Filler injection

 

Assessment

 

I would like to introduce you to my lovely friend, Rachel, who you can see has a beautiful face. When I asked her what she wanted treated, she mentioned it would be the jowl area, and she demonstrated this by taking her hands and lifting up the sides of her face. You may agree that this is a very common thing that patients tell us during a consultation, and ultimately what they mean is that they have noticed some sagginess in the face and they want it improved by a lifting procedure. Where the patients present with a blunting of the jawline, resulting in jowling, or they mention nasolabial folds, all of these things can be improved by a lifting procedure. Then, when I asked Rachel what would be her second treatment concern, she mentioned to me that ideally she would like to have some treatment to fill out her temple region. She had noticed that this had become increasingly hollow when she looked back through her previous photos. She also noticed that in this region she was starting to get a little bit of droop of the tail of the eyebrow. The third concern Rachel had was to do with her lip; she was happy with the width of her lip but she felt that the lips were too thin for her face. Finally, she also wanted some help in the region above her eyebrow. She noticed that when she raised her eyebrows she was getting a few little lines just in the region above. She has had some Botox, however, she was left with these residual lines that are, in fact, more obvious following the Botox treatment.

 

Let’s now have a closer look at the upper third of Rachel’s face, from the tricheon to the glabella. You will notice that the skin is very smooth, and this is because, as I mentioned, she has already had some Botox with another practitioner. Accordingly, we don’t see any static lines. The overall contour of her forehead is smooth, however, if we look closely we can already see some very prominent temporal crests and the hollow below this region. We are also aware that although the front of the forehead is convex, she has some flattening above the brows so when she frowns we see an excessively wide glabella, and when she raises the brows we see some residual dynamic lines above the brow. If I turn her to the side, you will now appreciate this area of flattening in her forehead just above the eyebrow. To some degree, this flattening is accentuating the lines that she gets because there is more skin laxity in this region due to the lack of bone support. If I now turn Rachel to the side, we notice that she has a very flat forehead as viewed from her lateral profile. Accordingly, some filling in this region would give her a more pleasing contour from the side profile and would also add support for the lax frontalis and forehead skin. Finally, if I tilt her head down this makes the temporal hollowing more apparent from this view.

 

Let’s now focus on Rachel’s middle third. We can see, as mentioned before, that she has a wide glabella, and a very flat and low eyebrow. We would prefer in a female patient to see a higher apex, at approximately two thirds the length of the eyebrow, which would sit above the lateral canthus. However, in Rachel’s case we can see that the eyebrow is low and horizontal, and that the tail of the brow actually sits below the head. Accordingly, we will aim to improve the shape of her eyebrow. The second observation we can make in the mid third is that we can see that underneath the eyebrow on both sides, Rachel has the appearance of deep orbital hollows, and these hollows have the effect of giving the eyes a sunken appearance, which makes Rachel look a little tired. Again, this is a target for augmentation with dermal filler, however, this procedure is for advanced practitioners only. Finally, if we get Rachel to smile we will notice that at the side of her eyes, during contraction, she still has some residual crow’s feet. Although she has received some botulinum toxin to this region, the fact that she is still making some lines means that we could give her some more support with dermal filler in this region.

 

Let’s now turn our attention to the under eye area. You can see at rest that there are just a few static lines, and the skin appears a little bit crepey. If I tilt her head down and she looks back up at the camera, you can see that there is a very faint groove in the tear trough region and a slight presence of eye bag in this region. If we are intending to treat her in the under eye area, we ought to just analyse the skin, so if I pinch the skin, lift it up, and then let it go, we notice that she has normal elastic recoil. I can’t see any scleral show at rest, and if I then pull the skin down and let go, she has a normal distraction. Accordingly, she would be safe to treat in this region with dermal filler. next, I want to have a look at the front of her cheek, and if I get Rachel to smile, you will notice that she appears to be a bit hollow just in the lateral aspect of the nose. In this region she is a good candidate for filling, and perhaps we could see this more clearly if I lay her back. We have a lovely convexity from the lateral part of the cheek, which becomes very flat in the anterior area. We need to leave this area slightly concave to allow for her smile, but she would benefit from a subtle fill.

