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By Nancy Groves; Reviewed by José R. Montes, MD, FACS, FACCS, ASOPRS
It is sometimes said that medicine is both an art and a science. This could be particularly true of oculofacial plastic surgery, according to surgeon José R. Montes, MD, FACS, FACCS, ASOPRS.
“Facial shaping with filler is a lot like painting in 3-D,” said Dr. Montes, professor, Department of Ophthalmology, University of Puerto Rico School of Medicine, and medical director of a clinic in San Juan specializing in eye and facial rejuvenation.
Dr. Montes urged surgeons to think of facial shaping as art.
“Get inspired by your patient,” he said. “Think of [the face] as like a block of marble stone, a lump of moist clay, a mound of beach sand, or an urban city wall. We are sculptors.”
Before getting down to the actual clinical task of facial shaping, the surgeon should step back and get a broader perspective of the patient.
“In theory, everyone has a signature feature. We can decide as doctors if we can do work on that salient feature to enhance it or whether we want to work around that feature to diffuse it,” Dr. Montes explained.
Symmetry is often considered an important component of patient assessment and facial rejuvenation. To illustrate this, Dr. Montes described using injectable fillers with a patient who had two signature features: a prominent nose and well-formed lips. His approach was to enhance the lips to minimize the nose prominence, striking a balance.
In sculpture and in facial shaping, ultimate artistic success depends on the underlying structure or frame, Dr. Montes said.
In the case of a negative vector patient, a midface concavity demanded convexity, attained with a two-pronged approach of tear trough injection and concomitant midface injection of hyaluronic acid (HA).
For a so-called congenital “peanut face” patient lacking facial lateral support, the solution was superficial and deep temporal injections using a poly-L-lactic acid biostimulant agent.
Dr. Montes also pointed out the importance of stepping in with injectables to complete restoration after trauma patients have undergone surgical reconstruction.
“Biostimulant agents allowed us to go the extra mile for a patient who had undergone multiple reconstructive procedures,” he said, describing a woman who was treated with a poly-L-lactic acid biostimulant agent following surgery for a gunshot wound.
He also addressed the common misconception that facial shaping is exclusively about adding volume, suggesting that reduction may also play a role.
For example, treatment of a patient with masseteric hypertrophy included neurotoxin in the lower facial area, while deficiencies in the midface and temporal zone were treated with a biostimulant.
Dr. Montes also described safe and effective injection techniques. The forehead is a commonly neglected area, but when treatment is clearly indicated, it is important to remember that the vascular structures on the upper orbital rim are deep but become more superficial 1.5 cm above the rim. Use small boluses 0.5 cc to 0.1 cc, manually spread, and make deep, centered injections to avoid the vascular bone.
Pain is less likely when avoiding the branch of supraorbital nerve located 1 to 1.5 cc medial to the temporal fusion line.
There are two schools of thought for temporal zone injection safety: superficial or deep technique. Dr. Montes’ view is that superficial injections are more efficient in terms of product use but that deep injections are safer.
“Make sure that if you want to go through the more advanced skill injection on the superficial temple you pick a filler that you can use through aspiration,” he said.
The periocular zone is where ophthalmologists have to “put their A game,” Dr. Montes said.
It is customary to use small particle fillers with lower HA concentrations and less hydrophilic materials. The basic technique for supraperiostial linear is a retrograde injection: apply anterior traction to the nose to better view the depression, inject on top of the bone, and use two-finger barricade protection to prevent filler migration.
In a negative vector patient, administer tear trough and midface injections at the same time. Shallow orbit patients will also benefit from dual injection in the tear trough and midface zone.
Surgeons have embraced the concept of volume conservation when treating the upper eyelid, but there are exceptions, such as patients who are unhappy with a deep upper lid.
Dr. Montes typically uses a 27-gauge, one-inch cannula below the orbicularis for safety and selects low HA concentration products that can be molded and placed as desired.
He also recommends coupling work in the roof area with the upper eyelid and temporal zone when possible. A deep injection can be used with the stronger products such as biostimulant agents, although a subcutaneous injection may be appropriate with HA or softer products.
Extra care is needed when using soft tissue fillers in the nose, Dr. Montes said.
He prefers a deep, midline injection using HA products with high G prime. He recommended a small needle and small (0.05 ml) boluses, along with a gradual injection. Make sure that the lateral sides of the nose keep their concavity and do not become too square, he advised.
José R. Montes, MD, FACS, FACCS, ASOPRS
This article is based on Dr. Montes’ presentation during Oculofacial Plastic Surgery Subspecialty Day at the American Academy of Ophthalmology 2016 annual meeting. Dr. Montes is a speaker, trainer, and consultant for Allergan, Galderma, Merz, and Valeant.