CHAPTER 44 ■ Filler Injection for Lateral Brow Lift 135
tered with a 30gauge needle and some ■ ■Post-Injection Instructions
local anesthetic (1% lidocaine with
1:100,000 epinephrine buffered with Immediate pressure and then ice is
sodium bicarbonate 1:9). When the pa helpful to minimize bruises. The brow
tient is numb, the product is inserted will swell and may need to be blended
via a long needle (1 to 1.5inch/2.5 to out laterally to the temple or the lateral
3.8cm needle) under the deep tight orbit to achieve a natural look.
thicker fascia just above the periosteum.
Once the needle is in place above the
bone but below the level of the brow ■ ■Risks
hairs, the injector will not be able to lift
the needle vertically away from the Minimal risks occur besides bruising
bone. A retrograde injection can then using the superficial technique as long
occur as the needle is withdrawn slowly. as the injections are smooth and even.
A second or third pass directed at a
slightly different angle could help build
a mound or roll of fullness in the area of ■ ■Pearls of Injection
the lateral brow.
Keep the injection at the tail of the brow
at or under the brow hairs initially to
Alternate Technique make the best use of the product and get
Filler is layered on the periosteum and the most lift. Also, keeping the volume
also in the subdermal tissue until ade at or below the level of the brow will
quate elevation of the brow is achieved. keep the brow lifting rather that poten
Massage into place after injection, and tially making the brow appear heavier.
confirm bilateral brow symmetry. Hyaluronic acid or calcium hydroxylap
atite may be used in this region. Con
sider treatment of the lateral orbicularis
■ ■Precautions muscle with BoNTA (see also Chapter 9).
Do not overinject this area. Be careful to
maintain symmetry.
136 SECTION IV ■ Filler Injection Techniques
Fig. 44.1 Filler is placed along the periosteum of the lateral orbital rim to produce a lateral browlift.
■ ■Additional Reading
Carruthers JD, Carruthers A. Facial sculpting
and tissue augmentation. Dermatol Surg
2005;31(11 Pt 2):1604–1612 PubMed
45
Filler Injection for Sunken Temples
ally, the hairline posteriorly, and the
Difficulty: zygomatic arch inferiorly. Several large
Patient Satisfaction: veins and arteries run superficially in
Risk: this region. The temporalis muscle fills
the temporal fossa. Injections are placed
through the muscle, down to the peri-
■ ■Indications osteum of the temporal fossa.
Hollowing of the temporal fossa can ■ ■Injection Technique
lead to a sunken or gaunt look that ages
the upper half of the face. Though fat Hyaluronic Acid
loss can occur from trauma or disease
states, the most common cause is natu- The superior and medial aspects of the
ral aging. Other causes include surgical temporal area provide the most benefit
deformities, HIV-associated lipoatrophy, aesthetically, and should be filled first.
or thin patients with little body fat. Injection of hyaluronic acid (HA) re-
quires use of a 1-inch (2.5-cm) needle to
inject deep onto the periosteum in the
■ ■Anatomic Considerations upper half of the fossa and then deep
onto or below the temporalis fascia more
The anatomic boundaries of the temple inferiorly. Depot injections must be
are the temporal line superiorly, the tail used in this region to minimize contour
of the brow and lateral orbital rim medi- irregularities. Placing the product deep
137
138 SECTION IV ■ Filler Injection Techniques
and then massaging it into place will them. If a vessel is traumatized, firm
ensure uniform volumization of the tem- pressure for several minutes will mini-
poral fossa. It would not be unusual to mize bruising.
use 1 cc of product in each temple in
moderately to severely sunken temples.
■ ■Post-Injection Instructions
Calcium Hydroxylapatite
Massage is helpful for the HA patients,
Calcium hydroxylapatite (CaHA) may be and mandatory for the PLLA patients.
injected into the temporal fossa and Cold compresses can help prevent both
gives a more firm feel to the temples. soreness of the temporalis muscle and
The injection technique is similar to that discomfort while chewing.
used for HAs.
■ ■Risks
Poly-L Lactic Acid
The depot technique similarly is used, Bruising is possible; apply firm pressure
laying product onto the periosteum. should a vessel be violated. Filling too
A 25-gauge needle of at least 1 to 1.5 close to the surface can result in an un-
inches (2.5 to 3.8 cm) in length is pref- even or lumpy appearance. Trismus may
erable to ensure deep placement. To be noted in some patients for 1 to 2 days
evenly spread the product, massage is posttreatment and will resolve without
performed by the injector just after treatment.
placement and by the patient for 5 days
posttreatment (for 5 minutes, five times
a day). With a 6- to 8-cc dilution of poly-L ■ ■Pearls of Injection
lactic acid (PLLA), 1 to 2 cc of product is
administered to each temporal fossa, The end point of treatment usually oc-
depending on the amount of atrophy. curs when the area is still slightly con-
Two or three treatment sessions may be cave to flat but not overcorrected to
required. An interval of 4 to 8 weeks bordering on convex. Proper depth of
between injections is recommended, and placement is the key to smooth results.
increased improvement continues for 3 It is hard to overfill this area. It is valu-
to 6 months after the final injection. able to look at both sides of the patient
to compare after completing the first
side. It helps to show the patient the dif-
■ ■Precautions ference in the two sides, as it is often
dramatic. This will give the patient an
There are many surface vessels in the idea of the treatment end point as well.
temple, and care should be taken to per- Because of the high vascularity in this
form depot injections between or below region, it is often helpful to perform a
CHAPTER 45 ■ Filler Injection for Sunken Temples 139
Fig. 45.1 Filler is placed deep to the temporalis muscle onto the periosteum to volumize the tem-
ples. Care is taken to avoid injury to the numerous vessels in this region.
reflux maneuver on the syringe before lactic acid. Dermatol Ther 2011;24:2–27
injecting the product to prevent intra- PubMed
vascular injection. Lambros V. A technique for filling the tem-
Some patients will notice an elevation ples with highly diluted hyaluronic acid:
the “dilution solution”. Aesthet Surg J
of the lateral brow with improvement of 2011;31:89–94 PubMed
the temporal hollowing.