 

Now, we will look at the lower third. When we start with the lower third, we notice that she has a reasonable definition of her philtral columns, however, both lips appear very thin for her face. She has a good width to her lip, but the upper lip in particular is thin. The chin is slightly wide for a female patient. You will notice that we ideally prefer a chin width of the same width as the nasal flare, but Rachel’s chin is certainly wider than this, almost the width of her mouth. We can see that she is also slightly hollow in the submalar region, and we can see static lines here at rest. When Rachel smiles, you will notice that these lines accentuate, and one of the reasons for this is the hollowness in the submalar region. Another reason is due to the fact that Rachel has a very well-developed masseter muscle that you can now see when she clenches her teeth. In patients who have a good, well-developed masseter muscle, you may notice that the smile causes the oral commissure to push the redundant skin in the anterior cheek against the bulk of the muscle during the smile animation, and then this causes a concertina effect with the skin. In some patients, we can improve this by actually debulking the masseter muscle with botulinum toxin. However, in Rachel’s case, I think she has a nice jawline and I want to preserve the volume in the lateral aspect of her jaw. Accordingly, I will not be treating her in the masseter with Botox. Instead, we will look to improve this redundant skin by lifting in the midface. As you can see, this will lead to an improvement both at rest and on animation when she is smiling. If we now focus on the lowermost part of her face we can see that Rachel’s chin is slightly excessively anteriorly rotated. She has a Class 2 malocclusion, which means her upper teeth ride over the bottom teeth. Therefore, as the chin rotates up she has a deep labiomental crease. We can treat this area to give her a longer and more defined chin.

 

Treatment plan

 

Now, we can see Rachel, and we notice that although she is young and has a beautiful face, she has several treatment indications. We can treat her in her temple as this will improve the hollow and also give support to the tail of the brow, which has started to droop. We can also treat Rachel in her cheek area to give lift to the lower face, we can treat her in the anterior cheek because she is getting a little degree of hollowing under the eye. We can then progress her treatment to the pre-auricular area, and in doing so we can cause a lifting effect, which will improve the redundant skin in the submalar hollow. We can then move on to treatment of her chin, which we have noticed is slightly wide and would improve with narrowing and elongation. We can treat her lips, which are thin and need a little bit more projection, and finally we can treat the upper orbital hollows and the forehead.

 

Temple treatment

 

We are treating Rachel in her right temple region. You will notice that I insert about 1 cm up and 1 cm down from the temporal fusion line. This is because the temple is more shallow in this region. You will see that the temporal fusion line prevents product from migrating superiorly, the lateral orbital rim will prevent anterior migration, and we want the product to fill inferiorly. Accordingly, I use my finger to stop any posterior migration of the product into the hairline. The depth of my needle is deep and ideally I am injecting into the temporalis muscle, which will then slowly fill up with the product. You can see underneath my finger I have marked out the course of the superficial temporal artery, and I can feel the pulsation of this vessel. It is vital in this region to fill very slowly, and before I injected you may have noticed that I aspirated to ensure that I wasn’t in a vessel. You may notice that when you inject an area like the temple that it does take a large volume of product, and it is for this reason that we often place it low down on patient’s priority list. However, in Rachel’s case I think it will have a high impact as she had some quite obvious hollowing and collapse of the tail of her brow. After I have finished injecting, I apply some compression just to ensure that there has not been damage to a vessel which could end up with bruising. When we notice her face after injection, we can see immediately that there is a much better fill compared to the non-treated side which is still hollow. When I look at the treated side there is a much smoother transition from the forehead to the temple region. There already appears to be a better support for the tail of the brow, and we can see this better as we zoom in. We are aware of a smoother transition from the forehead and we can see that the temporal crest is not as defined or visible as it was before we treated the temple region.

 

We will now move on to treatment of her left temple. As I inject her, you will notice that I am using my fingers again to prevent posterior spread. I insert my needle down onto periosteum and then aspirate. Once I can see a bubble in the hub of my syringe I will continue to inject the product in a deep level. After treatment of both sides, we can see that she has had a symmetrical improvement to both temporal regions. Even if it looks like the patient could do with more fill, I would always recommend that in a female patient we don’t overfill the temple, as again this could be seen as a male trait.

