Keywords
Dermal fillerFacial volumizingVolume lossAging faceHyaluronic acidHyaluronansCheek augmentationLip augmentationJawline enhancementScar revisionPerioral fillerFacial enhancementFacial liftingTemporary fillerInfraorbital fillerTear trough17.1 Techniques for Injection of Dermal Filler
The increasing popularity of dermal fillers has led it to become the second most frequently performed nonsurgical cosmetic dermatology procedure in the world to address the aging face (ISAPS 2017). Over time, the face develops different degrees of age-related conditions and it can be challenging to improve the appearance using only one type of filler. Several dermal fillers with varying levels of viscosity are now approved for use to address different facial concerns. There are varying levels of volume loss and different causes of lines and using several dermal filler options to correct facial volume loss will often achieve the best outcome.
Soft tissue filler placement in the superficial dermis (A), mid-dermis (B), and subdermal (subcutaneous) layer (C). Soft tissue fillers may also be placed just above the periosteum (D). Reproduced with permission from: Carruthers A, Carruthers J, Humphrey S. Injectable soft tissue fillers: Overview of clinical use. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. Copyright © 2018 UpToDate, Inc. For more information visit www.uptodate.com
Soft tissue dermal filler injection techniques. (a) Linear threading. (b) Depot\serial puncture. (c) Fanning. (d) Cross-hatching. Reproduced with permission from: Carruthers A, Carruthers J, Humphrey S. Injectable soft tissue fillers: Overview of clinical use. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. Copyright © 2018 UpToDate, Inc. For more information visit www.uptodate.com
In general, superficial defects require thinner fillers that can be placed closer to the surface of the skin and blended easily. It is important to realize, when these fillers are placed superficially, they can have a temporary blanching effect that should not be confused with the blanching or color change evident during a vascular event (Bray et al. 2010). The blanching of a superficially placed filler occurs immediately and resolves within seconds, whereas the blanching from vascular compromise may be delayed and remains for minutes to hours or longer (DeLorenzi 2014). Deeper defects tend to require more viscous filler and are generally placed deeper within the skin (Bray et al. 2010; Alam and Tung 2018). For safety purposes and more control of the outcome, a small volume of 0.10 mL per injection site is recommended (Moradi and Watson 2015).
Belotero Balance (HA with lidocaine) | Superficial dermis |
Juvéderm Ultra and Ultra Plus (HA with lidocaine) | Mid to deep dermis |
Juvederm Volbella (HA with lidocaine) | Lips |
Juvederm Vollure (HA with lidocaine) | Mid to deep dermis |
Juvéderm Voluma (HA with Lidocaine) | Deep dermis, subcutaneous to supraperiosteal |
Restylane Silk (HA with lidocaine) | Superficial dermis and lips |
Restylane Lyft (HA with lidocaine) | Deep dermis, subcutaneous to supraperiosteal |
Restylane (HA with lidocaine) | Mid to deep dermis; dermal-epidermal junction |
Restylane Defyne and Refyne (sodium hyaluronate with lidocaine) | Mid to deep dermis |
Radiesse (Calcium hydroxyapatite) | Subdermis |
Versa + and Versa (HA with and without lidocaine) | Mid to deep dermis |
Sculptra (PLLA) | Deep dermis |
17.1.1 Linear Threading Technique
Linear thread technique is useful for trough-like lines and folds that require lines of filler deposited along the length of the fold, for example naso-labial folds (NLF), vermillion border, oral commissures, or areas where a straight line of filler can soften the appearance of the area. Linear threading may be done by inserting the needle into the skin at a depth that would camouflage the filler and using the “push ahead” method whereby the needle is advanced as the filler is being injected. The retrograde method, where the needle is inserted completely and filler is deposited as the needle is withdrawn, may also be used. Both techniques are acceptable and are a matter of practitioner preference (Bray et al. 2010; Alam and Tung 2018). Some believe the push ahead method results in less trauma to the vessels and therefore less bruising, however, placement may not be as precise (Carruthers and Carruthers 2013; Bray et al. 2010; Alam and Tung 2018). Some of the benefits of linear threading are fewer needle punctures and less discomfort for the patient.
