Diapositiva 1 - Medicina Estetica – Università degli Studi di Roma

LA REGIONE PERIOCULARE
NELL’INVECCHIAMENTO DEL VOLTO
Prof. Francesco Carinci Dr. Anna Avantaggiato
La regione perioculare è un punto focale dell’estetica facciale. Il ruolo preminente della
vista fra gli organi di senso influenza la percezione dell’espressività dell’intera regione, ed è
non solo della poesia, la convinzione che gli occhi raccontino molto di ciò che noi siamo. Per
questo le alterazioni della regione perioculare, rappresentano motivo di consultazione
medico-estetica anche per pazienti relativamente giovani.
LA REGIONE PERIOCULARE
NELL’INVECCHIAMENTO DEL VOLTO
Prof. Francesco Carinci Dr. Anna Avantaggiato
Regione perioculare: confini
La regione perioculare appartiene, con la fronte, al terzo superiore del
volto ed è sottesa dal sopracciglio, dalla regione temporale, dalla
guancia nelle sue porzioni malare e zigomatica e dalla radice del naso.
ANATOMIA
J Craniofac Surg. 2015 Apr 30. [Epub ahead of
print]
Comparison Among Three Different Fixation
Techniques in Temporal Brow Lift Surgery.
Pascali M, Avantaggiato A, Bocchini I, Carinci
F, Cervelli V.
Pre-surgery
30,00
mm
28,00
26,00
Average
24,00
Endotine
Mesh
22,00
Suture
20,00
18,00
Head
Tail
1 year
30,00
30,00
28,00
28,00
26,00
Average
24,00
Endotine
Mesh
22,00
Suture
20,00
mm
mm
Post-surgery
Body
26,00
Average
24,00
Endotine
Mesh
22,00
Suture
20,00
18,00
18,00
Head
Body
Tail
Head
Body
Tail
Guancia
I solchi naso giugale e naso labiale sono i
limiti superiore ed inferiore del cuscinetto
adiposo della guancia.
Lo spostamento verso il basso di questo
grasso priva la rima orbitaria di parte del suo
ricoprimento. Anche il SOOF, strato di grasso
sottostante l’orbicolare scivola in basso e
l’orbicolare stesso tende ad assottigliarsi
superiormente .
Quindi la zona lungo la rima orbitale mediale
rimane praticamente senza tessuti molli tra
periostio e cute tranne che per l’orbicolare
che qui ha la sua inserzione periostale. La
progressiva ptosi adiposa causa
l’approfondimento dei solchi naso labiali
Invecchiamento perioculare:segni
-Abbassamento della coda del sopracciglio
-Allungamento e svuotamento palpebrale
-Appiattimento dell’area infraorbitale-malare
-Comparsa dei solchi naso-giugale ed infrapalpebrale.
Barton's grading system based on
anatomic analysis
Hirmand's classification system of the tear trough deformity based on clinical evaluation
INVECCHIAMENTO=ATROFIA
Cellulare
Arch Dermatol.
2008 May;144(5):666-72
Looking older:
fibroblast collapse
and therapeutic implications.
Fisher GJ, Varani J, Voorhees JJ.
Morfologica
La cavità orbitaria cambia
la sua forma e l’area infra
orbitaria si appiattisce.
La perdita di supporto osseo
produce ptosi dei tessuti
molli.
Intrinsic aging induces the down-regulation of transforming growth factor-β (TGF-β) and
connective tissue growth factor (CTGF) in the TGF-β-procollagen axis and leads to decreased
synthesis of type I collagen.
In photoaging, UV irradiation from the sun generates reactive oxygen species (ROS) which
activate growth factor and cytokine receptors on fibroblasts in the skin. Activated receptors
stimulate p38 and JNK, members of the MAPK signaling cascade, and c-Fos and c-Jun
subsequently combine to form AP-1 which stimulates matrix metalloproteinase (MMP)
transcription. Increased MMP transcription accelerates the degradation of collagen which
induces dermal matrix alterations. ROS generation and AP-1 formation induced by photoaging
can also lead to decreased collagen synthesis by blocking TGF-β type II receptor/Smad
signaling. ROS can also be generated from oxidative metabolism and accumulate during the
intrinsic aging process.
