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CASE DemonstrationS Applying Harmony Programme to Daily Practice Dr Peter Huang Plastic Surgeon


Dr Peter Huang currently heads the Rebecca Cosmetic Center in Taipei. Over the years, he has held stints in various hospitals in Taiwan including the position of a Plastic Surgeon for Cathay General Hospital and Attending Doctor at the Plastic Surgery Department of Taipei Medical University Hospital, Taiwan.

Dr Peter Huang Plastic Surgeon

Dr Huang received his medical degree from the China Medical University, Taiwan in 1989. After which, he commenced his housemanship in Cathay General Hospital and subsequently specialised in plastic surgery. He was also a Fellow at the Columbia University Hospital and Stanford University, USA in 1994 and 2002 respectively. Dr Huang is a Board Member for Taiwan Society for Burn Injuries and Wound Healing and also Dean of Plastic Surgeon at Min-Shen General Hospital. In addition, Dr Huang is the Executive Chairman of Elsye Aesthetic Center in Min-Shen General Hospital, Taiwan.


CASE DEMONSTRATIONS: AN OVERVIEW In these case studies, Dr Huang demonstrated the application of the Harmony Programme to provide personalised treatment tailored to his patients’ needs.

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Dehydration

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2 Weeks After Treatment Session III

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Before Start of Treatment

Dehydration

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Loss of elast icity

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2 Weeks After Treatment Session III

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ph ol Asym og met ry y

Before Start of Treatment

Dehydration

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Su rfa

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2 Weeks After Treatment Session III

SYLVIA

Loss of elast icity

Before Start of Treatment

Ms Yau

Loss of elast icity

MANDY

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SESSION I: Improving Morphology by Enhancing the Contour of the Lower Face and Correcting Temple Depletion

SESSION I: Improving Volume Loss through Facial Augmentation

SESSION I: Improving Morphology through Midline Correction

To achieve better symmetry and facial balance by providing nice contour to temple and chin using Restylane Perlane Lidocaine

To improve the facial contour and skin quality using Restylane Perlane Lidocaine and Restylane Lidocaine

To improve midline projection with Restylane Perlane Lidocaine

SESSION II: Improving Volume Loss and Reducing Dynamic Folds

SESSION II: Improving Sagging through Vector Lift

SESSION II: Improving Volume Loss at Upper Face

To soften the nasolabial folds and augment the infraorbital area using Restylane Perlane Lidocaine

To create a vector at hairline and achieve a midface lift

To attain a better contour at the upper face through augmentation of the temple area with Restylane Perlane Lidocaine

SESSION III: Improving Skin Quality

SESSION III: Skin Rejuvenation

SESSION III: Improving Volume Loss at Midface and Softening Dynamic Folds

To look more hydrated and reduce skin pores, scar marks and fine lines using Restylane Vital Light Lidocaine and botulinum toxin

To enhance skin quality using Restylane Vital Light Lidocaine

To create a smoother facial contour by softening the nasolabial folds and the hollowness of the cheeks using Restylane Perlane Lidocaine

Before start of treatment 2 weeks after treatment session III

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Case Demonstration I PATIENT’S SELF-ASSESSMENT AND NEEDS PERSONAL DETAILS

Mandy, 22 year-old female

AESTHETIC PROCEDURE BACKGROUND

Mandy has undergone chin augmentation and infraorbital fat grafting six months ago. She has also undergone botulinum toxin treatment for masseter muscle.

PATIENT’S MOTIVATION AND EXPECTATION

Mandy desires to look slightly younger and refreshed to make her more confident in her personal and professional relationships. She is sometimes worried about her appearance and wants to improve her facial features. She expects to see the treatment results in less than 3 months, as she is presently dealing with life changing events.

PATIENT’S MAIN CONCERN

The asymmetry in facial morphology and dry skin are major concerns for Mandy. She specifically desires to improve the facial balance and restore the volume loss around her temple area as these concerns affected her confidence level. She wishes to look more energetic and vibrant.

PHYSICIAN’S ASSESSMENT AND EVALUATION Overall Assessment Mandy has prominent asymmetry, as the volume depletion on her left is greater compared to the fullness or tightness of the skin on the right.

Temple area shows volume depletion Prominent volume depletion at infraorbital area

Lack of volume at the marionette line due to the volume loss at the prejowl area

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Dynamic folds on glabella

Dynamic folds on forehead

Some dynamic folds on nasolabial area Slightly pointed chin due to previous chin augmentation

Scar mark on her left eyebrow


Case Demonstration I

VISUALISING PATIENT’S NEEDS AND PLANNING RECOMMENDED TREATMENT OPPORTUNITIES Dr Huang plotted the severity assessment using the Harmony chart to better envision patient’s needs and laid out the treatment opportunities as shown: Severity Evaluation Scale 0 none

1 mild

2 3 moderate severe

SKIN

WRINKLES

Restylane Vital Light Lidocaine injection at the scar tissue and the midface area to

Dehydration

in ess Sk ughn Su rfa

Botulinum toxin injection at the glabellar frown to

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Loss of elast icity

+ reduce the appearance of nasolabial folds

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+ reduce surface roughness

St at

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ic

+ improve skin hydration

Restylane Perlane Lidocaine injection at nasolabial folds to

+ minimise the dynamic folds on the forehead

MORPHOLOGY

VOLUME

+ contour the lower face

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+ replace the lost volume and contour the temple area

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ph ol Asym og met ry y

+ balance the facial asymmetry

Restylane Perlane Lidocaine injection at hairline and infraorbital area to

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Restylane Perlane Lidocaine injection at the chin and the prejowl area to

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+ augment the infraorbital area

COMPREHENSIVE SKIN ANALYSIS Scars

0

Pigmentation

Visible pores

1

2

3

0

1

2

3

0

1

Vasculature

2

3

0

1

2

3

Fig 1: Assessment of skin quality and type

Based on the comprehensive skin analysis, Dr Huang proposed to inject Restylane Vital Light at the scar tissue and the midface area to reduce the scar mark on the left eyebrow and visible pores on the infraorbital area.

