Preperiosteal Plane Research Articles

Nonsurgical Rhinoplasty: Indications and Safety

IntroductionThe desire for minimally invasive procedures is driven by the rise of posting “selfies” to social media, as well as the new virtual working environment with webcams. With the camera constantly on faces, the rise for injectables will only continue. Soft-tissue fillers are an efficient and successful way to provide a patient with increased self-esteem. Nonsurgical rhinoplasty is a common and desired procedure to augment the appearance of one's nose. Soft-tissue fillers have been found to be safe; however, there can be complications. Some are less severe, such as: edema, hypersensitivity reactions, erythema, and ecchymosis, while other complications can be more severe, such as: infection, granuloma formation, arterial occlusion or embolization, and blindness. Nonsurgical rhinoplasty poses higher risk, given the vasculature of the nose, which is why education on this type of injectable is vital. MethodsThe purpose of this study was to assess the predictability and safety of nonsurgical rhinoplasty procedures while reviewing the proper techniques for a successful procedure. The aim was toward those oral and maxillofacial surgeons who perform nonsurgical rhinoplasty in an outpatient setting. A 3-year retrospective assessment of clinical outcomes and adverse events was performed in patients who had nonsurgical rhinoplasty between January 1, 2018, and December 31, 2020, as outpatient procedures. ResultsA total of 163 patients (147 female and 16 male), aged 15-77 years old, underwent nonsurgical rhinoplasty between January 1, 2018, and December 31, 2020. The fillers used for treatment included: Belotero, Juvederm Ultra XC, Restylane-L, RHA2, and Dilute Radiesse. All patients were satisfied, and none of the patients reported major complications from the procedure. ConclusionThe use of soft-tissue fillers for nonsurgical rhinoplasty is a predictable and relatively safe procedure. However, some serious complications can arise. Injections in the perinasal region can lead to the risk of blindness due to retrograde travel of material in the ophthalmic artery to the choroid and retina. All perinasal injections should be made deep to the perichondrial plane on the midline and deep to the preperiosteal plane in the lateral nose. The infraorbital foramen is a key landmark when placing fillers. It is typically about one-third the distance between the medial and lateral canthi and 11mm below the infraorbital rim. Injections medial to the infraorbital foramen should be performed with caution in order to avoid the angular artery as well as the dorsal and lateral nasal arteries. When injecting in the lateral nose, the injection should be made at the midpoint of the dorsal aesthetic line and the nasofacial groove to avoid the previously mentioned arteries. These arteries create an anastomosis with the ophthalmic artery, which is the artery involved in the high-risk complication of blindness. Blindness can occur immediately, be delayed, or have late onset ranging from days to weeks after the procedure. Aspiration techniques are crucial as the nasal vasculature is shallow and branched. Providers must also know techniques and strategies to manage various complications in the event that they arise to provide patients with the best possible outcome for full recovery. Overall, nonsurgical rhinoplasty is a procedure that should be recommended to cosmetic patients, but caution must be taken to ensure safety and surgeons need to have proper training.

Novel technique of non-surgical rejuvenation of infraorbital dark circles.

Infraorbital dark circles are a common esthetic concern which can be challenging to treat given their multifactorial nature. Under-eye darkcircles are seen in all skin types, with a strong familial component in darker skin types. Other major contributing factors include soft tissue and bony changes, skin changes, lifestyle contributions, and allergies. Involutional periorbital volumetric changes cause volume loss in the tear trough, naso-jugal and palpebro-malar grove, skin and subcutaneous tissues with tethering of the eyelid skin to the tear trough ligament, giving a sunken and hollow appearance to the lower lid. Associated prolapse of the orbital fat and thin skin can worsen the appearance of a dark circle. Hyaluronic acid fillers placed in the pre-periosteal plane in the tear trough, palpebro-malar and naso-jugal grooves, give good results in patients with thick eyelid skin and negligible fat prolapse. However, in patients with thin skin and moderate fat prolapse, authors have reported worsening outcomes with risk of Tyndall (blue-gray discoloration) and contour irregularities from visible lumps. To describe a novel technique to improve dark circles caused by a diffuse valley-type pre-septal tear trough deformity in patients with thin eyelid skin. Retrospective case note review of 330 eyelids treated with microdroplet subdermal placement of filler in the preseptal tear trough area by a single surgeon. This novel technique shows good esthetic outcomes in patients with dark circles, with good longevity and a low risk of complications.

Transposition Upper Blepharoplasty With Orbital Retaining Ligament Release.

