ABT School

I would be concerned about the following ‘danger’ areas:-

The inferior and superior labial arteries.

The labiomental and transverse mental arteries.

The ascending mental artery.

The modular artery and of course the facial artery.

The marginal mandibular branch of the facial nerve.

The buccal branches of the facial nerves

The mandibular nerve and the submandibular ganglion.

Cheek Anatomy and Ageing:

Midfacial aging involves a depression from topographical changes due to gravitational ptosis, volume deflation and maybe pseudoherniation of the Bichat’s fat. Understanding bone and fat volume loss is essential for effective treatment planning.

The first layer of the skin starting from the surface is the skin that is affected by both extrinsic (eg. pollution, UV rays) and intrinsic (eg. muscle movement repetition, hormonal imbalance) factors. Immediately deep to the dermis, superficial fat compartments of the midface constitute a dynamic soft tissue layer moving along with the underlying muscles. Through connective tissue fibres rising upwards to the dermis, superficial fat pads provide a strong attachment of the skin to the muscles.

The superior part of the cheek is supported by the infraorbital and lateral orbital fat pads. The medial region of the cheek is supported by the nasolabial fat pads. The middle cheek is comprised of the middle and superficial medial fat pads while in the lower border of the cheek, we find the superior jowl fat.

The lateral part of the cheek contains the distal part of the lateral temporal fat pad and the parotid gland which both contribute to its fullness.

It is vitally important to understand that filling of certain compartments may exacerbate sagginess, whilst filling others is less prone to do so, probably due to more stable anatomic boundaries.

The superficial fat compartments are the

1.Superficial nasolabial

2.Superficial medial cheek

3.Superficial middle cheek

4.Superficial lateral cheek

5.Superior temporal

6.Inferior temporal

7.Jowl fat compartment

These fat compartments do not cover the tear trough, lateral orbital thickening, or zygomatic arch.

The Superior and Inferior Superficial Jowl fat pads are placed underneath the superficial medial and middle cheek fat pads.

The superficial fat compartments behave differently on filling. The inferior part of the nasolabial, middle cheek, and jowl compartments descend on filling, but this does not apply for the medial and the lateral cheek compartments.

The deep fat compartments in the premaxillary space are the

1) deep pyriform

2) deep medial cheek

3) deep lateral cheek

4) deep nasolabial

5) medial and lateral sub-orbicularis oculi fat (SOOF).

Deeper lie the muscles : masseter , lower part of the orbicularis oculi muscle ,levator labii superioris alaeque nasi muscle , levator labii superioris, zygomaticus major and minor , risorius muscle , levator anguli and the buccinator .

The fascial layer at the temporal-malar region is comprised of 1) a Superficial layer(SMAS) -enveloping the muscles around the periorbital and perioral apertures that separates the superficial and deep facial fat, 2)Middle layer -beneath facial nerves, connecting with the parotid fascia, 3) Deep layer- identical to the temporal fascia.

The facial muscles are interconnected through this fascia forming a myofascial continuity( “anatomical trains”) which is of clinical importance as it enables a practitioner to predict the indirect effect of fillers via SMAS expansion

The lateral region of the cheek also contains the parotid gland. The parotid gland also contributes to the fullness of the cheek. The parotid gland also secretes digestive enzymes into the oral cavity for digestion.

The zygomatic bone (cheekbone/malar bone) is articulated with the maxilla, temporal bone, sphenoid bone, and the frontal bone forming

•The cheek prominence

•Part of the lateral wall and floor of the orbit

•Parts of the temporal fossa

•The infratemporal fossa



The temporal process of the zygomatic bone with the zygomatic process of the temporal bone form the zygomatic arch and join at a clinically important palpable suture.

Bone resorption understanding is important when planning facial rejuvenation. The maxilla, pyriform region, and superomedial and inferolateral orbital rims, resorb most.

The cheeks facial blood supply is provided by the facial, transverse facial, and infraorbital (IOA) arteries.



HA Fillers:

HA fillers are injectable soft gels aimed to counteract skin depression and changes because of tissue ageing and loss. They help by reducing the intensity of skin folds, wrinkles, lines, and creating facial volume in specific areas. The performance of crosslinked fillers depends on HA concentration, degree of crosslinking, elastic modulus, cohesivity, and type of crosslinking agent employed.

