Do you know where your fillers go?
An ultrasonographic investigation of the lips
Julia Vent 1, F. Lefarth 2a, Th. Massing 2b, W. Angerstein 2a
1) University of Cologne Medical Center, Department of Otorhinolaryngology, Head and Neck Surgery,
Cologne, Germany
2a) University of Duesseldorf Medical Center, Department of Phoniatrics and Pedaudiology,
Duesseldorf, Germany
2b) University of Duesseldorf Medical Center, Department of Phoniatrics and Pedaudiology, Medical
Acoustics and Audiology Unit, Duesseldorf, Germany
Fig. 1: lips of Nefertiti, Berlin, 2012
Page 1
Vent et al.: European Academy of Facial Plastic Surgery, Rome, May 9-12, 2012
HNO
Background
Augmenting the perioral region with injectable fillers is most
often performed by experience and palpation, without
knowing the exact, final position of the injected material.
To date, there are no in vivo investigations on the exact
positioning of injectable hyaluronic acid fillers within the lips,
and severe complications such as lip hematoma or
thromboembolism were rarely published 2,4.
The lips, and especially the modiolar region, have vivid blood
supply.
Thus, it was our aim to define the exact position of hyaluronic
acid in the lips immediately after injection, and 18 days postinjection.
Page 2
Fig. 2: blood supply of the lips1
HNO
Vent et al.: European Academy of Facial Plastic Surgery, Rome, May 9-12, 2012
Material and Methods
All
9 patients
were history
injectedtaking,
with Juvederm
Ultra III® and Ultra
After
a ®thorough
photo-documentation
was
Smile
, andA7status
additionally
with
unlinked hyaluronic
acid
performed.
quo
via
ultrasonography
as
well
as
®
.
(Juvederm
Hydrate
) The
exact
amounts, locations and
informed written
consent
were
obtained.
recorded.
• injection
Includedtechniques
in this pilotwere
study
were volunteers who agreed to
have the lower third of the face augmented.
Photographic
documentation,
as high
resolution
• Excluded were
subjects who as
had well
undergone
augmentation
ultrasonography
were performed.
A Hitachi
Hi Vision
Avius
in the past 6 months,
with known
allergies/
intolerance
ultrasound
system and
with who
linearsuffered
scannerfrom
(frequency
range: 6against lidocaine,
coagulopathies.
14
MHz) supplied images
of the instable
orbicularis
oris muscle
and
Dysmorphophobic
and psychic
persons
were also
the
surrounding
lip tissue.
Blood
vessels were detected by
discouraged
to have
injection
augmentation.
colour
Doppler
flowage
mapping.
Nine
females
(mean
55.0 years, range 41.2-66.1 years)
participated in this pilot study. Three women were
6 hadperformed
previouslybefore,
received
injectable after
filler
Theinjectable-naive,
examinations were
immediately
augmentations.
and
18 days after injection in 5 patients. Due to time
constraints, 4 patients were examined only once on day 1
and on day 18.
Page 3
Vent et al.: European Academy of Facial Plastic Surgery, Rome, May 9-12, 2012
HNO
Ultrasound
T
cutis
S
muscle
S
air in vestibulum
S
S
S
T
teeth
Fig. 4: transverse B-mode scan of augmented lower lip, orbiculars oris muscle relaxed
Fig 3
Fig. 3: systematic B-mode ultrasonography of the lips
1. static, at seven defined points (bars, T= transverse plane, S=
sagittal plane)
2. dynamic (from midline to right and from midline to left
modiolus)
3. Doppler sonography for identification of flow and vessels
Page 4
Vent et al.: European Academy of Facial Plastic Surgery, Rome, May 9-12, 2012
HNO
Results
•
Injected material distributed well within the lip tissue, and no embolism or
a
2
bb
*
* *
*
*
*
3
Fig. 5: paramedian, sagittal sonography scan of the right upper lip on day 1:
a) before and time
b) immediately
after, time
injection,
with
multiple intramuscular filler deposits;
1: during injection
2: day of
injection,
muscle structure
and
thickened
by injected
material
(female
timebulged
3: days 1-4
post
injection (pi),
time 4: days
5-9 pi, time
5: dayspatient,
10-14 pi aged 64 years).
Orbicularis oris muscle: 1) superficial and deep layer [divided into 2) pars peripheralis and 3)
pars marginalis], * filler deposits.
Page 5
Vent et al.: European Academy of Facial Plastic Surgery, Rome, May 9-12, 2012
cavum oris
cavum oris
• thrombosis
Minor bruising
occurred.occurred, which resolved within 7 to 9 days.
No hemorrhage
could
bedeposited
detected
ondeep
daylayer
18. (pars peripheralis) of
• Some
of this filler material
was
in the
orbicularis
oris muscle.
• the
Patients
showed
no dysfunction of the lips, and pain only
• However,
the injected
came up to 1 mm close to the arteries and veins of
immediately
aftermaterial
injection.
the lips.
• All 9 patients were satisfied with the results and would come
cutis
back for injection therapy.
cutis of side effects on a
• Graph 11 shows these patient ratings
2
1
visual analogous
scale (VAS):
3
HNO
Conclusions and Discussion
•
In our 9 patients, no compression of lip structures occurred, nor did any
severe complications result from injection.
• It is crucial to know the exact anatomy to minimize complications and risks
when injecting fillers. Position of injectables depends on the technique
such as depot, channel or tower ².
• Adverse events such as bruising or thrombosis can be avoided by
ultrasonographic control. One should always have hyaluronidase as a
rescue medication at hand.
• When in doubt, the exact location of injected fillers should be controlled by
Doppler ultrasound to avoid injury of arteries or veins.
• Maybe intramuscular depots cannot be so well massaged and distributed
as depots in connective tissue.
Acknowledgements:
• In
ourHitachi
opinion,
intramuscular
injectionsand
are
not absolute
contraindications
We
thank
for providing
the ultrasonograph
Allergan
for providing
Juvederm Ultra
®. al. ³. They may sometimes be necessary for an
as®, stated
by ®Lemperle
III
Ultra Smile
and Hydrateet
effective augmentation.
References:
• Because it was never monitored before, there are no limits or guidelines
1. R.
Wesker:
Dasand
Gesicht.
Bildatlas
klinische
Anatomie,may
KVM, Berlin
2012
yetRadlanski,
as to K.
how
deep
how
much
substance
be injected.
Further
2. G.
Sattler, B.
Sommer:
Bildatlas the
der ästhetischen
Augmentationsverfahren
mit Fillern,
KVM, Berlinfiller
2010
studies
must
quantify
exact depth
and the amount
of injected
3. G.
Lemperle, by
P. Rullan,
N. Gauthier-Hazan:
Avoiding and Treating
Dermal
Filler Complications, Plastic
materials
simultaneous
ultrasonography
during
injection.
4.
Reconstr Surg 2006 (Sept, Suppl1) 92S-107S
J. Niamtu III: Complications in Fillers and Botox, Oral Maxillofacial Surg Clin N Am 21 (2009) 13-21
Page 6
Vent et al.: European Academy of Facial Plastic Surgery, Rome, May 9-12, 2012
HNO