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CosmeticInjectionTechniques ATextandVideoGuidetoNeurotoxinsandFillers
SecondEdition ThedaC.Kontis,MD,FACS AssociateProfessor
TheJohnsHopkinsUniversityHospital
Board-Certifi edFacialPlasticSurgeon FacialPlasticSurgicenter Baltimore,Maryland
VictorG.Lacombe,MD
Board-Certifi edFacialPlasticSurgeon SantaRosa,California
SarahE.Faris,MA,CMI AssistantProfessor
VirginiaCommonwealthUniversity SchooloftheArts MedicalIllustrator Richmond,Virginia
Forewordby JeanD.Carruthers,MD,FRCSC,FRC(Ophth) Fellow,AmericanSocietyofOphthalmicPlasticandReconstructiveSurgery ClinicalProfessor,DepartmentofOphthalmology UniversityofBritishColumbia Vancouver,BritishColumbia,Canada
127illustrations
Thieme NewYork • Stuttgart • Delhi • RiodeJaneiro
Executive Editor: Stephan Konnry
Managing Editor: J. Owen Zurhellen IV
Editorial Assistant: Holly Bullis
Director, Editorial Services: Mary Jo Casey
International Production Director: Andreas Schabert
Editorial Director: Sue Hodgson
International Marketing Director: Fiona Henderson
International Sales Director: Louisa Turrell
Director of Institutional Sales: Adam Bernacki
Senior Vice President and Chief Operating Officer: Sarah Vanderbilt
President: Brian D. Scanlan
Library of Congress Cataloging-in-Publication Data
Names: Kontis, Theda C., author. | Lacombe, Victor G., author.
Title: Cosmetic injection techniques : a text and video guide toneurotoxinsand fi llers/ThedaC.Kontis,VictorG. Lacombe;SarahE.Faris,medicalillustrator;foreword byJeanD.Carruthers.
Description:Secondedition.|NewYork:Thieme,[2019]| Includesbibliographicalreferencesandindex.
Identifi ers:LCCN2018051037|ISBN9781626234574 (hardback:alk.paper)|ISBN9781626234581(e-book)
Subjects:|MESH:CosmeticTechniques|Face–surgery| Injections,Subcutaneous–methods|Neurotoxins–therapeuticuse|DermalFillers–therapeuticuse| Face–anatomy&histology
Classifi cation:LCCRD119.5.F33|NLMWE705|DDC617.5/ 20592–dc23
LCrecordavailableathttps://lccn.loc.gov/2018051037
Copyright©2019byThiemeMedicalPublishers,Inc.
ThiemePublishersNewYork 333SeventhAvenue,NewYork,NY10001USA +18007823488,customerservice@thieme.com
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Cover design: Thieme Publishing Group Typesetting by DiTech Process Solutions
Printed in India by Replika Press Pvt. Ltd.
ISBN 978-1-62623-457-4
Also available as an e-book: eISBN 978-1-62623-458-1
Importantnote: Medicineisanever-changingscienceundergoingcontinualdevelopment.Researchandclinicalexperience arecontinuallyexpandingourknowledge,inparticularour knowledgeofpropertreatmentanddrugtherapy.Insofaras thisbookmentionsanydosageorapplication,readersmayrest assuredthattheauthors,editors,andpublishershavemade everyefforttoensurethatsuchreferencesareinaccordancewith thestateofknowledgeatthetimeofproductionofthebook
Nevertheless,thisdoesnotinvolve,imply,orexpressany guaranteeorresponsibilityonthepartofthepublishersin respecttoanydosageinstructionsandformsofapplications statedinthebook. Everyuserisrequestedtoexamine carefully themanufacturers’ leafl etsaccompanyingeach drugandtocheck,ifnecessaryinconsultationwithaphysicianorspecialist,whetherthedosageschedulesmentioned thereinorthecontraindicationsstatedbythemanufacturers differfromthestatementsmadeinthepresentbook.Such examinationisparticularlyimportantwithdrugsthatare eitherrarelyusedorhavebeennewlyreleasedonthemarket. Everydosagescheduleoreveryformofapplicationusedis entirelyattheuser’sownriskandresponsibility.Theauthors andpublishersrequesteveryusertoreporttothepublishers anydiscrepanciesorinaccuraciesnoticed.Iferrorsinthis workarefoundafterpublication,erratawillbepostedat www.thieme.comontheproductdescriptionpage.
