Australian Doctor 2nd June 2023 02JUNE2023 issue | Page 23

CF

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Figure 4 . Muscles of mastication .

Box 1 . Indications for HA fillers

• Correction of volume deficiency .

• Enhancement of appearance .

• Alteration or enhancement of gender dimorphism .

• Amelioration of ageing changes .

• Superficial skin rejuvenation .

atrophy may be corrected with these

29 , 30 fillers ( see figure 5 ).

Enhancement

Cosmetic enhancement of adequate , but not optimal , facial characteristics may be addressed by these agents . This commonly takes the form of sculpting lips , optimising facial shape or enhancement of the brow shape or cheeks ( see figure 6 ). 31

Figure 5 . Pre- and post-treatment for acne scars .

Gender dimorphism

As discussed earlier , certain facial characteristics are innately feminising and some innately masculinising . The classic facial shape of a female is oval when viewed anteriorly and curvaceous when viewed from the side or at an angle , with concavities followed by convexities , forming the so-called Ogee curves of the female face ( the soft double S-curves seen from an oblique angle on the youthful face ). 32 Males , on the other hand , tend towards a flatter appearance , with sharp angles making up a more trapezoid structure .

Ageing changes

Determination of the age of an individual is , in part , defined by volume shifts and wrinkle production . Typically , support in the deep planes of the face diminishes with bone resorption . This occurs especially around the eyes , nose and mouth but also the bones of the mandible and maxilla laterally and centrally . The deep fat pads of the face also undergo resorption . All this allows gravity to affect the face , and it descends and rotates forwards — often making the ageing face saggy and unsupported .

Wrinkles also occur from the recurrent action over time on the skin surface and , to some extent , from superficial fat pad resorption .

Figure 6 . A patient before and after facial fillers and fractionated CO2 laser resurfacing .

Fillers can be used to add support for ageing facial tissues , as well as for filling wrinkles , especially in the perioral , periorbital and cheek regions ( see figure 7 ). 33

Superficial effects

An expanding market is the superficial use of specially designed fillers to improve the texture and glow of the skin . They act to restore the play of light on the skin , improving its even reflectance and making the skin appear younger and more lustrous .

PROBLEMS WITH HYALURONIC ACID FILLERS

ISSUES related to fillers have been noted over the past 20 years . Considering the large number of filler injections carried out each year , these events are relatively infrequent in percentage terms ; however , they can be devastating for the individual who is unfortunate enough to experience them .

Hyaluronidase , used off label , is an essential antidote for many of these filler issues .

Intravascular injection of filler

The frequency of bruising seen during / following HA injections , especially with needles , indicates that the injection has been intravascular at some stage in the treatment . This is usually minor and of no great medical consequence .

However , if a substantial amount of filler is injected into a vessel during a session , this may lead to a non-thrombotic embolism , resulting in significant necrotic complications in vessels supplied by the vessels into which the injection has been made . If the vessel affected is a large one , this may impact both cutaneous and deeper tissues . Many of the major vessels of the face are centrally located , with the lips , nose , periorbital area , glabella and forehead particularly at risk because of their relationship to the facial and ophthalmic artery angiosomes ( vascular supplied zones , see figure 8 ).

The first sign of intravascular injection is a flash of pallor or livedolike appearance ( blotchy vascularity ) that , if untreated , proceeds to necrosis of tissue with a herpes-like pustulation , tissue breakdown and slow repair ,