Filler injection

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Complete Reflection

 

Assessment

 

I would like to introduce you to Bianca, who is our next model. She is currently 33 years old. You can see that she has a beautiful face with very attractive features and a perfect oval face shape. When I asked Bianca how I could help her, she pointed to three things, first her chin, and following that she also wanted help with her smile, and you can see that she has a degree of gummy smile. The third area was infraorbital hollowing, or as she described it, dark eye circles. Let’s just examine her full face so we can see how we can plan her treatment. If we look at the upper third, we notice that she has a nice convexity from hairline down towards the eyebrow, and we can see that the upper third is generally well balanced. We are aware, however, that the eyebrows seem just a little bit low, and beneath the eyebrow we are aware of some heaviness in the upper eyelid. Accordingly, it will be difficult to raise the brow using a filler directly. However, she does have some bitemporal recession, and by adding support here we may be able to effect a small degree of brow lift. Moving on, we will now look at the infraorbital region. If I tilt her head down and ask her to gaze up towards the ceiling we will notice that this accentuates the infraorbital hollowing, and we can see that she is also quite deplete in the anterior cheek. Restoring volume in this area will just help to give her a better lid-cheek junction.

 

Now let’s have a look at her lips. Her lips have a good shape at rest, and she is already conforming to the ideal ratio, with the upper lip being about 40% and the lower lip being 60%. We can see that the peak of the Cupid’s bow is also well-defined. When she smiles, we are aware that we are seeing excessive gingival display, certainly more than 2 mm, and we can also see that the shape of the upper flattens out and almost disappears. We can certainly help by augmenting the lip. We will also add some Botox treatment to help with the excessive gummy smile. Finally, we can see the chin, and you will notice that in this frontal view that the chin appears to have a cobblestone appearance, especially if we compare the texture of the skin here with the skin of the forehead. Now let’s turn Bianca to the profile so we can examine her from the side view. You will notice that after I turn her to the side, if we follow the contour of the forehead down, she has a nice convexity of the forehead and she also has an attractive shape to her nose. You will notice, however, that the lip appears more projected than the upper lip, and then when we get to the chin which is retrognathic and posteriorly positioned compared to the forehead and the subnasale. In this view, we are also aware of quite significant depletion of the anterior cheek, resulting in a negative eye vector. Therefore, we can see that if we add volume in the anterior cheek and also define the cheekbone we will be able to improve the appearance of the under eye area. Finally, we will add some volume to the chin to give anterior projection and give balance to the profile, and our final touch will be to aim for a little degree of eyebrow elevation. The idea here is to balance the profile in the frontal view, and because of Bianca’s underlying attractive features we call this a beautification procedure.

 

Chin assessment

 

Let’s now have a look at the chin markings in the treatment of Bianca’s chin. If I take a line down from the medial canthus vertically, this will denote the lateral extent of the proposed chin width. This is also known as the nasal flare. You will notice that I have also drawn a small white circle, which denotes the target for the anterior projection. I already feel that she has adequate length, especially when we look at the chin from the lower lip to the tip of the chin. Therefore, I want to concentrate on giving her more anterior projection rather than inferior projection.

 

Chin treatment

 

We will begin Bianca’s treatment by giving some anterior projection. I am using Juvederm Voluma here, with a 27 gauge needle, and I insert the needle from an inferior direction, angling 45 degrees forward, going just past the boney mentum. I use the thumb, index finger, and middle finger of my non-injecting hand to compartmentalise the product. This is important to ensure that we maintain adequate chin width. I am pressing relatively hard, so that I ensure the product stays where I want it to be, and I am injecting a slow bolus. I will initially inject a total of 0.5 cc of product. The idea of starting with anterior projection in her case is because the chin was so retrognathic that the mentalis muscle was very tight. By injecting the bolus, it will relax the muscle and also give some anaesthesia for the rest of her chin treatment. At this time, I would like to see what effect the initial bolus has had on her chin.

 

When I sit her up, you will notice that the chin width is still within our desired parameters, and we can also see that there has been some reduction in the cobblestone appearance of the skin. From the profile view, we are aware that we have started to influence the anterior projection, however, we still need to add some more product. I will treat her in exactly the same way, by introducing my needle from the inferior direction and angling forward. However, this time I will just use my thumb and fingers from the lateral aspect so as I inject the product it can also flow a little bit more superiorly and anteriorly at the same time. I am injecting a slow bolus, and this time the total volume I will inject will be 0.3 ml of Juvederm Voluma. Initially, I am aware of quite an obvious bolus, and as I get her to extend her neck I can also see that there are two small deficiencies just lateral to the area I injected. These are simple to treat, so I inject the needle again from an inferior direction towards the deficit, and I am injecting the product from below from one side and then I go to the other side. In each side, the total volume injected will be 0.1 cc of Juvederm Voluma. After the injection, I will apply a gentle moulding just to ensure that the product is nice and smooth. When doing a chin treatment, it is a good idea to visualise from the end of the bed looking down so that we can ensure that we get a smooth contour with a good degree of symmetry on both sides. You can see this from the foot of the bed. The chin now has a nice oval shape without any obvious lumps or asymmetries.