INVECCHIAMENTO
Lab Anim Res. 2011 Mar;27(1):1-8. doi:
10.5625/lar.2011.27.1.1. Epub 2011 Mar 25.
Molecular mechanisms and in vivo mouse
models of skin aging associated with
dermal matrix alterations.
Hwang KA,Yi BR, Choi KC.
La morfologia ad “Y” della regione della guancia è la
conseguenza della ptosi dei tessuti molli prodotta
dall’atrofia ossea, muscolare, adiposa e cutanea e
contrastata dall’ancoraggio dei legamenti.
Gli occhi “cerchiati” sono la conseguenza di ombre
crate dal cambiamento di posizione di pelle, tessuti
sottocutanei, orbicolare e SOOF.
RIMODELLAMENTO DELL’ORBITA
La struttura scheletrica orbitale si riassorbe a
livello supero-mediale ed infero-laterale.
Changes in the Facial Skeleton With Aging: Implications
and Clinical Applications in Facial Rejuvenation
Aesth Plast Surg (2012) 36:753–760
Bryan Mendelson • Chin-Ho Wong
Invecchiamento
Muscolare
Solco naso-giugale
Tear trough
Orbicolare
pretarsale
Orbicolare
presettale
Orbicolare
orbitale
The aesthetically attractive lower eyelid
should display a relatively smooth transition
between the pre-septal and orbital portions
of the orbicularis oculi muscle and continue
into the upper malar region without a
definable transition point. (Glaser et al 2010)
Dzifa S. Kpodzo,
Foad Nahai,
and Clinton D. McCord
Malar Mounds and
Festoons: Review of
Current Management
Aesthetic Surgery J.
2014,
Vol. 34(2) 235–248
LEGAMENTI
Ligamento zigomatico- cutaneo
Osso e periostio malare sono connessi alla
cute da un ligamento che attraversa il grasso
sottomuscolare e sottocutaneo e che è
responsabile della formazione delle borse
malari.
Altri legasmenti non raggiungono la cute ma
collegano il periostio allo SMAS come nel
caso del legamento orbitale che connette il
periostio all’orbicolare.
The Composite Lift (HAMRA) preserves most (possibly all) of
the fat beneath the eye and repositions it (with its thin but
strong cover, the orbital septum) over the orbital rim,
smoothing the transition from lower eyelid to cheek.
Fat compartments in the upper eyelid.
The ROOF lies more laterally. This remains on the surface, between the orbicularis and the
periosteum, on the outside of the orbital rim and tends to descend also on the inside of the
eyelid, between the orbicularis and the septum.
The preaponeurotic fat pad, which rarely has to be excised, is found below the septum,
leaning on the elevator aponeurosis.
The lighter coloured nasal fat is situated more medially, next to the elevator aponeurosis,
and often bulges forming an unattractive bag, which can be removed. (Botti G.)
Saudi Journal of Ophthalmology
(2012) 26, 441–443
Imaging of eyelid lymphatic drainage
Julio C. Echegoyen; Kristin E. Hirabayashi,; Ken Y. Lin,; Jeremiah P. Tao.
Traditional descriptions of lymphatic drainage show eyelids emptying into the submandibular
or preauricular basin. However recent studies based on in vivo lymphatic imaging
(lymphoscintigraphy) show a possible predilection for the preauricular basin.
Results: The preauricular basin was the site of focal radioactive uptake in all 15 patients.
Avantaggiato A., Carinci F.
