FPSAM - Roundtable - 7

Dr. Cotofana: Sure. I am happy that we all agree that
we should stay in the midline of the nose. That is,
0.5 cm lateral to the midline, there is the transition
between bone and cartilage. Where the bone stops and
the cartilage begins, we have an artery emerging laterally on both sides. This artery is the terminal branch
of the anterior ethmoidal artery, which is one of the
branches of the ophthalmic artery. So, this is one of the
anatomic reasons to stay in the midline.
This artery connects into more superficial layers
with the lateral nasal artery. It also connects with the
alar artery, and with branches from the contralateral
side forming multiple anastomosis. Everybody says it
is just one connection from one side to the other, which
is the dorsonasal. But actually, we have anastomosis
everywhere, and one of the most prominent areas of
anastomosis is the tip of the nose.
So, when they connect, whether just left and right
and top and bottom, all of these arteries merge and
connect to the angular artery, which then also connect
to the supratrochlear artery.
This emergent point of the supratrochlear is where
the medial inferior aspect of the eyebrow is. Authors
from a previously published article concluded that
compressing this area can increase safety because one
can block the pathway from extraorbital to intraorbital.1
Dr. Dayan: Do you believe this method is effective?
Dr. Cotofana: If we know that the ophthalmic artery
has a total of 13 branches, and it connects to everywhere in the face, and we just block one of these
pathways, it is questionable. At the moment there is no
evidence against it, but also at the moment there is no
evidence for it either. So, we do not know.
But the thing is, we are trying to keep our patients
safe. This is why we try to do everything possible
within our means. As long as there is no evidence
against it, why not?
The other thing when we speak about the pros and
cons between the needle versus the cannula, it has been
shown that with the cannula, especially the 22-gauge
cannula, they need a significantly increased amount of
force to penetrate into the artery, and this can be
considered to be safer. This is why I agree with Steve
here about using a 22-gauge cannula, because if you go
higher up to a 27-gauge cannula, there is no difference
in the potential to penetrate an artery with a 10- and 7gauge cannula and a 27-gauge needle.
Everybody thinks needles are more precise. Recent
studies have shown that when you inject with a needle
and make contact with a bone, the product will migrate
along the created injection canal, which distributes the
product uncontrolled into more superficial areas, and
on the nose, the vessels are located in those more superficial layers.
ª 2020 by American Academy of Facial Plastic and Reconstructive Surgery, Inc.

However, another study has shown that if the injection canal is small, the product will be less likely to
spread into more superficial layers. And this would also
favor having a needle with a very very small diameter,
and injecting in contact with the bone because the
probabilities are higher that the product will stay down
and not migrate through the created injection canal.
When we summarize this, the nose is a high-risk
area, but we just need to be aware which layers inherit
greater risk, and if we think we are in that respective
layer, it does not give us 100% safety, because, for
instance, there are many cases done with a cannula that
have resulted in irreversible blindness.
My personal explanation for this is that the injector
was likely thinking he or she was deep, but actually
was not. And despite using a cannula, a 25-gauge or a
22-gauge, but not being in the right plane would still be
a potential risk. So, in this instance it is very important
to know which layer you are in.
Dr. Dayan: So which layer are you recommending?
You are below the SMAS, right?
Dr. Cotofana: Yes, correct. But we have to be aware
that, for instance, at the nasal ala, there is no layered
arrangement. Wherever there is no cartilage and where
there is no bone, we have no layered arrangement.
This also holds true for the tip of the nose. It is very
difficult to stay deep at the tip of the nose depending on
where we enter the soft tissues.
Dr. Dayan: So, if we are using a needle, we should be
either deep on the bone or superficial, just below
the skin. Are those the layers that are safer?
Dr. Cotofana: Yes, that is correct. With the needle,
the injector should be either deep in contact with the
bone in the midline or, if we want to stay superficial,
then really almost intradermally, as superficial as we
possibly can be.
Dr. Dayan: So, Kay and Sasha and Lisa, you all use
needles. Is this consistent with the way you are
Dr. Durairaj: I think that is consistent, and I also
agree with Sasha about using the insulin syringe with
the 31-gauge needle. Once you try that, you will never
switch to the other needle, because there is very little
injection force, and it is extremely precise. And I do
not mind the fact, Sebastian, that t0he filler can come
up and around the needle tip, because I actually like to
create vertical columns of support in that manner.
And I definitely agree with Lisa that when you aspirate and your hand moves, what is the point? So,
aspiration is a false sense of security. In contrast, the


FPSAM - Roundtable

Table of Contents for the Digital Edition of FPSAM - Roundtable

FPSAM - Roundtable - Cover1
FPSAM - Roundtable - Cover2
FPSAM - Roundtable - i
FPSAM - Roundtable - ii
FPSAM - Roundtable - 1
FPSAM - Roundtable - 2
FPSAM - Roundtable - 3
FPSAM - Roundtable - 4
FPSAM - Roundtable - 5
FPSAM - Roundtable - 6
FPSAM - Roundtable - 7
FPSAM - Roundtable - 8
FPSAM - Roundtable - 9
FPSAM - Roundtable - 10
FPSAM - Roundtable - Cover3
FPSAM - Roundtable - Cover4