Someoftheproductnames,patents,andregistered designsreferredtointhisbookareinfactregisteredtrademarksorproprietarynameseventhoughspecifi creference tothisfactisnotalwaysmadeinthetext.Therefore,the appearanceofanamewithoutdesignationasproprietaryis nottobeconstruedasarepresentationbythepublisherthat itisinthepublicdomain.
54321
Thisbook,includingallpartsthereof,islegallyprotectedby copyright.Anyuse,exploitation,orcommercializationoutside thenarrowlimitssetbycopyrightlegislation,withoutthe publisher’sconsent,isillegalandliabletoprosecution.This appliesinparticulartophotostatreproduction,copying, mimeographing,preparationofmicrofi lms,andelectronicdata processingandstorage.
IdedicatethissecondeditiontoDavidandAlexandra,fortheirloveandsupport;toMom,mygreatestfan;andto thememoryofmyfather,myangel.
Idedicate,withlove,thissecondeditiontomywife,Alice,andtomychildren,VictoriaandMax:youallmeanthe worldtome.
Wejointlydedicatethisbooktoourpatients,whosetrustandfeedbackallowustoimproveandrefi neour injectiontechniques.
21NeurotoxinInjectionforNecklaceLines
23NeurotoxinInjectionforNefertitiNeckLift .............................63
24NeurotoxinInjectionforMasseterHypertrophy
25NeurotoxinInjectionforParotidGlandHypertrophy
26NeurotoxinInjectionforSubmandibularGlandHypertrophy ......71
27NeurotoxinInjectionforGustatorySweating(FreySyndrome) ...73
29NeurotoxinInjectionforProfuselySweatingScalpandForehead ...78
30NeurotoxinInjectionforProfuselySweatingHands
32NeurotoxinInjectionforChronicMigraines
48FillerInjectionforSunkenUpperEyelids
50FillerInjectionforSunkenTemples .......................................141
51FillerInjectionforNonsurgicalRhinoplasty ............................144
52FillerInjectionforNasalValveStenting ..................................150
53FillerInjectionforMedialMidfaceHollowing..........................152
54FillerInjectionforCheekboneAugmentation
55FillerInjectionforSunkenCheeks
56FillerInjectionforCheekLift:deMaioTechnique
57FillerInjectionforChinAugmentation ...................................164
58FillerInjectionfortheMentalCrease
59FillerInjectionforJawlineRejuvenation .................................169
60FillerInjectionforMandibularAngleAugmentation ................171
61FillerInjectionforEarlobeRejuvenation ................................173
62FillerInjectionforAcneScars ...............................................175
63FillerInjectionforAgingHands
64FillerInjectionwithPoly-L-LacticAcidforFacialVolumizing (Sculptra) .........................................................................180
65FillerInjectionwithPoly-L-LacticAcidfortheDécolleté ...........183 66The “LiquidFacelift” ...........................................................186 67Gender-SpecificInjections ...................................................188
SectionVIFat-DissolvingInjections
69SubmentalFatReduction
SectionVIIAppendices
AppendixA:Neurotoxin/FillerInjectionTechniquesbyAdvancing DifficultyandInjector’sExperience .......................................202
AppendixB:SampleInformedConsentFormforNeurotoxin Injections ..........................................................................204
AppendixC:SampleInformedConsentFormforFillerInjections .........205
AppendixD:SampleInformedConsentFormforKybellaTreatment ....206
Foreword Dr.ThedaC.KontisandDr.VictorG.Lacombehavenow publishedtheircombinedexperiencesinthissecond editionoftheirpracticalhandbook, CosmeticInjection Techniques.The fi rsteditionwasnotonlyabestseller butalsohadsuchqualityvideosthattheywerethe mostaccessedvideosinallofThieme’slibrary.The authorshaveagaindoneasuperbjobinmakingfacial tissue “transparent” foreveryoneinterestedinthis increasinglyimportantsubjectarea.Newsubjectscoveredincludetheinjectableconsultation,choosingthe right fi ller,neurotoxinand fi llertreatmentforthe décolleté, fi llertothemandibularangleandjawline, thedeMaiotechniqueformidfacevolumization,neurotoxinsforsweatyscalpsandforeheads, fi llersfor fi ne lines,andgender-specifi cindications/injections.With thenewuseofsodiumdeoxycholatethereisafurther sectiononsubmentalfatinjections.