Volume restoration is an important component of aesthetic facial rejuvenation, particularly in the brow and upper eyelid regions. In this study, the authors describe transposition of the central, preaponeurotic fat pad in the sub-brow preperiosteal plane with full release of the brow during upper blepharoplasty. A retrospective review including all patients who underwent transposition of the upper eyelid central, preaponeurotic fat pad at the time of upper blepharoplasty. Patients with simultaneous brow lifting surgeries were excluded. The surgical technique involved placement of the preaponeurotic fat pad pedicle in the sub-brow space after full brow release for augmentation of sub-brow volume after performing upper blepharoplasty. Nineteen patients (n = 36 eyelids) were identified who underwent this transposition upper blepharoplasty technique. No complications or adverse events related to this procedure were observed. All patients were satisfied with their outcome. Transposition upper blepharoplasty with complete brow release is a safe, effective adjunct to blepharoplasty for upper eyelid and periorbital rejuvenation.

Use of High-Resolution Ultrasound (HRU) in the Assessment of Deep Injections of CHAP-Hyaluronic Acid (CHAP-HA) Fillers for Midface Lift

High-resolution ultrasound (HRU) imaging is a useful tool to study hyaluronic acid (HA) filler injection in the face. It is noninvasive, quick, well-tolerated, and can provide in vivo and dynamic information. The formations of pools or pearls in HA fillers could be observed real time during injection. The plane of injection could be determined accurately, and there were no specimen manipulation artifacts. It was observed that HA gel fillers with differing production technologies showed distinct spread and distribution patterns in the periocular tissues on HRU examination. The authors used HRU to assess deep injections of CHAP-Hyaluronic Acid (CHAP-HA) fillers for midface lift. 10 patients who underwent bilateral midface deep injections using CHAP-HA filler were examined with HRU before and immediately after treatment, and in 2 weeks and one month later. The CHAP-HA appeared as hypoechoic densities within the preperiosteal plane in HRU. CHAP-HA adopted variable morphology within the tissue depending on individual tissue densities and the compliance of the tissues in the plane of injection. CHAP-HA was unidentifiable with surrounding tissue after one month in 13 of the 20 injection sites. HRU allows in vivo study of CHAP-HA injection behavior and could be a tool for further studies of HA-tissue reactions.

Prévention du vieillissement, techniques chirurgicales récentes et voies d’avenir de la chirurgie du rajeunissement facial

Prevention of aging is mainly obtained through appropriate health practices, modulated by the genetic causes of aging. Causes of facial structural aging include gravity, volume loss, contraction of the mimic muscles and obviously biological aging of tissues. Among the very numerous new surgical technique of facial rejuvenation, we could point out: for the frontal region, obviously we are focus on the endoscopic and non-endoscopic frontal lifts. But also, we should note the transcutaneous Brow Shaping which with a well defined, step by step technique is indeed a simple way to improve a possible difficult situation; concerning the mid-face lift, as the main risk is the secondary eyelid malposition, a high Smas or a temporo-malar lift can be performed. It ensures a good temporal effect but there is nearly no improvement at the mid-pupilla level. A mid-face lift is nevertheless mandatory to achieve an efficient skin removal on the mid-pupilla line. This is performed most of the time with a complete orbicularis oculi muscle opening, and only with a small lateral opening in case of the concentric malar lift, which minimize the risk of eyelid malposition. Based on a new description of the lymphatic draining of the lower lid, a new treatment of the chemosis is proposed with a corticoid injection at infero-lateral part of the malar area, in the preperiosteal plane. For the oval, the DAO section and the suspension of the middle premasseter space beyond the anterior border of the masseter where the Smas overlies the buccal fat pad, stay efficients. Regarding the neck, the suspension of the posterior border of the platysma to the Loré's fascia, the digastric corset with or without a platysma corset are advanced and valuable techniques. Lately, a new option was described using a lateral skin-platysma flap to minimize platysma bands and even more recently a neck lift with fixation of the anterior platysma to the deep cervical fascia and suspension of the lateral platysma flap.

Midface rejuvenation surgery combining preperiosteal midcheek lift, lower blepharoplasty with orbital fat preservation and autologous fat grafting.

The aim of this study was to describe a technique for midface rejuvenation combining lower blepharoplasty, midcheek lift and autologous fat transfer. All patients who underwent a midface rejuvenation procedure performed by the same surgeon and using a classic subciliary blepharoplasty surgical approach were identified. The technique combined three distinct procedures: lower blepharoplasty with use of a transposition flap of orbital adipose tissue in the medial and central compartment to reduce the subpalpebral bags and attenuate the palpebrojugual sulcus; midcheek lift in the preperiosteal plane with trans-osseous fixation exerting traction on the soft tissues of the cheek along several vectors; autologous fat transfer to offset the loss of volume in the target area. Between January 2011 and December 2015, 14 patients were operated with the described technique. Long-term results were good and stable over time. Two complications in the form of ectropion were observed in the series but resolved with daily massages. The combination of lower blepharoplasty, midcheek lift and autologous fat transfer appear to enable treatment of midface ageing. The results were satisfactory and durable, and the procedure was well tolerated. The procedures could be combined with others for the treatment of the upper and lower face during the same surgical procedure.