■ ■Additional Reading
Fitzgerald R, Vleggaar D. Facial volume
restoration of the aging face with poly-l-
46
Filler Injection for Nonsurgical
Rhinoplasty
■ ■Anatomic Considerations
Difficulty:
Patient Satisfaction: Knowledge of the ideal proportions of
Risk: an attractive nose will be necessary as
well as knowledge of the basic anatomy
of the bony, cartilaginous, and soft tis-
■ ■Indications sue structures involved. It is also im-
portant from a safety standpoint to be
Because the nose occupies the center of aware of the key vascular channels to
the face, mild asymmetries can be quite avoid intravascular injections.
striking. Rhinoplasty surgery is not al-
ways a perfect procedure, and postsur-
gical defects can be difficult to correct. ■ ■Injection Technique
As a result, the use of fillers in small
quantities to treat specific nasal defor- When injecting a hollow or void in the
mities has become a way to fine-tune nose, it is best to start deep on the bone
postsurgical noses. In addition, in some or cartilage and perform a retrograde
patients who refuse surgery or who are injection with a threading movement
not surgical candidates, a nonsurgical so as to avoid a direct depot injection
approach to their nasal concerns may that could possibly flow into a blood
be possible by the use of filling agents. vessel.
140
CHAPTER 46 ■ Filler Injection for Nonsurgical Rhinoplasty 141
Dorsal Hump better define the tip, and can also in-
crease the tip projection and increase
To straighten a dorsal hump, inject both tip rotation. The thickness of the skin
above and below it as needed to
straighten the dorsal profile. This tech- and the amount of scar tissue in the area
will determine whether and to what ex-
nique can also be used on a wide nose
to give the illusion of a higher and nar- tent this technique will be successful.
rower nasal profile.
Risks
Saddle Nose Deformity Nasal injections must be placed in an
avascular plane, either preperiosteal or
In these cases, there is little to no sup- pre-perichondral. Care should be taken
porting cartilage at the base of the con- not to inject into the dermis to avoid the
cavity; therefore, it is necessary to inject dermal vascular plexus.
into the immediate dermal/subdermal
plane to thicken the skin layer to allow
improved bridging from the bony dor- ■ ■Precautions
sum to the cartilaginous tip. Secondary
injection to the deeper plane below will Often if there are large pores in the area
help to further support and elevate the being injected, the needle may need to
concave area and augment the bridge be passed at a deeper or different angle
contour. if product begins to extrude through
one of the dilated pore tracts. Over-
Twisted/Crooked Nose injection of a given area can lead to
blanching or even intravascular occlu-
When dealing with the twisted nose, it sion. Restylane is the preferred hyal-
is possible to imagine a single line that uronic acid (HA) for the nose, because
passes through the midline. Usually there the hydrophilic nature of Juvéderm ac-
are portions of the twisted nose that centuates edema in this region. Calcium
will wind in a C or S shape onto either hydroxylapatite (CaHA) may be used;
side of the midline. By filling the con- however, because of its permanence, the
cavities the nose will appear straighter. injector should proceed with extreme
caution.
Drooping Tip
When there is little tip definition and ■ ■Post-Injection Instructions
a droopy tip, a new, more rotated and
defined tip can be “created” by placing Ice and pressure are helpful to prevent
filler depot injections into appropriate bruising. The product will swell some
anatomic locations. The injections can with an HA and feel firmer to palpation
mimic a tip graft that will augment and the first week and then blend in more
142 SECTION IV ■ Filler Injection Techniques
a
b
Fig. 46.1a–d (a) Dorsal hump. Filler can be placed above and below a dorsal hump to straighten
the dorsal profile. (b) Saddle nose. The concavity of the dorsum seen in the saddle nose deformity
can be improved nonsurgically by using filler.
CHAPTER 46 ■ Filler Injection for Nonsurgical Rhinoplasty 143
c
Fig. 46.1 (Continued) (c) Crooked nose. Filler is placed along the periosteum or perichondrium in
the concave aspect of the nasal sidewall to give the illusion of a straight dorsum. Pre- (left upper and
lower panels) and post- (right upper and lower panels) injections along the right nasal sidewall improve
a mildly crooked nose in a patient with a persistent deformity after closed reduction of a nasal frac-
ture. (continued on next page)
144 SECTION IV ■ Filler Injection Techniques
d
Fig. 46.1 (Continued) (d) Droopy tip. Filler can be used as a “tip graft” to define and elevate a ptotic
tip.
a b
Fig. 46.2a, b (a) Mild right lateral nasal sidewall depression post rhinoplasty. (observe the light re-
flexes) (b) Improvement of right sidewall depression by placing filler in the defect.
CHAPTER 46 ■ Filler Injection for Nonsurgical Rhinoplasty 145
naturally. The patient should expect that so as not to inject into a vessel and cre-
the areas injected will look raised and ate an occlusion or embolic situation.
welted at first. Swelling should improve Proceed with caution in post-rhinoplasty
within about 2 to 4 days. patients because prior surgery may com-
promise the blood supply to the nasal
skin, which may increase the chance of
■ ■Risks skin necrosis.
The most significant risks involve injec-
tion into a vessel that could lead to vas- ■ ■Additional Reading
cular necrosis. Retrograde injections and
avoiding high pressure on, or blanching Andre P. New trends in face rejuvenation by
of, the skin during treatments can help hyaluronic acid injections. J Cosmet Der-
matol 2008;7:251–258 PubMed
prevent this devastating complication. Humphrey CD, Arkins JP, Dayan SH. Soft tis-
Because of the high risk of vascular com- sue fillers in the nose. Aesthet Surg J
promise in these areas, consider using 2009;29:477–484 PubMed
only HAs in this region. Redaelli A. Medical rhinoplasty with hyal-
uronic acid and botulinum toxin A: a
very simple and quite effective technique.
■ ■Pearls of Injection J Cosmet Dermatol 2008;7:210–220
PubMed
Undercorrection is recommended in this
region. Also, keep the needle in motion
47
Filler Injection for Nasal
Valve Stenting
septum and the lateral crus of the lower
Difficulty: lateral cartilage. The external nasal valve
Patient Satisfaction: refers to the area created by the ala, col-
Risk: umella, and nasal floor.