Cosmeticsurgeonshavetheprivilegeofusing transcutaneoustreatmentstorestorepatients’ faces totheirnaturalbest.Thisbookwithitsvideosisa laboroflovewrittenbyhighlyrespectedauthorswho discussvariationsintechniquesfromtheEastandthe WestCoastsoftheUnitedStates.Irecommendittoall readerswhochoosetoreviewtheirtreatmentplans fromstartto fi nishandwhovaluelearningfrom expertswhoteachwithpassionaswellasknowledge.
JeanD.Carruthers,MD,FRCSC,FRC(Ophth) Fellow,AmericanSocietyofOphthalmicPlasticand ReconstructiveSurgery ClinicalProfessor,DepartmentofOphthalmology UniversityofBritishColumbia Vancouver,BritishColumbia,Canada
Preface IhearandIforget. IseeandIremember. IdoandIunderstand.
– attributedtoConfucius(551–479BCE)
Wearepleasedtopresentthisrevisedsecond editionof CosmeticInjectionTechniques:ATextand VideoGuidetoNeurotoxinsandFillers .Thisnew editionincludesnew fi llersandnewtechniquesas wellasinformationonfat-dissolvinginjections. Theaccompanyingvideoshavealsobeenupdated. Ourreadersfoundthe fi rsteditiontobeahandy quick-referenceguideaswellasaguidetonew injectiontechniques.Patientsintheof fi cehave enjoyedlookingthroughthistextsotheymay betterunderstandtheinjectionstheyareaboutto receive,andinjectorshavefoundthediagramsto beusefulforpatienteducation.
Thenumberofnon-surgicalfacialenhancements hascontinuedtoskyrocketsinceour fi rsteditionwas published.Asaconsequenceofpatientdemand,many physicians,nurses,andphysicianassistantshavebegun totreatsuchpatients.Thisbook,withitsaccompanying videos,ismeanttobeaguideandquickreferencefor themanyprofessionalsandparaprofessionalswho havebecomefacialinjectors.Itisnot,however,a trainingmanualforthenaiveinjector.Wehighlydiscouragethenoviceinjectorfromusingthisbookasa primeroninjections.Inouropinion,nothingcan replacetrainingthatisofferedbycoursesandby one-on-onepreceptorships.
Thisbookisdesignedtoaugmenttheknowledgeof abeginnerinjectorandtotraintheexperienced injectorinhowtoperform “fi nesse” injections.The facecanbeshapedandminorirregularitiesand asymmetriesimprovedbyperformingthetechniques wedescribe.Inaddition,wehopetohelptheinjector “lookthrough” theskintotheunderlyinganatomy. Thiswillhelpwithboththetargetsofinjectionand theimportantstructurestoavoid.Theauthorsare awarethatthereismorethanonewaytotreatagiven anatomicregion.Itwasouraim,byhavingauthors fromtwoverydifferentlocales(theEastandtheWest CoastsoftheUnitedStates)anddifferentpractices,to describethe “best” injectiontechniquebycomparing ourtechniquesofinjection.Incaseswherethe authors’ techniquesdiffermarkedly,bothtechniques arepresented.
Theproductsdescribedh ereinareallU.S.Food andDrugAdministration(FDA)-approved fi llers andneurotoxins;however,mostofthetechniques describedareconsidered “ off-label ” usesofthe products.Thedosesofproductsdescribedserveas ageneralguideforinjection.Whiletheutmostcare wastakentoassuretheaccuracyofthedosages listed,weurgeinjectorstousetheirbestjudgment orexperienceintheunlikelyeventthatamisprint suggestsaninappropriatedose.Thecommentswe makeaboutspeci fi cproductsareoftenouropinion derivedfromclinicalobservation.Othersmayhave differentobservationsclinically,andwerespect thesevariationsinclinicalpracticesandresults.