Mesenchymal Stem Cells Researches and Clinical Applications in Facial Aging
Current Tissue Engineering, 2015, 4, 000-000 1 2211-5420/15 $58.00+.00 © 2015
Bentham Science Publishers
Livelli terapeutici
Osseo (innesti)
Neuromuscolare (BoNT-A)
Sottocutaneo (fat grafts/stem cells)
Cutaneo
-Epidermic0 (Cosmeceutici, Peelings,
Dermoabrasione, Laser resurfacing)
-Dermico (Radiofrequenza, Biostimolazione,
Biorivitalizzazione, Fillers)
Osseo
J Craniofac Surg. 2005 Jul;16(4):526-30.
Clinical outcome of 285 Medpor grafts used
for craniofacial reconstruction.
Cenzi R, Farina A, Zuccarino L, Carinci F.
Aesthetic Plast Surg. 2012 Aug;36(4):917-27.
doi: 10.1007/s00266-012-9911-4. Epub 2012
Jun 9.
Facial reconstruction using porous highdensity polyethylene (medpor): long-term
results.
Niechajev I
Implantation of porous polyethylene in the
facial region is a safe procedure. Currently,
Medpor seems to be the best alloplastic
material available as a facial bone substitute.
It is long-lasting, with a low frequency of
complications, morbidity similar to procedures
involving autologous grafts, and high overall
patient satisfaction.
Neuromuscolare
BoNT-A exerts its predominant action in the peripheral nervous system. Diffusion has
been reported to contralateral facial muscles upon unilateral BoNT-A application as well
as remote spread from the site of injection, even to arm muscles, upon facial muscle
injection. Alimohammadi M et al. Acta Derm Venereol. 2014 Jan;94(1):32-7. doi:
10.2340/00015555-1647.
Documented possibilities of still unknown pharmacological BoNT-A effects emphasize the
importance of correct administration of the toxin in terms of injection-points, dose
selection, and appropriate effect surveillance
Dose and injection technique must be
adjusted and individualized based on the
variable anatomy and function/mass of
muscles in the forehead and upper face as well
as on patient goals.
Optimal aesthetic outcomes can be achieved
by skillfully balancing the opposing effects of
the frontalis muscle and its intricate
interactions with the procerus, corrugator
supercilii, depressor supercilii, and orbicularis
oculi muscles.
Aesthetic Plast Surg. 2013 Oct;37(5):975-83. doi:
10.1007/s00266-013-0178-1. Epub 2013 Jul 12.
Understanding the functional anatomy of the
frontalis and glabellar complex for optimal
aesthetic botulinum toxin type A therapy.
Lorenc ZP, Smith S, Nestor M, Nelson D, Moradi A.
Acta Derm Venereol. 2014 Jan;94(1):32-7. doi: 10.2340/00015555-1647.
Correlation of botulinum toxin dose with neurophysiological parameters of efficacy and
safety in the glabellar muscles: a double-blind, placebo-controlled, randomized study.
Alimohammadi M, Andersson M, Punga AR.
Study design: The same injection volume, 0.1 ml, was given to all subjects in 5 standardized
injection points using electromyography (EMG)-guided technique with disposable hypodermic
needle electrodes to ensure central muscle injection.
Group I received 1 unit/injection (total 5 units); group II received 2 units/injection (total 10 units);
group III received 4 units/injection, (total 20 units); and group IV received 0.9%NaCl/injection.
La riduzione dei potenziali di azione motori
registrati nel corrugatore correla con la dose
di BoNT-A.
Comparsa di abnorme attività EMG
spontanea 2-4 settimane dopo l’iniez. che
depone per una denervazione farmac.
L’iniezione nell’area glabellare provoca
disturbo della trasmissione muscolare
(subclinico) anche nell’orbicolare a 2 sett.
senza segni EMG.
