Filler injection

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Complete Reflection

 

Assessment

 

I would like to introduce you to Mike, who is 32 years young. Let’s start by performing a full face assessment. When we look at the shape of his face, we can see that essentially it is rectangular, which is ideal for a male face shape. However, on closer inspection, we do see that although he has good width at the level of his cheeks, by the time we get down to his jaw he starts to taper in towards the chin. Ideally, for a man, we should have a jaw width which is the same as the cheek width.

 

When we analyse Mike’s lower face, from the subnasale to menton, we can see even at rest that there appears to be some dimpling of the skin in the region of his chin. This is almost certainly due to contraction of his mentalis, and when we get him to contract the muscle here, we can see that dimpling worsens considerably.

 

Let’s have a look at his lower facial region as viewed from the lateral profile. This will often give an idea of the treatment that is required. We can see, especially in the side view, that his chin is retrognathic, or retrusive, and appears underdeveloped when compared to his upper and mid face. The lower portion of the chin is particularly retrusive, and he appears to have a prominence just above. The sum total of this is that it gives him a weak profile, and we can see that adding volume to the chin would substantially improve this. He also has a poorly developed jawline, so we can add volume here to give definition and projection to the posterior aspect of his jaw.

 

Chin and jaw anatomy markings

 

Let’s discuss the strategy in treating the chin. You will see that I have made some markings, and if we look closely we can see there is a central protuberance with a hollowness above and below it. This in effect creates a valley-hill-valley appearance. What we ideally want is a smooth contour all the way down from the lower lip. The second point is that we can see his chin width is ideally going to be within the white lines. Female patients have an ideal chin width of about the same width as the nose, but in men the chin should be wider, ideally in line with the oral commissures. In Mike’s case, as well as projecting his chin anteriorly, we also want to increase the chin width by injecting along the mandible at these points.

 

Let’s now look at the strategy of chin injection from the side. We can see that at the bottom part of his chin, below the protuberance, he needs some anterior projection. However, if we only inject in that area below this central projection, we may get a very unnatural result. This is because it will make a deeper hollow between the chin and the lip in the area we call the labiomental sulcus. Accordingly, we need to begin his treatment by treating in the labiomental crease, and then we will progress to an inferior treatment. For those of you familiar with the MD Codes, this is a level C1 followed by C2 and C4.

 

In this lateral position, we notice Mike has a very poor jawline definition. Accordingly, we want to add some structure here to give him better definition both at the angle of the jaw and also more anteriorly leading up to the chin. The red dotted line shows us the region of the mental artery exiting from the mental foramen. However, in this region one of the biggest dangers will be the facial artery. The facial artery crosses the mandible just anterior to the masseter muscle, and we can often feel the pulsation of this vessel along the mandible. This vessel has a tortuous course towards the modiolus and then up to the nasal alar. Therefore, whenever we are doing any jaw treatment, we ought to use a cannula to avoid damage to this very important structure.

 

Jaw treatment

 

Let’s now look at the treatment of the jaw. I have made two white lines to denote the angle of the jaw in this region, and the idea is to first create some projection in this region. I will use Voluma in a syringe with a needle, and my idea is to inject just above the angle. I will clean the area then inject the product perhaps 1 cm above, and the idea is to inject the product down onto the periosteum. I aspirate and then inject a bolus down onto bone very slowly. The bolus will have the effect of increasing the width of the jaw when we view Mike from the front. It is important in this region to inject very slowly, and as we mentioned before this is a relatively safe area because we are away from the facial artery. However, we are close to the parotid gland so it is important to be as deep as possible when we inject our product. I have injected a total of 0.5 mls of Voluma as one single bolus, and we can already see a little bit of projection as Mike is lying down. After giving Mike the projection, the next step is to create some definition from the angle of the jaw towards the chin. You will notice that I am drawing two horizontal lines, which denote the region that I want to sculpt, and because of the danger here, namely the facial artery, it is imperative to use a cannula.

 

I will use a 25 gauge, 38 mm cannula, and I will make sure that my entry point is very superficial. I do this by ensuring that my needle is entered at a very acute angle. Once I withdraw the needle, I insert the cannula and ensure that I am in the subcutaneous plane. You can see that I have easy passage of the cannula and I will now lay a series of linear threads of product going back towards the ascending ramus of the mandible and coming back towards my entry point. I use a finger to protect the underside of his jaw, because I don’t want the product to spill over as this would defeat the purpose of treatment and may lead to some enhanced blunting of the jaw. I will use half a syringe of product on each side, and I am careful to ensure that I do not lay too much product down in any one area. It is not unusual when using this technique to see the product quite visible below the skin, but because this is Vycross and we can massage it down, this does not tend to be an issue. You will see that I have a little bit more posteriorly, and use a little less anteriorly, because this will help with creating the desired shape and definition that we want to achieve. After I finish, I will remove the cannula and just give the area a very gentle mould. Again, we do not want to over massage, as this may reduce the definition that we are seeking to achieve.

 

After treating his right side, you can already see that we have got quite a significant projection of the jawline leading down to the chin, compared to the untreated side. On his left, we can still see that the jawline is blunt and ill-defined. However, on the treated side we are now aware of a sharp mandibular border with a very prominent angle of the jaw, which supplements his very well projected chin. Accordingly, we will now turn our attention to his left side so that we can replicate the result for his right jaw treatment.