 

Cheekbone and pre-auricular treatment and analysis

 

I am treating Rachel in the cheekbone area. You will notice that I have marked out the upper and lower borders of her zygomatic arch to aid my contouring. You will also see that although I have used a sterile drape over her hairline to keep the field clean, there are some stray hairs that have popped out beneath the sheet. This is poor clinical practice and it is important to ensure that this does not happen, this is purely a mistake on my part. I am pinching the skin to ensure I inject at a deep level, and I am using the fingers of my non-injecting hand to ensure that the product that I do place is even, and ideally I want to create a comet shape here, so the idea would be that I would have more product at the anterior aspect of the cheekbone and less over the zygomatic arch like the tail of a comet. You will notice that at the apex of her cheekbone is well-projected, and this is done intentionally. If I find that after treatment I have projected too much, I can simply massage it down. The product I am using is Voluma, and I am using a 25 gauge, 38 mm cannula. The advantage of using Voluma is that it gives us good lift and projection, however, being a Vycross product it is also very malleable. Accordingly, if we find that we have given her too much projection we can simply mould the product into a better shape.

 

We are treating Rachel now in the pre-auricular area with Juvederm Voluma to give her a lift. I will do this with a 25 gauge cannula after placing my entry needle in at a superficial angle. I then insert the cannula holding it like a pen, and I can then adjust my grip on the cannula and lay a series of linear threads in a fanning motion. My depth here is superficial because I want to be between the skin and the parotid fascia in the subcutaneous plane. You will notice that from a single entry point I can fan around in a wide arc, and the idea here is to place the product and then use it to mould and lift the skin in a superior and posterior vector, thereby improving the redundant skin that we saw in the submalar hollow. Sometimes you will notice that there is a bit of resistance here, and that can be from the masseteric cutaneous ligaments. In Rachel, you will notice that the cannula did go well, but if you do encounter any resistance do not force the cannula, simply inject a small amount of product so this will open up the tissue plane, facilitating an easier passage. Again, like the temple, this area can take up a lot of product, however, in Rachel’s case I have used 0.5 ml.

 

After treatment, you will notice that there is already a significant improvement. Her right cheekbone is elevated and projected, and this has given her a very noticeable lift on the treated side. We can see the prominence of the cheekbone and underneath it a nice and very elegant contouring. We can also see that the lateral canthus has started to tilt upwards to approximately a 3 degree inclination, and this is a feature of a youthful eye. Let’s now have a look at the actual cheek itself; on the treated side we can see that we have a high apex, whereas on the non-treated side you will see that the apex is low, in fact it is below the level of the nose. On the treated side, the apex of the cheek is much higher, and this has been achieved by injecting along the zygomatic arch and also lifting in the pre-auricular area. The redundant skin on the left is still lax, while on the treated side it is much more taut following treatment. If we look at the left jawline, it appears blunter, whereas on the right, treated side we have a sharper jawline inclination. Finally, we can see that when she smiles, on the treated side, the smile lines have been reduced substantially while they remain present on the treated side, and if I tilt Rachel’s face down, this will further exemplify the fact that we still have a lot of saggy, redundant skin, whilst on the right it is reduced considerably.

 

We move on to the treatment of Rachel’s left cheek. As before, I am using a cannula, and the most important issue when we are treating the cheekbone is to ensure that we place our product deep, otherwise if we get into the superficial fat pads, when the patient smiles, they will have a very unnatural animation and a very poor aesthetic result. As before, I use the non-injecting hand to guide the placement of the product. After finishing the cheekbone, we move on to treat in the pre-auricular area, and remember that in this area we are superficial so that we do not inject product in the parotid fascia. After treating this area, she will just require a little gentle massage to mould the product.