■ ■Injection Technique
■ ■Indications
Topical anesthetics or intranasal 4% Xy-
Collapse of the internal and external locaine is adequate anesthesia for this
nasal valves is generally treated surgi- procedure. Avoid using injected local
cally. In patients who have not had ad- anesthesia as it will change the shape of
equate improvement after surgery, or the valve and negate the filler effect.
those who refuse surgery, filler can be
used to stent the valve and prevent col-
lapse with inspiration. Internal Nasal Valve
Very small amounts of filler are depos-
ited intranasally in the area of the lateral
■ ■Anatomic Considerations crus or scroll region until the patient
notices improvement in the airway. Be-
The internal nasal valve is the acute fore injection, ask the patient to rate
angle formed by the junction of the the nasal patency on a scale of 1 to 10.
146
CHAPTER 47 ■ Filler Injection for Nasal Valve Stenting 147
Inject a small amount of filler and ask ■ ■Post-Injection Instructions
the patient to rate the airway patency
again. Inject until the nasal patency is None. Bruising is unlikely.
acceptable.
■ ■Risks
External Nasal Valve
Very small amounts of filler are placed Over-injection can weigh down the ala
along the alar rim until there is im- and worsen collapse.
provement of collapse during deep
inspiration.
■ ■Pearls of Injection
■ ■Precautions Optimal results are obtained with
thicker fillers like calcium hydroxylapa-
Lumpiness may be seen externally if tite or more concentrated hyaluronic
over-injected. acid fillers.
a b
Fig. 47.1a, b (a) Filler is injected intranasally at the scroll region to stiffen the internal nasal valve.
(b) Filler can be used to strengthen a collapsed ala and improve the external nasal valve.
148 IV ■ Filler Injection Techniques
■ ■Additional Reading Nyte CP. Spreader graft injection with cal-
cium hydroxylapatite: a nonsurgical tech-
Nyte CP. Hyaluronic acid spreader-graft in- nique for internal nasal valve collapse. La-
jection for internal nasal valve collapse. Ear ryngoscope 2006;116:1291–1292 PubMed
Nose Throat J 2007;86:272–273 PubMed
48
Filler Injection for Medial
Midface Hollowing
■ ■Injection Technique
Difficulty:
Patient Satisfaction: Hyaluronic acid (HA) or calcium hy
Risk: droxylapatite (CaHA) may be injected
into this area for facial volume restora
tion. Injection may be placed deeply
onto the periosteum or more superfi
■ ■Indications cially in the superficial subcutaneous
tissue. A fanning technique can ensure
Facial aging is a complex combination of even placement of the product. Massage
volume loss and tissue ptosis. However, after placement helps to evenly distrib
midface hollowing can be seen with ute product and allows the injector to
facial aging or occasionally in younger palpate any areas that were not fully
individuals who present with an ana injected.
tomically flattened midface.
■ ■Precautions
■ ■Anatomic Considerations
Bruising is common in this area. The
The medial midface is the triangular angular artery runs lateral to the nose,
zone below the infraorbital rim, lateral and care must be taken not to injure this
to the nasal sidewall and medial to the vessel, either by compression or embo
infraorbital foramen adjacent to the sub lization. Avoid injecting into the infra
malar region. orbital nerve foramen.
149
150 SECTION IV ■ Filler Injection Techniques
Ask the patient to refrain from ap ■ ■Post-Injection Instructions
plying heavy pressure on the injected
cheeks (either from ice after treatment Ice and pressure are helpful to prevent
or pressure from sleeping) to prevent bruising. The product will swell some
flattening the revolumized areas. with HA or CaHA and feel firmer to pal
a
b
Fig. 48.1a, b (a) Anteromedial subdivision of the midface lies medial to the infraorbital nerve,
lateral to the angular artery and inferior to the infraorbital rim. (b) Filler may be placed along the
periosteum and massaged into place to improve a flattened midface.
CHAPTER 48 ■ Filler Injection for Medial Midface Hollowing 151
pation the first week and then blend in superficial plane may require the use of
more naturally. needles.
■ ■Risks ■ ■Additional Reading
There are minimal risks of injection in Funt DK. Avoiding malar edema during
this area. The most difficult aspect of midface/cheek augmentation with dermal
injection here is ensuring symmetry. fillers. J Clin Aesthet Dermatol 2011;4:32–
36 PubMed
Raspaldo H. Volumizing effect of a new hy
■ ■Pearls of Injection aluronic acid subdermal facial filler: a
retrospective analysis based on 102 cases.
To reduce the risk of vascular injury, J Cosmet Laser Ther 2008;10:134–142
PubMed
consider the use of cannulas in this re Tansavatdi K, Mangat DS. Calcium hydroxyl
gion when performing deep injections. apatite fillers. Facial Plast Surg 2011;27:
Finetuning of the injection in a more 510–516 PubMed
49
Filler Injection for
Cheekbone Augmentation
patients with aging of the midface dis-
Difficulty: play a fat pad of the lateral malar promi-
Patient Satisfaction: nence, referred to as the “malar mound.”
Risk: This triangular prominence results from
the orbital retaining and zygomatico-
cutaneous ligaments.
■ ■Indications
■ ■Injection Technique
Fillers may be used to augment the
cheekbones, or lateral malar prominence. Topical anesthesia may be used for this
(Alternatively, permanent malar im- procedure. Fillers with lidocaine may be
plants may be inserted surgically or fat placed deeply at first injection to anes-
augmentation can be performed.) thetize the infraorbital nerve. Dental
blocks are discouraged and may actually
distort the anatomy. To volumize the
■ ■Anatomic Considerations lateral malar prominence, fillers may be
placed through the intraoral or percuta-
The malar bone and overlying soft tis- neous route. Intraoral injection does not
sue from the lateral malar prominence. predispose the patient to infection. Filler
High cheekbones contribute to a youth- can be placed deep in the subcutaneous
ful arc seen in three-quarter view. Some tissue and pre-periosteal planes.
152
CHAPTER 49 ■ Filler Injection for Cheekbone Augmentation 153
To camouflage the malar mound, hy- few days to minimize flattening of the
aluronic acid (HA) fillers can be placed product.
more superficially (deep dermal or sub-
cutaneous) over the retaining ligaments.
■ ■Risks
■ ■Precautions Bruising is possible. The greatest chal-
lenge with performing this procedure is
This is a very safe injection location; HA ensuring symmetry.
or calcium hydroxylapatite (CaHA) may
be used.