17.1.2 Cross-Hatch and Fanning Technique
The cross-hatch technique is quite literally several linear threads laid in one direction and the addition of a second group of linear threads going in the perpendicular direction to create a lattice work of filler. This technique can be appropriate for areas requiring a substantial amount of filler to re-volumize a broader area such as the cheek (Alam and Tung 2018). Again, more than one technique may be suitable for a specific area and placement of suitable filler in appropriate depths can produce the best outcome.
The fanning technique places a small to moderate amount of filler in a triangular or fan shape. Using one needle insertion site, advancing the needle into the area for correction, depositing filler as the needle is pulled half way to 2/3 out of the skin, avoiding complete withdrawl of the needle. Then, the needle is re-directed in an arc-like fashion until a fan shaped area of filling is achieved (Alam and Tung 2018).
17.1.3 Serial Puncture Technique
The serial puncture technique places small to large amounts of filler into varying depths of the face depending on the characteristic of the deficit (Alam and Tung 2018). Superficial lines, for example, can be treated effectively with a very small amount of lower viscosity filler placed in the shallow dermis or even just beneath the epidermis multiple, tiny depots and in close proximity to the previous site. The resulting tiny papules smooth out nicely over 24–48 h and provide a good correction of tiny, superficial lines.
Deeper deficits benefit from larger depots of filler placed in the deep dermis or periosteum levels (Alam and Tung 2018). While there are more needle puncture sites with the serial puncture technique, there is less risk of penetrating vessels. Additionally, serial puncture can be used as a superficial technique in a higher layer of skin over the deeper placement of filler into the dermis in patients who need volume restoration via boluses in the deeper planes (Carruthers and Carruthers 2013; Alam and Tung 2018). This approach works well in patients with deep NLFs who also have superficially etched lines from photodamage in the same area.
17.2 Indications for Dermal Filler
While there are many indications for dermal filler and multiple products available, only approved uses are recommended. Currently, there are various products that cause different results. Some products are considered permanent, such as fat, silicone, or surgical implants, whereas others, such as hyaluronans, poly-L-lactic acid (PLLA), and calcium hydroxylapatite (CaHA), are temporary. The temporary products will be discussed in this text.
Common sites of dermal filler injection; glabella, infra-orbital, NLF, melomental, cheeks, and jawline. Photo courtesy Beth Haney, DNP, FNP-C, FAANP
17.3 Cheek Augmentation
The cheeks are an important facial structure that convey the appearance of youth. Full cheeks are often noted in young children and give a cheerful look to the face. When the cheeks begin to flatten with aging, the face loses the youthful appearance and it looks as if the entire face begins to drop. A widely accepted image of youth is an inverted triangular shaped face where the cheeks are the widest area and the chin/jawline is the smaller area (Coleman and Grover 2006). In aging, the cheek bones and the fat pads atrophy, the cheeks begin to transform and flatten, the jowls are accentuated, and the triangle becomes reversed (Whitaker and Bartlett 1991; Shaw et al. 2010; Pessa et al. 2008; Binder and Azizzadeh 2008).
Practitioners are now able to replace the lost cheek volume and create a more youthful appearance using a variety of dermal filler products. Temporary products include hyaluronic acid (HA), PLLA, and CaHA (Merz 2016a; Allergan 2013; Galderma 2016a, 2018). Surgical lifting is also an option for patients however, surgery alone will not replace lost volume that occurs with aging. Rather, surgery removes excess skin and improves tissue ptosis through elevation (Biskupiak and Sclafani 2010; Austin and Weston 1992). Many times, when patients opt for the surgical lift, the additional procedure of re-volumizing with dermal filler creates the best outcome.
Hinderer lines drawn to identify the malar eminence (blue dot). Lines are drawn from the lateral canthus of the eye to the angle of the mouth, the second line is drawn from the nasal crease to the tragus. Photo: B. Haney, DNP, FNP-C, FAANP
Before and after cheek augmentation with HA dermal filler. Photo: B. Haney, DNP, FNP-C, FAANP
Prior to starting cheek augmentation, pointing out facial asymmetries and documenting them with photographs will help manage expectations and assist the patient in understanding possible corrections (Carruthers and Carruthers 2005). Assessment of the face from the front, sides, and diagonally at close range and from two to three feet away will give the practitioner a comprehensive view of the patient’s face and provide good information on the deficits and necessary correction (Carruthers and Carruthers 2013).