-Grandezza del muscolo e dosaggio possono spiegare la
variabilità dell’effetto in soggetti diversi
-L’effetto massimo per dosaggi di 5 o 10 U totali si ottiene più
tardivamente (4 settimane)
-Il reale effetto neurofisiologico dura molto di più dei 3-4
mesi previsti, infatti nei gruppi con dosaggi di 10 o 20 U
nessun soggetto ha ottenuto una completa restitutio a 24
settimane. La completa reinnervazione si è avuta solo nel
gruppo con dosaggio di 5 U e questa è avvenuta a 12
settimane.
-La maggior differenza estetica tra il gruppo delle 5 U
rispetto a quello delle 20 U è stata che in quest’ultimo si è
avuto un effetto sulla parte mediale del frontale.
Adiposo/Rigenerativo
In the mid-90s, Coleman noted that the
positive effect of structural fat grafting was
beyond the filling effect; in fact, a visible
improvement in skin texture, pigmentation
and tropism was always observed after his
meticulous procedure
Coleman SR. Structural fat grafting: more
than a permanent filler.
Plast Reconstr Surg 2006 Sep;118(3
Suppl):108S-120S.
The use of more and more thinner cannulas for harvesting and reinjecting adipose tissue has revealed that although the positive
effect is always present, in nanofat, after the emulsification of the
fat, there is disappearance of vital adipocytes.
Thus, clinical improvement must be linked to the mesenchymal
stem cell component that has been typed in this method
Syringe with microfat in a condition before the
emulsi!cation process and syringe with a
homogeneous fat emulsion after the
emulsi!cation process. Note the dfference in
color and consistency.
A standard 3-mm Mercedes type liposuction
cannula with large side holes (2 × 7 mm) and a
3-mm multiport cannula, containing several
sharp side holes of 1-mm diameter. The sharp
side holes augment the harvesting yield.
Tonnard P, Verpaele A,
Peeters G, Hamdi M,
Cornelissen M, Declercq
H.
Nanofat grafting: basic
research and clinical
applications.
Plast Reconstr Surg 2013
Oct;132(4):1017-1026.
Current Tissue Engineering
2015, 4, 000-000 12211-5420/15 $58.00+.00 © 2015 Bentham Science Publishers
Mesenchymal Stem Cells Researches and
Clinical Applications in Facial Aging
Anna Avantaggiato and Francesco Carinci
A 33-year-old woman with lower eyelid blepharochalasis and dark
coloration of the lower eyelid skin extending into the nasojugal
groove.
(Right) Seven months after fat redraping, blepharoplasty, and
intradermal injection of 1.6 cc nanofat in the lower eyelid and
pigmented nasojugal groove.
Cutaneo
-Epidermic0
Cosmetici e cosmeceutici,
Peelings e Dermoabrasione,
Laser resurfacing
-Dermico
Radiofrequenza,
Biostimolazione,
Biorivitalizzazione,
Fillers
PROPRIETÀ DI SOSTANZE VEGETALI:
(Da U. Borellini “Cosmetologia” 2010
PROTETTIVA SOLARE: alcuni oli e burri vegetali
contengono frazioni insaponificabili in grado di
filtrare le radiazioni solari (oli di oliva, di avocado, di
sesamo, di soia, di crusca di riso e del burro di karité
che è il più attivo).
ANTIRUGHE ED ELASTICIZZANTE: estratti
contenenti fitoormoni e saponine come quelli del
ginseng e del luppolo.
EPITELIZZANTE CHERATOPLASTICA: è
caratteristica di piante contenenti allantoina,
flavonoidi e acidi triterpenici, come la centella
asiatica, la liquirizia (acido glicirretico),la
consolidala, l’echinacea e la calendula.
ANTIEDEMIGENA DRENANTE: l’escina è una
saponina presente nei semi di ippocastano che
agisce sulla permeabilità e fragilità capillare,
anche l’esperidina sinergicamente con la
vitamina C è il flavonoide degli agrumi e
protegge l’integrità dei vasi sanguigni.
