FPSAM - Roundtable - 8

cannula might be even more so a false sense of security. It is a dilemma. Everything we do in the nose is
But I love the idea of staying directly on the bone, and
then when I am at the tip of cartilages, I am skiving my
needle right against cartilage and just below the skin.
Dr. Dayan: Sasha?
Dr. Rivkin: Yes, that is the depth that I try to go into.
But because as I am injecting I am moving the needle, I
take care not to stay in one place for any amount of
time at all. I will go through different layers, but I try to
stay relatively deep.
Also, I agree with Kay. Like her, I try to build columns to give support and maximal projection height to
the tissues that I want to augment. I like creating defined shapes.
Dr. Dayan: Sebastian, if someone uses a needle,
and they transect through a vessel on their way
down to the bone, is it possible that the filler could
retrograde through the canal that you just created
with the needle, and then it could enter into a vessel?
Dr. Cotofana: Yes, that is absolutely possible. It is
called a ''through-and-through phenomenon.'' The
problem is that when you aspirate, the tip of the needle
is extravascular, and then your aspiration is negative,
but the pathway of the needle is through the vessel.
When you apply the product, aspiration is negative,
the product can still migrate into the vessel. This is one
of the reasons why aspiration is so controversial.
However, recent studies have shown that actually if
you use the proper needle size and product-G prime
combination, preinjection aspiration works pretty
well. Then you can even have aspiration times < 2 s,
independent of product type used.
Dr. Dayan: To what product are you referring to in
Dr. Cotofana: I find this to be true across a variety of
different products. It just depends on the G prime. If
you have a high-G prime product, you can even aspirate if the needle size is appropriately chosen, for instance, with a 27-gauge needle.
Dr. Dayan: How important is it to inject slowly or to
inject at a tangential plane?
Dr. Cotofana: Injecting slowly is very important.
A recent study has shown that fillers behave like nonNewtonian fluids.2 This means that the viscoelastic
properties are a little bit different, and when you start the
initial part of the injection, you have a very high pressure

to start the movement of the filler. This is different as
compared with regular Newtonian fluids such as water.
When you start the injection procedure, you instantly exceed the systolic blood pressure, which is 60
to 80 mmHg in the nose, and then you can even push
the bolus against the arterial bloodstream. This is why
we always recommend injecting very slowly with low
pressure, because then you can still be below the arterial blood pressure, which could potentially prevent
the bolus from going against the stream into the ophthalmic arterial circulation.
Dr. Grunebaum: I would like to clarify the recommended ''safe,'' or let us call it ''safer'' layer for
lateral ala. Let us take, for instance, somebody who is
pinched for whom you are trying to give the appearance of putting the lateral ala on tension, the way we
would, say, with a lateral crural strut graft.
It is not superficial. I picture myself subdermal,
between where I would imagine the anatomic position
of the ala is just on top of that.
Dr. Dayan: So, do you mean the supraalar crease?
Dr. Grunebaum: Yes. But I mean also along the rim,
where people get pinched if they have been overresected laterally. I seek others' opinions on where the
safer plane is for that, because I do not think we have
clarified that.
Dr. Dayan: You are talking about lateral to the
lateral crus? In the fatty tissue?
Dr. Grunebaum: Yes. Or maybe even a little more
Dr. Durairaj: So the crease?
Dr. Dayan: The crease or where you put a rim graft,
or where you put a lateral crural-alar or strut
Dr. Grunebaum: Let us say either or both, because
both areas can have defects postrhinoplasty.
Dr. Dayan: Well, I mean, I think post-rhinoplasty,
that area gets really thin and scarred, and sometimes it is really hard to get filler in there. But I
have had great results with getting filler in there
and kind of like subsizing and breaking up the scar.
I always do get a little bit nervous when I treat that
area, but I have had nice results. And I also put it
along the rim, like a rim graft, and I have had good
results there as well.
But I feel a lot more comfortable with the 22gauge cannula. I know that nothing is 100% safe,
ª 2020 by American Academy of Facial Plastic and Reconstructive Surgery, Inc.


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