According to Lapa (2017) with the definition rheology we mean the physical characteristics that affect the filler’s behavior in shearing, vertical forces, compression, gravity and muscle stretch after injection.

The factors influencing the HA fillers rheology characteristics are :1)Elasticity modulous (G and E) 2) Viscosity3) Normal Force 4)Cohesivity(Molliard et al.2018).

Upon injection viscosity will determine the extrusion force of the material. The lower the viscosity, the lower the force. Viscosity and cohesivity profile will determine the material’s ability to spread into the tissues. HAs with low viscosity may flow and spread more and therefore are used for superficial lines(Molliard et al.2018).

The normal force is the force from the gel perpendicularly to its surface when it is compressed,therefore the higher it is , the bigger is the skin projection achieved by the filler.

The elastic modulus( G’) measures the resistance to dynamic shearing forces and the elastic modulus (E’ )shows resistance to dynamic compression . These features should be balanced and this may be accomplished with proper filler placement(Molliard et al.2018).

Last cohesivity and normal force will determine the longevity of the material and its resistance to the endogenous hyaluronidase and mechanical stress(Molliard et al.2018).

In terms of determining a gel’s clinical application, the key rheological property is elastic modulus (G’). G’ captures the sum of a number of factors affecting gel strength, namely CLHA concentration, starting molecular weight, type of crosslinking and the presence of unmodified HA. G’ is the primary determinant of tissue projection, as it is a measurement of firmness and a gel’s resistance to force (be it muscular or gravitational). In terms of rheological tailoring, a firmer gel with a higher G’ is more resistant to deformation, but may feel lumpier upon implant and potentially cause more pain, inflammation and edema. Higher-G’ products are therefore indicated for deeper planes of injection and in areas such as the malar cheek, chin and jawline. Conversely, a lower-G’ gel will be softer and provide a more natural feel upon implant, and may thus be better suited for the treatment of soft tissues such as the lips and periorbital area, and of less-dynamic wrinkles. Intermediate G’ products are an effective solution for dynamic wrinkle correction, support and contouring in areas of facial animation, such as the midface. A second important parameter to be considered in treatment rheological tailoring is cohesivity, defined as the capacity of a material not to dissociate, due to the affinity of its molecules for each other.

A high-viscosity, low-cohesivity product will disperse in the dermis as micro boluses, providing more tissue projection than expansion. Conversely, a low-viscosity, high-cohesivity product will distribute homogeneously within the dermis, providing tissue expansion along a predominantly horizontal vector.

Aspiration is a prerequisite when performing fillers placement.

Scenario 2:

Perioral area:

As early as the third decade, gradual structural changes in the perioral area, including the formation of perioral rhytides, may be noticed. These findings are both a consequence of intrinsic factors, such as hormonal changes and genetics, and extrinsic factors including lifestyle habits, such as smoking, cumulative photodamage, and repetitive contraction of musculature.

Perioral rhytides can be classified as follows: (1) dynamic rhytides, (2) static rhytides, or (3) cobblestoned textural change in advanced stages. Dynamic perioral rhytides are only present upon contraction of the orbicularis oris muscle, while static perioral rhytides are present even at rest. With the progression of ageing, these categories are not necessarily mutually exclusive. By the time a patient develops a cobblestone texture, they typically also have both dynamic and static rhytides.

During the initial consultation, practitioners should examine the perioral area to identify the anatomic type of perioral rhytides, discuss patient expectations, and explore the patient's amenability to postprocedural downtime.

HA Fillers for the perioral area:

In the perioral area, the following considerations are particularly important. Select an HA filler with a low elastic modulus (G'). Injection technique tends to be more superficial, so one may choose an HA product that has decreased risk of the Tyndall effect.

Key danger zones include injection of the upper lip between the orbicularis oris muscle and mucosa, as this is where the anastomotic arch of the superior labial artery lies. Avascular necrosis of the mucosal lip is overall rare, as injections are composed of smaller depots placed superficial to the mucosal lip where the labial artery lies. Lower risk injection sites include the vermilion border and the lower lip.