Facing the Worst Risk: Confronting the Dorsal Nasal Artery, Implication for Non-surgical Procedures of Nasal Augmentation.

The nose is a dangerous site for filler injection. This study investigated the anatomy of the dorsal nasal artery at the upper part of the nose to clarify how ocular complications occur. Dissections were performed in 50 noses of the embalmed cadavers. Either the soft embalming or formaldehyde embalming processes were used. The dorsal nasal artery is not a constant artery. The artery traveled in the subcutaneous tissue layer of the nasal dorsum on the transverse nasalis muscle and its midline nasal aponeurosis which connected the muscles on both sides. Bilateral dorsal nasal arteries existed only in 34%. In 28% of the specimens, a single and large dorsal nasal artery was presented. The diameter was 0.4 ± 0.2mm when bilateral dorsal nasal arteries were present and 0.7 ± 0.3mm in a single artery. The largest artery was 1.2mm. The artery usually crossed the midline at the middle third part of the nose over the upper lateral cartilages to form an anastomosis with the contralateral lateral nasal artery as the oblique nasal artery in 14%. The artery might descend and communicate with the ipsilateral lateral nasal artery in 6% or descended as a midline artery and form the nasal tip plexus in 8%. In 38% of the specimens, the arteries became small, formed a subcutaneous plexus and randomly distributed on the superficial layer of the subcutaneous tissue in the upper two-thirds of the nose. During the injections at the upper (bony) and middle (cartilaginous) part of the nose for nasal dorsal augmentation, the injector has to make sure the cannula tip is in the preperiosteal plane by reinsertion of the cannula if needed, due to the chance of encountering the large single dorsal nasal artery at the midline. 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 .

Microanatomical Location of Hyaluronic Acid Gel Following Injection of the Temporal Hollows.

To examine the microanatomical location of hyaluronic acid gel injected within the temporal hollows of cadaver specimens. The temporal hollows were injected subcutaneously with hyaluronic acid gel in 6 fresh frozen human cadaver hemifaces. Temporal soft tissues were dissected to a preperiosteal plane and fixated in 95% alcohol. A soft tissue section extending from skin to temporal bone was obtained for each specimen. Histologic examination was performed using hematoxylin and eosin stain. In 5 of 6 specimens, at least 95% of the hyaluronic acid was located within the subcutaneous fat. In 1 of 6 specimens, approximately 35% of the material was located within the subcutaneous fat and 60% was located within the superficial temporal fascia. Two specimens had 5% located within the temporalis muscle. In 1 specimen, hyaluronic acid was found to encompass a superficial muscular artery within the superficial temporal fascia. This study elucidates the location of hyaluronic acid gel after subcutaneous injection within the temporal hollow. Histology confirmed consistent placement of the gel within the subcutaneous tissues, but it also showed that injection in this region may produce unintended deeper location of filler, and a significant perivascular collection of the material. The proximity of dense temporal fascial and muscle arterial networks in this region may pose risk for perivascular injection and associated complications.

Anatomical Position of Hyaluronic Acid Gel Following Injection to the Eyebrow

To examine with histology the anatomical location of hyaluronic acid gel injected to the eyebrow of cadaver specimens. The authors dissected 5 fresh hemifacial cadaver specimens following preperiosteal injection of hyaluronic acid gel to the eyebrow. Following tissue fixation, full-thickness soft-tissue sections were obtained followed by histologic examination. Histologic examination revealed the location of hyaluronic acid gel at the intended preperiosteal plane in all 5 specimens. Very dense retro-orbicularis oculi fat septa appeared to limit the anterior displacement of filler in each specimen. This study provides a greater understanding of the anatomical barriers and boundaries that help to determine, in part, the anatomical position of hyaluronic acid gel when injected to the preperiosteal eyebrow. The high degree of histologically confirmed consistency of product location of eyebrow injections noted in this study stands in contrast to the variability of position of gel injected in the infraorbital hollows.

