FPSAM - Roundtable 2021 - 2

EXPERT PANEL DISCUSSION
location. Which thickness or thinness of filler is
going to be best to utilize there is an essential part of
the decision making.
Dr. Dayan: Dr. Sabrina Fabi: As mentioned,
NASHA has been around since 2003. How important
is it to you that NASHA has been, and remains,
well tested and well studied?
Dr. Fabi: Exceptionally important. It certainly offers
me a level of comfort, especially with a rise in the
reporting of delayed-onset inflammatory reactions that
we see with certain other products.
Dr. Dayan: Dr. Sebastian Cotofana: As you know,
there are different sizes ofG prime: Lyft, Silk, and
Restylane all have slightly different indications, but
they overlap, too. How important is the rheology of
these products to where we place them in the
anatomy, whether it is the dermis, mid dermis, deep
dermis, or subcutis?
Dr. Cotofana: The rheology influences where the
product is injected. Because we know from various
studies of different groups that once the product is in
the tissue, it distributes, and this distribution depends
highly on the G prime. It depends on, of course, injection
pressure and the needle or cannula that you
use, but also highly on the product because as you
can imagine, a softer product will diffuse into other
tissue layers, as opposed to a very rigid and high G
prime product that would stay exactly where you
place it. All aspects are influenced by rheology.
Dr. Dayan: Thank you Dr. Cotofana. I want to
bridge over to XPresHAn, the expression technology,
is also aHA. OftheseHAs there is Refyne, there
is Kysse, and there is Defyne. These products have a
higher percentage of cross-linking: Refyne 6%,
Kysse 7%, and Defyne 8%, which means these
products have the ability to move with the tissue
and, therefore, may affect the way we treat patients.
Dr. Fabi, when you treat a patient, especially
around the lower third ofthe face, how important is
that ability for the product to move with the face?
Dr. Fabi: We coauthored an article on this topic. To
answer your question, the ability for the product to
move with the face plays a significant role, especially
in a very dynamic area such as the lower face where
there might not be underlying bone in some areas to
support the product; however, I must also emphasize
that respecting the anatomy, knowing where you're
injecting your product, the product you choose to use,
how much of the product is placed, and then the level
of expertise of the injector are essential components to
quality outcomes.
2
Dr.Dayan:Dr.Rosengaus, canyoucommenta little bit
about the depth of where you place the product whetheryou'reusingXpresHAnortheNASHAproducts?
Dr.
Rosengaus: One must take into consideration that
product selection is dependent on both what you want
to achieve with the product itself-support and lift, or
flexibility-and integration. Along with these considerations,
the depth of injection is another concept
that has to be included in the algorithm of selection.
And the higher the particle size, and the higher the
support, the more important it is to inject deeper.
Dr. Dayan: Dr. Durairaj, let us say someone has a
deep marionette line or a deep oral commissure.
How important is the technique you choose to use,
whether it is threading, serial puncture, linear
retrograde, crosshatching, and fanning-what
causes you to vary the technique or approach you
use when treating these lines and folds?
Dr. Durairaj: That is a great question. Especially in
that lower aspect of the face, it is so important to build
buttresses of support. The corners of the mouth and the
oral commissures tend to hang and droop and that is in
addition to the gravitational and fat changes that cause
jowling, and so I am always strategizing to build
vertical buttresses of support along the oral commissures
of the mouth. I tend to inject deeper there, and
one of the reasons I do like the XPresHAn technology
there is because the molecules are thick, the G prime is
robust, and it does give a lot of support, and yet it has
the stretchability and movement in the tissue.
To add to that, I think that the soft tissues around the
mouth and lower face tend to hang off the face as the
skeleton ages and changes; we have bone density
change, we have dental change, gingival change, and so
the skin of the mouth and lips and cheeks becomes this
loose, hanging envelope. The more one can build an
architecture that gives strong buttresses of support in
the inferior face, the lower part of the face, themore one
will have a natural look, but you also really need the
movement. You do not want to have a sausage-y rubbery
looking appearance to the lower face because the
human brain can really just detect when movements are
not natural and fluid. Personally, I like injecting the
NASHA there, and am using that deeper retrograde
linear injection technique to build those buttresses.
Dr. Dayan: Dr. Cotofana, can you comment about
the labiomandibular ligament, which is not a true
ligament, versus the mandibular ligament, which is
a true ligament. Is there a way that you can suggest
that we inject the product so that we work best
against the forces of the true ligaments that are tied
down to the bone?
ª 2021 by American Academy of Facial Plastic and Reconstructive Surgery, Inc.

FPSAM - Roundtable 2021

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