LENITIVA: capacità di alleviare uno stato
infiammatorio cutaneo caratteristica di
vegetali contenenti azuleni, flavonoidi e
mucillagini come la camomilla, la malva, la
calendula, i fiori d’arancio, l’aloe, l’altea e la
passiflora.
ANTIARROSSAMENTO: proprietà delle
saponine triterpeniche e steroidiche e quindi
dalle ruscogenine contenute nel rusco, dagli
antocianosidi del mirtillo, dal gingko e
dall’hammamelis.
SCHIARENTE: Achillea millefoglie, cetriolo,
limone e uva ursina.
COSMECEUITICI
Vitamine A, C ed E
Fitoestrogeni
Acido Lipoico (Tioctic acid)
DMAE (dimetilaminoetanolo)
Peptidi biomimetici (botox like)
Although the role of acetylcholine as a neurotransmitter is well known,
growing evidence points to acetylcholine as a ubiquitous cytokine-like
molecule that regulates basic cellular processes such as proliferation,
differentiation, locomotion, and secretion in a paracrine and autocrine
fashion. Indeed, this modulatory role may contribute to the cutaneous
activity of DMAE. Although its mechanisms of action in the skin remain to
be elucidated, evidence suggests that the skin is an active site of
acetylcholine synthesis, storage, secretion, metabolism, and receptivity.
Muscarinic acetylcholine receptors have been localized to keratinocytes,
melanocytes and dermal fibroblasts, whereas nicotinic acetylcholine
receptors have been found in keratinocytes.
Contiene due peptidi biomimetici miorilassanti. Si tratta in questo caso
del GABA (acido gamma-ammino butirrico) e dell'Acetyl Hexapeptide-8.
Aesthetic Plast Surg. 2007 Nov-Dec;:711-8.
Dimethylaminoethanol affects the viability
of human cultured fibroblasts.
Gragnani A, Giannoccaro FB, Sobral
CS, Moraes AA, França JP, Ferreira AT, Ferreira
LM.
Dimethylaminoethanol reduced the
proliferation of fibroblasts, increased cytosolic
calcium, and changed the cell cycle, causing
an increase in apoptosis in cultured human
fibroblasts.
Pharmazie. 2009 Dec;64(12):818-22.In
vivo skin effects of a dimethylaminoethanol
(DMAE) based formulation.
Tadini KA, Campos PM.
Histometric evaluations showed that
formulations with or without DMAE increased
the viable epidermis thickness, but only
the DMAE-supplemented formulation led to
increased dermal thickness. DMAE also
induced increase in collagen fiber thickness,
which was observed in the histopathological
study.
High Potency Eye Lift
A hydrating treatment to lift, brighten and tighten
the eye area. With Phospholipids, Pycnogenol and
DMAE.
.5 fl oz / 15 mL
Am J Clin Dermatol. 2005;6(1):39-47.
The role of dimethylaminoethanol in
cosmetic dermatology.
Grossman R.
In a randomized clinical study,
3% DMAE facial gel applied daily for 16 weeks
has been shown to be safe and efficacious (p <
0.05) in the mitigation of forehead lines and
periorbital fine wrinkles, The acute skinfirming effects have been confirmed by
measures of cutaneous tensile strength
L’unguento contiene almeno 67 unità/grammo di attività biologica. Un'unità di attività biologica
corrisponde alla concentrazione di estratto di Saccharomices Cerevisiae (espressa in mg/ml)
necessaria per incrementare il consumo di ossigeno di 1 mg di pelle addominale di topo secca di
1% alla fine del periodo di 1 ora.
L'estratto di cellule di Saccharomices Cerevisiae contiene metaboliti cellulari di basso peso
molecolare quali amminoacidi e peptidi di peso molecolare tra 6000 e 12000 d, composti in
maggioranza da acido glutammico. Insieme a questi sono presenti anche carboidrati, composti
da trealosio principalmente e da glucosio. È stato accertato che alcuni di questi componenti
sono naturalmente sintetizzati dalle cellule epiteliali quando esse vengono sottoposte a lesioni
di origine meccanica o fisiologica.
