Filler injection

Consultation and assessment



In this video, I would like to introduce you to Mereena, who is 32 years young, and she has come to us specifically requesting treatment to her chin. When I asked her why she wanted to treat this region, she mentioned that the part of her face that she doesn’t like is in the region of the mouth corners and the slight excess of skin here. However, she quite rightly states that she is too young at 32 to go for active treatment here, so she feels that if she were to get some additional support in the chin and perhaps also in the cheek we could improve this area. Accordingly, what we will do is treat Mereena in the zygomatic region to get a little superior lift and following that we will give her some additional support in the anterior part of the jaw and chin. If that doesn’t alleviate the issue, we can then move on to treating the jawline for some posterior lift.



When we look at the chin from the front view, we can see there’s a natural dimple, and I asked whether this is something that she’s precious about and wants to keep. She said she doesn’t actively want to remove it, but if in the course of the treatment it disappears, she’s ok with that. Some people do like to keep the dimple because it may be a family trait or something that they’ve been known for, but other people are quite happy if it goes away. The second view that I really need to assess is in profile, so I’m going to move her towards me. When we look at her in profile, we can see that there is some degree of chin recession and she has some horizontal microgenia. The labiomental region at the moment is okay, but if we extend the inferior part of the chin forward, we see that there might be an issue in the labiomental which will deepen. Accordingly, I will treat this part of the chin first, and then I will look to see if I need to augment the labiomental region. Normally, I would start here, but sometimes we move the order of the treatment around.



Injection Markings



Let’s now discuss the injection markings for Mereena’s treatment. If I rotate her to the side, you will notice I have demarcated the upper and lower border of the zygomatic arch. I will inject in three discreet boluses along the zygomatic arch, injecting more product anteriorly and less as I go posteriorly. The idea here is to project and lift the central and lateral part of the zygomatic arch. When I look at the chin, the first thing I’ve done is drawn a line in the midline to make sure that I keep the injection symmetrical. We notice that there’s quite a lot of mentalis activity causing some dimpling. If I turn her to the side, I’ve demarcated the posterior limit of where I want to inject. I don’t want to add any product where there is already heaviness in the middle part of the jaw. I will start by injecting in the prejowl sulcus and move anteriorly. You will notice that in this region I can inject deep and I want to inject onto the bone to get maximum projection. However, if I do need to inject in the labiomental crease, this depth has to change – it needs to be more in the subcutaneous. So the depth here will be subcutaneous and the depth here will be deep. The technique of injection will be using a needle to inject boluses in the zygomatic arch, needle to inject boluses along the bone, and then cannula for the soft tissue if that region is required.



Midface Treatment



We will start by injecting along the zygoma, and we begin by cleaning the area of treatment with a steret. I’m going to pinch the skin, retract posteriorly, and then insert my syringe perpendicularly where the little white dot was. I go down to the level of periosteum and aspirate. Once I’ve aspirated, I will slowly start injecting a total of 0.2 ccs of product. The idea here is that we want to create projection, so I’m careful not to over massage, and then I’ll inject another bolus just behind the first one. Again, retract, pull, insert, aspirate, and inject another bolus, this time 0.1 ccs. Finally, the most posterior one, so the same technique – retract, pinch, down to periosteum, aspirate, and inject the final 0.1 ccs. After the injection, I apply some gentle moulding and, if there is any bleeding, we apply some gentle pressure.



Let’s see the result of treating one side of her cheek. I think you can see quite clearly that this is the treated side, we’ve got a better definition of the cheekbone compared to the untreated side where it’s flatter, but more importantly it’s already started to slim and lift the jawline. If we compare the untreated side, which looks heavier and wider, we can see that on the treated side, by lifting the tissue, it’s narrower and slimmer.



We’re going to clean the area before injecting, and the sequence on the left side is exactly the same as for her right side: retract, insert perpendicular, down to periosteum, and inject the first 0.2 ccs of product. This is in bolus form onto the periosteum. Coming out, moving more posteriorly, aspirating, and continuing to inject. As I go posterior, I am injecting less product, and if there’s no active bleeding, I’m happy to continue to inject. Following the injection, I want to apply a little traction and a little compression. Now we can see, after treating both sides, that by widening the midface it’s had the effect of restoring the oval shape, which means that we get a greater impact when we treat the chin.



Chin Treatment



To treat her chin, I’m going to use a different product; I’m using Juvederm Volux, which is a relatively recent introduction to the Vycross range. It is 25 mg of hyaluronic acid using the Vycross technology, and it has the highest lifting capacity of any product in the range. To inject, I will put my index finger along the jowl area, and I will put my thumb along the inferior border of the mandible. This stops the product going laterally and inferiorly. I then take my syringe, and I inject deep down onto the periosteum. I aspirate and slowly inject a bolus of 0.1 ccs. I will then apply gentle pressure to ease that bolus and smooth it out. I’m going to miss out the next region because treating here can widen the chin, which is a more masculine trait. I want to concentrate the product more anteriorly, so we move onto the anterior part of the chin in the inferior pole. To treat this, I am going to get Mereena to extend her neck. To inject in this region, I am going to start below the chin, retract the chin tissue, and let it fall back onto the needle, and now I will inject after aspirating. I will use my fingers to stop any lateral spread – I don’t mind it spreading medially – and I will inject a total of 0.2 ccs of product. I will then inject from the other side, lifting the tissue, letting it fall back down, stopping the product going into the other side, and injecting another bolus of 0.2 ccs. In total there are 0.4 ccs in the anterior part of the chin. I’m then going to mould the area that I’ve injected, and while I’m waiting for that, I can finish off by injecting the prejowl area on her left side. After cleaning, I change my finger position so this time I have my thumb along the jowl and my finger along the inferior border of the mandible and then perpendicular, aspirate, and another 0.15 ccs.



Let’s have a look to see what our first series of injections has achieved. As we can recall from before, Mereena’s chin looked pretty good from the front view in any case, so I need to turn her laterally towards me. Now what we can see is that there seems to be some advancement of the lower pole of the chin forward without compromising the labiomental region, so we still have a decent angle from the lip into the chin. However, it does benefit her more if I can bring the chin a little bit more anteriorly.



I will now concentrate on this central area, we are going to sterilise the treatment area, and I will finish off the rest of my product in this region. This time, I am injecting into the midline, squeezing from the sides and allowing the product to roll up more anteriorly and superiorly to fill this area of volume deficit, like so. I’m going to remove my markings so we can make a meaningful assessment. Immediately post-treatment, we can see that we have managed to restore a very nice shape to Mereena. We’ve managed to accentuate the cheekbones, which has given a bit of extra width in the midface, and at the same time, we’ve got a better continuity from the cheek to chin. We’ve almost completely eradicated any excess she had at the mouth corners, and we can see that more in the oblique view. We’ve got almost full continuity on both sides by extending the chin anteriorly and lifting the cheek posteriorly. Finally, if I turn her shoulders and face her towards me, we can now see that the resting position of the chin is absolutely perfect. If we take a measurement from the glabella to the subnasale and the pogonion, this will give us a particular angle. We’ll use the photography to calculate the change in that angle, but we can see visually that there is a nice anterior positioning of her chin.