Filler injection


General assessment


I would like to introduce our next patient, Hanna, who is currently 30 years old. When I asked her what she was ideally looking to improve, she mentioned that she had three primary concerns. Her first concern was her chin, she described this as a ‘witch’s chin,’ by which she meant she had a little bit of excessive projection, and she felt that the chin was dominant. Her next indication was the under eye hollows, and finally she was seeking to improve the shape and size of her lips. Let’s just have a look at her face shape: when we look at her from the front, we can see that she’s young and attractive, and in line with that she has a very nice dominant cheekbone that you can see leading down. However, she also has a very dominant jaw, which gives off a bit of a square shape in her face. We do know that the ideal face shape for a female is a heart formed by the cheekbones coming down into a delicate chin, or an oval, but in Hanna’s case, the angle of the jaw gives a bit of squaring. We can see that if were able to contour the jawline, we would potentially make her more attractive and give her a more delicate lower face shape.


Mid third assessment


Looking at Hanna’s mid third, the first thing we will do is look at her from the oblique. We can see that she has a nice projected cheekbone angle, and this gives her a youthful and attractive OG curve. Again, from the front view we can see that the cheekbone is well-defined, giving good lateral support, and she has some contouring below this, which is deemed to be very attractive. If I look at the anterior cheek, we can see that she is already well projected and full. Accordingly, because she is complaining of under eye hollows, she will need direct treatment in this region as her lateral and anterior cheek are already well projected. One final thing that Hanna mentioned is that she feels she has nasolabial folds – we can see these more obviously when she smiles. What I have shown her, however, is that if we did add a little bit of support to both the lateral and anterior portion, we can see a lifting effect in this region. Accordingly, we are better off giving lateral support and a lift rather than treating these folds directly.


Injection site markings and treatment


We will treat Hanna’s tear trough directly. I am going to use a cannula here, and I’ve got a 23 gauge needle to make my entry hole. I then use a 25 gauge, 38 mm cannula, and the product I’m using here is Juvederm Volbella. You will notice that I inserted the cannula holding it like a dart, but now I have changed my grip so I can inject and protect the orbital rim and infraorbital foramen. At the same time, I will gently manipulate and mould the small amount of product that I am injecting. It is vital in this delicate area not to overinject the product because you can end up with swelling and Tyndall effect. At the moment I am under the muscle, but I when I get more medial, because the muscle is so closely adhered to the bone, we become a little bit more superficial and actually inject into the muscle itself. The whole time that I am injecting, I am careful to manipulate the product. After withdrawing the cannula, I will finally just use my hands to give a little bit of massage in the area, but in the tear trough it is vital not to press too hard otherwise you may displace the product and actually lose the result.


We repeat the procedure on the other side. Again, you will notice that I use my cannula in a pen- or dart- like grip, and once my cannula is under the skin I can adjust my grip on the syringe, using my non-injecting hand just to guide the placement of the tip of the cannula, taking care not to touch any part of the cannula to keep it sterile. The whole time that I am injecting, I am very aware of injecting a small amount of product and changing position. At the moment, I am in the medial most aspect, and you will see the tip of the cannula here as I have to be superficial. With one entry point, I can swing around and inject the medial, middle, and lateral parts of the infraorbital hollow. The most important aspect of this treatment is to undertreat – if we do inject too much product in this delicate region, it can lead to lumpiness and an unsightly appearance. After I have injected the product, I withdraw the cannula and I will assess the result. I often use a cotton swab to do a gentle massage and mould of the product.


Treatment outcome immediately post-treatment


We have Hanna here at 6 weeks following some Botulinum toxin and some dermal filler treatment. The first thing to notice is a significantly improved facial shape. We can see due to the masseter Botox treatment that she has now a more feminine, oval, or heart-shaped face. This is due to a diminution in the projection of the angle of the jaw when we treated the masseter. We can see that when she frowns, she has practically no activity of the procerus or corrugator. When she raises her brow, there is some movement but the lines are diminished. This is the perfect ideal for frontalis treatment, because we preserve movement but we reduce the lines. If you look at her brow shape, you will also notice that the tails of the brow have lifted and are more aesthetically pleasing. When we look at the chin, we notice that it is now soft and there is no longer the cobblestone appearance she had pre-treatment. If we turn Hanna to the side we will notice that the chin is still slightly projected anteriorly, but considerably less so than pre-treatment. If we turn her to the other side and she smiles, we will notice that the little line she had in her cheek was also reduced substantially following treatment to her masseter. Also notice the significant improvement to the under eye area after treatment.