For facial rejuvenation by injection techniques, we inject permanent and temporary fillers into the skin. Since the needle is not intended to penetrate deeper than the dermis, we often assume that nerves located somewhat deeper are not at risk of damage.
However, it is important to understand that nerve damage – not necessarily the result of direct damage, they can also be caused by indirect effects. In the event of early complications such as infection or skin necrosis, their spread will lead to damage to the nerves passing below. Late complications after injections, such as granuloma or infection, are fraught with the same consequences.
Riccardo Frati – Specialist in plastic and cosmetic surgery, PhD student of Professor Gasparotti, the founder of modern liposuction techniques. At the moment, Riccardo Frati is a practicing doctor in a private hospital in London – Highgate Hospital.
Procedure for the introduction of fillers and injectables
The right angle of filler injection, the right time and the right patient for this procedure – the main components of patient safety. I have come across cases where patients were injected with fillers without prior preparation, without wiping the injection site with alcohol. But this is – a very important first step that should never be skipped.
Step Two – proper anesthesia with local anesthetics.
Third step – make sure the patient is in a comfortable position. Remember that any movement during the injection of fillers can cause damage.
Step four – it is important to accurately mark potential hazard zones and areas to be avoided.
Step Five – choose the appropriate technique for introducing fillers.
A lot of research has gone into the study of the facial nerves and has provided us physicians with two-dimensional guidelines on the subject. Twelve years later, a very interesting study was carried out, the purpose of which was to determine the different layers of the facial nerves in relation to the temporal branch of the facial nerve.
We wanted a 3D view of the nerves, rather than the 2D view available at the time, and we got it. Briefly, the layered structure of the face can be described as follows:
- leather;
- subcutaneous tissue;
- superficial musculoaponeurotic system of the face;
- superficial temporal fascia.
Areas to pay attention to when injecting fillers
Especial care must be taken in the zygomatic arch area, as there is a risk of damage to the temporal branch of the facial nerve.
The marginal mandibular branch of the facial nerve is also a danger zone. Its location is quite easy to determine – it is a circle with a radius of approximately 1.5 – 2 cm, located between the crease of the corner of the mouth and the middle part of the jaw.
The marginal mandibular branch of the facial nerve, resembling the premaxillary sulcus and the upper part of the chin, approaches the surface for innervation of the depressor lip depressor muscle and the depressor depressor of the mouth corner. This position of the marginal mandibular branch of the facial nerve increases the risk of its damage when fillers are injected into this area of the face.
Another important area – a triangle formed by the zygomatic eminence, the fold of the corner of the mouth and the posterior border of the mandibular angle. The most common injection site for fillers is the cheeks and nasolabial folds. It is in this area that the zygomatic and buccal branch of the facial nerve passes, which, in my opinion, is a very vulnerable place.
There are many nerves on the terminal branches. In the event of an infection or granuloma, the consequences can be very deplorable.
Also, when introducing fillers into the area of the zygomatic minor and major muscles, care must also be taken, since cross-innervation is typical for this area.
I do not consider it necessary to talk about the supraorbital and supratrochlear nerve, since it is mainly botulinum toxin that is injected into the forehead, not fillers.
Infraorbital nerve. This zone is located 1 cm below the orbital ridge, under the central pupillary line. It is the infraorbital nerve – an area where extreme care must be taken to avoid damaging the nerves.
This is one of the most common problems with local anesthetic injection. As a result, the patient may get numbness of the upper part of the nose, cheeks and upper lip.
There is an area with a radius of 1.5 cm 1 cm below the lower edge of the orbit. It is in this area that the infraorbital nerve passes (see figure).
And the last thing you need to pay attention to, – mental nerve, which is very easy to find. It is located in the middle part of the upper jaw under the second premolar. A blocker is inserted into this area to immobilize the lower lip. When doing this, care must be taken not to damage the mental nerve.
When injecting fillers into the premaxillary region, we must take into account the superficial location of such nerves. This area contains a large number of nerves, damage to which can lead to a loss of sensation in the patient, as a result of which he may bite his lip.
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