Prática de Shadowing: How to inject the nasolabial fold and avoid complications - Aprenda a falar inglês com o YouTube

So it's important to fill the piriform fossa when aging has started to show in that way.

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So it's important to fill the piriform fossa when aging has started to show in that way.

So you can sometimes give a little bit of elevation to the to the top lip in certain cases.

The way that I was taught many years ago was the one

that I think is worth knowing about that I think is most at risk

if you do the deep bolus on the periosteum is actually blocking the

Today we're talking about injecting the nasolabial fold or the piriform fossa.

So why is this area important?

So super important part of aesthetics because it's one of the key parts of the face that shows aging quite early on.

So I think you can often see this on a 38 year old,

you can see the process happening.

So nasolabial fold is almost a hinge point on the face.

So it's relatively mobile with a couple of ligaments,

but it becomes as the cheek descends as you get older and as it loses volume,

it starts to become a point where the skin flexes

and also where even the three-dimensional shape of the cheek and the midface can change.

So it's a place many injectors will look at treating relatively early on.

People are way better these days at treating the cheek as well at the same time.

But it's that important aspect that it's early and significant in terms of ageing of the midface.

Tell me more about the anatomy.

So the pre-orbicularis oculi fat pad is the inferior border.

You have obviously the muscle just above, just medial to that.

The most medial part of the space is the depressor nasi muscle.

So this muscle is just the one that pulls your nose down.

Laterally you have the deep medial fat pad and then the muscles that pass over it.

These are important because just above the muscles is also the fat pad

and this is where the artery runs just over the surf,

over the roof of the space.

So the depths are really important,

the three-dimensional anatomy is really important and I was going to show that to you on this little model here today.

Okay so this the piriform fossa which lies next to the piriform aperture gets its name from this aperture.

So right next to the aperture,

and by the way, piriform means pear-shaped.

So all it means is it's the shape of the pear.

And of course, we like to think of fancy names.

Whoops, I've knocked off the depressors, septi.

And the little fossa, the little indentation next to the piriform aperture is the area that has a potential space.

This means you can inflate it.

Some experiments have been done where they put air and also filler into it,

and it tends to fill this space.

It's a discrete space with several different boundaries that hold it.

So importantly, inferiorly, you've got the orbicularis oculi fat pad underneath it,

the poof, as we talked about.

Then medially, you've got the depressor septi as one of the boundaries.

So that's fallen off this model.

I'm going to stick it back on.

It's the medial boundary.

And then over the roof of this potential space is where the fat pad is and the artery.

So it's very important.

You can see by this structure here,

the facial artery and it becomes the angular artery runs over the space.

As we roll back the fat pad you can see where the space is

and this is really where we should be injecting.

The point that's also really worth understanding is if I remove this structure

which represents the piriform fossa you can see in the superior

lateral aspect of it there are probably a few strands near the bone of the infraorbital artery.

So these are the two arteries that can be injured when you're injecting here.

You have with this laid on top you have the facial artery where it becomes the angular artery

and then underneath it more superiorly and laterally you are very close to the infraorbital artery.

You also have the nerves that supply the top of the lip

so you will often find patients find this a little bit uncomfortable

if you just touch the nerve here but

that is a safer way of injecting in many ways than injecting more superficially which we're going to discuss in some detail.

So it's important to fill the piriform fossa

when aging has started to show in that way

And the reason aging demonstrates itself in the Perseform Fosso is because of bone loss,

number one, and fat loss, number two.

And then thirdly, when you've lost a little bit of bone and fat,

the muscles tend to become hypodynamic.

So that means they move more as you get older,

you get almost caricaturish.

