produced subtle and natural results. In addition, with increase in life expectancy, people are socially active until a later stage and more people seek to recover younger versions of themselves and do not wish to alter their faces. The shift allowed minimally-invasive cosmetic procedures to meet the patients’ desires and thus underwent tremendous advancement since 2005.

According to statistics from the United States on data from 1997 to 2013, the number of people who received surgical cosmetic procedures increased by 73%, whereas the number of people who received minimally-invasive cosmetic procedures increased by 356%.

Filler administration, a minimally-invasive procedure, offers the advantages of immediate results, short recovery time, high satisfaction relative to the convenience of the procedure, average results relative to ease of procedure, and ease of repeat treatments. Disadvantages include low profitability due to price competition, limitations in procedural outcomes when compared to surgery, short duration of effect, sensation of a foreign body, post-procedure swelling, intra- and post-procedure pain, and concerns about procedure process including anesthesia. However, filler types and quality have improved markedly and volumizing filler procedures are supplanting fat graft procedures. Fillers are used beyond the scope of merely filling out superficial wrinkles and depressions. Fillers can create facial shape harmonization and even improve skin quality.

Although filler injections have become prevalent recently, the actual practice of using substances such as Vaseline to fill depressed areas was practiced as early as the 1900s. Subsequently, paraffin wax with a low-melting point was used and became very popular as a filler material for nearly 20 years. However, these substances have disappeared from the market as they caused adverse events with serious sequelae. Then during the 1940s, liquid silicone injections into the breast, hip, and face became very popular in the US. However, this too was plagued by reports of foreign body reactions and the practice of using chemical substances as fillers was discontinued. Even in Korea, there have been reports of removing foreign substances from patients who experienced adverse events. These patients had illegally received filler injections from unlicensed practitioners and the substances removed were identified as paraffin wax and industrial silicone.

In 1976 collagen fillers were introduced but failed to gain much popularity for various reasons. In 1996, first-generation HA filler Hylans was introduced for the first time. That same year, second-generation HA filler Restylane entered the market. Widespread use of fillers was observed in the 2000s. Introduction of Restylane in Europe was followed by the introduction of Juvéderm in 2000. The company that manufactured Juvéderm was acquired by an American company in 2006 and is still being produced today. Subsequently, many new products have been introduced, including Teosyal (2003), Esthelis (2005), Stylage (2007), Glytone (2008), and Hylaform (2008). European countries are still producing various types of HA-based fillers. Currently, these countries have established their positions as industry leaders and produce approximately 300 different filler products (Table 1.1).

Table 1.1

History of Injectables

Patients today seek three-dimensional contouring and rejuvenation of the entire face over adding volume to a specific part of the face, removing wrinkles, or making the face look slimmer. Standards of beauty are ever-changing and relative. They are influenced by many factors including historical period, culture, and geographical location. Accordingly, there is a need for objective standards or references to define the attractive face archetype that people desire. Undertakings of this mission have persisted since ancient times. Artists and scholars historically used the concept of the golden ratio to define the ideal form and stated that when the face is divided into numerous compartments in relation to the eyes, nose, and mouth, the ratio of shortest and longest sides that make up each compartment should have a ratio of 1:1.618 to be considered beautiful. As an example, Dr. Stephen Marquardt, an American oral and maxillofacial surgeon, created the Marquardt mask so that individuals can measure how close his/her face was to the ideal ratio. In the Marquardt mask, ratios such as lower lip-nasal tip distance: nasal tip-sellion distance and width of the eye: sellion-lateral canthus distance are measured. Marquardt claimed that the facial ratios of people recognized around the world as being beautiful have ratios that are closer to the golden ratio masks that he created for each ethnicity.

However, many questions have been raised as to whether Marquardt’s claim is valid. Indeed, there are counterclaims stating that when the Marquardt mask was used to create the ideal beautiful female face using 3D graphics, the resulting