■ ■Pearls of Injection
■ ■Post-Injection Instructions Lateral malar augmentation may be per-
formed through a single entry point on
Ice may be used as needed, but instruct each cheek. Cannulas may be used for
the patient not to press firmly on the the deep injections.
injected site or sleep on that side for a
154 SECTION IV ■ Filler Injection Techniques
a
b
Fig. 49.1a, b (a) The zygomaticomalar subdivision of the midface lies inferior to the infraorbital rim
and lateral to the infraorbital nerve. (b) The prominence of the cheekbones is improved by augment-
ing the zygomaticomalar region. Injection may include deep injection along the infraorbital rim and
zygomatic arch as well as a more superficial injection to camouflage the malar mound.
CHAPTER 49 ■ Filler Injection for Cheekbone Augmentation 155
■ ■Additional Reading ment. Dermatol Surg 2006;32:881–885,
discussion 885 PubMed
Carruthers JD, Carruthers A. Facial sculpting Mendelson BC, Muzaffar AR, Adams WP Jr.
and tissue augmentation. Dermatol Surg Surgical anatomy of the midcheek and
2005;31(11 Pt 2):1604–1612 PubMed malar mounds. Plast Reconstr Surg 2002;
Lowe NJ, Grover R. Injectable hyaluronic acid 110:885–896, discussion 897–911 PubMed
implant for malar and mental enhance-
50
Filler Injection for Sunken Cheeks
filling these regions may be performed
Difficulty: as an adjunct to rejuvenation surgery.
Patient Satisfaction:
Risk:
■ ■Anatomic Considerations
The area under the zygomatic arch and
■ ■Indications lateral to the nasolabial fold and modio-
lus comprises the submalar and buccal
Hollowing of the cheeks can be seen in regions of the midface.
some patients who present with serious
volume deficits. The loss of malar and
buccal fat pads often can lead to a wind- ■ ■Injection Technique
swept post-facelift appearance as well
as wrinkled cheeks, deepened naso- Topical anesthesia is usually sufficient
labial folds, and the presence of jowls. for these injections. The injection tech-
In many cases, the hollow submalar nique should be a grid or fanning pat-
and buccal concavities are better suited tern, spreading the product in a medial
to augmentation than surgery; however, to lateral fashion. The plane of injection
156
CHAPTER 50 ■ Filler Injection for Sunken Cheeks 157
is usually at the dermal–subcutaneous A gentle post-injection kneading mas-
junction. Gentle massage after injection sage can be helpful.
helps to smooth irregularities.
■ ■Risks
■ ■Precautions
This is a low-risk procedure; however,
Injecting too superficially in this region if very large volumes of product are
can result in ridges or striping of mate- necessary, the excess filler can “weigh
rial. Placing the product in deeper planes down” the cheek. In these excessively
will necessitate using more material. hollow patients, consider using poly-L
Lumpiness in this region is common after lactic acid (PLLA) or fat augmentation.
injection, and the injector should mas-
sage the area after injection to ensure
even placement of product. Placement of ■ ■Pearls of Injection
product too deeply will project some of
the volume into the oral cavity because Inject at different levels and massage to
the buccal area is not supported by bone. evenly disperse product. Large volumes
of product are necessary to properly
correct these areas. To best treat a pa-
■ ■Post-Injection Instructions tient on a modest budget, begin the in-
jection medially and near the inferior
Ice and pressure are helpful to prevent aspect of the zygomatic arch. The goal
bruising. The product will swell some is to ease the transition from the high
and will feel firmer to palpation the first to low regions and creates a less sharp
week, and then blend in more naturally, step-off transition.
158 SECTION IV ■ Filler Injection Techniques
a
b
Fig. 50.1a, b (a) The submalar and buccal regions of the midface lie inferior to the zygomatico-
malar region and lateral to the infraorbital nerve. (b) Filler is placed at different depths in a crossed
fanning technique to elevate the submalar and buccal hollows.
CHAPTER 50 ■ Filler Injection for Sunken Cheeks 159
■ ■Additional Reading Raspaldo H, Aziza R, Belhaouari L, et al. How
to achieve synergy between volume re-
Cattin TA. A single injection technique for placement and filling products for global
midface rejuvenation. J Cosmet Dermatol facial rejuvenation. J Cosmet Laser Ther
2010;9:256–259 PubMed 2011;13:77–86 PubMed
51
Filler Injection for Chin Augmentation
wants a smooth contour across the cen-
Difficulty: ter of the chin.
Patient Satisfaction:
Risk:
■ ■Anatomic Considerations
The bone structure of the mandible can
■ ■Indications be too “squared,” “pointed,” or “weak,”
and filler can be used creatively to shape
The weak chin is usually best addressed or augment the chin. During injection,
with a permanent surgical solution such be cognizant of the location of the men-
as an alloplastic implant. However, aug- tal nerves and adjacent vessels exiting
mentation with a filler can be a good the mental foramen.
alternative in the following situations:
the patient needs only small amounts of
augmentation; the patient is elderly or ■ ■Injection Technique
a poor surgical candidate; the patient is
already scheduled to undergo lower fa- There are two basic techniques that are
cial volume restoration; the patient is useful for filling the chin: deep depot
looking for immediate results without injections onto the periosteum to truly
surgical downtime or great expense; the mimic a surgical implant; and fanning,
patient is considering a chin implant but threading-type injections in the sub-
is hesitant about receiving a permanent dermal plane that spread over a broad
implant; the patient has a cleft chin and area. The more superficial injection tech-
160
CHAPTER 51 ■ Filler Injection for Chin Augmentation 161
niques should be at the dermal subcuta- initially will appear swollen and more
neous junction so as to add volume as rounded than it will appear once the
well as to firm the overlying skin, which edema subsides.
is often less firm than it once was. With
the threading technique, a longer 1- to
1.5-inch (2.5- to 3.8-cm) needle and a ■ ■Risks
27- to 30-gauge work best. The depot
is easily placed along the border of the Minimal risks occur, besides bruising,
mandible as long as the mental foramen with the superficial technique if the
is avoided. injections are smooth and even. When
injecting deeply onto the bone, there are
more inherent risks for damage to the
■ ■Precautions mental nerve and possible intravascular
injection if a depot injection is used.
