Filler injection

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Complete Reflection

 

General assessment

 

I’d like to introduce you to Clare, who is 29. She has two concerns, and the first one relates to her under eye area. She feels she has a darkness here, which is possibly more apparent if we tilt her head down, and you will notice that she has a groove extending from her medial canthus to the mid-pupillary line, so she has a very early tear trough. This gives the eye darkness, and makes her look a little bit more tired. She can, however, cover this up with makeup. Her second concerns relates to her chin, she feels that she has an excessive shadow beneath her lip, because the chin is rotated up. If we look at her face, we notice that this gives her a shortened chin, and as the chin rotates up, the shadow below the lip deepens.

 

Chin assessment

 

Let’s analyse the lower third of Clare’s face. We notice this deep shadow that is formed due to the upward rotation of the chin in this region. As I rotate her to the side, we can see the extent of the anterior rotation in side profile. As she smiles and I lower her lip, we can see that she has a class 2 occlusion which means the lower dental arcade is retruded compared to the upper dental arcade. This gap between the lower teeth and the tissue of the lower lip allows the mentalis muscle to rotate the chin up, thereby worsening the gap below the lip and above the chin. This leads to an apparent shortening of the chin when viewed from the front. Our goal is to extend the chin by filling in this gap, opening up the labiomental angle. Those of you familiar with the MD Codes will know this region as C1. If we only treat the inferior aspect of her chin, we will get an exaggerated anterior projection, creating a ‘witch’s chin.’

 

Injection site markings

 

I have made the markings for Clare’s chin treatment. We will begin by treating the labiomental crease. As I mentioned previously, this is area C1 for those of you familiar with the MD Codes. The idea is that we will treat this region from the sides using a cannula to fill out the area and prevent any upward rotation. We will treat from both sides in turn. This will give us an elongation and lengthening of this region, and at the same time also inject the inferior pole of the chin, which will subsequently add to the elongation that we can create.

 

Chin treatment

 

We will now treat Clare in the chin region. We begin by treating her labiomental crease, and we will do this with a cannula and our product of choice here is Juvederm Voluma. We place our entry needle just lateral to the extent of the labiomental crease and our depth here is critical. We must not be too superficial otherwise we will see the product visible under the skin. However, we cannot be too deep or we will be inside the oral cavity near the gingival sulcus. Accordingly, our depth is mid level in the subcutaneous or intramuscular plane. Having entered the cannula through the skin, we will then use the finger of the non-injecting hand to guide the placement. We are injecting anterograde threads of product, which serve the purpose of opening up the tight tissue here, but also providing some comfort to the patient as the Lidocaine in the product will give some anaesthesia. It is important to inject slowly. If you do find that there is some resistance in this region, you can ask the patient to open their mouth as this will relax the mentalis.

 

We begin by injecting the labiomental crease, and I will use a total or approximately 0.3 mls in this region. I am feeling the whole time with my non-injecting hand to ensure that the product placement is evenly distributed throughout this region. Do remember that treating in the midline is more sensitive than the edges, so the patient may feel this a little bit more, and it is worth warning the patient before the treatment. I am always amazed at how much product can be injected here, and it’s not unusual for patients to require up to 1 syringe per side. Once you are satisfied that you have achieved a good and even fill in the labiomental crease, without removing the cannula from the entry point, we can simply swing it up and point the tip of the cannula down to the inferior part of the chin. We can then inject some more product in the inferior pole to give us more lengthening. In this region, we only inject the product in the midline so that we can keep the chin narrow, in line with a normal female chin width, which should ideally be the same width as the nasal flare. Again, those of you familiar with the MD Codes will know this as area C2. Having injected 0.3 mls in the labiomental crease, I will be injecting a total of 0.2mls in the inferior part of the chin to give the elongation.

 

Following treatment to her right side, you will notice that this side appears more open, whereas the other side is more closed and rotated. We will now proceed to treat her left side. When treating two parts of the face, it is vital to achieve symmetry, and there are two ways that you can do this; firstly, by ensuring you inject the same quantity of product on both sides, and secondly, ensuring that you remain at the same depth. Accordingly, I injected 0.3 mls on her left labiomental crease and 0.2 mls on the inferior pole. I now massage to improve the elongation that we have achieved with our filler. After this type of treatment, it is always worth checking inside the mouth to ensure you have not inadvertently injected product inside.

 

Immediate treatment outcome

 

Following treatment to the chin, we can immediately see there appears to be an elongation and a decreased shadow between the lip and the chin. We can see that the balance from the base of the nose to the upper lip, and lower lip to the tip of the chin, has been improved substantially. When I turn her to the side, you will notice that we have managed to improve the labiomental angle, but it still remains a little retruded. Accordingly, she is somebody who could have more product injected into this region.

 

Treatment outcome at 4 weeks

 

Let’s analyse Clare’s results from the profile. I have a before photo on the left and a photo taken 4 weeks after her treatment on the right. I think what is very obvious is the significant improvement in her labiomental angle, and you can see that she has significant chin elongation, and this angle is much more open. In addition, the nasolabial angle formed by the nose and the lip, which pre treatment was very obtuse, is now much narrower, in keeping with the ideal female aesthetic. This has resulted in Clare having a much more pleasing profile.