Following specific techniques and guidelines is suggested however, since every face is unique and has specific deficits, the aesthetic practitioner will need to use subjective judgment in addition to standard protocols. Knowledge of facial anatomy and the various properties of the different dermal fillers used is crucial in obtaining an excellent outcome (Binder and Azizzadeh 2008).
17.3.1 Types of Dermal Fillers for Cheek Augmentation: Temporary
17.3.1.1 Hyaluronic Acid Fillers
When using HA, the higher density fillers are preferred in the cheek because of the volumizing effect they provide (Ave and Issa 2018). Cheek augmentation with the higher density HAs requires deep placement of the dermal filler to avoid lumps. The results are immediate and typically last 6–24 months depending on the amount of filler used, location, and desired effect (Moradi and Watson 2015; Allergan 2013, 2016a; Galderma 2018; Narurkar et al. 2016).
Topical anesthetic can provide comfort from the initial pierce of the needle and should be applied 30 min prior to the procedure, if necessary (Allergan 2013; Galderma 2018). However, topical anesthetic is not always needed since most HA fillers now have lidocaine in the HA gel. Needles are included in the packaging of the HA fillers and are recommended to use unless the practitioner prefers cannulas which are available tools but incur an additional cost. Boluses of product ranging from 0.1 to 0.2 mL are recommended to avoid an excessive amount of product in one place and prevent incompatible pressure on surrounding structures, however in some cases, larger boluses may be appropriate (Allergan 2013).
Typically, the needle is inserted at an angle perpendicular to the bone. With any filler injection it is important to control the needle direction since the filler will be deposited where the bevel of the needle tip is located. Novice injectors often focus on the skin where the puncture occurs rather than where the needle tip is actually located after insertion.
After inserting the needle, it is important to aspirate before injecting product to ensure the needle is not in a vessel. Be aware however, there may not be an immediate flash of blood because of the pressure gradient in the tissues, so it is recommended to hold the plunger back for 7–10 seconds each time (Cohen et al. 2015; Scheuer et al. 2017). Unfortunately, aspiration might not always confirm intravascular insertion of the needle and currently, there is not a completely reliable method to determine this so close observation of the skin during injection is essential. In addition, knowledge of danger zones and facial structures is crucial to avoid serious side effects (Scheuer et al. 2017).
Insertion of the needle to the supraperiosteum under the muscle allows the product to be deposited deeply and it is easily concealed by the overlying tissues (Alam and Tung 2018). After the needle is removed, the area can be massaged to the desired shape and contour if necessary. Additional sites along the malar eminence and the infra-malar triangle provide correction and re-volumization to the mid-face (Binder and Azizzadeh 2008; Narurkar et al. 2016). Occasionally, cheek augmentation will improve the appearance of hollow infra-orbital (tear trough) spaces. If not, additional treatment under the eye with a lower G-prime HA may be warranted.
17.3.2 Collagen Stimulators
17.3.2.1 Poly-L-Lactic Acid (PLLA)
PLLA works by causing fibroneogenesis. PLLA microspheres are injected within a dilute aqueous suspension and require more than one treatment spaced weeks to months apart because the neogenesis takes time to occur (Engelhard et al. 2005; Humble and Mest 2004). The product is injected into various depths of the skin, depending on the area of the face, using a very dilute solution to avoid side effects including nodule formation. Training by experienced practitioners on the use of this product is crucial since there are specific techniques that should be mastered with PLLA (Humble and Mest 2004).
PLLA can be placed in the subcutaneous layer of the cheeks, NLF, and lower face using a cross-hatch or fanning technique and small (0.1 –0.2 mL) amounts of product. The zygoma, mandible, and maxillary areas can be injected deeply onto the periosteum using slightly larger (0.2 –0.3 mL) amounts of product (Carruthers and Carruthers 2013). Practitioners should use caution because nodule formation can occur with PLLA if injected too superficially.
Additionally, some facial structures such as the parotid gland, masseter, blood vessels, and areas near the eyes and lips should be avoided when using PLLA to prevent nodule formation from product clumping. Massaging the area after injection is also recommended to help prevent nodule formation. Aspiration with every injection is important to avoid intravascular injection (Narins 2008; Schierle and Casas 2011). The patient should be instructed to continue massaging the area over the next few days. A popular regimen is using the rule of 5’s; 5 min, 5 times a day for 5 days (Carruthers and Carruthers 2013).