Determine where the mental foramen
and nerve are located, and stay away
from that region when injecting. If a chin ■ ■Pearls of Injection
implant is already in place, use careful
sterile technique and avoid directly in- Evaluate the chin from all angles to
jecting into or onto the implant to avoid ensure that it looks proportionate and
seeding the implant with bacteria. balanced all over, as symmetry will be
important as well as challenging when
trying to fill a whole midline structure.
■ ■Post-Injection Instructions Massage of the area will aid in smooth-
ing any injection irregularities.
Immediate pressure and then ice are
helpful to minimize bruises. The chin
162 SECTION IV ■ Filler Injection Techniques
a
b
Fig. 51.1a, b (a) Filler is placed on the periosteum and/or in the subcutaneous tissue to increase
prominence of the chin. (b) Filler may be placed subcutaneously to camouflage a chin cleft.
CHAPTER 51 ■ Filler Injection for Chin Augmentation 163
■ ■Additional Reading Wise JB, Greco T. Injectable treatments for
the aging face. Facial Plast Surg 2006;22:
Andre P. New trends in face rejuvenation by 140–146 PubMed
hyaluronic acid injections. J Cosmet Der-
matol 2008;7:251–258 PubMed
52
Filler Injection for the Mental Crease
muscles elevates the lower lip and con-
Difficulty: tributes the mental crease.
Patient Satisfaction:
Risk:
■ ■Injection Technique
This is a painful area to inject; a topical
■ ■Indications or dental block may be utilized. Filler
is injected at multiple levels in the der-
The mental crease (or chin crease) is the mis and subdermal subcutaneous tissue
horizontal crease between the lower lip to elevate the crease. A combination of
and chin, and it can be quite deep in linear threading both parallel and per-
some individuals. pendicular to the crease can be used.
Deeper creases can be treated with depot
techniques.
■ ■Anatomic Considerations
The paired mentalis muscles originate ■ ■Precautions
on the incisor fossa of the mandible and
insert directly onto the dermis of the Superficial injection of some hyaluronic
chin skin. Contraction of the mentalis acids (HAs) will result in bluish blebs of
164
CHAPTER 52 ■ Filler Injection for the Mental Crease 165
Fig. 52.1 The mental crease can be improved by injection of filler in the subcutaneous tissue be-
neath the concavity.
material. Do not over-inject this area. in conjunction with BoNTA injection to
Massage after injection to maximize the mentalis, the duration of any filler
smoothness. in this area is significantly improved.
Neurotoxin may be injected into the
mentalis muscles as in treatment of the
■ ■Post-Injection Instructions peau d’orange chin (see Chapter 18),
which may also help to flatten the men-
Ice as needed; bruising is possible. tal crease.
■ ■Risks ■ ■Additional Reading
This is a very safe area to inject. Deep Brandt FS, Cazzaniga A. Hyaluronic acid
creases may require a large amount of fillers: Restylane and Perlane. Facial Plast
filler. Surg Clin North Am 2007;15:63–76, vii
PubMed
Romagnoli M, Belmontesi M. Hyaluronic
acid-based fillers: theory and practice. Clin
■ ■Pearls of Injection Dermatol 2008;26:123–159 PubMed
Filler used alone in this area tends to last
for very short periods of time. However,
53
Filler Injection for
Jawline Rejuvenation
changes in the submental platysmal
Difficulty: angle. Filling the prejowl area, both in
Patient Satisfaction: the area of the marionette lines as well
Risk: as in the area at and below the mandi-
ble, creates a much more pleasing ante-
rior mandibular contour. Augmentation
of the prejowl sulcus occasionally must
■ ■Indications
be addressed when surgical options are
planned, either by the use of filling
Prejowl sulcus fat loss and descent of the agents or by the use of prejowl surgical
midface can accentuate the formation implants.
of the jowls. By filling the concave area
just anterior to the jowl, a straighter,
more youthful jawline can be achieved. ■ ■Injection Technique
However, the formation of jowls is mul-
tifactorial, and often a facelift is the only Hyaluronic acids (HAs) are commonly
treatment that can adequately lift or re- used in this area. They may be injected
move the jowl. at the dermal subcutaneous junction so
as to add volume as well as to firm the
overlying skin, which is often less firm
■ ■Anatomic Considerations than it once was. A threading technique
with 1- or 1.5-inch (2.5- to 3.8-cm) nee-
Aging changes of the jawline are a re- dles and a 27- or 30-gauge needle works
sult of draping of excess skin, sagging of best. The injection needs to bridge all
buccal fat, loss of prejowl fullness, and the way from the high point of the jowl
166
CHAPTER 53 ■ Filler Injection for Jawline Rejuvenation 167
and blend forward to the firm level por- ■ ■Precautions
tion of the chin.
Bruising is very common with the sub-
Alternate Technique dermal injection. Care needs to be taken
to avoid the mental foramen, as pares-
Subdermal injections may be combined thesias could occur with a direct injec-
with depot injections along the mandi- tion into the foramen.
ble. For these deep injections, HA, cal-
cium hydroxylapatite (CaHA), or poly-
methylmethacrylate (PMMA) can be ■Post-Injection Instructions
used safely, and these deep injections ■
can mimic a true prejowl implant. This Immediate pressure and then ice are
technique requires more product vol- helpful to minimize bruising.
ume than do the more superficial injec-
tions to achieve a similar effect.
■ ■Risks
Minimal risks occur, besides bruising,
with the superficial technique if the in-
jections are smooth and even.
■ ■Pearls of Injection
Massage the product to shape it and re-
a create the mandibular jawline. Include
injection along the inferior aspect of the
mandible to fill in the entire prejowl
concavity. Consider using a cannula for
injection into this region, as precision of
filler placement is not required in this
location.
■ ■Additional Reading
b
Fig. 53.1a, b (a) Filler can be placed in the pre- Fedok FG. Advances in minimally invasive
periosteal or subcutaneous planes to augment facial rejuvenation. Curr Opin Otolaryngol
the prejowl sulcus. (b) Filler can also be placed Head Neck Surg 2008;16:359–368 PubMed
subcutaneously in a linear fashion. A combina- Wise JB, Greco T. Injectable treatments for
tion of these techniques may be required for op- the aging face. Facial Plast Surg 2006;22:
timal correction. 140–146 PubMed
54
Filler Injection for Earlobe
Rejuvenation
■ ■Injection Technique
Difficulty:
Patient Satisfaction: Hyaluronic acid (HA) should be placed
Risk: in the subcutaneous tissue in a U-shape
until adequate filling of the earlobe is
seen. Alternately, poly-L lactic acid (PLLA)
may be used in a similar fashion, but the
■ ■Indications results will take longer to achieve.