 

Let’s now sit Bianca up so we can see her from the side profile. We are aware of even better anterior projection of the chin but this now does mean that due to the excessive projection of the lower lip and the lower pole of the chin, we have a deepening of the labiomental crease, and we now need to treat in this area to get a better contour from lip down towards the chin. The labiomental crease is conventionally treated with a cannula. However, in Bianca’s case because the deficit is relatively narrow I am happy to treat with a needle. I have marked the deficit I want to treat, and I want to place a bolus of product at the tip of my needle. Accordingly, I will enter with the needle length laterally and I insert my needle in the superficial plane. I start by injecting of 0.1 cc of Juvederm Voluma at the midline, and after this I will also inject a retrograde linear thread of 0.5 cc of Juvederm Voluma as I withdraw my needle. After injecting on one side, I will do exactly the same on her left side. Again, I am inserting the needle approximately 1 needle-length away from the midline, and my depth here has to be superficial because if we are too deep we may inadvertently inject inside the oral cavity. I inject the bolus at the midline to get the maximum projection in this region, and then having done that I withdraw the needle and inject a retrograde linear thread of the product as I withdraw. After a little bit of gentle manipulation and moulding, I also want to create a better contour from the labiomental crease to the lower pole of the chin, and I can do this again using a superficial needle technique. I take my needle from just below the labiomental crease and I inject in a superficial plane, targeting the point of the needle towards the lower pole of the chin. I am injecting a linear thread of 0.1 cc of product. I repeat this injection on her right side. As I mentioned previously, this entire treatment can also be done using a cannula, and I would recommend a 25 gauge, 40 mm cannula.

 

We can now reassess the impact of these injections on her chin shape and profile. When I look at her in the frontal view, I am aware that almost all of the cobblestone appearance of the chin has disappeared and when I turn her to profile view I am very happy with the anterior projection I can see a definite improvement in the depth of the labiomental crease. At this point, I have noticed that there is, however, a flatness or deficiency in the anterior aspect of her chin which is not ideal aesthetically. Accordingly, I am aware of the need to inject a small amount of product to correct this anterior deficiency. I can do this using a superficial needle injection approach and targeting just the anteriormost part of the chin. To do this, I will simply draw on the area that corresponds to the flatness and I use a very superficial approach, targeting the tip of my needle back towards the soft tissue. Again, you’ll notice how my thumb and forefinger are just allowing the product to be contained in a very specific area, with a small bolus of 0.1 cc of the Juvederm Voluma. I apply a gentle moulding following the injection. At this stage of her treatment, I am happy with the result obtained so far. I am aware, however, that we may need to inject a little bit more product in a future session just to get the amount of projection.

 

Lip treatment

 

Let’s now have a look at Bianca’s lip treatment. I am going begin by decanting some Juvederm Volbella into a 32 gauge, 0.3 ml syringe just to aid in precision. We are going to be using a lip tenting technique because this will allow me to give projection but also increase the vertical height of the upper lip as viewed from the frontal view. I insert the needle at the vermillion border and I inject in the superficial plane down towards the lower pole of the lip. I am injecting very small amounts of product, approximately 0.02 cc of the product in every linear thread. However, as I go from medial to lateral I will also decrease the quantity of product injected just to ensure that we don’t get excessive projection of the lateral aspect of the lip because this can lead to a ‘sausage’ appearance. We can now see, having injected one side, that we definitely have increased vertical dimension of the lip compared to the non-treated side. I will now move to the left side of the lip and repeat the treatment. When you try this type of treatment, do pay attention to try and ensure that you inject exactly the same quantity and exactly the same number of linear threads on each side. This will help to ensure that you get symmetry in the lip treatment. Again, you can see as I am injecting an almost instant improvement in the vertical height of the lip as we inject. You may also notice that my non-injecting hand is just tethering the skin to give me a little bit of traction to inject against. I have injected approximately a total of 0.25 cc into each side of the upper lip, and I will now balance this with injections into the central part of the lower lip.

 

The lower lip technique is very similar, but rather than a tenting I am going to inject from the cutaneous aspect into the red vermillion, and inject a small bolus of product, 0.05 cc on each side. This is to ensure we maintain the balance between the upper and lower lip. You will remember from the profile that the lower lip already had adequate projection, so this is just to ensure that we maintain the ratio after having injected the upper lip. If we now view the lip from the front we are aware of a much better augmentation, and we notice that we have still maintained the shape. When she smiles we still have the gingival display, but the shape of the lip is holding. This tells us that after treatment with botulinum toxin we ought to have significant improvement in her smile. If we turn Bianca to the side, we can see that whereas before we had excessive projection of the lower lip, we now see that the balance of projection from upper to lower is much better.

