Filler injection




I would now like to introduce our next patient, Phoebe, who is currently 61 years old. She came to me presenting with three main concerns. The first was a degree of jowling at the side of her face, and she would prefer to have a lift in this region. Her second concern was the presence of frown lines, and her third concerns was her lip area and the region around her lips in general. Let’s have a look at her in a little bit more detail. When we look at her upper third, from the thricheon to the glabella, we can see that essentially the majority of the forehead is relatively smooth, however, we can see some static lines, especially in the frown region – and of course when there are static lines, we know that there will be dynamic lines. If we look at her raising her eyebrows, we can see that when she does this, she makes some dynamic lines in her forehead, but there’s also a lot of redundant skin below the brow. Accordingly, we should test her for the presence of compensated brow ptosis. We do this by getting her to close and open her eyes, and she does this relatively well. However, if I now get her to just track my swab with her eyes so she follows it, as we go higher up, you will notice if you look carefully at her left brow that on the extreme upper gaze her left brow starts twitching up. This means she could be developing compensated brow ptosis. Accordingly, we have to be careful if we consider treating her with Botulinum toxin in the frontalis. The rest of her forehead, however, is smooth and she has a good fullness in both of her temples.


We will now move on to assessing her mid third. Here, you can see that she has good projection of her lateral cheek area, however, the most obvious deficit here is a hollowness and a groove in the infraorbital region, which gives the appearance of eye bags. She also has some hollowness in the upper orbital region. Let’s now move on to the lower third, and obviously this is the area where we will see the most treatment indication. We can see bilateral nasolabial folds with a degree of heaviness above, and we can also see that there is elongation of the cutaneous white lip, with an increased distance from nose to lip. We can see that both lips are thin, and finally we are aware of bilateral marionette lines with jowl formation.


Let’s now turn her to the side, and we can see that the nasolabial fold, the marionette line, and the jowl itself are all due to inflation and dissent of tissue from the midface. Accordingly, a lifting procedure would give her a good treatment response. There are a number of ways we can exert this lift, and ideally Phoebe is a very good candidate for surgery. However, she has declined this option and therefore we will plan this treatment with non-surgical options.


Marking and strategy


We can see that the main issue here is her jowl, and I will mark this off in the red pencil as this is a “no go” area and we must be careful not to inject any product here. Ideally, we need to exert a lift in various vectors so we need to get a vector in the superior direction, the posterior lateral direction, the posterior, and the anterior. We can see that if we can indeed lift along these four vectors, we can get an overall improvement in her jowl area. This will form the strategy of treatment of the sagginess in Phoebe’s lower face. After we have made an improvement in this saggy area, we can then turn our attention to treating her lip. If we have a look at the lip, we will notice that there is a reasonable volume within the lip, however, both lips are very inverted so what we have to do first of all is add support to the surrounding tissue before everting her lip. If needs be we can enhance the lips after the eversion.


Cheekbones treatment


I will begin by treating Phoebe in the cheekbone area. I pull back the skin, insert the needle onto the bone, aspirate, and then inject a bolus of 0.1 ml of Juvederm Voluma. I am at the mid point of the zygomatic arch, and this area is also known as CK1 to those of you familiar with the MD Codes. After I have done this, I move on slightly more anteriorly to the lateral most projection of the zygomatic arch. Again, I withdraw and inject onto the bone, this time with a bolus of 0.2 mls. We could treat this area with a cannula, however, in Phoebe’s case I’m injecting her to see if she does indeed get a response to filler treatment, and this will determine if we continue with the rest of her treatment. After I pull back the syringe, ideally what I want to do is see if there has been any improvement in lift. It is important at this stage not to overmould or massage. When I look at Phoebe after an injection of just 0.3 ml to her lateral cheek, I’m already aware that there is an improvement in the jawline compared to the untreated side, and the treated side appears a little but thinner in comparison. Finally, I’m also aware of a slight improvement in the nasolabial fold on the right compared to the left hand side. Accordingly, I am happy to continue with her treatment.


Anterior cheek treatment


I will now treat Phoebe in the anterior cheek, and I am treating her at the base of her infraorbital groove, my target here being the suborbicularis oculi fat in the medial aspect. Using Juvederm Volift, I inject onto the bone, aspirate, and inject a small bolus of 0.15 ml here. The idea is to give support to the deep fat below the groove, and because I am lateral to the mid-pupillary line, I am happy to use a needle. I will give gentle pressure here to mould the product along the groove.


Nasal base treatment


Having injected her in the anterior cheek, I will now turn my attention to treating her at the piriform fossa. I’m approaching from a lateral angle and guiding my needle underneath the nostril at the base of the piriform fossa. I aspirate because this is a major danger zone, being the territory of the facial artery, and as I inject this product – about 0.2 ml – we will see that the fossa starts to fill and the nose on the right side starts to rise due to the support provided by the filler. It is vital to ensure that you are touching bone when we treat in this area.