When treating superficial static vertical rhytides, multiple tiny serial punctures of filler can be injected along the length of the line. For deeper static rhytides, this technique can be combined with the use of a cannula to provide additional layered correction. An approach to treat static rhytides would be to first insert the cannula just above the oral commissure, and thread it towards the midline of the upper cutaneous lip. Along this path, identify vertical static rhytides, and inject filler perpendicular into each individual line. Because the cannula is at the subcutaneous level, this approach provides deeper volume restoration which plumps up the skin and subsequently softens lines. One can then perform multiple tiny serial punctures of filler more superficially in the dermis along the length of the rhytides to further soften their appearance.

Complications:

An ever-increasing interest in perioral rejuvenation with dermal fillers reflects the aesthetic importance of this region. However, filler injections in the lips and perioral area have been associated with various complications.

Such complications are classified according to severity (mild, moderate, severe) or by the time of onset: immediate (within 24 h after injection), early (24 h to 4 weeks post-procedure), and late or delayed (>4 weeks after injection). While most complications are mild and manageable, vascular compromise, infections, and the development of delayed-onset nodules may significantly undermine the ultimate esthetic outcome and cause substantial morbidity.

Informed consent - provide the patient with cooling off time between consultation and treatment. Provide written and verbal information, and give the patient time to ask questions. Patients should sign consent forms just prior to treatment.

Patients should not be treated if they are suffering from active infection (herpetic or other), as these can lead to reactivation, or have recently undergone or are planning to undergo other procedures, typically within a week (such as dental cleaning). Patients with autoimmune or allergic disorders are not ideal filler candidates due to the risk of developing delayed inflammatory nodule formation. Patients should not be treated for 3-4 weeks pre or post vaccines. Aseptic techniques, including hand washing, use of gloves, and meticulous cleansing and prepping of the patient’s face should always be implemented. Filler injection can be carried out using a blunt cannula or sharp needle, typically 25–32 gauge in size. Proponents of cannula use maintain that cannula injections result in less bruising and swelling while improving safety by decreasing the risk of intra arterial filler deposition. Postprocedure instructions should be provided. Patients are typically instructed to avoid exertions, travel, and makeup for 24 hours. Cold compresses, oral supplements such as Arnica, and topical products may be employed to decrease bruising and swelling. Patients should be encouraged to return in 2 weeks for repeat evaluation.

Injection with the linear or fanning techniques with superomedial advancement of the needle works well. The product should ideally be placed in the deep-dermal plane for superficial rhytids along the medial aspect of the fold to achieve desired results and avoid arterial injury. For deep folds with a significant superior component, depot placement at the periosteum of the alar base should be conducted first as this may minimise the amount of superficial product needed. Addition of the cross-hatching technique to the cutaneous upper lip can further help correct prominent folds. Care should be taken to avoid injecting lateral to the fold in the nasolabial mound as that can accentuate the fold’s appearance. The use of a cannula in this area can be helpful to avoid arterial injury.

The facial artery continues deep to the nasolabial fold becoming more superficial as it approaches the nose. Therefore, injections in the nasal base should either be placed superficially or deep on the periosteum to avoid the vasculature.



Scenario 3:

Informed consent, considerations prior to treatment:

Provide the patient with cooling off time between consultation and treatment. Provide written and verbal information, give the patient time to ask questions. Patients should sign consent forms just prior to treatment.

Patients should not be treated if they are suffering from active infection (herpetic or other), as these can lead to reactivation, or have recently undergone or are planning to undergo other procedures, typically within a week (such as dental cleaning). Patients with autoimmune or allergic disorders are not ideal filler candidates due to the risk of developing delayed inflammatory nodule formation.

Patients should not be treated for 3-4 weeks pre or post vaccines.

Aseptic techniques, including hand washing, use of gloves, and meticulous cleansing and prepping of the patient’s face should always be implemented. Filler injection can be carried out using a blunt cannula or sharp needle, typically 25–32 gauge in size. Proponents of cannula use maintain that cannula injections result in less bruising and swelling while improving safety by decreasing the risk of intra arterial filler deposition.

Postprocedure instructions should be provided. Patients are typically instructed to avoid exertions, travel, and makeup for 24 hours. Cold compresses, oral supplements such as Arnica, and topical products may be employed to decrease bruising and swelling. Patients should be encouraged to return in 2 weeks for repeat evaluation.