 

Cheekbone treatment

 

We will do a very subtle cheekbone enhancement in Bianca purely to improve the point of light reflection. We have taken a line which is vertically down from the lateral orbital rim, and this line is transecting another line from the upper alar to the upper tragus. The cross section of these two lines will denote the area that I want to augment to give her better light reflection. I am using some ice in a sterile glove to give her just a little bit of anaesthesia before injecting, and it also gives us some vasoconstriction to reduce the occurence of bruising. I re-sterilise the area and then I will use Juvederm Voluma with a 27 gauge needle. I insert the needle deep onto the periosteum and then I aspirate to ensure that I am not injecting intravascularly. I then retract the skin and inject a slow bolus. Initially, I am injecting 0.1 cc of the product and then I will just partially withdraw my needle and inject another 0.05 cc of product on top of the first bolus. This ensures that I get slightly more projection. I will often see a very obvious bolus, as you can see here, but it does not concern me because one of the advantages of using the product that I have chosen is that it is mouldable, and therefore I can adapt it to any shape I want to. You will now see a very subtle enhancement of the cheekbone on the treated side compared to the untreated side which remains more flat. Because I feel she already has an attractive face shape, I don’t want to give her any more enhancement.

 

Temple treatment

 

I will now move on to treating Bianca’s temple. Remember, the idea of this treatment is to improve the height of the lateral tail of the brow. I have already made my markings, and for a detailed explanation of how and where to inject the temple, please see other demonstrations in the temple section. I will inject the product deep onto the periosteum, which will then spread the product back into the temporalis muscle. I am using a finger of my non-injecting hand to prevent the spread of the product back towards the hairline, and I am injecting a small bolus of 0.3 cc of Juvederm Voluma. The idea is that by augmenting the temple we will get some support for the lateral brow. After injecting the product, I will just gently mould and then we can have a look to see if this has had any impact on the brow. We can see that compared to the non-treated side the height of the brow remains the same, however, if we look at the tail of the brow we can see that it has a better position than the untreated side.

 

Tear trough treatment

 

I would now like to demonstrate the treatment of Bianca’s tear trough. If I apply light pressure onto the globe of the eye with the eye closed, you will see that the infraorbital foramen herniates through the orbital septum. This is denoted by the upper, dotted black line. The white line is the orbital rim. Accordingly, I want to be below both of these lines when I inject my product. I am using a 27 gauge cannula, so I am making an entry hole with a 25 gauge needle. I insert my needle and then when I insert the cannula you will notice that I get a little bit of bleeding. If this happens when you are using a cannula, just simply apply some pressure until the bleeding stops. At this point you can reintroduce the cannula gently holding it like a pen, and try and get the depth of the cannula deep because the ideal depth to inject this product will be onto the periosteum. You will notice that I am using the finger of my non-injecting hand so that I know where I am injecting at all times. I inject the majority of the product deep, especially in the middle part of the tear trough. However, as I go more medially, I will want to adjust my depth and I am injecting slightly more superficially. You can see how I do that simply by adjusting the syringe. I go up to the medial canthus but I am careful not to inject too much product otherwise it may be visible as a lump. The important thing when injecting in the tear trough is to always undertreat. I now apply gentle massage and I am careful not to be too vigorous because it will move the product. At the end of the treatment we can see there has been a considerable improvement in the treated side in terms of the infraorbital hollowing. However, there is a small haemotoma caused by the cannula entry which is causing some degree of distortion. This will settle in a few days.

 

BTX gummy smile

 

I am now treating Bianca with botulinum toxin to help improve her gummy smile. Please check the other videos in this section for a detailed explanation of the underlying anatomy and the injection points. I will use a total of 2 units of toxin per side, and the muscle that I am targeting is the levator labii superioris alaeque nasi. I inject in the canine fossa at a deep level, and I inject 2 units on one side, followed up by an injection on the other side with a further 2 units.

 

Outcome

 

Let’s now review Bianca at the end of her treatment. When we look at her in the frontal view, we notice that we have just given very subtle improvements to a number of features in her face. Treating her temple has given her better support to the tail of the brow, we have improved the infraorbital hollowing, and we have given quite substantial improvement in the lower face, particularly in the shape of her lip and also in the chin. We can see that when she smiles, at present, she still has some degree of gingival display but the shape and form of her lip is maintained better during animation. If I turn her to the side and we look at her profile we can see quite an important impact; if we look at her profile going from forehead down towards the nose and compare, we are now aware of considerably better lip balance in terms of projection and also in the position of the chin. We can also see a good improvement in the negative vector under her eye and a better point of light reflection. I had the benefit of seeing Bianca at 6 weeks post-treatment, and you will see from this photo that now, using a combination of dermal filler and botulinum toxin, we have managed to create a much better smile. You can see that during animation she now has a pleasing smile with less gingival display, and also that the anterior cheek is better projected.