Anatomical Position of Hyaluronic Acid Gel Following Injection to the Infraorbital Hollows

To examine with histology the anatomical location of hyaluronic acid gel injected to the infraorbital hollows of cadaver specimens. The authors dissected 5 fresh hemifacial cadaver specimens following preperiosteal injection of hyaluronic acid gel to the infraorbital hollows. Following tissue fixation, full-thickness soft tissue sections were obtained along the medial, central, and lateral lower eyelid/midface of each specimen. Histologic examination of the anatomical location of hyaluronic acid gel was performed using hematoxylin and eosin and Hale colloidal iron stains. Histologic examination of the central and lateral lower eyelid/midface sections revealed a significant portion of hyaluronic acid gel in either a postorbicularis or a subcutaneous plane in 8 of 10 sections. Only 2 sections displayed hyaluronic acid gel solely within a preperiosteal plane. The medial sections revealed hyaluronic acid gel resting in either a preperiosteal or an intraorbicularis plane. Soft tissue structures such as deep fat compartment septa and the orbicularis oculi muscle appeared to play a significant role in influencing the resting position of hyaluronic acid gel. In most specimens, the location of a significant portion of hyaluronic acid gel following injection to the infraorbital hollows differed from the intended injection plane. Soft tissue structures including fat compartment septa and the orbicularis oculi muscle appear to influence the resting position of hyaluronic acid gel. Careful attention should be used to avoid overfilling the thin soft tissue layers of the medial infraorbital hollows or tear trough.

Small Incision Preperiosteal Midface Lift for Correction of Lower Eyelid Retraction

Postblepharoplasty lower eyelid retraction is often due to scarring of the middle lamellae and/or vertical shortening of the anterior lamellae. Traditional reconstructive techniques involve a transconjunctival incision combined with a spacer graft. Other techniques involve a subperiosteal midface dissection or limited preperiosteal dissection. Elevation of the midface reduces the gravitational effect of the cheek on the eyelid and recruits skin for the anterior lamella. This study evaluates a technique for correction of lower eyelid retraction using a preperiosteal midface lift via a lateral canthal incision in a series of patients. Twenty-eight patients (56 eyes) with postblepharoplasty lower eyelid retraction were evaluated. Preoperative evaluations for inferior scleral show, corneal staining, and epiphora were documented. The patients underwent bilateral preperiosteal midface lift and canthoplasty via a lateral canthal incision. Follow-up ranged from 12 to 18 months. Average preoperative inferior scleral show was 1.96 mm (range, 1-3 mm). Seventy-eight percent of patients had epiphora, and 54% had corneal staining. Average postoperative lower eyelid position was +0.07 mm (range, 0 to +1 mm) above the inferior limbus. Average change in lower eyelid position relative to the inferior limbus was 2.04 mm. In all eyes, the final lower eyelid position was either at the inferior limbus or above it. All eyes had resolution of epiphora and corneal staining. Two patients required revision of lateral canthus on one side to improve symmetry. Mobilizing the midface in the preperiosteal plane through a lateral canthal incision provides excellent elevation and support of the eyelid. The small incision allows easy access to adhesions along the inferior orbital rim and to the preperiosteal plane beneath the entire midface. Preperiosteal midface lift combined with canthoplasty provides significant improvement of postblepharoplasty lower eyelid retraction.

Periorbital Contour Abnormalities: Hollow Eye Ring Management with Hyalurostructure

Purpose:A new technique for treating “periorbital hollowing” with hyaluronic gel filling using a unique cannula designed specifically for periorbital use.Method: The study was conducted from December 2008 to July 2009. All the patients presenting to the Alcazar aesthetic and Orbital clinic for periorbital contour abnormality complains where included. A total of 26 patients (52 injections) in both functional and aesthetic categories were identified. The inclusion criteria where contour abnormalities in the periorbital area. These included contour abnormalities of the periorbital and brow region that presented clinically as: “hollow eye ring” and “hollow cavities” and “deflated eyebrow”. The aim was to evaluate a new technique with a cannula specific for periorbital injections. This was designed in consultation with the author and was manufactured by the Thiebaud Company. Treatments where performed using local anaesthesia (emla 5% and an injection of 1% Xylocaïne adrenalised to 32-gauge needle) using the same protocol as Coleman lipostructure but using hyaluronic acid gel. The hyaluronic acid gel used in each case was Restylane (Q-Med-Sweden). Follow-up was over 6 months and performed photographically and with a patient self-evaluation questionnaire. The clinical postoperative assessment examined for bruising or swelling postinjection. The rates of complication were compared to published results and the authors own series before switching to the new cannula.Results: After analysis of the patient responses 24 patients (92%) with a 6 months’ follow-up were satisfied or very satisfied of aesthetic result after hyalurostructure of periorbital region. The use of the specially designed cannula led to less complication. There were 3 cases of bruising (3/52) and 4 cases of lymphatic stasis (4/52). We also noted fewer surface irregularities and a better distribution of the product as the injection was a retro orbicular pre periosteal plane).Conclusion: Treatment of the periorbital region and tear trough by hyaluronic acid injection has been described previously. But often the risks of this delicate anatomic region and bruises caused by needles followed by the appearance of hollow eye ring due to deposition of haemosiderin have limited the development of this technique. We propose a new treatment for hollow eye rings and for peri orbital region adapted from Lipostructure but with hyaluronic acid and facilitating treatment protocol of that region with improved aesthetic results: hyalurostructure.