NLFs treatment approach:

Injection with the linear or fanning techniques with superomedial advancement of the needle works well. The product should ideally be placed in the deep-dermal plane for superficial rhytids along the medial aspect of the fold to achieve desired results and avoid arterial injury. For deep folds with a significant superior component, depot placement at the periosteum of the alar base should be conducted first as this may minimise the amount of superficial product needed. The addition of the cross-hatching technique to the cutaneous upper lip can further help correct prominent folds. Care should be taken to avoid injecting lateral to the fold in the nasolabial mound as that can accentuate the fold’s appearance. The use of a cannula in this area can be helpful to avoid arterial injury.

The facial artery continues deep to the nasolabial fold, becoming more superficial as it approaches the nose. Therefore, injections in the nasal base should either be placed superficially or deep on the periosteum to avoid the vasculature.

# # # Best 6 Dermal Fillers Techniques in the UK

Here are the top six techniques for achieving flawless results with dermal filler procedures:

1. **Linear Threading Technique**
- **Description**: This method involves injecting a continuous line of filler beneath the skin for smooth, natural-looking volume enhancement.
- **Procedure**:
- Insert the needle at a chosen point.
- Inject the filler consistently while gradually withdrawing the needle.
- **Ideal for**: Long, flat areas needing even distribution.

2. **Serial Puncture Technique**
- **Description**: Involves multiple, closely spaced punctures to inject small amounts of filler directly into the skin for subtle enhancements.
- **Procedure**:
- Perform a series of small injections along a wrinkle or fold.
- **Ideal for**: Superficial lines and areas requiring precision.

3. **Fanning Technique**
- **Description**: Uses multiple strands of filler injected through a single entry point, creating a fan-like distribution for even and natural-looking results.
- **Procedure**:
- Redirect the needle at multiple angles from the same insertion point after the initial injection.
- **Ideal for**: Larger areas needing broader filler distribution.

4. **Cross-Hatching Technique**
- **Description**: Involves a crisscross pattern of injections to evenly distribute the filler for a smooth, voluminous effect.
- **Procedure**:
- Combine linear threading and serial puncture techniques.
- Lay down parallel lines of filler, followed by another set of perpendicular lines.
- **Ideal for**: Areas needing comprehensive volume restoration.

5. **Depot Technique**
- **Description**: Injects a bolus (or ‘depot’) of filler at a specific point, commonly used for deeper areas requiring a concentrated volume.
- **Ideal for**: Areas like the cheeks where more volume is needed.

6. **Layering Technique**
- **Description**: Involves layering fillers in multiple sessions for significant volume restoration or contouring, ensuring gradual and natural-looking enhancement.
- **Ideal for**: Patients needing significant volume restoration.

# # # Key Considerations
Regardless of the technique, understanding facial anatomy is crucial to prevent complications. Practitioners should be trained to manage potential side effects or allergic reactions.

# # # Conclusion
A thorough consultation before treatment is essential to understand the patient’s desires, set realistic expectations, and create a tailored treatment plan. The goal is to enhance the individual’s unique features without overshadowing them.

As new products and techniques continue to emerge, the true art of dermal fillers lies in understanding the patient's face and aspirations. By combining skill, artistry, and a patient-centric approach, practitioners can achieve the best outcomes, ensuring each patient leaves looking and feeling their absolute best.

Clinical Anatomy of the Cheek:

The cheek is one of the midface's most noticeable aspects and a key component of facial beauty. Some of its constituent layers include skin, subcutaneous tissue, muscles, fat pockets, bone, and the superficial musculoaponeurotic system (SMAS).

Skin and Subcutaneous Tissue:

As we age, our cheek skin becomes less elastic and comparatively thicker. The subcutaneous tissue, located beneath the skin, is home to the superficial fat compartments (Standring, 2016)

Superficial Musculoaponeurotic System (SMAS):

The fibromuscular layer that surrounds and serves as a structural foundation for the muscles of facial expression is known as the Superficial Musculoaponeurotic System (SMAS). It facilitates face motions by joining the dermis and facial muscles (Standring, 2016)

Muscles:

The levator labii superioris, the risorius, and the zygomaticus major and minor are important cheek muscles. Facial gestures like smiling and lifting the upper lip use these muscles (Rohrich et al., 2008)