XAF5 selectively binds a G protein-coupled receptor and modifies a key
metabolic pathway involved in lipid metabolism and adipocyte
maturation. XAF5 directly inhibits adipocytes in cell culture and reduces
adiposity in five preclinical models and around the human eye.
XAF5 Ointment is currently in Phase 2 development for reduction of
steatoblepharon (excess eyelid fat), submental fat, and for other
indications.
Peelings
Charitomeni Vavouli, Andreas Katsambas, Stamatis Gregoriou, Anca Teodor,
Carmen Salavastru, Adina Alexandru, & George Kontochri
Chemical peeling with trichloroacetic acid and lactic
acid for infraorbital dark circles
Journal of Cosmetic Dermatology, 12, 204—209, 2013 Wiley Periodicals, Inc.
The combination of trichloroacetic TCA 3.75%
and lactic acid 15% showed encouraging results
on improving periorbital hyperpigmentation
Laser: Xantelasmi
Maschio aa 38 pre
15 gg post Er Yag
Laser: Xantelasmi
Femmina 45 aa pre
15 gg post Er Yag
Radiofrequenza
Histology of the human ex vivo specimen after
treatment with 50% of the maximum device working power
(27.50 W): the thickening of the collagen fibers in the papillary
dermis is appreciated, whereas the blood vessels in the
dermal papillae do not display any alteration (box). Light
microscopy, hematoxylin and eosin staining, bar 400 lm.
Nicoletti et al. Photomedicine and Laser Surgery 2014
Singola seduta
Pre
Post
Ciclo di terapie
Pre
Post
Singola seduta
Pre
Post
Ciclo di terapie
Pre
Post
Avantaggiato A, Palmieri A, Carinci F, Pasin M,
Bertuzzi GL.
Biostimulation and
biorevitalization: effects on
human skin fibroblasts.
Annals of Oral & Maxillofacial Surgery 2013 Mar
01;1(2):11.
BIOSTIMULATION is a stimulation of the anabolic functions of dermal fibroblasts such as
replication, protein synthesis and production of extracellular matrix components (ECM).
BIOREVITALIZATION is a direct supplementation of hyaluronic acid (HA) alone or added to
other molecules (i.e. vitamins).
In order to verify the different metabolic effects of BS and BR fibroblast cell cultures, RNA
extraction, cDNA synthesis and PCR were performed.
Results
BS and BR produce different effects in fibroblast cell cultures, thus showing that they are
different therapies.
Neutrophil elastine is activated by BS and to a lesser extent by BR. Hyaluronan synthase 1 is
activated to a higher extent by BR using the medical device with the lowest HA content.
Neutrophil elastase, responsible for the degradation of one of the fibrillar components of
ECM, is activated to a lesser extent by BS.
Rejuvenation Res. 2014 Jun;17(3):285-90. doi:
10.1089/rej.2013.1511. Epub 2014 Jun 11.
Fibroblasts behavior after N-acetylcysteine and
amino acids exposure: extracellular matrix gene
expression.
Avantaggiato A, Palmieri A, Bertuzzi G, Carinci F.
Up-regulation of
elastin-, hyaluronic
acid-, and GDF6encoding genes
supports the evidence
of clinical
improvement induced
by NAC
biostimulation in the
prevention and
correction of skin
aging.
Aesthetic Plast Surg. 2014 Oct;38(5):1011-6. doi:
10.1007/s00266-014-0380-9. Epub 2014 Jul 16.
Role of antioxidants in dermal aging: an in vitro
study by q-RT-PCR.
Avantaggiato A, Bertuzzi G, Vitiello U, Iannucci
G, Pasin M, Pascali M, Cervelli V, Carinci F.