Werealizethatthisbookwillbeutilizedby injectorswithdifferingskilllevels.Inanattemptto promotesafetyintheuseoftheseproducts,wehave devisedaratingscaleforeachtechnique.Eachinjectiontechniqueisevaluatedintermsofdif fi cultyfor thetrainer,risksinvolvedinperformingtheinjection,andpatientsatisfactionwiththeresults. AppendixAliststhechaptersbydegreeofdif fi culty, asacrossreferenceforinjectorswhowouldliketo safelyadvancetomorechallenginginjectiontechniques.Theratingsystemissummarizedasfollows:
Degreeofdiffi cultyfortheinjector:
● Easy
●● Intermediate
●●● Advanced
●●●● Expert(onlyexpertinjectorsshouldattempt theseinjections)
Patientsatisfactionwiththeprocedure:
● Variableresults,resultsmaybesubtle
●● Goodresults,patientsusuallypleased
●●● Highpatientsatisfaction,predictableresults
Risksofcomplications:
● Low
●● Medium
●●● High
Theproductsdescribedinthisbookinclude Botox,Dysport,Xeomin,Restylane,RestylaneLyft, RestylaneSilk,RestylaneRefyne,RestylaneDefyne, JuvédermVolbella,JuvédermVollure,Belotero,Radiesse,
Sculptra,andBellafill.Theseproductsarethemost commonlyused fillersandneurotoxinsatthetimethis manualisbeingwritten.Newproductsarecontinually beingdevelopedandmaybeavailablebythetimeof publication.However,becausewehavenoexperience withthesenewproducts,theyarenecessarilynot describedinthissecondedition.Experiencedinjectors, however,willbeabletoextrapolatethetechniquesand dosingstrategiesdescribedinthisbooktonewerproducts,iftheysodesire.
Disclosures: ThedaC.Kontisisaspeaker/trainerfor AllerganandforGalderma.VictorG.Lacombeisa
speaker/trainerforAllerganandforGaldermaand servedasaprincipalinvestigatorforJuvédermVoluma.
Disclaimer: Thematerialpresentedisacompilation oftheclinicalexperiencesoftheauthors.Off-labeluses ofFDA-approvedproductsaredescribed.Aqualified healthcareprofessionalshouldbeconsultedbefore usinganytherapeuticprocedurediscussed.Readers shouldverifyallinformationanddatabeforetreatingpatientsoremployinganytherapiesdescribedin thispublication.
Acknowledgments Theauthorsbelievedthatasimplifi ed,well-illustrated, andthoroughguidetoinjectableswasneededin themedicalliterature.TheeditorsatThiemePublishers,inparticularTimothyHiscock,trustedour vision,andinthe fi rsteditionweproducedoneof thebest-sellingbooksandmostaccessedvideosin Thieme ’scollection.Weweredelightedwhenasked toproducethissecondedition.
Weappreciatetheeditorialsupportandassistance fromJ.OwenZurhellenandSueHodgsonatThieme,
whokepttheprojectmovingforward.Thequalityofthis bookhasmuchtodowiththe fi neartworkofour medicalillustrator,SarahE.Faris,whograciouslyagreed tocontinuetheworkinthisedition.Herattentionto detailandartisticskillmadethistextbookonethatisnot onlythoroughbuteasytoreadandunderstand.
Finally,andmostimportantly,wethankour patientswhohaveagreedtohavetheirprocedures fi lmedsothatmedicalprofessionalscanlearnsafe andeffectiveinjectiontechniques.