So by stabilizing that area,

by re-volumizing it, you're going to also provide some support for the muscles

that support the lip

so you can sometimes give a little bit of an elevation to the to the top lip in certain cases

and this also will create a more natural movement

or a more harmonious movement when the patient smiles

so it's also a way that you can treat the gummy smile

and it will also partly support the cheek now i don't

most people wouldn't recommend using this injection to support the cheek

but it's one of the like I always say a push

and a pull go really well together

so we need a little bit of push a little bit of pull

and this is the support underneath so you can elevate the midface by using that area so there's several reasons to treat.

So how do you decide on the best technique to use?

It feels more stable to me I think it lasts a bit longer using a deep injection onto the periosteum.

The other approach that I might use might be with a cannula

but my experience is it seems to be less effective

and it is lying usually a little bit more superficial in the fat rather than on the periosteum

when you use a cannula

and that just has a couple of downsides to it in terms of tissue integration and stability in my experience.

So for those reasons I probably use the needle on the bone technique a little bit more than cannula.

Depends what else I'm doing on the face.

It's often appropriate in different people and more holistic treatments to use the cannula as well.

But that's the one I currently use the most.

The way that I was taught many years ago was basically to inject just underneath the dermis.

And this has definitely gone out of fashion.

And it's basically because you have the infralar artery,

a branch of the facial artery that comes off just under the nose.

It's pretty vulnerable if you're at the wrong level here.

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And similarly, the facial artery itself is a bit more vulnerable when you're at intermediate depths.

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For most injectors, there's one thing you do get by going deep is when you touch the bone,

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you know exactly what level you're at.

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There's no doubt.

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So what are the complications in this area?

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Obviously blocking the facial artery and blocking the infraorbital artery are the most common complications from treating the nasolabial fold.

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The one that I think is worth knowing about

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that I think is most at risk if you do the deep bolus on the periosteum is actually blocking the infraorbital artery.

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So I'm aware of a case where this happened.

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It's an area where the amount that you use in one spot is quite high and this automatically makes it more dangerous.

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Anywhere where you're injecting a bolus in one spot,

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it's safe if you're not in something but

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if you are in something the scale of the injury is much bigger

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and this is what I think happened in this particular case

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which is a blockage of the infraorbital artery and then flowing back

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and blocking the last part of the maxillary artery because that's where the infraorbital artery comes from.

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And this means damage to the blood splice in the midface and the nasopharynx and the palate.

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So really internal type injuries,

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very awful experience and we would hate that to happen to anyone.

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And hopefully by watching this it'll make you a little bit safer.

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I believe what happens in those cases is all to do with angle

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and I have talked about this before but I'll demonstrate it again on this if we...

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The facial artery is normally in the fat so if you're putting the needle in like this,

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you should, even if you go through the artery,

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you should be touching the bone.

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So you're going to be safer automatically as far as the facial artery is concerned.

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The problem with the bony injection comes when you're angled slightly up.

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So a good place to enter would be about here and you'd be underneath the artery.

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But if you're a novice injector and you angle up slightly,

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as you go deeper and deeper,

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you get more and more superior.

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You get closer and closer to these little vessels where the infralortal artery enters.

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And if you happen to land on one of them

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and they are deeper I've seen this on cadavers you'll find them deeper than the other vessels

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because they do emerge from the periosteum and then you might block

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that maxillary artery so it's very important that your angle is correct

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so it's this sort of angle I mean that changes everything

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if you're angled up slightly and this can just be

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that you're standing in a different position on the bed

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and it doesn't take much much to it

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but you really want to make sure that you're angled in such a way

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that as you get deeper you get further away from the infrarbital artery rather than closer to it.

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So that's a good way of thinking about it.

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If I go in at this angle,

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I'm getting closer the deeper I get.

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If I go in at this angle,

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I'm getting further the deeper I get.

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And that should help you stay safer and avoid blocking that blood vessel.

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Thank you very much for watching.

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I hope you learned a thing or two about the piriform fossa.

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Let me know what you think in the comments and we will see you next week.

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Prática de Shadowing: How to inject the nasolabial fold and avoid complications - Aprenda a falar inglês com o YouTube

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