QUELL THE SWELL One of the key advantages to the intraoral injection approach over transcutaneous injections is the reduction of bruising and swelling, Michael Jasin, M.D., F.A.C.S., tells Cosmetic Surgery Times . This, he says, not only allows patients to go about their activities immediately, but helps avoid the challenges that swelling presents when trying to inject just the right amount of filler for the desired aesthetic results. "With the intraoral approach, you don't get that kind of tissue reaction and swelling that you get from a transcutaneous injection because there aren't as many needle sticks," explains Dr. Jasin, Medical Director of the Jasin Facial Rejuvenation Institute in Tampa, Fla. "Less swelling means you get less distortion at the treatment site, allowing you to better monitor your degree of correction and get a more precise idea while injecting of how close you are to your endpoint."
Since there is no needle trauma just below the skin, bruising is also kept to a minimum. "The injections are all below the muscle and fat, so anything that relates to that doesn't tend to show through," he explains. Dr. Jasin said he uses the intraoral approach on most of his mid-face correction work, and adds that the only time his filler patients do have bruising or swelling is if some transcutaneous injections are provided to supplement the intraoral injection.TRICKS OF THE TROUGH According to Dr. Jasmin, another key benefit of the intraoral approach is that it gives the cosmetic practitioner the ability to place the filler precisely in the plane in which volume has been lost — particularly in tricky places like the tear trough. "If you inject an intradermal or even a subdermal filler in the tear trough, you have to inject on top of the orbicularis occuli muscle, but the volume loss is actually below that muscle," he observes. "Superficial injection in that area is just camouflaging the volume loss going on below the muscle." In addition to volume in a place that may not be ideal, superficial injection in the tear trough can cause problems such as nodules. "Most of the problems with any kind of filler in the mid face result from superficial injection in the subdermal plane. You reduce that potential if you're placing the filler below the orbicularis occuli muscle," he says.
The deeper placement of filler provided by intraoral injection gives an overall evenness of volumization and a more natural feel, with areas such as the cheek and tear trough gaining a smoother transition, Dr. Jasin adds. "All of the tissue planes are elevated simultaneously, providing a smoother correction to places like the tear trough and cheek, instead of having the bulk of the volumization placed superficially." The intraoral approach takes an advanced level of skill and anatomic knowledge, however, and it's not for everyone. Even skilled injectors need to use extra caution to avoid injecting directly around the temporal nerve and the mental nerve, Dr. Jasin notes.
RISK AVERSE Many injectors have avoided the intraoral approach due to concern about the higher risk for infection presented by going through the mouth. Few cases have been reported, but there has nevertheless been enough anecdotal evidence to turn some away. "I've abandoned the intraoral method because, theoretically, there's a risk for infection, and although I haven't seen it, I've heard about it," cautions Steven H. Dayan, M.D., a clinical assistant professor at the University of Illinois and a facial plastic surgeon.