 

Anterior cheek treatment

 

We now move on to the treatment of Rachel’s right anterior cheek. I am using a 23 gauge needle to allow me to pass a 25 gauge cannula, and the product I will be using here is Juvederm Volift. I need to be deep, and therefore I am pinching the skin to allow me to pass the cannula at the deep plane. I want to target the medial aspect of the suborbicularis oculi fat, or medial SOOF, and also the deep medial cheek fat pad. I use my finger to protect the orbital rim and also to remind me of the position of the infraorbital foramen. The final use for my non-injecting hand is to allow me to detect how much product I am injecting in this area. It is vital not to over inject in the anterior cheek, as we know the lip elevator muscles run in this region, and if we have too much product it can interfere with the smile. After removing the cannula I will give the area a gentle massage just to ensure it is smooth. It is ideal to analyse the patient from above, and we can see her right treated cheek now has a very soft and natural convexity in line with the lateral region, especially when we compare it with the untreated side, which remains flat in comparison.

 

To achieve symmetry when I treat Rachel’s left cheek, I will use the same quantity of product and ensure that I am injecting at the same depth as the right side. In this case the total quantity of product used is 0.3 ml of Juvederm Volift.

 

Chin treatment

 

We are treating Rachel in the chin region, and we will begin by treating in the labiomental crease. I am using a 25 gauge cannula and my product of choice here is Juvederm Voluma. I start from a lateral approach and as I inject I am injecting anterograde with very small amounts of product. This is because this region is very sensitive, particularly so in the midline. However, as we continue the treatment the Lidocaine in the product will give the patient some numbing. I use my non-injecting hand both to stretch the skin and also to guide the product placement so that I know I am not causing any overfilling in this region. I will use a total of 0.3 ml in the labiomental crease, and the idea here is to decrease the transition between the lower lip and the central protuberance of the chin. This will start by giving us an elongation of this region and reduce the anterior projection that we saw during the analysis. After I have injected the labiomental area, I can swing my cannula up and inject a further 0.2 ml of product at the inferior tip of the chin. This time, I will inject only in the midline as this will cause both an elongation and also ensure narrowing of the chin. I am aiming to keep the chin as narrow as the nasal flare. After treating, we can already see that on the side that we have just filled, she is more open compared to the untreated side, where we are still aware of some depressions between the lip and the chin. When I treat the other side of her chin as always, to ensure symmetry, I have to make sure I inject the same amount of product and I also make sure I inject it at the same depth as the other side. In the labiomental crease I will begin by injecting 0.3 ml of the Voluma, and we notice that Rachel is very comfortable now that the Lidocaine has had its effect, and I am using my non-injecting hand just to guide the product placement. After treating the labiomental crease, I can swing my cannula up and then start injecting at the lower tip of the chin, where I will deposit 0.2 ml of product. For those of you familiar with the MD Codes, the first zone is C1 and the second zone is C2.

 

While Rachel is lying down, if we just observe her chin from the front view we are already aware of a narrowing due to the filling. If I take a spatula and run a line down from the side of her nose, you will notice that the width of her chin is now almost exactly the same as her nasal flare, which was our intention before treatment.

 

Cheek and chin outcome

 

We now see Rachel after treatment of her cheeks and her chin, and we are immediately aware of a better and improved facial shape. The improvement in her cheek has now been matched by an elongation in her chin, and also a narrowing of the chin width, which is more in line with the nasal flare. If we turn Rachel to an oblique view, we will notice that not only is the chin longer and narrower, but it is also less anteriorly projected due to treatment in the labiomental crease. This gives a better profile when viewed from the side.

 

Lips treatment

 

We are treating Rachel in her lip, and when we analysed her perioral region it was evident that Rachel required an eversion of her lip. When we evert the lip, we need to place the product in the posterior, or deep, aspect of the lip. This is exactly where we have the superior and inferior labial arteries, and so accordingly my preference when we do this technique is to use a cannula. I am using a 25 gauge cannula and my product of choice here is Juvederm Volift. You will notice that I place my entry point just lateral to the oral commissure, because this will allow me access to the upper lip and the lower lip. I am placing the product beneath the wet/dry border and slightly below the muscle, and it is important to lay very little product in regular strands. You may notice that the cannula is struggling a little bit, and one of the reasons for this is that Rachel has had previous lip filler treatment. Often when patients have had lip filler there might be some residual product which causes a degree of fibrosis, making it harder to inject.