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PERSONALISED TREATMENT PLAN After thorough facial evaluation and discussion with Mandy, the three sessions of the overall treatment plan was proposed. SESSION I

SESSION II

SESSION III

Morphology and Volume Loss

Asymetry, Volume Loss and Wrinkles

Wrinkles, Scars and Skin

The most severe deformity was concerned with the facial asymmetry and imbalance at the temple and chin. Therefore, the first treatment focussed on correction of morphology.

The focus of the second treatment was the restoration of volume loss and wrinkles at the infraorbital area to achieve a smooth midfacial contour.

The skin roughness and hydration needed to be targeted to improve the skin quality and further enhance the outcomes of first and second sessions.

Temple and chin

Nasolabial folds and infraorbital area

Forehead, midface and glabellar

3.0 ml Restylane Perlane Lidocaine

2.0 ml Restylane Perlane Lidocaine

1.0 ml Restylane Vital Light Lidocaine 12 units Botulinum toxin

Treatment Session Treatment Focus

Treatment Rationale

Treatment Area Products and Total Injection Volume

TREATMENT SESSION I:

Improving Morphology by Enhancing the Contour of the Lower Face and Correcting Temple Depletion Treatment Session I focusses on the treatment of Mandy’s facial asymmetry and imbalance at the temple and chin.

Dehydration St at

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Treatment Area Product Injection Technique Injection Accessories Injection Plane Injection Volume

0.5 ml

m e

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0.2 ml

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Temple

Chin and parachin Restylane Perlane Lidocaine

Deep injection using bolus technique

Deep injection using bolus technique

29 gauge sharp needle

29 gauge sharp needle

Below the deep temporal fascia

Deep to the bone

0.8 ml on right side 1.0 ml on left side

0.5 ml on the parachin on each side 0.2 ml on the anterior border of the chin

Fig 2: Session I injection techniques and procedure at a glance 6

1.0 ml

0.5 ml

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0.8 ml


Case Demonstration I

Detailed Procedure

Temple Area + Mandy has prominent volume depletion at the temple area on her left compared to her right. Therefore, it would be ideal to first treat the right side. + To augment the temporal area, inject 0.8 ml of Restylane Perlane below the deep temporal fascia, using bolus technique with a 29 gauge sharp needle (Fig 3). The injection must be performed very slowly, ensuring that it is evenly distributed, because the temporal fossa is a small confined space. Use fingers to gently massage the area to ensure that Restylane Perlane is uniformly distributed. + Repeat the procedure on the left side. In this case, a greater volume (1.0 ml) of Restylane Perlane is injected on the left, as volume depletion is more severe on this side. A

B

Fig 3: Deep injection using 29 gauge needle after penetrating the deep temporal fascia

Chin Area + In order to identify the injection sites, it is recommended to ask the patient to tilt her head upward, under bright light, to better assess the chin and visualise the blood vessels. This is to avoid penetration of any blood vessels and prevent bleeding. + Once the injection sites are identified, using the bolus technique, inject Restylane Perlane deep at each site of the prejowl area (Fig 4). Use fingers to gently massage the area, so that Restylane Perlane is evenly distributed. A

B 4

1

1

2

3

Fig 4: Deep injection at the prejowl (right side) Note: More bleeding may be noticed in this area, as the patient has previously undergone chin augmentation.

+ Subsequently, inject 0.2 ml of Restylane Perlane at the anterior border of the chin (Fig 5). Gently massage the area again to distribute Restylane Perlane evenly. A

Fig 5: Deep injection at the chin

B

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+ The injection procedure is then repeated at the prejowl on the left (Fig 6), and the whole chin area is massaged to uniformly distribute Restylane Perlane and achieve the desired shape. + A total volume of 0.5 ml was injected into the prejowl area, to shape a smooth and rounded chin. A

B

1 2

1

3

Fig 6: Deep injection at the prejowl (left side) Note: After the injection procedure on one side, it is advisable to observe the treatment area from the top, in order to identify if additional volumes are required at any site. In this case, additional volume was injected at the anterior projection of the chin.

GENERAL FOLLOW-UP + After each treatment session, it is advised to have a follow-up call on the second day to ensure that the patient is doing well and to address any of his/her concerns + Immediate follow-up is advised if the patient has any adverse events

TIPS

+ Face-to-face follow-up should be scheduled two weeks after the treatment

GENERAL ADVICE FOR PATIENTS + Immediately after the treatment, do not massage the face in order to allow the Hyaluronic Acid Fillers to absorb water from the surrounding tissues, for better results + Do not wash your the for at least one hour after the treatment + There may be swelling for two days which will resolve with time

RESULTS AND FOLLOW-UP The procedure enhanced the contour of Mandy’s temple and chin, thereby improving her facial symmetry and balance. During the follow-up meeting at the second week, Dr Huang decided to proceed with the second session that would continue to improve morphology and target volume loss. BEFORE

Fig 7: Results of first treatment session

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AFTER


Case Demonstration I

TREATMENT SESSION II:

Improving Volume Loss and Reducing Dynamic Folds The second treatment session focussed on the midface area, which involved augmenting the infraorbital area and reducing the nasolabial folds. This created a smooth contour and a better projection of the midface. The patient had previously undergone facial fat grafting on the midface. However, volume depletion on the left was still greater when compared to her right. Augmenting this area would further improve the contour of the lower face.

Dehydration St at

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Loss of elast icity

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Treatment area Product Injection Technique Injection Accessories Injection Plane

Injection Volume

g gin Sag

0.6 ml

0.5 ml

0.5 ml

m e

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ph ol Asym og met ry y

0.4 ml

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Nasolabial folds

Infraorbital

Restylane Perlane Lidocaine Bolus technique

Multi-layered technique

29 gauge sharp needle

21 gauge Pix’L cannula

Deep at the preperisteal layer

Deep submuscular plane at the midface below the orbital rim

0.5 ml on each side

0.4 ml on right side 0.6 ml on left side

Fig 8: Session II injection techniques and procedures at a glance

SPECIAL CONSIDERATIONS + For the injection at the infraorbital area, it is recommended to perform the injection procedure using a Pix’L cannula. Hence, it is advisable to inject local anaesthesia to the area to ensure patient comfort.

