Letter to the Editor
Aesthetic Surgery Journal
2022, Vol 42(1) NP89–NP90
Filler Anatomy © The Author(s) 2021. Published
by Oxford University Press on behalf
of The Aesthetic Society. All rights
reserved. For permissions, please
e-mail:
[email protected] https://doi.org/10.1093/asj/sjab348
Peter Velthuis, MD; Leonie Schelke, MD; www.aestheticsurgeryjournal.com
and Sebastian Cotofana, MD, PhD
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Editorial Decision date: September 8, 2021; online publish-ahead-of-print October 1, 2021.
Although human anatomy is universal, medical special- other structures such as muscles, the parotid gland,
ties have their own ways of approaching anatomy based lymph nodes, and large arteries. Although filler injec-
on particular scientific and educational needs, hence tions into the superficial fat compartments are relatively
terms such as cadaver anatomy, clinical anatomy, and sur- routine, the thickness of this space may be limited. For
gical anatomy. Having delivered many training sessions instance, over the parotid gland it can be as small as 1
of ultrasound imaging of the face, the authors gradually to 2 mm. The authors have seen numerous cases of hy-
have reached the conclusion that “filler anatomy” differs aluronic acid deposits inside the parotid gland leading to
from surgical anatomy or any other form of anatomical clinical nodules with or without inflammation (Figure 1).
instruction. Also, we have seen patients injected into the proper
Recently we published two articles on doppler plane, the subcutis overlying to the parotid, but with a high
ultrasound analysis of the face in cosmetic medi-
G-prime hyaluronic acid substance, giving rise to unsightly
cine in the Aesthetic Surgery Journal.1,2 Utilizing the nodules.
standard positions given in part 1, clinicians may visu- As for the structures deep to the SMAS, it is im-
alize clear reference structures from which the anatomy portant to ensure the exact placement of the filler,
of that area of the face can be explored. In part 2, the whether in contact with bone or clearly above the bone.
courses of the major vascular structures in the face Furthermore, avoiding injecting inside a muscle may
are described. This work focuses on translating ca- be important. We have observed that it is virtually im-
daver anatomy to ultrasound images. This manner of possible to avoid the masseter muscle when injecting
employing ultrasound imaging may be helpful, for in- deep on the lateral mandible. Subsequent muscle action
stance, in avoiding intra-arterial filler injections. Also
knowing the exact location of the infraorbital foramen
can help injectors avoid damage to the nerve. However, Drs Velthuis and Schelke are physicians, Department of
to optimize filler treatment strategies, other anatom- Dermatology, Erasmus University Medical Center, Rotterdam, the
ical information should prevail, hence the term filler Netherlands. Dr Cotofana is a professor of anatomy, Department
of Clinical Anatomy, Mayo Clinic College of Medicine and Science,
anatomy. Rochester, MN, USA.
Understanding the layering of the tissues beneath
the epidermis/dermis is of the utmost importance. The Corresponding Author:
superficial musculo-aponeurotic system (SMAS) div- Dr Sebastian Cotofana, Department of Clinical Anatomy, Mayo Clinic,
College of Medicine and Science, Mayo Clinic, Stabile Building 9-38,
ides this space into superficial and deep compartments. 200 First Street, Rochester, MN, 55905, USA.
Superficial to it are fat pads and smaller vascular struc- E-mail: [email protected];
tures. Deep to the SMAS are deep fat pads and various Instagram: @professorsebastiancotofana
NP90 Aesthetic Surgery Journal 42(1)
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A B
Figure 1. (A, B) Ultrasound images showing nodules in the parotid gland. HA, hyaluronic acid filler; SMAS, superficial
musculo-aponeurotic system.
can spread the material to unwanted sites. In contrast, Disclosures
injecting right under a muscle may render a positive The authors declared no potential conflicts of interest with re-
myomodulation effect. We have shown that movement spect to the research, authorship, and publication of this letter.
of the deep medial cheek fat pad during muscle activity
is almost absent, whereas the superficial fat compart- Funding
ments regularly move back and forth.3 Filler injected
The authors received no financial support for the research,
deeply probably lasts longer and upon smiling and gives
authorship, and publication of this article.
a much more natural effect. Because of the small size of
the deep fat pad, injections should be performed under
REFERENCES
ultrasound guidance or after ultrasound verification.
These examples highlight that the benefits of ultrasound 1. Velthuis PJ, Jansen O, Schelke LW, et al. A guide to
imaging are a mix of improved safety and improved aes- doppler ultrasound analysis of the face in cosmetic
thetic outcome. medicine. Part 1: standard positions. Aesthet Surg J.
2021;41(11):NP1621-NP1632.
Ultrasound imaging has been utilized in cosmetic med-
2. Velthuis PJ, Jansen O, Schelke LW, et al. A guide to
icine only a few years; thus, there is more to learn about
doppler ultrasound analysis of the face in cosmetic
its potential of improving outcomes of soft tissue filler medicine. Part 2: vascular mapping. Aesthet Surg J.
injections. To the authors, it is clear that ultrasound filler 2021;41(11):NP1633-NP1644.
anatomy is not about the exact terminology of anatomical 3. Schelke L, Velthuis PJ, Lowry N, et al. The mobility of
structures, but rather about recognition of the different the superficial and deep midfacial fat compartments: an
echogenicities of fat, muscles, fibrous sheet, etc, and their ultrasound-based investigation. J Cosmet Dermatol. 2021.
subcutaneous orientation. doi: 10.1111/jocd.14374 [Epub ahead of print].