 

After injecting her upper lip, we will then inject the lower lip. Because I prefer, especially in Caucasian patients, to have a bigger lower lip than upper lip, I will use more product when I inject her lower lip. Again, I am making sure that I find my cannula into the posterior aspect and once I am in the midline I will progress to inject the product. I have used a total of 0.2 ml in Rachel’s upper lip and I will use 0.3 in her lower lip. I will inject more product in the central part and less in the lateral aspect, and this will preserve her natural lip shape. If you inject too much product laterally, it gives the lip a ‘sausage’ shape, which is unaesthetic and unnatural. I should mention here that Rachel has not had any anaesthetic and she is tolerating the procedure extremely well.

 

We will then treat her left side. Again, as with all parts of the body, when we are treating both sides we have to ensure symmetry. This is most important in the lip so, as on her right, we will inject 0.2 ml in her upper lip and then 0.3 ml in her upper lip. You can see the tip of the cannula just below the Cupid’s bow, and you can already see the eversion as I am injecting the product. Without removing my cannula, you will notice that I can swing down and access the lower lip. One of the advantages of the cannula treatment is that it is considerably less traumatic for the lip. Because the lips are so vascular, repeated needle punctures can result in haematoma and bleeding, which makes it difficult for us to assess the progress of the treatment. After finishing with the cannula to evert the lips we can already see substantially more display of the red vermillion.

 

To treat her Cupid’s now, I will move on to using the Volift with a needle. I favour using a cotton bud to ensure that we maintain the defined shape of the Cupid’s bow. I insert my needle at the Glogau-Klein point and then inject a very small linear thread of 0.01 ml on each side. By using the cotton bud, you will notice that we maintain the nice defined ‘v’ shape of the Cupid’s bow. I am treating Rachel now in the philtrum area. The depth is very superficial, and I insert my needle just at the Glogau-Klein point towards the columella, and I inject a linear thread, injecting slightly more just before I pull my needle out of the skin. I use a finger and thumb again just to get a little bit more definition. This can be tender for the patient and very small volumes are required. Make sure you inclinate your needle towards the columella so that the columns are not parallel, but slightly narrow towards the nose.

 

We then move on to treating the lower lip for a gentle volumisation and eversion. I am injecting from the cutaneous portion and I will use a bolus of 0.05 ml in the lower lip. I repeat this on the other side, again using my finger and thumb to localise the product.

 

Treatment outcome

 

We can now see Rachel following treatment to her temple. Her lateral cheek, anterior cheek, chin, lip area, and also the Cupid’s bow and philtral columns. We are immediately aware of a better proportion of both the upper and lower lip, and this is balanced out by a beautiful improvement in her overall facial shape. If we look at the lips themselves they have more projection as viewed from the front, and when I turn her to the side she has gone from having a very flat angle in the philtrum to having a more youthful projection with a little elevation just at the tip where the lip begins. So she started flat and now she has a better projection and eversion in this area.

 

Brow and forehead treatment

 

Before treating Rachel in the brow and forehead region, let’s just assess the markings. You will notice that her brow is very horizontal and flat, and the tail drops significantly below the head of the brow. Accordingly, we want to try and support the brow so that she has a higher apex. When we tilt her head down and she raises her brows you will notice some lines above the brow due to redundancy of the skin and also deflation of the retroorbicularis oculi fat. Therefore, our target will be to reinflate this fat pad, and we will do so by using a filler and a cannula, and our entry point will be below the tail of the brow. We will also inject her forehead, especially in the central region, to give her a bit more convexity in this area.

 

We are treating Rachel in the eyebrow region to both elevate the brow and give support to the tissue behind it. We are using Juvederm Volift, and I am using a 27 gauge cannula. I made an entry point at the tail of the brow, and it is vital to ensure that we inject the product in the deep plane. When we do this, we will be injecting in the retroorbicularis oculi fat, or ROOF for short. It is also important to ensure that the product stays below the orbital rim otherwise the product might drop below and actually make the brow look more ptotic at rest. After getting the correct placement for the tip of the cannula I will use the thumb and finger of my non-injecting hand just to guide placement of the filler. It is important in this region to inject slowly and with very small amounts as the brow is an unforgiving region. If we over inject here the patient can look swollen. I have injected a total of 0.2 ml and I am already aware of a substantial improvement in the height of the apex of the brow. I will now inject the patient for the infraorbital hollow. This time, the location of the cannula is altogether different. I want to get my cannula underneath the orbicularis oculi muscle and above the orbital septum, and this time I will aim to inject just under the orbital rim. I am using Juvederm Volbella now instead of the Volift that I used for her eyebrow. Once I can see the tip of my cannula in the medial orbital rim, I will inject small amounts of product. As with the eyebrow, it is vital not to over inject in this area. Following this treatment, you should warn patients that they may look swollen for a day or two. I will give gentle massage to ensure adequate placement and then I will inject the other side.