Fig 9: Injection of local anaesthesia at the infraorbital area

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Detailed Procedure Nasolabial Folds + To reduce the nasolabial folds, feel the hollows at the maxillary bone using the non-injecting hand and position a 29 gauge sharp needle at 45° Using bolus technique, inject 0.5 ml Restylane Perlane when you feel the needle tip hit the bone. + Repeat the procedure on the other side. A

B

Fig 10: Deep injection at the nasolabial groove (right side) Note: The injection must be performed carefully and very slowly without moving the needle. Inject deep into the bone, avoiding any soft tissue to ensure that blood vessels, particularly angular artery and facial artery, are not punctured. Injecting into the periosteal layer at one injection point helps to avoid accidental penetration of blood vessels which can cause embolism.

Infraorbital Area + Inject 0.4 ml Restylane Perlane at the infraorbital area with a 21 gauge Pix’L cannula using the multi-layered injection technique that tapers from the base to the surface (Fig 11). The base layer is wider than the successive layers of injection to produce a 3D volume appearance. A

B

Fig 11: Multi-layered injection technique at the infraorbital area (right side) Note: The injection must be below the orbital rim. Use the non-injecting hand to feel the area of injection.

+ Gently massage the infraorbital area to uniformly distribute Restylane Perlane. + Repeat the injection procedure at the nasolabial and infraorbital areas on the other side, and massage the whole area. As volume deficiency at the infraorbital area is more severe on the left as compared to the right, a greater injection volume is needed at the left side (0.6 ml [left] vs 0.4 ml [right]).

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Case Demonstration I

RESULTS AND FOLLOW-UP The procedure helped to soften and decrease the shadows at the deep nasolabial folds and re-established the cheek volume. This created a better facial balance for Mandy, producing a smoother and more defined ogee curve. The treatment also gave Mandy an alluring youthfulness and vitality to her appearance (Fig 12). BEFORE*

Dr Huang had a follow-up meeting with Mandy and decided to proceed to improve her skin quality in the final session.

AFTER

Fig 12: Results of second treatment session *Photo after first treatment

TREATMENT SESSION III: Improving Skin Quality

The first two treatment sessions improved the overall contour of Mandy’s face. The third session focussed on improving the skin quality that involved correcting the skin pores, improving the skin hydration as well as reducing the scar tissue and frown lines. Dehydration St at

mic Dyna

Loss of elast icity

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Treatment Area Product

Injection Technique

Injection Accessories Injection Plane Injection Volume

g gin Sag

Minute amount

12 units

0.5 ml

0.5 ml

m e

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ph ol Asym og met ry y

Botulinum toxin

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Scar tissue

Glabellar Frown

CHEEK

Restylane Vital Light Lidocaine

Botulinum Toxin

Restylane Vital Light Lidocaine

Injections to expand the scar

-

Multi-needle tool under negative pressure of vacuum

30 gauge needle

29 gauge sharp needle

Vital Injector Gun

Intradermal below the scar tissue

Into the muscle at the glabellar fold

Intradermal (1.2 mm in the middermis)

Minute amount

4 units on each injection site

0.5 ml on each side

Fig 13: Session III injection techniques and procedure at a glance

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Detailed Procedure Reducing the Scar Tissue + Inject minute amounts of Restylane Vital Light intradermally to expand the scar tissue (Fig 14). A

B

Fig 14: Intradermal injection at the scar tissue to expand the scar Note: Once the scar is expanded, it can be improved with neovascularisation and neocollagenesis. New endogenous collagen growth further helps in reducing the scar.

Reducing the Glabellar Frown Lines + Squeeze the skin between the two eyebrows and inject 12 units of botulinum toxin in total using a 29 gauge sharp needle at the three injection sites (4 units/site) as shown in Fig 15. A

B 3 1

2 1

Fig 15: Botulinum toxin injection at the glabella to reduce frown lines

Correcting Skin Pores and Improving Skin Quality + The Vital Injector Gun is equipped with a suction cup which has five needles allowing five injections of Restylane Vital Light to be injected simultaneously to aid treatment in large skin areas. It can also be programmed to deliver consistent repeating volumes of Restylane Vital Light at a particular depth, 1.2 mm beneath the dermis layer, ensuring consistent placement. + Place the needle block of the Vital Injector Gun into the cheek just under the eye to start the procedure and press the trigger to deliver Restylane Vital Light to the area. Then, using the imprint of the needles on the cheek as a guide, move the Vital Injector Gun along the cheek and deliver the next aliquots. Move down the midface in a systematic approach to deliver Restylane Vital Light into the cheek. Once one line has been completed in the midface, move the Vital Injector Gun back to the top of the midface, and repeat. Continue the injections until the entire cheek area has been injected with Restylane Vital Light (Fig 16). The injection procedure is then repeated on the left side (Fig 17).

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Case Demonstration I

A

B

Fig 16: Restylane Vital Light injection using Vital Injector Gun A

B

Fig 17: Restylane Vital Light injection on the left side of the face Note/Tips: The needles of the Vital Injector Gun penetrates 1.2 mm deep, that is, within the mid-dermis. The mid-dermis is the best layer for Hyaluronic Acid hydration and to stimulate collagenesis. Restylane Vital Light helps to improve skin hydration and minimise skin pores within a week’s time. A cold compress can be used to relieve pain and bruising.

RESULTS AND FOLLOW-UP Mandy’s skin looked more hydrated and supple. At the same time, her skin appeared smoother with reduced pores, scar marks and fine lines. Restylane Skinboosters treatment involves multiple injection sites and therefore requires special follow-up care. BEFORE*

2 WEEKS AFTER SESSION III

BEFORE*

2 WEEKS AFTER SESSION III

Fig 18: Results of third treatment session after two weeks *Photo after second treatment

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Case Demonstration SUMMARY Mandy was concerned with her overall facial balance and dry skin that resulted in enlarged skin pores, making her look dull. These concerns affected her confidence level. Dr Huang performed a thorough facial analysis and developed a personalised treatment plan for Mandy using the Harmony Programme. The procedures helped Mandy to achieve a desired heart-shaped face and her skin looked more hydrated and supple making her look young and fresh.

