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Rhinoplasty Bizrah: RELATED FACIAL SURGERY : Filler Injections

March 27, 2017 by basharbizrah0

Aging of the face is characterized by atrophy of the cutaneous fat, bone absorption and loss of elasticity of the skin. The older inelastic skin cannot accommodate the smaller facial framework, resulting in redundancy, sagging, wrinkling, the development of nasolabial folds, marionette lines and loss of fullness of the lips and cheeks. Lipo-augmentation may be the only procedure required to recreate harmony and youthfulness, or it may be considered as an ancillary technique to compliment laser or chemical peel, rhinoplasty and facelifting. The most common regions that require lipo-augmentation are the lips, cheeks, nasolabial folds and marionette lines. About 60% of the transferred fat is absorbed within six months , so repeated lipo-augmentation procedures are required three to four times, preferably at four months intervals, in order to achieve long term results.

Facial Marking: The surgeon sits facing the patient at eye level and marks the regions to be augmented. The patient should have a mirror or be asked to mark out any additional areas of concern.

Anaesthesia:
One must take great care to avoid causing pain during the first procedure, in order to encourage the patient for repeated future procedures.

  • Emla cream is used for fourty five minutes on the marked regions.
  • Oral or intravenous sedation is recommended.
  • Nerve block to bilateral intraorbital and mandibular nerves. 2% Xylocaine with adrenaline 1:200,000 injected in a small quantity just over the nerve. Large quantities of infiltration should be avoided in order not to disrupt our filling assessment.

Fat Preparation:

  • Full aseptic technique of the abdomen (donor site). (Fig. 18 – 26)
  • ‘Nick’ the skin with No. 11 blade at the suprapubic or transumbilical.
  • Prepare the Klien solution (250ml Normal saline – 12.5ml 1% Xylocaine, 1:200,000 adrenaline – 6.25 Sodium Bicarbonate). Then inject using the Klien’s pump connected to cannula and wait for about thirty minutes.
  • The fat is obtained by sixty cc syringe connected to lipo-suction cannula obtaining about fifty ml of harvested fat.
  • Then the syringe is placed in a vertical position for ten minutes until the separation is complete, the fat moves up and the fluid down.
  • More pure fat is achieved by centrifuging for one minute, which will clear about 20-25% more fluids. Centrifuging will help to achieve symmetrical and accurate results.
  • The pure fat is then transferred to five cc syringe which is then connected to the injector syringe.

Lipo-augmentation (Newman) technique :
We use the Newman multilayered lipo-augmentation technique, which places fat into various tissue levels from the subcutaneous plane to the muscular and submuscular plane in a fan-shaped pattern. On average 30-40% of the transferred fat would survive during the first transplant, 40-50% during the second transplant and 50-60% during the third transplant. Therefore, repeated fat transplants every four months for three consecutive sittings, may afford long term results for up to five years.

Lower lip: An entry site is made below the vermillion border with great care taken not to nick the lip or the vermillion line, which could result in a notch-shaped deformity. The majority of the fat transplant should be placed in the middle one- third of the lower lip with less fullness created in the lateral two-thirds. Lip enhancement can most successfully be obtained by visualizing three multilayered planes of augmentation. The first plane lies very superficial and just underneath the vermillion border to create the “natural curl ” of the lip. This plane is generally augmented with less than 0.5ml injected steadily while the cannula is being pulled out. The second plane is achieved by passing the cannula up and over the top of the orbicularis muscle to the level of the mucocutaneous junction and again inject approximately 0.5ml over an even distribution. The lip is then observed for its aesthetic shape and a decision is made as to the need for augmentation of the third intramuscular plane. The same is repeated on the opposite side with attention given to leaving a small central depression to create a more natural looking lip.

Upper lip: The configuration of the upper lip is different from the lower lip in that it is more elongated laterally and fuller just under cupid’s bow. Every effort should be made to maintain the natural shape of cupid’s bow to avoid creating the “hotdog lip” that we see when transplants are done from one commissure to the other. Two separate entry sites are placed above the vermillion border at the peak of each cupid’s bow. Augmentation is accomplished by utilizing the identical three planes of filling as in the lower lip. If the lip begins to “flip” or “curl” and exposes more mucosa, a third level may be attempted into the muscle.

Nasolabial Folds: The entry site for transplantation is usually made at the distal two-thirds of the nasal labial fold. Augmentation is performed with four to five passes, placing a total of three to four cc on each side. A second entry site is made below the lateral alar rim (at the top of the nasolabial fold) to augment the teardrop deformity with another one ml of fat. Care must be taken not to augment on the lateral side of the defect, which could accentuate the fold and increase the fullness of the ptosing cheek.

Marionette lines and jaw lines: A subtle but consistent triangular-shaped depression often appears at the inferior extension of the marionette lines along the mandibular rim. To correct this, an entry site is made at the midpoint between the lateral commissure and mandibular rim. Approximately 1-1.5ml of transplant is placed in this triangular-shaped depression. Care is taken not to augment in the lateral aspect of the depression to avoid accentuation of the jowl. Transplants are only made in the subcutaneous layer because multilayered injections may produce trauma to the marginal mandibular nerve or facial vessels in this area. For correction of the upper marionette lines, this same site or a separate entry site can be used below the midline of the lower lip. A Newman-Brandow cannula can then be rotated laterally in the subcutaneous tissue to reach the lateral commissure. Care must be taken to avoid lateral migration of fat by using the fingers of one’s opposite hand to pinch the skin while injecting approximately one to two ml.

Cheeks: Depending on the deformity and degree of the fat atrophy, the cheek may be augmented by entering over the malar eminence or through the previous entry site made at the lateral nasal alar. When there is a moderate degree of medial cheek ptosis, it is better to avoid the medial approach and attempt to augment laterally. This is done in multiple layers by using three to five cc of fat, which is placed from

the submuscular plane to the subcutaneous plane. Approximately seven to eight passes may be made, placing an equal amount along a long tunnel, rather than placing a large ball of five to six ml in a single spot. When entering medially, one must be cautious to avoid injecting fat close to the entry site, which could make the nasal labial fold and medial cheek ptosis look worse.

Postprocedure Care:

  • At the end of the procedure, the face is cleansed with aseptic solution and the markings erased away.
  • The patient is brought to a complete sitting position. The surgeon, at this stage, more accurately assesses the symmetry and the need for any refilling before the patient leaves the room.
  • Steri-strips are placed over the entry sites.
  • Patients are advised not to use make-up for seven days.
  • Dressing applied over the donor site.
  • Ice packs or ice soaked gauze applied over the lips, nasolabial fold, marionette lines or cheeks.
  • Excessive facial movement of chewing or laughing are best avoided for the first two weeks to avoid fat manipulation.
the submuscular plane to the subcutaneous plane. Approximately seven to eight passes may be made, placing an equal amount along a long tunnel, rather than placing a large ball of five to six ml in a single spot. When entering medially, one must be cautious to avoid injecting fat close to the entry site, which could make the nasal labial fold and medial cheek ptosis look worse.

Postprocedure Care:

  • At the end of the procedure, the face is cleansed with aseptic solution and the markings erased away.
  • The patient is brought to a complete sitting position. The surgeon, at this stage, more accurately assesses the symmetry and the need for any refilling before the patient leaves the room.
  • Steri-strips are placed over the entry sites.
  • Patients are advised not to use make-up for seven days.
  • Dressing applied over the donor site.
  • Ice packs or ice soaked gauze applied over the lips, nasolabial fold, marionette lines or cheeks.
  • Excessive facial movement of chewing or laughing are best avoided for the first two weeks to avoid fat manipulation.

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