MenuofAccompanyingVideos Video6.1 NeurotoxinInjectionforGlabellarFrownLines
Video6.2 NeurotoxinInjectionforGlabellarFrownLines
Video6.3 NeurotoxinInjectionforGlabellarFrownLines
Video6.4 NeurotoxinInjectionforGlabellarFrownLines,ForeheadWrinkles,SmileLines,andCrow’sFeet
Video6.5 NeurotoxinInjectionforGlabellarFrownLines,ForeheadWrinkles,andLowerEyelidRoll
Video6.6 NeurotoxinInjectionforGlabellarFrownLinesandForeheadWrinkles
Video6.7 NeurotoxinInjectionforGlabellarFrownLinesandDimpledChin
Video6.8 NeurotoxinInjectionforGlabellarFrownLines
Video6.9 NeurotoxinInjectionforGlabellarFrownLines
Video6.10 NeurotoxinInjectionforGlabellarFrownLines
Video7.1 NeurotoxinInjectionforForeheadWrinkles
Video7.2 NeurotoxinInjectionforForeheadWrinkles
Video7.3 NeurotoxinInjectionforForeheadWrinkles
Video7.4 NeurotoxinInjectionforForeheadWrinkles
Video7.5 NeurotoxinInjectionforGlabellarFrownLines,ForeheadWrinkles,SmileLines,andCrow’sFeet
Video7.6 NeurotoxinInjectionforGlabellarFrownLinesandForeheadWrinkles
Video7.7 NeurotoxinInjectionforGlabellarFrownLines,ForeheadWrinkles,andLowerEyelidRoll
Video7.8 NeurotoxinInjectionforForeheadWrinkles
Video7.9 NeurotoxinInjectionforForeheadWrinkles
Video8.1 NeurotoxinInjectionforGlabellarFrownLines,ForeheadWrinkles,SmileLines,andCrow’sFeet
Video8.2 NeurotoxinInjectionforLowerEyelidRoll
Video8.3 NeurotoxinInjectionforSmileLinesandCrow’sFeet
Video8.4 NeurotoxinInjectionforSmileLinesandCrow’sFeet
Video8.5 NeurotoxinInjectionforSmileLinesandCrow’sFeet
Video9.1 NeurotoxinInjectionforLateralBrowLift
Video10.1 NeurotoxinInjectionforChemicalBrowLift
Video10.2 NeurotoxinInjectionforChemicalBrowLift
Video11.1 NeurotoxinInjectionforGlabellarFrownLines,ForeheadWrinkles,andLowerEyelidRoll
Video12.1 NeurotoxinInjectionforBunnyLines
Video13.1 NeurotoxinInjectionforNasalTipLift
Video15.1 NeurotoxinInjectionforElevatingtheOralCommissures
Video16.1 NeurotoxinInjectionforLipLift
Video17.1 NeurotoxinInjectionforSmoker’sLines
Video18.1 NeurotoxinInjectionforGummySmile
Video19.1 NeurotoxinInjectionforDimpledChin
Video19.2 NeurotoxinInjectionforGlabellarFrownLinesandDimpledChin
Video19.3 NeurotoxinInjectionforElevatingtheOralCommissuresandforDimpledChin
Video19.4 NeurotoxinInjectionforElevatingtheOralCommissuresandforDimpledChin
Video19.5 NeurotoxinInjectionforDimpledChin
Video20.1 NeurotoxinInjectionforPlatysmalBanding
Video21.1 NeurotoxinInjectionforNecklaceLines
Video22.1 NeurotoxinInjectionfortheDécolleté
Video23.1 NeurotoxinInjectionforNefertitiNeckLift
Video24.1 NeurotoxinInjectionforMasseterHypertrophy
Video24.2 NeurotoxinInjectionforMasseterHypertrophy
Video28.1 NeurotoxinInjectionforProfuselySweatingUnderarms
Video35.1 DentalBlock1
Video35.2 DentalBlock2
Video38.1 FillerInjectionforNasolabialFoldsandElevatingtheOralCommissures
Video38.2 FillerInjectionforNasolabialFolds,MarionetteLines,andElevatingtheOralCommissures
Video38.3 FillerInjectionforNasolabialFolds,MarionetteLines,andElevatingtheOralCommissures
Video38.4 FillerInjectionforNasolabialFolds,MarionetteLines,ElevatingtheOralCommissures,and JawlineRejuvenation
Video38.5 FillerInjectionforNasolabialFolds,MarionetteLines,andJawlineRejuvenation
Video38.6 FillerInjectionforNasolabialFolds,MarionetteLines,ElevatingtheOralCommissures,and MentalCrease
Video38.7 FillerInjectionforNasolabialFolds,ElevatingtheOralCommissures,TearTroughDeformity,and SunkenCheeks
Video38.8 FillerInjectionforNasolabialFolds,MarionetteLines,andJawlineRejuvenation
Video38.9 FillerInjectionforNasolabialFolds,ElevatingtheOralCommissures,MentalCrease,and JawlineRejuvenation