Su rfa

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Vo lu m el oss

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“I feel more confident and beautiful� 14

m e

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m e

Vo lu m el oss

Su rfa

Su rfa

Loss of elast icity

m e

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mic Dyna

g gin Sag

St at ic

ph ol Asym og met ry y

Dehydration

ro ce

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Vo lu m el oss

in ess Sk ughn

e nc r ala Imb Mo

lu Vo

St at

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Dehydration

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2 WEEKS AFTER SESSION III

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m e

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e nc r ala Imb Mo

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e nc r ala Imb Mo

g gin Sag

St at

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mic Dyna

e nc r ala Imb Mo

ph ol Asym og met ry y

Dehydration

ro ce

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ic

Loss of elast icity

in ess Sk ughn

s kle rin W

St at

Loss of elast icity

Dehydration

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s kle rin W

Su rfa

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AFTER SESSION II

Loss of elast icity

AFTER SESSION I

BEFORE

lu Vo


Case DEMONSTRATION II

Case Demonstration II PATIENT’S SELF-ASSESSMENT AND NEEDS PERSONAL DETAILS

Yau, 34 year-old female

AESTHETIC PROCEDURE BACKGROUND

Yau previously underwent botulinum toxin treatment for masseter muscle to minimise the angular appearance of her square-shaped face, midfacial Hydraluronic Acid Filler injection to improve the volume loss at the nasolabial area, and liposuction to gain a more satisfying body.

PATIENT’S MOTIVATION AND EXPECTATION

Yau desires to look slightly younger and refreshed. She is always worried about her looks and concerned about what her partner, friends and family think about her appearance. While she expects immediate treatment results, she is anxious about the success of the treatment.

PATIENT’S MAIN CONCERN

The volume deficiency at the periorbital area is the major concern for Yau. She specifically desires to improve the tear trough and restore the volume loss around her eyes. She wishes to achieve a more energetic and vibrant look that would help her receive more compliments from her friends and family.

PHYSICIAN’S ASSESSMENT AND EVALUATION Overall Assessment Yau has prominent asymmetry, volume depletion and loss of elasticity on the left compared to her skin on the right. Her facial imbalance is also due to a lighter upper face and a heavier lower face. She has an overall sagging appearance.

Dynamic and static wrinkles/ folds at the forehead and frown

Volume depletion at the temple area Facial asymmetry due to slight fat accumulation on right side

Marked dehydration of the full face

Volume deficiency at the infraorbital area and severe tear trough deformity

Dynamic wrinkles and crow’s feet

Hypertrophy of the masseter muscle

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VISUALISING PATIENT’S NEEDS AND PLANNING RECOMMENDED TREATMENT OPPORTUNITIES Dr Huang plotted the prospective severity assessment using the Harmony chart to better envision patient’s needs and laid out the treatment opportunities as shown: Severity Evaluation Scale 0 none

1 mild

2 3 moderate severe

SKIN

WRINKLES

Restylane Vital Light Lidocaine injection at the midface and forehead to + increase skin hydration and elasticity

Dehydration

in ess Sk ughn

VOLUME

Su rfa

mic Dyna

Loss of elast icity

+ reduce the appearance of nasolabial folds

s kle rin W

St at

ro ce

ic

+ reduce surface roughness, visible scars and pores

Restylane Perlane Lidocaine injection at nasolabial folds to

Restylane SubQ Lidocaine injection at hairline to + restore volume loss and contour of the temple + tighten the skin by injecting on the hairline

MORPHOLOGY

ph ol Asym og met ry y

g gin Sag

Restylane Perlane Lidocaine injection at infraorbital to

m e

+ balance the facial asymmetry

Vo lu m el oss

e nc r ala Imb Mo

Restylane SubQ Lidocaine injection at hairline to

lu Vo

+ augment the infraorbital area Restylane Lidocaine at the tear trough to + correct the tear trough

COMPREHENSIVE SKIN ANALYSIS Scars

0

Pigmentation

Visible pores

1

2

3

0

1

2

3

0

1

Vasculature

2

3

0

1

2

3

Fig 1: Assessment of skin quality Based on the comprehensive skin analysis, Dr Huang proposed to inject Restylane Vital Light at the midface area and the forehead to improve the overall skin quality.

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Case DEMONSTRATION II

PERSONALISED TREATMENT PLAN After thorough facial evaluation and discussion with Yau, the three sessions of the overall treatment plan was proposed. SESSION I

SESSION II

SESSION III

Volume Loss, Facial Imbalance and Dynamic Folds

Volume Loss, Sagging and Elasticity of Skin

Wrinkles and Skin

Treatment Rationale

The most severe deformity for Yau was the volume loss at the tear trough and midface. The first treatment focussed on restoring the lost volume at the midface and around the eyes.

The focus of the second treatment was volume restoration at the temple to lift the midface.

The skin roughness and hydration needed to be targeted to improve the skin quality and further enhance the outcomes of the first and second sessions.

Treatment Area

Infraorbital area, nasolabial folds, tear trough and upper eyelid

Hairline

Forehead and midface

3.0 ml Restylane Perlane Lidocaine and 1.0 ml Restylane Lidocaine

4.0 ml Restylane SubQ Lidocaine

1.0 ml Restylane Vital Light Lidocaine

Treatment Session

Treatment Focus

Products and Total Injection Volume

TREATMENT SESSION I:

Improving Volume Loss through Midface Augmentation Session I focussed on the overall volume loss at the midface. It is important to note that targeting volume loss and morphology in the initial sessions helps to improve the contour of the face and also to some extent improves the skin quality. Dehydration St at

mic Dyna

Loss of elast icity

ic

ro ce

s kle rin W

Su rfa

in ess Sk ughn

0.3 ml

0.3 ml

0.2 ml

0.2 ml

1.0 ml

Treatment Area Product

g gin Sag

m e

Vo lu m el oss

e nc r ala Imb Mo

ph ol Asym og met ry y

1.0 ml

lu Vo

Nasolabial foldS

0.5 ml

Infraorbital

Restylane Perlane Lidocaine

0.5 ml

Periorbital area (Upper eyelid)