Fat Compartments:

There are several unique fat compartments in the cheek. The midface is given dimension and contour by the deep fat pads, which include the buccal fat pad, sub-orbicularis oculi fat (SOOF), and deep medial cheek fat. The nasolabial fat and the malar fat pad are two examples of superficial fat compartments (Mendelson and Wong, 2013)

Bone:

The maxilla and zygomatic bones comprise the skeletal framework supporting the cheek. These bones provide the cheeks with their prominence and structural stability (Standring, 2016)

Arterial Supply of the Midface

The external carotid artery and its branches, together with the internal carotid artery system, give the majority of the arterial flow to the midface, which includes the cheeks.

Facial Artery:

The facial artery, a branch of the external carotid artery, provides significant blood to the midface. It passes through the mandible, bending around the inferior border before rising to the angle of the mouth, where it gives rise to the angular arteries, superior labial, and lower labial arteries (Standring, 2016)

Transverse Facial Artery:

The transverse facial artery is a branch of the external carotid artery originating from the superficial temporal artery. The vein horizontally crosses the cheek, supplying blood to the surrounding skin, masseter muscle, and parotid gland (Standring, 2016)

The infraorbital artery

The infraorbital artery, which nourishes the cheek, upper lip, and lower eyelid, is a branch of the internal maxillary artery. It emerges from the infraorbital foramen (Standring, 2016)

Zygomaticofacial and Zygomaticotemporal Arteries

The zygomatic area of the cheek is supplied by the zygomaticofacial and zygomaticotemporal arteries, which are minor branches of the internal maxillary artery (Standring, 2016).



Image: (Anon., 2021)

Image: Nerve supply of Face (Keswick, 2019)(Nguyen and Duong, 2022b)

Understanding the intricate architecture of the cheek and its artery supply is imperative for administering dermal fillers safely and effectively and minimizing the risk of vascular problems.

Surface Facial Topography Changes Observed
Specific surface topography alterations that suggested the need for dermal fillers would have been evaluated to develop a treatment strategy focused on the midface. Usually, these modifications consist of:

Loss of Malar Prominence:

Resorption of the underlying bone structure and atrophy of the fat compartments can cause the cheekbones to look less prominent, giving the illusion of a flattened midface (Mendelson and Wong, 2013).

Nasolabial Folds:

Deepening of the nasolabial folds, which are the lines that extend from the corners of the lips to the sides of the nose, is a frequent indicator of midface ageing. The malar fat pad's descent and general volume loss in the midface are the causes of this (Rohrich et al., 2008).

Tear Troughs and Hollows:

As we age, the tear trough—the region behind our eyes—may become more noticeable, giving the illusion of sunken or hollowed out. The decrease in midface support and subcutaneous fat is the cause of this (Lambros, 2007).

Sagging and Jowling:

As the SMAS deteriorates and loses structural support, the cheek tissue's descent can cause sagging skin and the development of jowls along the jawline (Ghavami et al., 2009).

Midface Volume Loss:

According to Mandelson and Wong (2013), a generalized loss of volume in the midface, which includes the cheeks, results in a less defined and youthful-looking facial contour.

Impacts on Facial Aging
The ageing process of the face is a multifaceted process that involves
Bone Resorption:

As people age, their face's bones—especially the zygomatic and maxilla bones—resorb, which results in a loss of structural support and alterations to the features of the face (Mendelson and Wong, 2013).

Soft Tissue Atrophy:

Sagging and volume loss in the face are caused by the atrophy of the deep and superficial fat compartments. Fat redistribution exacerbates this process, resulting in empty and prominent places (Rohrich et al., 2008).

Skin Changes:

As we age, our skin loses its suppleness and collagen, which causes drooping, wrinkles, and fine lines. The loss of collagen and elastin fibres influences the general aged look of the skin (Ghavami et al., 2009).

Changes in Muscles:

Changes in the muscles responsible for facial expression can also cause dynamic wrinkles and changes in facial expression (Lambros, 2007).

Comprehending these topographical alterations and the underlying anatomical and physiological processes is essential for developing dermal filler treatments that effectively restore youthfulness and address the unique issues associated with midface aging.