Preauricular treatment for lift


We now move on to treatment of the lateral cheek, or preauricular area, and we do this to give a lift and improve the sag. I have inserted my needle in a very superficial angle because my plane for injection here is subcutaneous. I hold my cannula like a dart, and then readjust my grip, before laying linear threads of product as I fan the cannula around. It is important not to be deep in this plane, because we have the parotid gland and parotid duct below this region. The idea here is to lay the product in a very thin sheet, and you may encounter some resistance here, particularly from the masseteric cutaneous ligaments. If you do encounter resistance, do not force the cannula, but inject a little bit of product, as you will find that this will open up the tissue plane, facilitating an easier passage of the cannula. If the patient has had previous facelift surgery, or extensive scarring in this region, you may find it difficult to pass the cannula, in which case you could switch the product to Juvederm Volift. You will notice that from a single entry point with the cannula, I am able to fan around in a wide arc, so I can fill a lot of this preauricular area. Finally, after withdrawing the cannula, the most important part of treating within this area is good, firm massage.


We now see Phoebe after we have treated her cheekbone area, the anterior cheek, and the lateral cheek, and already we are aware that her jawline appears smoother, there is less show of her eye bag, and her face also looks slimmer on the treated side compared to the non treated side. We can see with her head tilted that there is thicker jowl on the untreated side.


Chin, prejowl, and marionette treatment


We now move on to the treatment of Phoebe’s chin area. I am going to be treating her in the labiomental crease, also known as area C1 in the MD Codes. I introduce a 23 gauge needle just lateral to the area to be treated, which will then facilitate my being able to pass my 25 gauge cannula. It is important to use your non-injecting hand to guide the cannula and indicate which areas are still to be filled. This can be an uncomfortable procedure for the patient, so it is a good idea to inject the product anterograde because the Lidocaine in the product can start numbing the tissue. It is important to ensure that you have the correct depth here: if you are too here you could end up injecting the product within the oral cavity. The midline is a particularly painful area, so do warn the patient of this before treatment. You will notice that we are looking to fill the areas of depression between the lip and the protuberance of the chin to give a better transition from the lip to the chin and also add support for the lower lip. After I have treated in the labiomental crease, I will make sure that I have not injected any product within the oral cavity.


I now move to treating the prejowl sulcus. Because the area here in Phoebe is relatively deficient, I will use a cannula. In a milder case, I may have used a needle for this purpose. I am injecting from the front to the extent of the base of the fold, and I will inject more product at the base of the fold and less as I withdraw. The idea here is to add support from the base and then work our way up to the oral commissure. I am laying linear threads of product, always putting more product at the base of the fold and less as I withdraw. I am also using a finger on the mandible edge to make sure that the product stays in place and doesn’t slip round under the mandible, as that can worsen the effect of the jowl.


After treating the prejowl area, I swing up my cannula to start treating the deep component of the marionette line. I am in the deep plane here, and I will always ensure that I am injecting the product medial to the fold. You will see that as I go more superior, I will finally end up injecting just below the oral commissure, and you will be able to see the tip of the cannula beneath this. I am laying product from the fold coming more medially towards the midline. This treats the deepest component of the marionette line and again adds support to the corners of the mouth before we do our lip treatment. Having treated the deep component of the marionette line, we can now start influencing the more superficial part. I have changed the product to Juvederm Volift, and I will lay a series of horizontal linear threads like the rungs of a ladder. I will move from inferior to superior and I will always make sure that I stay medial to the marionette fold. As I ascend more superiorly, the inclination of my needle also becomes more superficial and the last linear thread that I lay will almost be in line with the bottom vermillion border of the lower lip.


Jawline treatment


We will now treat the jawline, because this will influence the posterior vector of lift. Remember, this is in the region of the facial artery, so it is vital that we remain superficial. I make a cannula entry point and now my cannula inclination is very superficial in the subcutaneous plane. I will look to see the end of my cannula is at the angle of the jaw, and I will inject the product in linear threads. The purpose of this is to add posterior support and give some definition and projection of the jaw posterior to the area of the jowl. My product of choice here is Juvederm Voluma. I am constantly injecting linear threads, and I am using the finger of my non-injecting hand to ensure that my product placement is regular. I prefer to inject at the level of the mandible or slightly superior. The problem with being inferior to the mandible is that we can actually accentuate the effect of the jowling.