Tear trough

Restylane Lidocaine

Injection Technique

Bolus technique

Multi-layered injection technique

Retrograde linear technique

Retrograde linear technique

Injection Accessories

29 gauge sharp needle

21 gauge Pix’L cannula

21 gauge Pix’L cannula

30 gauge sharp needle

Deep at the preperisteal layer

Deep submuscular plane underneath the orbital rim

Just under the muscle

Underneath the muscle

0.5 ml on each side

1.0 ml on each side

0.3 ml on each side

0.2 ml on each side

Injection Site/Plane

Injection Volume

Fig 2: Session I injection techniques and procedure at a glance 17


SPECIAL CONSIDERATIONS + For the injection at the infraorbital area and the upper eyelid, it is recommended to perform the injection procedure using a Pix’L cannula. Hence, it is advisable to inject local anaesthesia to the area to ensure patient comfort.

3 2 1

Fig 3: Injecting anesthesia at the infraorbital area and upper eyelid

Detailed Procedure To reduce the appearance of nasolabial folds + To reduce the nasolabial folds, feel the hollows at the maxillary bone using the non-injecting hand and position a 29 gauge sharp needle at 45°. Using bolus technique, inject 0.5 ml Restylane Perlane when you feel the needle tip hit the bone. + Repeat the procedure on the other side.

Fig 4: Deep injection at the nasolabial groove Note: The injection must be performed carefully and very slowly without moving the needle. Inject deep till the bone, avoiding any soft tissue to ensure that blood vessels, particularly angular artery and facial artery, are not punctured. Injecting into the periosteal layer at one injection point helps to avoid accidental penetration of blood vessels which can cause embolism.

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Case DEMONSTRATION II

To restore the volume loss at infraorbital area + With the help of a 21 gauge Pix’L cannula, inject Restylane Perlane using the multi-layered injection technique that tapers from the base to the surface (Fig 5). The base layer is wider than the successive layers of injection to produce a 3D volume appearance. After injection, gently massage the area to ensure even distribution of Restylane Perlane. A

B

Fig 5: Injection at the infraorbital area Note: The injection must be below the orbital rim, and always use the non-injecting hand to feel the area of injection. The injection must be performed very slowly.

To improve volume depletion at the periorbital area by injecting the upper eyelid + Create the entry point using a sharp needle (Fig 6A) and then, with the help of a 21 gauge Pix’L cannula inject Restylane just underneath the muscle in a retrograde linear manner (Fig 6B). After the injections, gently massage the area to ensure that Restylane Perlane is evenly distributed (Fig 6C). A

B

C

Fig 6: Injection at the upper eyelid underneath the muscle Note: Never force the Pix’L cannula into the tissue while injecting in the upper eyelid. The injection plane should be at the loose connective tissue. Tilt the cannula upwards to better visualise the position of the needle before performing the injection.

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Correcting the tear trough + Inject a very small volume of Restylane into the medial part of the tear trough (Fig 7). Gently massage the area to evenly distribute Restylane. Then, repeat the injection at the lateral part of the tear trough and massage the area. A

B

2

1

1

Fig 7: Injection at the tear trough Note: The patient must be in sitting position while performing injections at the tear trough. It is also advisable to ask the patient to look upwards in order to better visualise and assess the area of injection. To assess the position of the needle tip, it is advisable to bend the needle at 45â ° prior to injection. The injection volume at the tear trough is very little due to the support from previous injection at the infraorbital area.

RESULTS AND FOLLOW-UP Volumetric augmentation of the midface provided a slight lift to Yau’s midface creating a smooth facial contour. The procedure also helped to soften the nasolabial folds and reduce the tear trough (Fig 8).

BEFORE

Fig 8: Results of first treatment session

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AFTER

During the follow-up meeting at the second week, Dr Huang decided to proceed with the second session that would continue to target volume loss at the hairline and improve sagging, as well as loss of elasticity.


Case DEMONSTRATION II

TREATMENT SESSION II:

Improving Sagging by Vector Midface Lift The second treatment session focussed on creating a vector at the hairline to perform a facelift so as to tighten the skin and reduce sagging.

Dehydration St at

mic Dyna

Loss of elast icity

ic

ro ce

s kle rin W

Su rfa

in ess Sk ughn

2.0 ml

g gin Sag

m e

Vo lu m el oss

e nc r ala Imb Mo

ph ol Asym og met ry y

2.0 ml

lu Vo

Temple (hairline)

Treatment Area Product

Restylane SubQ Lidocaine

Injection Technique

Retrograde fanning technique

Injection Accessories

21 gauge Pix’L cannula

Injection Plane Injection Volume

Subsuperficial 2.0 ml on each side

Fig 9: Session II injection techniques and procedure at a glance.

Detailed Procedure

Creating a Vector Lift + Create a puncture at the hairline using a sharp needle. With a 21 gauge Pix’L cannula and using the retrograde fanning technique, inject 2.0 ml of Restylane SubQ into the subsuperficial fascia (Fig 10). A

B

Fig 10: Restylane SubQ injection at the hairline

21


+ Once filler has been injected, it should be pulled in the direction of the arrows along the vector of the face and press the filler to fix the lift (Fig 11).

Fig 11: Lift and stretch the skin towards the vector Note: Ensure that the injection is performed underneath the superficial temporal fascia. Assess the area of injection and if the skin still appears loose, additional volume of Restylane SubQ may be injected. Typically, a volume of 2.0 ml on each side is adequate.

RESULTS AND FOLLOW-UP The procedure helped to tighten the skin, thereby reducing sagging and improving elasticity of the skin. This created a smooth transition giving Yau a refined and youthful appearance (Fig 12).

BEFORE*

Fig 12: Results of second treatment session *Photo after first treatment

22

AFTER

Dr Huang had a follow-up meeting with Yau and observed that the second session improved her skin elasticity from moderate to mild. He decided to further improve her skin quality in the last session.