Rheological and Cohesivity Properties to Consider for Optimal Outcomes
To get the best results, it is crucial to consider the rheological and cohesivity qualities of dermal fillers when choosing them for midface treatment. Once injected, these characteristics affect how the filler behaves, affecting its capacity to raise tissues, blend in with surrounding structures, and provide the look of actual tissue.

Viscosity:

The term "viscosity" describes the filler's flow resistance. Fillers with a higher viscosity are thicker and more able to give significant lift and volumization. A high-viscosity filler is usually recommended for the midface, where substantial structural support and volume restoration are required (Kablik et al., 2009).

Elasticity (G'):

The filler's capacity to regain its original shape following deformation is gauged by its elastic modulus (G'). A more excellent G' denotes a more elastic filler for regions like the cheeks that need lifting and structural support filler. High-elasticity fillers are superior at preserving form and volume in the face of dynamic facial expressions (Kablik et al., 2009).

Cohesivity:

The filler's capacity to cling to one another and preserve its structure without dispersing is called cohesion. High cohesivity produces a smooth, uniform augmentation and guarantees the filler stays in place after injection. According to Sundaram et al. (2010), this characteristic is essential for producing a natural appearance and stopping the filler from migrating.

Plasticity:

The filler's capacity to conform and adjust to the surrounding tissues is known as its plasticity. Suitable plasticity fillers are more straightforward to shape before and after injection, enabling accurate midface contouring and achieving desired aesthetic results (Sundaram et al., 2010).

Hydrophilicity:

How much water it absorbs may impact the filler's volume and durability. For instance, hydrophilic fillers like hyaluronic acid may absorb water and increase their volume after injection. Selecting a filler with the right hydrophilicity can facilitate reaching the intended degree of volume increase (Rivkin, 2013).

Clinical Implications

A doctor can consider these rheological and cohesivity features to choose a dermal filler that will give the appropriate lift, volume, and natural look for midface rejuvenation. The aim is to select a filler that will support the cheek structures, blend nicely with the surrounding tissues, and keep its volume and form over time to produce a young and attractive result.

Treatment Plan for Midface Dermal Filler Injection
Goals:
Restore the cheeks' volume and shape.
Improve the support for the midface.
Minimize the nasolabial folds.

Injection Tools:
Needles: For accurate filler implantation in deeper layers, 27G or 30G needles are often utilized (Lafaille and Benedetto, 2010).
Cannulas: According to DeLorenzi (2013), 22G or 25G blunt-tipped cannulas can be utilized for a safer, more extensive filler distribution and a lower risk of vascular problems.
Syringes: Pre-filled syringes with the chosen dermal filler



Selecting a Dermal Filler:

High Viscosity and High G' Filler: For lifting and structural support, a hyaluronic acid-based filler with high viscosity and elasticity is the best option (Kablik et al., 2009).

Restylane Lyft and Juvederm Voluma are two examples.



Injection Techniques:
Patient Get Preparation:

Use an antiseptic solution to clean the treatment area.
Note proposed injection sites and anatomical landmarks.
For pain relief, apply a topical anesthetic or utilize fillers that have already been combined with lidocaine.

Technique of Injection:

Needle Technique: For bolus injections, inject the filler into the subperiosteal and subtalar planes for structural support using a 27G needle. To prevent intravascular implantation, aspirate before injecting (Lafaille and Benedetto, 2010).
Cannula Technique: Pass a blunt-tipped cannula through one entrance site (zygomatic or infraorbital area, for example). Move the cannula forward to fan the filler along the subtalar and deep medial cheek fat areas (DeLorenzi, 2013).

Placement and Volume:

Malar Region: To improve cheek lift and contour, inject 0.5–1.0 mL of each side deeply into the SMAS.
Nasolabial Folds: To soften folds, use a linear threading approach in the dermis with 0.3–0.5 mL on each side (Rohrich et al., 2008).
Tear Trough: If necessary, apply a tiny quantity (0.2–0.3 mL per side) of fat (SOOF) in the sub-orbicularis oculi (Lambros, 2007) to lessen hollowing.

After Care:

Use cold compresses to minimize edema.
Tell the patient to refrain from intense exercise, high temperatures, and touching the treated region over the next 24 to 48 hours.
Schedule a follow-up appointment in two weeks to review the results and handle any problems.