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I would like to introduce our next patient, Amanda, who has had some previous facial surgery. She also has some permanent lip implants, which means we would tend not to treat her in the lower face. If I turn her to the side and we get a photo of Amanda from when she was younger, we can make some interesting observations – I find old photographs a very useful consultation tool because not only do they tell us what changes have happened in a patient’s face, they also tell us what attributes a patient may or may not have had in their youth. For instance, if we analyse Amanda’s face here, we could be forgiven for thinking she has a very flat brow, and the tail of the brow has started to droop. However, when we looked at the photo, we could see that this has been the shape of her brow even from a number of years ago.
The biggest change has been in the upper orbital sulcus – she now has significant hollowing here which wasn’t present earlier, as she was previously very full in this region, which gave her eye a very youthful look. Also, we have noticed that she has now got some bitemporal recession, which is worse on the right side. Accordingly, the two most rejuvenating procedures for Amanda would be temple filling and upper orbital filling.
Temple markings and treatment
I’m treating Amanda in the temple. I have marked out the temporal fusion line, and I take a ruler to make a mark approximately 1 cm along and I will also go 1 cm down. This is ideal because it allows us to treat at the shallow end of the temple fossa where we can reach the lowest depth of the fossa with a relatively short needle. I retract the skin and insert my needle, and when I’ve reached the lowest part of the temple, I aspirate to ensure that I am not within a vessel. I will then slowly start injecting my product, which in this case is Juvederm Voluma. Ideally, we would want to inject the product onto the periosteum, however, the temporalis muscle is so densely adherent to the periosteum that we cannot get below it. Accordingly, the product will track up the needle path and fill out the temporalis muscle.
I will begin by injecting approximately 0.5 ml of the Voluma in this location, and then assess the fill to see if I need any more treatment. My fingers are preventing posterior spread of the product towards the hairline. The temporal crest prevents superior spread of the product towards the forehead, and the lateral orbital rim will prevent anterior spread. After removing the needle, I gently press down on the product, and I will often compress the gauze for a few seconds, in case we have inadvertently hit a blood vessel. After removing the gauze, I can make an assessment of how effective the treatment has been already. So if I look at Amanda, I notice that there is a small degree of hollowness just below the area that I have injected, and I am not too concerned about this because the chewing action will help dissipate the product both inferiorly and posteriorly. However, there is a small area of volume deficiency just above the brow at the junction of the temporal crest and I would like to inject this with just a little bit of product. Accordingly, I will give the area another clean, retract the skin, and reinsert my syringe until I am down onto the bone. I will then aspirate so that I am confident I am not in a vessel, again using my finger to prevent posterior spread, I will continue to inject the Juvederm Voluma.
Do remember that the deep temporal fascia which lies above the temporalis muscle communicates with the buccal space in the submalar region of the midface. Accordingly, if we were to inject the product in the temple, we can get a filling out of the lower face, which can make somebody look chubbier. After I’ve injected the remainder of my syringe, which is another 0.5 ml, I will remove my syringe and apply further compression. I am now injecting Amanda in her left temple, so I retract the skin and I am injecting 1 cm up and 1 cm down from the temporal fusion line. I insert my needle until I hit the periosteum, aspirate, then inject a slow, steady bolus of 5ccs of Voluma. As this temple was less hollow than the other side, I need less product on her left side.
Eyebrow markings and treatment
When I’m proceeding to treat Amanda in her orbital hollow, I’m going to be using a cannula, as this is a very delicate area. I pinch the skin and insert a 23 gauge needle, and then I will use a 25 gauge, 35 mm cannula, and my product will be Juvederm Volbella. It’s absolutely vital in this region to ensure that you are at the correct depth, which is below the orbicularis oculi muscle, but above the orbital septum. I must stress that this particular technique should only be undertaken by experienced injectors who are familiar with the periorbital region. You will see the tip of my cannula, and also in red, I have outlined the area of maximum hollowness and deficiency which I want to fill. The trick here is to inject very small amounts of product and lay the product just under the orbital rim. I am constantly feeling with the finger of my non-injecting hand to ensure that I am in the right plane and that I’m not over injecting. As she has a more obvious deficiency in the medial aspect, I have injected more product there and less in the lateral aspect of the orbital hollow.
Following treatment, it is important to use your hand, and perhaps a cotton swab to gently mould and massage the product so we can see the amount of fill we have managed to achieve. This area is very vascular, and it’s not unusual for the patient to bleed from the entry point of the cannula, so it’s worth holding a little bit of compression over needle entry point for a minute or two to prevent hematoma formation. Let’s have a look at Amanda now, following treatment to her right side; we can immediately see that the eye is considerably less hollow and less sunken, and we can see less of her upper eyelid skin.
We will now treat her on the left. The technique will be exactly the same. I apologise for the fact that my left hand is obscuring the view of the cannula entry, but I am essentially pinching the skin below her eyebrow to allow the entry of the cannula. I hold a cannula like a pen for greater precision and control while I insert it, and once I have got the correct tissue plane, I can adjust my grip. As I mentioned previously the depth here is below the orbicularis oculi muscle but above the orbital septum. I am aiming for the innermost medial portion of the orbital rim, which I can palpate with the middle finger of my non-injecting hand, and I will proceed to inject small amounts of product. On her right side, I injected a total of 0.3 ml of product, and I will do the same on this side. In this area, it is vital to ensure that you do not overtreat, and undercorrection is much more preferable.
Immediately following treatment, you can see that Amanda is fuller in the temple, with better support of the lateral brow. She also has a greater degree of fullness in the area below the brow, in the upper orbital region. Clearly, she has considerable swelling, and we will allow this to settle before analysing further.