Case DEMONSTRATION II

TREATMENT SESSION III: Skin Rejuvenation

The first two treatment sessions improved the overall facial contour and volume of the patient. The third session focussed on improving the skin quality that involved correcting the pores, improving hydration and reducing scar tissue and pigmentation. Dehydration St at

mic Dyna

Loss of elast icity

ic

ro ce

s kle rin W

Su rfa

in ess Sk ughn

Treatment Area Product Injection Technique Injection Accessories Injection Plane

g gin Sag

m e

Vo lu m el oss

e nc r ala Imb Mo

ph ol Asym og met ry y

1.0 ml

lu Vo

Skin (midface and upper face) Restylane Vital Light Lidocaine Multi-needle tool under negative pressure of vacuum Vital Injector Gun Intradermal (1.2 mm deep in the mid-dermis)

Injection Volume

1.0 ml

Fig 13: Session III injection techniques and procedure at a glance

Detailed Procedure

Correcting skin pores and improving skin hydration at the midface and forehead + The Vital Injector Gun is equipped with a suction cup which has five needles allowing five injections of Restylane Vital Light to be injected simultaneously to aid treatment in large skin areas. It can also be programmed to deliver consistent repeating volumes of Restylane Vital Light at a particular depth beneath the dermis layer, ensuring consistent placement. + Place the needle block of the Vital Injector Gun into the cheek just under the eye to start the procedure and press the trigger to deliver Restylane Vital Light to the area (Fig 14). Then, using the imprint of the needles on the cheek as a guide, move the Vital Injector Gun along the cheek and deliver the next aliquots. + Move down the midface in a systematic approach to deliver Restylane Vital Light, and once one line has been completed on the midface, move the Vital Injector Gun back to the top of the midface, and repeat.

23


+ Continue the injections until all of the midface area has been injected with Restylane Vital Light (Fig 14A). + The injection procedure is then repeated on the left side (Fig 14B) followed by the forehead (Fig 15). A

B

1 4 7

2 5 8

3 6

Fig 14: Restylane Vital Light injection using Vital Injector Gun on the midface

1 2 3 4

Fig 15: Restylane Vital Light injection on the forehead Note: The needles of the Vital Injector Gun penetrate 1.2 mm deep, that is within the mid-dermis. The mid-dermis is the best layer for Hyaluronic Acid hydration and to stimulate collagenesis. This procedure gives excellent results when combined with botulinum toxin treatment.

RESULTS AND FOLLOW-UP

Yau’s skin looked more hydrated and supple. At the same time, her skin appeared smoother with reduced pores and scar marks. Skinboosters treatment may be traumatic and special care should be provided to the patient. BEFORE*

2 WEEKS AFTER SESSION III

Fig 16: Results of third treatment session after 2 weeks *Photo after second treatment

24


Case DEMONSTRATION II

Case Demonstration SUMMARY Yau was always insecure about how people perceived her appearance. She was concerned with her facial asymmetry and sagging skin around her eyes. Moreover, the marked dehydration of her skin made her look tired and dull. Dr Huang performed a thorough facial analysis and developed a personalised treatment plan for Yau using the Harmony Programme. The procedures helped to improve the contour of Yau’s face as well as her skin texture, providing a smoother, relaxed and more youthful look.

Su rfa

ph ol Asym og met ry y

Vo lu m el oss

g gin Sag

m e

Vo lu m el oss

m e

Vo lu m el oss

Su rfa

Su rfa

Loss of elast icity

m e

lu Vo

mic Dyna

g gin Sag

St at ic

ph ol Asym og met ry y

Dehydration

ro ce

s kle rin W

Vo lu m el oss

in ess Sk ughn

e nc r ala Imb Mo

lu Vo

St at

mic Dyna

g gin Sag

Dehydration

ro ce

ic

ph ol Asym og met ry y

2 WEEKS AFTER SESSION III

s kle rin W

m e

in ess Sk ughn

e nc r ala Imb Mo

lu Vo

e nc r ala Imb Mo

g gin Sag

St at

mic Dyna

mic Dyna

e nc r ala Imb Mo

ph ol Asym og met ry y

Dehydration

ro ce

ic

ic

Loss of elast icity

in ess Sk ughn

s kle rin W

St at

Loss of elast icity

Dehydration

ro ce

s kle rin W

Su rfa

in ess Sk ughn

AFTER SESSION II

Loss of elast icity

AFTER SESSION I

BEFORE

lu Vo

“My friends compliment on my glowing skin!” 25


Case Demonstration III PATIENT’S SELF-ASSESSMENT AND NEEDS PERSONAL DETAILS

Sylvia, 20 year-old female

AESTHETIC PROCEDURE BACKGROUND

Sylvia has not undergone any aesthetic procedure previously.

PATIENT’S MOTIVATION AND EXPECTATION

Sylvia is extremely worried about her appearance and wants to improve her facial features. She expects to see the treatment results in less than 3 months.

PATIENT’S MAIN CONCERN

Sylvia’s main concern is her flat nose and sunken cheeks. She wishes to feel less self-conscious about her appearance.

PHYSICIAN’S ASSESSMENT AND EVALUATION Overall Assessment Sylvia has prominent volume depletion on her left compared to the right resulting in asymmetry. Her face is imbalanced, due to lack of midline projection, indicated by a short chin and flat nose. Her skin quality is good, as she is young.

Deficiency at dorsum and tip of the nose

Wide zygomatic arch

Prominent volume depletion at the temple, infraorbital and lower face

Nasolabial folds and marionette lines Slightly flat chin

26

Prejowl deficiency

Sunken cheeks


Case Demonstration III

VISUALISING PATIENT’S NEEDS AND PLANNING RECOMMENDED TREATMENT OPPORTUNITIES Dr Huang plotted the severity assessment using the Harmony chart to better envision patient’s needs and laid out the treatment opportunities as shown: Severity Evaluation Scale 0 none

1 mild

2 3 moderate severe

WRINKLES

Dehydration

in ess Sk ughn

mic Dyna

Loss of elast icity

+ reduce the appearance of folds

s kle rin W

St at

ro ce

ic

Su rfa

Restylane Perlane Lidocaine injection at nasolabial folds and marionette lines to

MORPHOLOGY

VOLUME

ph ol Asym og met ry y

g gin Sag

+ augment and contour the temple + augment the chin and cheek

m e

+ provide a better projection to the nose

Restylane Perlane Lidocaine injection at chin, temple and cheek to

Vo lu m el oss

e nc r ala Imb Mo

Restylane Perlane Lidocaine injection at nose to

lu Vo

COMPREHENSIVE SKIN ANALYSIS Scars

0

Pigmentation

Visible pores

1

2

3

0

1

2

3

0

1

Vasculature

2

3

0

1

2

3

Fig 1: Harmony chart and assessment of skin quality Based on the comprehensive skin analysis, Dr Huang determined that Sylvia’s skin quality is very good and treatment for skin is not needed.