The earlobes flatten with age and lose
their volume. This flattening combined ■ ■Precautions
with elongated piercing holes can re-
sult in the downward hanging of stud None.
earrings. Re-volumization of the lobes
contributes to a more youthful look and ■Post-Injection Instructions
more attractive earring positioning. ■
Ice as needed.
■ ■Anatomic Considerations
■ ■Risks
Fill the lower aspect of the earlobe to
provide structural support to the ear- None; this is a very safe procedure to per-
ring and restore volume to the earlobe. form, yielding high patient satisfaction.
168
CHAPTER 54 ■ Filler Injection for Earlobe Rejuvenation 169
■ ■Pearls of Injection
This is a nice technique to offer patients,
especially when looking for an appro-
priate place for the last little bit of prod-
uct remaining in the syringe after treat-
ment of other facial areas.
■ ■Additional Reading
Hotta T. Earlobe rejuvenation. Plast Surg Nurs
2011;31:39–40 PubMed
Fig. 54.1 Hyaluronic acid may be placed in the
earlobe both to support a hanging pierced ear-
ring and to restore volume to the deflated aging
lobe.
55
Filler Injection for Acne Scars
■ ■Anatomic Considerations
Difficulty:
Patient Satisfaction: Prior to injection of the scar, the injector
Risk: may perform a “stretch” test to deter
mine if the scar will improve with filler
injection. If the scar flattens out with
skin stretching, the scar will likely elevate
■ ■Indications and improve with filler. If it does not ele
vate, it may require release of the dermal
Severe cystic acne can lead to large attachments by subcision, or it may re
depressed facial scars. These scars can quire direct excision. Most injections will
include depressions in the dermis as be placed intradermally or in the imme
well as the subdermal fat. The shadow diate subdermal plane. To prevent lumpi
ing of these depressed scars can ac ness in areas with thin skin such as the
centuate their deep appearance, and temple and the lower eyelid, very small
elevation with fillers will minimize the amounts of filler should be injected.
shadowing and improve the overall
skin contour. Although some flattened
scars and concavities can be improved ■ ■Injection Technique
with fillers, enlarged pores and ice
pick scars will not improve with such Any filler may be used for these injec
injections. tions; however, we commonly use hyal
170
CHAPTER 55 ■ Filler Injection for Acne Scars 171
uronic acids (HAs). The injection tech swell some with an HA and feel firmer to
nique should start with a 30gauge palpation the first week and then blend
needle so as to layer and crosshatch the in more naturally. The patient should ex
intended area with multiple passes from pect that the areas injected will look
different angles. Part of the correction raised initially.
requires subcision within the dermis
and subdermis to break up fibrosis and
scar tissue. The action of the needle ■ ■Risks
moving back and forth across the scar
will disrupt the fibrous attachments Minimal risks besides bruising and Tyn
deep to the scar and permit its eleva dall effect from overly superficial injec
tion with filler. A significant amount of tion into the dermis.
force is necessary to introduce the prod
uct into the scar area. If no resistance is
met, then the needle is probably too ■ ■Pearls of Injection
deep. It is best to introduce the needle 4
to 5 mm away from the edge of the scar The force of the injection and the pres
area so that the product does not escape ence of the product in the expanded
out of the puncture site when the nee space of the scar can actually stimulate
dle is withdrawn or when the next pass neocollagenesis. Unless adequate release
is made from a different angle. of scar tissue is performed at the center
of a depressed scar, filling the area can
create a mound that will accentuate the
■ ■Precautions shadowing at the base of the scar.
Consider layering fillers, placing cal
If there are large pores in the area being cium hydroxylapatite (CaHA) deeply in
injected, the needle may need to be the subcutaneous tissues and HA more
passed at a deeper or different angle if superficially in the deep to superficial
product begins to extrude through one dermis. Restylane has more lifting qual
of the dilated pore tracts. Overinjection ities than does Juvéderm and is pre
of a given area can lead to blanching or ferred for acne scars. Collagen is also
even intravascular occlusion. an excellent scar elevator. Polymethyl
methacrylate (PMMA) may be used as
well, usually several days after subcision
■ ■Post-Injection Instructions has been performed.
Ice and pressure are helpful to prevent
bruising and lumpiness. The product will
172 SECTION IV ■ Filler Injection Techniques
Fig. 55.1 Some acne scars may be elevated by placing filler deep to the scars. Scars that do not el-
evate with filler alone may require subcision to release dermal attachments prior to injection.
■ ■Additional Reading Goldberg DJ, Amin S, Hussain M. Acne scar
correction using calcium hydroxylapatite
Carvalho Costa IM, Salaro CP, Costa MC. in a carrierbased gel. J Cosmet Laser Ther
Polymethylmethacrylate facial implant: a 2006;8:134–136 PubMed
successful personal experience in Brazil for Smith KC. Repair of acne scars with Dermi
more than 9 years. Dermatol Surg 2009; colP35. Aesthet Surg J 2009;29(3, Suppl)
35:1221–1227 PubMed S16–S18 PubMed
56
Filler Injection for Aging Hands
extensor tendons. For deeper injections,
Difficulty: the injector must be aware of the loca
Patient Satisfaction: tion of the interosseus muscles and the
Risk: five metacarpal bones of the hand.
■ ■Injection Technique
■ ■Indications
Hyaluronic acid (HA) or calcium hy
The back of the hand is an area that droxylapatite (CaHA) can be used to aug
often shows a person’s age even while ment this region. These fillers provide
the face and body are well maintained instant gratification and a soft, even
and physically fit. The aging hands fill in the space between the skin and
manifest dyschromias, loss of fat, thin the interosseous muscles. The injections
ning of the skin, and grooving of the should be performed as if there are
spaces between the extensor tendons of separate compartments between each
the fingers. metacarpal. It is best to avoid injecting
directly over the tendons and bones, as
it is more likely to lead to surface irregu
■ ■Anatomic Considerations larities. As the area being injected is a
long narrow compartment with many
For superficial injections of the hand large veins throughout, it is best to us
dorsum, the anatomic concerns include a long needle (either 1 or 1.5inch/2.5
a superficial venous arcade and the long to 3.8cm, 25 to 27gauge) to inject
173
174 SECTION IV ■ Filler Injection Techniques
product deep to veins and the skin into pation the first week and then blend in
the deep subcutaneous layers or right more naturally. The patient should ex
above the muscle if necessary. All injec pect that the areas injected will look
tions should be performed as retrograde raised and welted at first. Swelling
threading or fanning to avoid vessel in should settle down within about 2 to
jection. PolyLlactic acid (PLLA) is also 4 days. Vigorous massaging is necessary
another excellent choice in this area and with the PLLA injections for the next 5
it should be diluted to approximately to 10 days.