 

We can use the same entry hole for the cannula treatment of the eyebrow and the infraorbital hollow. The important caveat here is to remember that not only are we changing the product, but we are also changing the depth of the placement. Just to remind you, the eyebrow is injected in a deep plane above the orbital rim, whereas the upper orbital hollow is injected more superficially below the muscle and just under or inferior to the orbital rim.

 

I am treating Rachel in her forehead with filler, and I will use a cannula for this purpose, and I have made some markings to guide the placement of my product. I am using a lateral approach so that I can use my cannula in the horizontal direction. This is particularly advantageous because the vessels have a vertical orientation. My product of choice here is Juvederm Volift, and you will notice that I am pinching the skin and the frontalis so that my cannula will lie between the galea and the periosteum. It is important to inject small amounts of product, and the other advantage of using the cannula is that it is easier to ensure a natural and even result. When we use a needle in this region, there are vertical septae which can trap the product, leading to a lumpy appearance. By using the cannula, we can bypass this problem. One caveat I would advise is to always measure the length of the cannula. In most people, the central part of the forehead is where we have the deepest concavity. When you make your entry point, if the cannula tip does not reach the midline, you can end up with a situation where you have a lot of product over the lateral aspect of the forehead but we leave a deep line down the middle. This will, of course, look very unnatural, so before treatment it is worth measuring the entry point to ensure that after inserting the cannula you will adequately reach the midline from both sides. As mentioned, I am using my non-injecting hand to both elevate the skin and also gently mould the product that I am injecting. Do not worry if you can see visible product below the forehead skin because, as we have mentioned previously, this is a Vycross product and it is therefore very easy to mould and massage it as you can see me doing now.

 

After I have treated her right side I will move on to treating her left side. Just to reiterate, as I have said all along Rachel’s treatment, the most important aspect to achieving symmetry, when treating one side and then the other, is to always make sure that you have the same amount of product and inject at the same depth. In the forehead, this depth is deep to the muscle and the quantity will be 0.3 ml of product per side. Just like I did on the right, you will notice that I am constantly rearranging my cannula to ensure that I am filling the areas that require the product, and I use the finger and thumb of my non-injecting hand to help me guide where I should be injecting.

 

Final treatment outcome

 

We can now see Rachel following treatment to her forehead, and if I turn her to her side we will notice that she now has a more youthful convexity in the forehead compared to the rather flat orientation she had before treatment to this region. I now have a before and after photo of Rachel. The after photo was taken approximately 5 weeks post-treatment. I think it shows some very important and significant changes which I would like to now discuss. I should mention here that in the after photo she does have some light makeup on and also some lipstick. The first change to notice is that there appears to be a better contour of the forehead when viewed from the front. There are less shadows, and this follows the filler treatment that she received. We can also see in the before photos she has very sharp demarcated temporal crests. These are less obvious in the after photo, and there is a better transition from forehead to the temple and the temples are better filled.

 

A very significant improvement is in the eyebrow. In the before photo the brow is flat and horizontal, whereas in the after photo she has the head of the brow going up to an apex approximately two thirds along its length. The apex lies above the lateral canthus, and the tail is about level with the head. This conforms to the perfect female brow shape. We notice that she has good projection in the lateral cheekbones and a better transition from the cheek to the anterior cheek. We can also see another significant improvement in the lip; she now has a better eversion, projection, and volumisation of the lip, with a better defined Cupid’s bow and also philtral columns. We are aware that there is considerable elongation and narrowing of the chin, and the full result is that she has a better face shape, which shows off her beautiful features.