Video38.10 FillerInjectionforNasolabialFolds
Video40.1 FillersforFineLinesandSkinBoosters
Video40.2 FillersforFineLinesandSkinBoosters
Video41.1 FillerInjectionforMarionetteLines
Video41.2 FillerInjectionforMarionetteLines,LipAugmentation,andElevatingtheOralCommissures
Video41.3 FillerInjectionsforNasolabialFolds,MarionetteLines,andJawlineRejuvenation
Video41.4 FillerInjectionsforNasolabialFolds,MarionetteLines,andJawlineRejuvenation
Video41.5 FillerInjectionsforNasolabialFolds,MarionetteLines,ElevatingtheOralCommissures,and MentalCrease
Video41.6 FillerInjectionsforNasolabialFolds,MarionetteLines,ElevatingtheOralCommissures,and JawlineRejuvenation
Video42.1 FillerInjectionforLipAugmentation
Video42.2 FillerInjectionforMarionetteLines,LipAugmentation,andElevatingtheOralCommissures
Video42.3 FillerInjectionforLipAugmentation,ElevatingtheOralCommissures,andforVerticalLipLines
Video42.4 FillerInjectionforLipAugmentation
Video43.1 FillerInjectionforNasolabialFolds,MarionetteLines,ElevatingtheOralCommissures,and MentalCrease
Video43.2 FillerInjectionforLipAugmentationandforElevatingtheOralCommissures
Video43.3 FillerInjectionforNasolabialFolds,ElevatingtheOralCommissures,TearTroughDeformity,and SunkenCheeks
Video43.4 FillerInjectionforNasiolabialFolds,MarionetteLines,ElevatingtheOralCommissures,and JawlineRejuvenation
Video43.5 FillerInjectionforMarionetteLines,LipAugmentation,andElevatingtheOralCommissures
Video43.6 FillerInjectionforLipAugmentation,ElevatingtheOralCommissures,andforVerticalLipLines
Video43.7 FillerInjectionforElevatingtheOralCommissures
Video43.8 FillerInjectionforElevatingtheOralCommissures
Video43.9 FillerInjectionforElevatingtheOralCommissures
Video43.10 FillerInjectionforElevatingtheOralCommissures
Video44.1 FillerInjectionforLipAugmentation,ElevatingtheOralCommissures,andforVerticalLipLines
Video44.2 FillerInjectionforVerticalLipLines
Video44.3 FillerInjectionforVerticalLipLines
Video45.1 FillerInjectionforGlabellarFrownLines
Video47.1 FillerInjectionforTearTroughDeformityandCheekboneAugmentation
Video47.2 FillerInjectionforTearTroughDeformityandMedialMidfaceHollowing
Video49.1 FillerInjectionforLateralBrowLift
Video49.2 FillerInjectionforLateralBrowLift
Video49.3 FillerInjectionforLateralBrowLift
Video50.1 FillerInjectionforSunkenTemples
Video51.1 FillerInjectionforNon-SurgicalRhinoplasty
Video52.1 FillerInjectionforNasalValveStenting
Video53.1 FillerInjectionforMedialMidfaceHollowing
Video54.1 FillerInjectionforCheekboneAugmentation
Video54.2 FillerInjectionforCheekboneAugmentation
Video55.1 FillerInjectionforNasolabialFolds,ElevatingtheOralCommissures,TearTroughDeformity,and SunkenCheeks
Video56.1 FillerInjectionforCheekLift:ThedeMaioTechnique
Video58.1 FillerInjectionfortheMentalCrease
Video58.2 FillerInjectionforNasolabialFolds,MarionetteLines,ElevatingtheOralCommissures,andMental Crease
Video59.1 FillerInjectionforJawlineRejuvenation
Video59.2 FillerInjectionforNasolabialFolds,MarionetteLines,andJawlineRejuvenation
Video59.3 FillerInjectionforNasolabialFolds,MarionetteLines,andJawlineRejuvenation
Video59.4 FillerInjectionforJawlineRejuvenation
Video61.1 FillerInjectionforEarlobeRejuvenation
Video63.1 FillerInjectionforAgingHands
Video63.2 FillerInjectionforAgingHands
Video64.1 FillerInjectionwithPoly-L-LacticAcidforFacialVolumizing(Sculptra)
Video64.2 FillerInjectionwithPoly-L-LacticAcidforFacialVolumizing(Sculptra)
Video69.1 InjectionTechniqueforSubmentalFatReduction