27


PERSONALISED TREATMENT PLAN After thorough facial evaluation and discussion with Sylvia, the three sessions of the overall treatment plan was proposed. SESSION I

SESSION II

SESSION III

Facial Imbalance

Volume Loss and Asymmetry

Dynamic Folds and Volume Loss

The most severe concern for Sylvia was the imbalance at the midline. Therefore, the first treatment focussed on improving the midline projection.

The focus of the second treatment was restoration of the volume loss at the temple to achieve a smooth contour and better balance of the face.

The nasolabial folds and sunken cheeks needed to be targeted to further improve the midface.

Treatment Area

The midfacial triangle (nose root, nose tip, chin and parachin)

Temple

Nasolabial folds and cheek

Products and Total Injection Volume

2.5 ml Restylane Perlane Lidocaine

2.0 ml Restylane Perlane Lidocaine

2.0 ml Restylane Perlane Lidocaine

Treatment Session Treatment Focus

Treatment Rationale

TREATMENT SESSION I:

Improving Morphology through Midline Correction Treatment Session I focussed on the treatment of Sylvia’s facial asymmetry and imbalance at the midline. Dehydration St at

0.3 ml

mic Dyna

Loss of elast icity

ic

ro ce

s kle rin W

Su rfa

in ess Sk ughn

0.2 ml

Treatment Area Product Injection Technique Injection Accessories Injection Plane Injection Volume

Vo lu m el oss

e nc r ala Imb Mo

g gin Sag

0.5 ml

lu Vo

1.0 ml

Chin and parachin

Nose

Restylane Perlane Lidocaine Bolus technique

Bolus technique

29 gauge sharp needle

29 gauge sharp needle

Deep to the bone

Deep into the nasal dorsum and tip

1.0 ml on the chin 0.5 ml on parachin (each side)

0.3 ml on nasal dorsum 0.2 ml at the nasal tip

Fig 2: Session I injection techniques and procedure at a glance. 28

0.5 ml

m e

ph ol Asym og met ry y


Case Demonstration III

Detailed Procedure

Augmentation of the lower face + Sylvia has a very flat chin and a wide zygomatic arch. Therefore, augmenting the chin in addition to widening the mandible will give a better facial balance. + In order to identify the injection site, it is recommended to ask the patient to tilt the head upward, under bright light, to better assess the chin and visualise the blood vessels. This helps to avoid penetration of the blood vessels and in turn, prevent bleeding. + To elongate the chin, using a 29 gauge needle, slowly inject 1.0 ml Restylane Perlane into the midline when the needle tip hits the bone (Fig 3A). Then, inject minute volumes into the sides to give a better projection (Fig 3B). + Gently mould to distribute the injected Restylane Perlane to achieve the desired shape. A

B

Fig 3: Augmenting the chin

+ Inject very slowly and use the non-injecting hand to feel the injected volume (Fig 4A). + To get the desired projection, slightly withdraw the needle in between the injections, and check if Restylane Perlane is injected into the soft tissue (Fig 4B). B

TIPS

A

Fig 4: Tips for chin injection

29


+ To improve the marionette lines and achieve a better contour of the lower face, inject 0.5 ml Restylane Perlane into the parachin (Fig 5A). Gently massage the area to distribute Restylane Perlane evenly. + The injection procedure is then repeated at the prejowl on the left side, and the whole chin area is massaged to uniformly distribute Restylane Perlane and mould the desired shape (Fig 5B). A

B

1 12 3

4

Fig 5: Augmenting the parachin Note: It is recommended to ask the patient to raise their chin, to better visualise the asymmetry and identify injection sites. After performing injection at the parachin area, it is advisable to observe the area of injection from the top, to identify if the contour is smooth or if additional volumes are required at any site. In this case, additional volume was injected at the right side.

Augmentation of the nose + To augment the nose, first inject Restylane Perlane at the nose root (Fig 6A; injection site 1), using bolus technique with a 29 gauge sharp needle. + Gently mould and massage the area after each injection to check if further injection is required to avoid over-correction. + Then inject Restylane Perlane into the nasal dorsum (Fig 5; injection sites 2, 3 and 4) and gently massage the area. + Finally, it is recommended to use a bent needle and inject from the base of the columella to the nasal tip, in order to avoid vascular complications (Fig 6B). This injection will not only augment the nasal tip, but may also help to lengthen the columella simultaneously. + When the injection is complete, gently massage the area to provide the desired shape to the nasal tip. A

B 2

3

4

1

Fig 6: Deep injection using 29 gauge needle, (A) at the nasal base and dorsum (B) from base of columella, for augmenting the nasal tip

30


Case Demonstration III

RESULTS AND FOLLOW-UP The procedure gave Sylvia a better midline projection by improving the shape of the nose and providing a better contour to her chin (Fig 7).

BEFORE

AFTER

During the follow-up meeting, Sylvia mentioned that she was satisfied with the improvement in the appearance of her nose. Dr Huang decided to proceed with the second treatment session that would target volume loss at her upper face.