10 cc per vial prior to injection. This high
dilution and injecting deeply prevents
the occurrence of nodule formation. ■ ■Risks
The most significant risks involve in
■ ■Precautions jection irregularity and the product not
feeling and looking smooth. It is impor
With so many large and torturous ves tant to massage uneven areas soon after
sels in this area, hitting one or even a injection so as to avoid a longer term
couple is often inevitable. Ice ahead of problem, though an even injection tech
time and quick firm pressure on the site nique is always more effective than any
of injection as soon as the needle is with amount of massage.
drawn can minimize hematomas or very
large bruises from forming.
■ ■Pearls of Injection
■ ■Post-Injection Instructions Undercorrection is usually safest, as well
as injecting with the needle in motion
Ice and firm pressure are helpful to pre so as not to inject into a vessel and cre
vent bruising. The product will swell ate an occlusion or embolic situation.
some with an HA and feel firmer to pal
CHAPTER 56 ■ Filler Injection for Aging Hands 175
Fig. 56.1 Filler is placed subcutaneously and massaged into place to improve the hollows of the
aging hand.
■ ■Additional Reading Edelson KL. Hand recontouring with calcium
hydroxylapatite (Radiesse). J Cosmet Der
Brandt FS, Cazzaniga A. Hyaluronic acid fill matol 2009;8:44–51 PubMed
ers: Restylane and Perlane. Facial Plast Surg
Clin North Am 2007;15:63–76, vii PubMed
57
Filler Injection with Poly-L Lactic Acid
for Facial Volumizing (Sculptra)
■ ■Anatomic Considerations
Difficulty:
Patient satisfaction: Prior to injecting this product, it is essen-
Risk: tial to have a thorough understanding of
the facial aging process to accurately re-
store volume to a more youthful shape.
PLLA is not intended to be injected into
■ ■Indications the muscle. Therefore, the injections
should be directed either into the more
The aging face undergoes lipoatrophy superficial subcutaneous planes in the
and essentially “deflates” prior to suc- lower face or near the periosteum below
cumbing to the effects of gravity. Fat the muscles of the upper face.
augmentation of the face is gaining in
popularity; however, poly-L lactic acid
(PLLA) may provide similar results with- ■ ■Injection Technique
out the need for a surgical intervention.
In addition, many thin faces are part of a Currently injectors are required to be
body that is also depleted of fat, so with trained by an injector trainer prior to
no adequate donor site for fat augmen- use or purchase of this product in the
tation, PLLA may be a viable alternative. United States. Re-suspension of product
PLLA is a biostimulatory filler, and mul- is performed preferably 48 hours prior
tiple treatments are necessary. to injection, but may be reconstituted
176
CHAPTER 57 ■ Filler Injection for Facial Volumizing 177
anywhere from 20 minutes to 3 days not an on-label use. Depot onto the peri-
prior to the procedure using preserved osteum is used for volumization of the
water. Preserved water is preferred be- upper half of the face in all areas above
cause it allows a longer shelf life after the inferior border of the orbicularis
rehydration. (If saline is inadvertently oculi muscle. Due to the suspension par-
used for re-suspension, the product ticle size of the PLLA product, it is neces-
should not be used.) The volume of water sary to use at least a 26-gauge needle
used should be 5 cc or more per vial. Xy- and preferably a 25-gauge needle to in-
locaine (1 or 2%) should be added to each ject. With both the depot and the fan-
vial (1 to 3 cc) just prior to performing ning and threading techniques, the use
the injections to increase patient com- of a 1.0- to 1.5-inch (2.5- to 3.8-cm)
fort. Some injectors advocate using li- needle makes for many fewer puncture
docaine with epinephrine 1:100,000 to sites and more efficient placement of the
theoretically minimize bruising. The product.
authors do not use this mixture and
have not found that its benefits have
outweighed its complications. ■ ■Post-Injection Instructions
Targeted on-label areas for injection
include the temples, nasolabial folds, The patients are instructed to perform a
cheeks, pre- and post-jowl regions, and deep tissue massage of the injected areas
melolabial folds. Advanced areas that for 5 minutes, five times a day, for the
lead to good results in experienced hands next 5 days. Bruising can be quite sig-
include the brows, tear troughs, mid- nificant, and patients should be warned
face, lateral orbital rim, and backs of that they may need to be camouflaged
the hands. Injection is placed in the su- for upward of a week or more because
perficial subcutaneous or pre-periosteal of the volume of injection and the size of
planes, not intradermally or in the lips the needles.
or lip lines. Typically a patient will re-
ceive a single vial for the upper half of
the face and a single vial for the lower ■ ■Precautions
half of the face at each treatment ses-
sion. A pan-facial volumization often Nodule formation is the great fear for
requires the use of at least six vials over those injecting this product and is due
three sessions. In severe cases, much in most case to faulty technique. Overly
more can be used. concentrating the particles in one area
Injection techniques include linear and not placing the injection at the right
threading in a grid pattern, which is an plane are the most common reasons for
on-label use, along the cheeks and the clumping of the product and subsequent
whole lower face, or fanning, which is collagen overgrowth or granulomatous
178 SECTION IV ■ Filler Injection Techniques
reaction. The occurrence of nodules ■ ■Pearls of Injection
and injection sequelae has diminished
greatly due to the higher dilutions used Do not attempt this injection without
and the injection training requirement the proper training. Make sure patients
by the manufacturing company. understand that it will take several treat-
Do not inject this product in the circu- ments at 4- to 6-week intervals to see
lar muscles of the face—the orbicularis results. It is almost impossible to over-
oculi and oris—as there is increased in- inject a patient with PLLA.
cidence of nodules in these areas. To prevent the syringes or needles
from plugging, it is advisable to keep the
product warm at or above room temper-
■ ■Risks ature when ready to inject. Also, after
adding the water reconstitute, allow the
Intravascular injection is possible, espe- product to sit for 48 hours without agi-
cially along the nasal–alar junction. Per- tating. When you are ready to add the
form a reflux maneuver on the syringe lidocaine, gently vibrate, stir, or agitate
prior to injections in this area. One for 5 to 10 minutes to fully suspend the
consolation, despite the blanching or particles. Try to avoid shaking the vial
hematoma, is that the product is almost and causing the production of foam, as
entirely watery and that any embolic this tends to increase clogging of the
event will be self- limiting compared needle.
with a solid injectable substance.
