Master Techniques in Otolaryngology - Head and Neck Surgery: Facial Plastic Surgery by Unknown

Author:Unknown
Language: eng
Format: epub

Injection

If the patient is not under general anesthesia or deep sedation, a local nerve block is beneficial as it reduces excess contour changes from the local infiltration itself. Infraorbital and supraorbital regional nerve blocks are often used. Additional local anesthetic infiltration may be added as needed. For full face injection, the following port locations are typically created using an 18-gauge needle: superior brow, temporal hairline, medial cheek, zygoma, lateral upper lip near the commissure, prejowl sulcus, chin, ear lobule, submental sulcus, and neck (Fig. 29.7). All parts of the face are accessible through a combination of these ports (Fig. 29.8). The skin and soft tissue are stabilized with the nondominant hand, and the cannula is inserted and advanced through the tissues to the appropriate plane. Adipose tissue can be injected with an anterograde movement of the cannula toward the recipient area and on the withdrawal motion of the cannula depending on location. Thinner tissue or subcutaneous injections are usually best injected as the cannula is withdrawn, but operator experience and preference are the determining factors. Once the cannula has reached the desired location, the plunger of the 1-mL syringe is gently pushed while the cannula is withdrawn depositing between .01 and .05 mL per pass in most cases. This retrograde injection of adipose tissue allows for a more controlled and safer application of adipose tissue and reduces the risk for contour irregularities. One should be very judicious in applying pressure on the plunger, and if the adipose tissue does not exit the syringe with minimal pressure, it should be withdrawn and checked for obstruction. This smooth, incremental placement allows for optimal surface area contact with native tissues and increased nutrition and neovascularization. It also reduces the risk of large lumps or other surface contour irregularities. I typically dilute the adipose tissue by 20% by adding 2 mL of lactated Ringer’s to 8 mL of adipose tissue to be used in the periorbital region and temple of other areas of thin tissue in a subcutaneous plane.

FIGURE 29.5 Machine that is used for centrifuge.

FIGURE 29.6 Adipose tissue is centrifuged at 3, 5, and 10 minutes to see how much infranatant is present. There is concern that centrifuge greater than 3 minutes may be linked with less viability of adipose tissue.

FIGURE 29.7 An 18-G needle is inserted to allow for injection of adipose tissue into the anterior triangle. Through this, one can also access the entire cheek area.

A major goal of the technique is to achieve the distribution of adipose tissue parcels into multiple tissue planes, moving from deep to superficial, using a fanning technique when appropriate:

Deep: above the periosteum

Middle: within the muscle and deep subcutaneous plane

Superficial: within the subcutaneous plane

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