Fig 7: Results of first treatment session

TIPS

GENERAL ADVICE FOR PATIENTS + Immediately after the treatment, do not massage the face in order to allow the Hyaluronic Acid Fillers to absorb water from the surrounding tissues, for better results + Do not wash the face for at least one hour after the treatment + There may be swelling for two days which will resolve with time

31


TREATMENT SESSION II:

Improving Volume Loss At Upper Face The second treatment session involved augmenting the temple area in order to achieve a better contour of the upper face. Augmenting this area would also provide a smooth transition to the midface. Dehydration St at

mic Dyna

Loss of elast icity

ic

ro ce

s kle rin W

Su rfa

in ess Sk ughn

0.8 ml

g gin Sag

m e

Vo lu m el oss

e nc r ala Imb Mo

ph ol Asym og met ry y

1.2 ml

lu Vo

Temple

Treatment Area Product Injection Technique Injection Accessories Injection Plane Injection Volume

Restylane Perlane Lidocaine Deep injection using bolus technique 29 gauge sharp needle Below the deep temporal fascia 1.2 ml on right side 0.8 ml on left side

Fig 8: Session II injection techniques and procedure at a glance

32


Case Demonstration III

Detailed Procedure

Augmenting the temple + To augment the temporal tissue, inject 1.2 ml Restylane Perlane below the deep temporal fascia using bolus technique with a 29 gauge sharp needle (Fig 9). The injection must be performed very slowly without moving the needle because the temporal fossa is a small confined space. + Gently massage the area and repeat the procedure on the left side. As the temple area on the left is less hollow when compared to the right, a lesser injection volume (0.8 ml) was used on left side.

Fig 9: Deep injection using 29 gauge needle after penetrating the deep temporal fascia Note: Always be careful while injecting into the temple to avoid piercing the important vasculature in this area. It is advisable to remain closer to the hairline while injecting. Do not move the needle while injecting to avoid bleeding and swelling. After performing injection on one side, assess the injected area to identify if additional volumes are required at any site. In this case, additional volume was injected towards the brow area (Fig 9B).

RESULTS AND FOLLOW-UP The procedure enhanced Sylvia’s facial symmetry and balance by providing smoother contour to her temple (Fig 10). Dr Huang had a follow-up meeting with Sylvia where he decided to continue improving the volume loss at the midface. BEFORE*

AFTER

Fig 10: Results of second treatment session *Photo after first treatment

33


TREATMENT SESSION III:

Improving Volume Loss At Midface and Softening Dynamic Folds The third session focussed on improving the nasolabial folds and the hollowness of the cheek to provide a smooth contour to the overall face. Dehydration St at

mic Dyna

Loss of elast icity

ic

ro ce

s kle rin W

Su rfa

in ess Sk ughn

g gin Sag

0.5 ml

0.5 ml

lu Vo

Nasolabial folds

Treatment Area

Infraorbital area and Cheek

Restylane Perlane Lidocaine

Product Injection Technique

Bolus injection

Bolus injection

29 gauge sharp needle

29 gauge sharp needle

Deep to the maxillary bone

Subcutaneous layer

0.5 ml on each side

0.5 ml on each side

Injection Accessories Injection Site/Plane

0.5 ml

m e

Vo lu m el oss

e nc r ala Imb Mo

ph ol Asym og met ry y

0.5 ml

Injection Volume

Fig 11: Session III injection techniques and procedure at a glance

Detailed Procedure

Reducing the nasolabial folds + To reduce the nasolabial folds, feel the hollows at the maxillary bone using the non-injecting hand and position a 29 gauge sharp needle at 45째. Using the bolus technique, inject 0.5 ml Restylane Perlane when you feel the needle tip hit the bone (Fig 12). + Repeat the procedure on the other side. A

Fig 12: Deep injection at the nasolabial groove

34


TIPS

Case Demonstration III

+ Injection into the maxillary hollow may help in narrowing the nostrils, providing a better overall effect + Injecting into the periosteal layer with one injection point helps to avoid accidental penetration of blood vessels which can cause embolism

Augmenting the cheek + Identify the cheek hollows and inject 0.5 ml Restylane Perlane using a 29 gauge sharp needle (Fig 13) into the subcutaneous layer of the cheek to fill up the hollows. + Repeat the procedure on the other side. A

B

1

3

2

4

1

Fig 13: Subcutaneous injection at the cheek

RESULTS AND FOLLOW-UP The third treatment session helped to soften the nasolabial folds and re-established the cheek volume, creating a better balance of the midface (Fig 14). Dr Huang had a follow-up session with Sylvia two weeks after the third treatment session to determine her satisfaction with the overall treatment. BEFORE*

2 weeks after SESSION III

Fig 14: Results of third treatment session after 2 weeks *Photo after second treatment

35


Case Demonstration SUMMARY Sylvia was mainly concerned with her flat nose and sunken cheeks. These concerns made her extremely self-conscious about her appearance. Dr Huang performed a thorough facial analysis and developed a personalised treatment plan for Sylvia using the Harmony Programme. The procedures helped Sylvia to achieve an optimised projection and facial balance. It also improved the shape of her nose, providing Sylvia an attractive profile.

Su rfa

ph ol Asym og met ry y

Vo lu m el oss

g gin Sag

“I look good and feel beautiful!� 36

m e

Vo lu m el oss

m e

Vo lu m el oss

Su rfa

Su rfa

Loss of elast icity

m e

lu Vo

mic Dyna

g gin Sag

St at ic

ph ol Asym og met ry y

Dehydration

ro ce

s kle rin W

Vo lu m el oss

in ess Sk ughn

e nc r ala Imb Mo

lu Vo

St at

mic Dyna

g gin Sag

Dehydration

ro ce

ic

ph ol Asym og met ry y

2 WEEKS AFTER SESSION III

s kle rin W

m e

in ess Sk ughn

e nc r ala Imb Mo

lu Vo

e nc r ala Imb Mo

g gin Sag

St at

mic Dyna

mic Dyna

e nc r ala Imb Mo

ph ol Asym og met ry y

Dehydration

ro ce

ic

ic

Loss of elast icity

in ess Sk ughn

s kle rin W

St at

Loss of elast icity

Dehydration

ro ce

s kle rin W

Su rfa

in ess Sk ughn

AFTER SESSION II

Loss of elast icity

AFTER SESSION I

BEFORE

lu Vo


NOTES

37


NOTES

38


Case DEMONSTRATION II

39


Dr huang case 1 3 40pp final lr sp  
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