CHAPTER 57 ■ Filler Injection for Facial Volumizing 179
Fig. 57.1 Multiple techniques may be used to inject PLLA. The depot technique is generally used to
augment the temples. A grid technique may be used for the cheeks and pre- and post-jowl regions.
The injection also may be placed along the nasolabial fold. Alternatively, a fanning technique can be
used. A combination of these techniques is also acceptable.
■ ■Additional Reading lactic acid. Dermatol Ther 2011;24:2–27
PubMed
Fitzgerald R, Vleggaar D. Facial volume res- Lacombe V. Sculptra: a stimulatory filler. Fa-
toration of the aging face with poly-l- cial Plast Surg 2009;25:95–99 PubMed
58
The “Liquid Facelift”
correctly and artistically, the techniques
Difficulty: discussed in this book can be used alone
Patient Satisfaction: or in combination to improve a patient’s
Risk: appearance and “set the clock of aging
back” 5 to 10 years.
■ ■What Is a Liquid Facelift? ■ ■What a Liquid Facelift Is Not
A combination of fillers and neurotoxins The liquid facelift is not a replacement
can be used to rejuvenate the face. This for traditional facelift surgery. No amount
technique can be offered to patients who of fillers and toxins can reposition the
are not willing to undergo surgical treat- superficial musculoaponeurotic system
ments. This technique can contour the (SMAS), improve the jowls, and remove
face and rejuvenate wrinkles and folds. fat and excess skin from the neck. It is
The results are temporary and repeated important to accurately counsel patients
treatments are usually necessary, but about what fillers and neurotoxins can
overall, the patients note a fresher, more and cannot do for them. Be sure that pa-
youthful appearance. tients have the correct expectations prior
“Liquid facelift” is somewhat of a mis- to treatment.
nomer, as it is not truly a facelift. Used
180
CHAPTER 58 ■ The “Liquid Facelift” 181
a b
Fig. 58.1a, b Three-dimensional volume assessment of a patient before and after treatment with
10 cc Restylane and 50 units of Botox.
■ ■Complementary Procedures toxins (see Chapter 7) and augmenting
the lips with fillers (see Chapter 37) can
Fillers and neurotoxins can be used as be nice adjuvants to facial rejuvenation
an adjunct to facial surgical procedures. surgeries.
Treatment of the crow’s feet with neuro-
59
Management of Filler
Injection Complications
Fortunately, the most common compli- lower face. Treatment of the lower lids
cations from filler injections are minor with the puncture technique is difficult
and temporary, and may include swell- and can cause excessive bruising while
ing, bruising, and lumpiness. Rarely, trying to manipulate the product. In this
more serious complications can occur, region, 20 to 50 units of hyaluronidase
even in the best trained hands. By hav- (Vitrase, ISTA Pharmaceuticals, Irvine,
ing thorough knowledge of facial anat- CA) can be used. Vitrase is sheep- derived
omy and understanding the filler prop- (Ovine) hyaluronidase supplied in 200
erties, most serious complications can U/1 cc vials (20 units/0.1 mL).
be avoided.
■ ■Herpetic Outbreak
■ ■Tyndall Effect
When injections are placed in the lips,
Some hyaluronic acids (HAs) will refract patients who have experienced prior
blue light if placed too superficially or if herpetic outbreaks may have a flare-up
they migrate superficially. of symptoms. Valtrex (500 mg) is typi-
cally started 3 days before injection
Treatment
and continued for 1 week afterward.
A 20-gauge needle is used to puncture More aggressive therapy with higher
the pool of product, and the product is dosing and acyclovir creams is pre-
expressed through this tract. This is the scribed if herpetic eruptions occur de-
preferred treatment for product in the spite prophylaxis.
182
CHAPTER 59 ■ Management of Filler Injection Complications 183
■ ■Nodules/Lumpiness that biofilms play a role in this
condition.
Clumps of product may occur after
injections.
Treatment
Oral fluoroquinolones (ciprofloxacin,
Treatment
levofloxacin) or macrolides (clarithro-
Massaging the product at the time of mycin or azithromycin) may be used for
injection can lessen the occurrence of up to 6 weeks. Steroids and nonsteroidal
these lumps and bumps. Warm com- anti-inflammatory drugs (NSAIDs) may
presses and massage often help improve encourage the formation of biofilms and
these lumps over time. Hyaluronidase should be avoided in these conditions.
can be used if HA lumps are unaccept-
able to the patient.
■ ■Vascular Compromise
■ ■Granulomas Can be due to intravascular injection,
vasospasm, or external compression. Im-
Granulomas are reactions to product mediate blanching of the skin is seen
that can be seen several months after during injection.
injection.
Treatment
Treatment
• Stop injection immediately.
Granulomas may be treated with Kena- • Massage the area.
log injections, oral methylprednisolone, • Apply warm compresses.
and oral antibiotics. Some advocate using • Consider use of hyaluronidase (even
5-fluorouracil (5-FU) for treatment. Ex- if a calcium hydroxylapatite [CaHA]
cision is also an option. was used).
• Apply topical nitropaste.
• Prescribe aspirin PO.
■ ■Delayed Hypersensitivity • Follow the patient frequently;
photodocument the injury and its
Erythema of the skin surrounding the progress.
injected product can be seen weeks to • Consider consulting colleagues for
months after injection. It is theorized assistance/advice.
184 SECTION IV ■ Filler Injection Techniques
a
b
Fig. 59.1a–f (a) Blanching seen acutely at the time of vascular occlusion. (b) Purpura noted after
facial artery occlusion.
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