The aesthetic result of PLLA treatment occurs over time and is not immediately noticeable. The tiny particles of PLLA become encapsulated by fibrous tissue and provide generalized volumization and can last more than 18 months (Schierle and Casas 2011). The result from PLLA treatment can take more than one session for the patient to appreciate any difference in appearance. Because of the delayed onset of fibroneogenesis, some practitioners inject PLLA and an HA filler during the treatment session for immediate improvement (Attenello and Maas 2015).
17.3.2.2 Calcium Hydroxyapatite (CaHA)
CaHA is an additional option for cheek volumization and is composed of calcium hydroxyapatite spherical particles in a gel base (Merz 2016a). A conservative approach is recommended since this product naturally provides a correction ratio of 1:1 and no need to add extra amounts, unlike the HAs which can require a small amount of over correction. CaHA provides an immediate effect that is appreciated by patients, but it also stimulates fibroneogenesis over time that likely accounts for its longevity of 1–2 years or longer (Galderma 2016a; Narins 2008; Schierle and Casas 2011). As with any dermal filler, avoidance of vascular injection and danger zones is key.
17.4 Lip Enhancement
The aging process includes thinning of the lips and the formation of upper and lower lip lines (Austin and Weston 1992). Chronic orbicularis oris muscle contraction and sun exposure also contribute to the aging of peri-oral area and these are discussed in other chapters.
Pain control is an important consideration when treating the lips. Patients report they have previously had their lips augmented and the treatment was so painful, they didn’t think they would do it again. Lidocaine is now in the gel of the majority of fillers and provides a more comfortable experience for patients (Allergan 2016a, b; Galderma 2016b, 2017). Additionally, if the patient has no allergy to any ingredient of a topical anesthetic, application of an anesthetic cream is can prevent pain from the initial needle penetration. Allowing the topical anesthetic to absorb for about 20–30 min typically results in reasonable anesthesia and a more relaxed and comfortable patient.
a patient with thin lips would like them fuller,
a patient with full lips would like them enhanced,
a patient would like lip enhancement but very subtle or “unnoticeable,”
a patient would like already large, augmented lips even larger,
a patient would like correction of a scar that makes lips look uneven.
- 1.
A patient with thin lips may require more than one treatment over several months and up to a year to gradually achieve full lips in a natural progression. A common mistake is to attempt to create full lips on a patient who does not have the space for a large amount of filler. The result can be an unnatural or oddly shaped lip. Very small amounts (up to 0.1 mL total) placed in the vermillion border of the upper and lower lips combined with linear threading and possibly adding small boluses to the body of the lip gives a natural, slightly fuller look. Gradual progression over several treatment sessions can give the patient a chance to make interim decisions on the final outcome. Usually, a total of 0.5 mL is sufficient for the first session but because the treatment is influenced by subjective interpretation, evidence on amount is limited (Cohen et al. 2013).
- 2.
The patient who wants enhanced lips is usually younger who would like their natural lips fuller. Occasionally, the patient will have a naturally wide smile and prefer a pouty look with more fullness in the center of the lips and an accentuated cupid’s bow. In this patient, it would be important to avoid adding filler to the lateral edges of the lip. Other patients might like the lower lip larger than the upper or vice versa. Linear threading technique in the body of the lips using small amounts in each of the four sections (up to 0.2 mL each) provides natural plumping. In addition, serial punctures of tiny aliquots (<0.01 mL each) to the upper vermillion border provides a slight upturn in appropriate patients.
- 3.
The patient who wants unnoticeable lip augmentation requires a thorough consultation, since the best way to achieve unnoticeable results would be to do nothing. The consultation should include establishing the purpose of the visit because if s/he didn’t want even a slight difference, there is question as to what effect the patient expects to achieve. Alternatively, the patient may be disappointed in the end result if no difference in the lips is appreciated so it is important to clearly articulate exactly what effect the patient would like to achieve. Gentle discussion regarding the option of using a small amount of product for example, 0.5 mL of filler, to try out the procedure is important. This will give the patient the opportunity to appreciate the outcome and determine if they would like additional enhancement. Another option would be to delay or avoid treatment in extremely apprehensive or anxious patients until they feel comfortable. Giving the option of treatment delay increases confidence and allows the patient to have more control. If the patient decides to move forward with treatment, verbalization of the possibility s/he may return for another 0.5 mL when the initial swelling and healing subside is important to discuss with the patient.
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