Rejuvenation Res. 2015 Feb 1. [Epub ahead of print]
COMPARISON AMONG BIO-REVITALIZING INJECTIVE PRODUCTS: A STUDY ON SKIN
FIBROBLAST CULTURES.
Avantaggiato A, Girardi A, Palmieri A, Pascali M, Carinci F.
Human dermal fibroblasts were seeded on a layer of five different commercial
medical devices containing 6.2, 10, 10bis, 13 and 20 % respectively of HA. The
products differ not only in the HA concentrations but in the content and quality of
other ingredients, moreover one of these products contains cross-linked HA.
Rejuvenation Research
Editor-in-Chief:
Aubrey D.N.J. de Grey
ISSN: 1549-1684 • Online ISSN: 15578577 • Published Bimonthly
Latest Impact Factor* is 3.931
*2013 Journal Citation Reports®
published by Thomson Reuters, 2014
HA concentration seems to be inversely correlated to the Elastin genes activation. As
regard to Neutrophil Elastase gene, the two medical devices with the higher concentration in
HA displayed the greater effect.
Genes encoding for the HA synthase 1, Hyaluronidase 1 and Desmoplakin are enhanced but the
HA content of the different products seems to be not directly related to genic activation so
the explanation for the differences must be researched in further elements that are distinctive
of the specific device.
Arch Dermatol. 2008 May;144(5):666-72
Looking older: fibroblast collapse and therapeutic implications.
Fisher GJ, Varani J, Voorhees JJ.
Acido jaluronico cross-linkato=riempitivo inerte?
L’azione meccanica di stiramento prodotta dall’iniezione intradermica di un filler a base di HA stimola la
produzione di collagene.
Biopsie cutanee a 4 settimane dall’iniezione di CLHA (B) e soluzione salina (A)
(A) Saline vehicle (control) or (B) cross-linked hyaluronic acid filler (CLHA)
L’immunoistochimica evidenzia la presenza si procollagene tipo I (rosso), le frecce nere indicano l’HA, le
bianche i fibroblati attivati e distesi .
Le crocette nere evidenziano fibrille collagene stipate probabilmente derivate dalla conversione del
procollagene I in collagene I.
Sagittal diagram of the prezygomatic space bordered
superiorly by the orbitomalar ligament and inferiorly by the
malar septum and zygomatico-cutaneous ligament.
The malar septum runs from the inferior orbital rim to just
above the zygomaticocutaneous ligament, dividing the
prezygomatic space into preperiosteal fat and suborbicularis
oculi fat. (Kpodzo et al. Aesthetic Surgery J. 2014, Vol. 34(2)
235–248)
Iniezione con ago 30 G in boli sottoperiostei
NASHA gel 15 mg/ml, lidocaina 3mg
J Cosmet Dermatol. 2014 Mar;13(1):79-84.
doi: 10.1111/jocd.12075.
Under eye infraorbital injection technique:
the best value in facial rejuvenation.
Shetty R.
Injection of filler at infraorbital points could
instantly lift the face up, elevating the point
of shadow and shifting the point of highest
light reflection to the ideal malar point.
0.5 + 0.5 ml
Pre
Dopo 7 gg
Recommendations for hyaluronic acid filler to be
injected depending on the grade of severity
Sharad J.
Dermal Fillers for the Treatment of Tear Trough Deformity: A Review of Anatomy,
Treatment Techniques, and their Outcomes.
Journal of Cutaneous and Aesthetic Surgery. 2012;5(4):229-238. doi:10.4103/0974-2077.104910.
Marking of tear trough filler (injection points
and direction of needle)
Philippe Berros, M.D. Lilian Lax, M.D. Frédéric Bétis, Ph.D.
Hyalurostructure Treatment:
Superior Clinical Outcome through a New
Protocol—A 4-Year Comparative Study of Two
Methods for Tear Trough Treatment
(Plast. Reconstr. Surg. 132: 924e, 2013.)