 

We will speed up the process on this side. You may recall that we begin by injecting the Voluma deep onto the bone of the mandible. We aspirate and then inject a bolus of 0.5 mls at the angle. Remember, the idea here is to create projection and increase the width as viewed from the front. Once we have finished injecting the bolus, we will switch back to our cannula to create the definition along the jawline itself. To recap; we are using a 25 gauge, 38 mm cannula and we will lay linear threads of product in a superficial plane to create and sculpt the jawline definition. We will use a total of 0.5 ml of product, and it is important to make sure that these linear threads are evenly spaced, otherwise we can get a lumpy and unnatural projection in the region. This is a very safe plane, as we will be above the masseteric fascia. Do not worry if it appears a little lumpy at the end of the treatment, because being a Vycross product you can massage and mould it quite easily.

 

Chin treatment

 

Let’s look at treatment of Mike’s chin. Because he has a very tight mentalis muscle, I am going to begin by injecting a small bolus of product into the anterior aspect of his chin. I inject my needle just beyond the bone. I aspirate, and then after compartmentalising the chin with my finger and thumb, I will inject a small bolus. This is so that the Lidocaine in the product can both give him a little bit of numbing, and also help relax the mentalis muscle. I inject a total of 0.3 mls of Voluma in this region, and my index finger is preventing spreading of the product into the protuberance that he has above the lower chin hollowing.

 

We will treat the labiomental crease with a cannula. I use a 23 gauge needle to make a prehole so that I can pass a 25 gauge 38 mm cannula into this region. My preferred product here is Voluma. The most important consideration in this region is depth; we cannot be too superficial otherwise the product may appear lumpy, but if we are too deep clearly we will end up in the oral cavity in the gingival sulcus. Accordingly, the depth here is midline. Be aware that this can be very tender, especially in the midline, so it can be useful to just inject small amounts of product initially so that the Lidocaine in the product can give the patient a bit of anaesthesia while you inject the rest of it. You can see what I am attempting to do as I am using the product to fill in the hollows between the area of the oral commissure and the central protuberance of the chin. In doing so, I want to create a better contour in this region. I am using a series of linear threads, both anterograde and retrograde, and you will notice that I am injecting very slowly. Even if there is a little bit of discomfort at the beginning of the procedure, as we progress it will get a little bit more comfortable for the patient.

 

Once I have started injecting and I am happy that the labiomental crease region is filling out (looking at my syringe I can see that I have deposited 0.6 mls of product at this stage), what I will then do is look to swing the cannula round and add the width that I was discussing initially. To do this, I withdraw the cannula to change the orientation and bring it down just adjacent to the tip of the chin. I am now in a deep plane along the mandible. I will go ahead and increase a little bit of width projection by using the product in this region. I estimate that I will use approximately 0.3-0.4 mls of product in this location. After treating his right side, we are aware of a better transition from the lip towards the chin, with a reduced labiomental crease in this region. We can also see that there is better support and structure in this region as well as improved width of the chin following treatment.

 

Now, let’s repeat the procedure on the other side, treating in exactly the same way as we did on the right. It is important when you treat a structure like the chin to make sure you inject the same amount of product on both sides, otherwise you can easily create an asymmetry that was not there before treatment. As on the right side, after treating the labiomental crease, I have angled my cannula down to add some width at the base of the chin next to the tip. Following the treatment, we will give him a little bit of mould and massage to distribute the product evenly.

 

Now, having treated his labiomental crease, we go back to using the voluma with a needle to give him further anterior projection. I pass my needle just over the bone, angling forward, and after aspiration I will then use the fingers of my non-injecting hand to help localise the product. I push down on the prominent area at the front of his chin, and I will also and prevent too much lateral spread. I will inject this now as a bolus, making sure that I keep my syringe so that I am injecting in the midline. However, as I do feel that he needs a bit more product on one side compared to the other I can just swing my syringe around accordingly. Once I feel that I have given him an adequate anterior projection, I can withdraw and look at the result.

 

Following treatment to his chin, we can see that Mike now has a more dominant chin with a smoother contour. You can also see that the width has improved, and that the width is now in line with his oral commissures, so it is definitely improved from the anterior view. If we turn Mike to the side, we can also see an improvement in the anterior projection, which is again smoother, without the steep protuberance that he had prior to treatment. The strategy to treat Mike’s jaw is that we want to first create projection at the angle of the jaw, and we can do this by injecting a bolus. We can then create definition going down towards his chin.

 

Immediate outcome

 

Let’s have a look at Mike now following treatment. We are aware of a much better projected and wide jawline and a smoother chin compared to pretreatment. The dimpling has all but vanished and the contours have improved substantially. If we look at him from the side, we are aware of significantly improved jawline definition and anterior chin projection. All of these factors combined give mike a much stronger profile and add character to his lower face, in keeping with his upper and mid face. We will see Mike in 6 weeks to view the results of his treatment.

 

Treatment outcome at 6 weeks

 

This is Mike 6 weeks after his treatment and you can see he has a very fresh look about him and his static lines have diminished considerably in his upper face. If I ask Mike to frown, you will notice that he still has a flicker of movement, but compared to his frown pre-treatment, it is considerably less complex and less extreme than before treatment. If I get Mike to raise his eyebrows, again, he has good movement, but we will see that compared to before we treated him, he has considerably less dynamic lines, however he is still maintaining some movement. This is the ideal balance to achieve with botulinum toxin treatment. Now, we will get him to smile, and you can see he has a very natural and pleasing smile that maintains his eyes in an open position. Prior to treatment, when he had a big smile, he was getting almost collapse, especially of the lateral orbital portion, resulting in his eyes looking practically closed. Now, on full smile, his eyes remain open, which is of course far more pleasing to the eye.

 

Finally, I will look at Mike in the front and turn him to the side, where I am already looking at a very nice definition of his jawline, and a good anterior projection of his chin, therefore compared to pre-treatment, he has a much stronger character and a stronger profile than before we treated him. So, in Mike, we have managed to achieve an impactful yet natural treatment with combination botulinum toxin and fillers. We’ve also managed to significantly enhance his masculinity.