Complications on
periorbital injections.
Lump or surface irregularities (above, left),
hematoma (above, right),
edema (center, left) and its treatment with
hyaluronidase (center, right),
and migration of hyaluronic acid (below, left),
and its treatment with hyaluronidase (below,
right).
Cosa fa la differenza?
 In tutti i casi è stato usato lo stesso HA con
cannula 25 G previa preincisione con ago 23 G,
massaggio e raffreddamento post per 5 min e
raccomandazione di non praticare sport o
SPA per le 48 ore successive, nei casi con più
complicanze era stata praticata anest. locale
pre e crema antibiotica corticost. post
Nel gruppo con meno complicanze invece:
-Raffreddamento pre- iniezione
-Posizione del foro di accesso nella regione malare 10 mm sotto il bordo orbitario
anziché immediatamente sotto la rima orbitaria lateralmente ( canto est.)
-Iniezione lenta in miniboli
-Massaggio leggero
-1mg/kg cortisone per os per 48h dopo il tratt.
Plast Reconstr Surg. 2012 Apr;129(4):995-1012. doi:
10.1097/PRS.0b013e3182442363.
Blindness following cosmetic injections of the face.
Lazzeri D, Agostini T, Figus M, Nardi M, Pantaloni M, Lazzeri S.
Twenty-nine articles describing 32 patients were identified. In 15 patients, blindness occurred
after injections of adipose tissue; in the other 17, it followed injections of various materials,
including corticosteroids, paraffin, silicone oil, bovine collagen, polymethylmethacrylate,
hyaluronic acid, and calcium hydroxyapatite.
CONCLUSIONS:
Some precautions may minimize the risk of embolization of filler into the ophthalmic artery
following facial cosmetic injections. Intravascular placement of the needle or cannula should
be demonstrated by aspiration before injection and should be further prevented by
application of local vasoconstrictor. Needles, syringes, and cannulas of small size should be
preferred to larger ones and be replaced with blunt flexible needles and microcannulas when
possible. Low-pressure injections with the release of the least amount of substance possible
should be considered safer than bolus injections. The total volume of filler injected during the
entire treatment session should be limited, and injections into pretraumatized tissues should
be avoided. Actually, no safe, feasible, and reliable treatment exists for iatrogenic retinal
embolism. Nonetheless, therapy should theoretically be directed to lowering intraocular
pressure to dislodge the embolus into more peripheral vessels of the retinal circulation,
increasing retinal perfusion and oxygen delivery to hypoxic tissues.
Plast Reconstr Surg. 2014 Dec;134(6):1197-201. doi:
10.1097/PRS.0000000000000754.
Blindness caused by cosmetic filler injection: a review of cause
and therapy.
Carruthers JD, Fagien S, Rohrich RJ, Weinkle S, Carruthers A.
Vascular occlusion causing blindness is a rare yet greatly feared complication of the use of facial
aesthetic fillers. The authors performed a review of the aesthetic literature to ascertain the
reported cases of blindness and the literature reporting variations in the vascular anatomy of
the human face. The authors suggest a small but potentially helpful addition to the accepted
management of the acute case. Cases of blindness, mostly irreversible, from aesthetic filler
injections have been reported from Asia, Europe, and North America. Autologous fat appears
to be the most frequent filler causing blindness. Some cases of partial visual recovery have
been reported with hyaluronic acid and calcium hydroxylapatite fillers. The sudden profusion of
new medical and nonmedical aesthetic filler injectors raises a new cause for alarm about
patient safety. The published reports in the medical literature are made by experienced
aesthetic surgeons and thus the actual incidence may be even higher. Also, newer injectors may
not be aware of the variations in the pattern of facial vascular arborization. The authors present
a summary of the relevant literature to date and a suggested helpful addition to the protocols
for urgent management.
GRAZIE
PER L’ATTENZIONE