Mid-treatment outcome


We can now see Phoebe after we have treated her right side for sagginess. We can see that on the treated side she has better lateral cheek projection and there is some diminution of her infraorbital groove and eye bag compared to the non-treated side. We can see she appears slimmer, with less nasolabial fold compared to the untreated side. If you look at the jowling, it is considerably heavier on the non-treated side compared to her right. Now, if we turn her from the oblique angle, we can see that the nasolabial fold and the whole sag on the untreated side is still considerable, whereas on her right side we have already managed to get some degree of lifting from the treatment we have performed so far. The idea is that there is still some degree of jowling, but this may improve over time. Finally, if I tilt her head down, you will notice the degree of heaviness or sag still present on the untreated side compared to the treated. We will now treat her left side.


Left side combined treatments


We have edited this footage and I will just summarise the injection points. So we are injecting on the midpoint of the zygoma with Voluma as a bolus. We then come more anterior and repeat the bolus of Voluma onto the lateral most prominence of the zygoma. We then inject Volift as a bolus into the medial SOOF and anterior cheek followed by placement of Volift onto the piriform fossa to add support to the base of the nose. We then move on to treating the lateral cheek with Voluma to lift the nasolabial fold and marionette region in a fanning technique.


After this, we can progress to treatment of the chin. We begin by treating the labiomental crease with the cannula. Again, the product here is Voluma. Following this area, we move on to treating the prejowl sulcus, again, with Voluma and a cannula. From the same entry point, we will also treat the marionette line by treating the medial deficiency in this region. After this, we then move on to treating the jawline with the cannula and Voluma, adding support here for a posterior vector. Finally, we will treat the superficial portion of the marionette line with Volift and needle in a series of horizontal linear threads like the rungs of a ladder. We then apply some gentle massage post treatment, and we can see Phoebe now with a nice symmetrical result following the treatment of her sag. We can see an improvement in the jowl and an improvement in the jawline. She is now in the perfect position for us to progress to treatment of her lips.


Lip treatment


As we are requiring an eversion of the lips, we will use a cannula for this purpose. I use an entry point that will allow me to access both the lower and upper lip. My product of choice here is Juvederm Volift, as I need a little bit more lift than Volbella would give me. I want to aim my cannula into the posterior compartment of the lip to get the eversion. This will line up the wet/dry border. Because both the inferior labial artery in the lower lip and the superior labial artery in the upper lip run in this region, this is the main reason we want to use a cannula. This can be a little bit uncomfortable for the patient, but once the Lidocaine in the product has its effect it is usually very well tolerated. The other advantage of the cannula is that we only need one entry point for each compartment of the lip, whereas with a needle we need to make multiple punctures. It is vital to ensure that you inject the same amount of product into each compartment as the idea with the lip is that we want the maximum symmetry from both sides. After treating the lower lip, we can then withdraw the cannula and swing it round to enter the deep compartment of the upper lip. You can use the fingers of the non-injecting hand to help you guide your cannula into the correct placement. Do bear in mind that this contaminates the glove, and I will change the glove before progressing to her left side. I am ensuring that I inject very little product in the upper lip compared to the lower lip, and my total volume would be 0.3 mls in the lower lip and 0.1 in the upper lip. I will have more product in the centre part of the upper lip and less as I withdraw my cannula.


After treating her right side, we move onto treatment of the left side. Again, I choose an entry point between the upper and lower lip just lateral to the oral commissure, but do bear in mind that this is the region of the facial artery so you should be careful of the depth of the entry needle. After placing the cannula, you need to ensure that it enters the posterior compartment of the lip to ensure we get the maximum eversion. Visually, you need to be constantly looking at the lip to ensure that you are injecting in a symmetrical fashion, and you can use the finger of the non-injecting hand to give you a guide as to the amount of volume replacement that you are managing to achieve. After injecting the lower lip, as previously, I am swinging the cannula round to inject the upper lip. As on her right upper lip, I will inject 0.1 mls of Voluma in the posterior compartment.


After treating Phoebe with the cannula and Volift for eversion, I am now moving on to using the Volift with a needle just to give her a gentle enhancement. I will treat her just below the vermillion border to give her a little bit more projection, volume, and show of the red lip. I will treat her in the medial aspect of her upper lip, and after doing this I am keen to define her Cupid’s bow. My preferred technique here is to use an instrument like a cotton bud to help us create definition. I am using Volift and my entry of the needle is from the Glogau-Klein point very superficially towards the midline. I inject very little product here, maybe 0.01 or 0.02 mls. I will inject from both sides, and the cotton swab helps to compartmentalise the product and ensure that we obtain the definition that we require. After this treatment, I will use a cotton swab and some Vaseline to massage the product and get a better spread throughout the tissue of the lip.


Immediate treatment outcome


We can now see Phoebe at the end of her lip treatment. Immediately, we are aware of a much more youthful projection of her lip. We can see that this compliments the new face shape that we have managed to achieve by projecting her cheek and also lifting and defining the jawline. Remember, this is just post-treatment. If we see her from the oblique side, pulling up on the posterior and superior vectors gives very little additional lift, and we can see that her result is symmetrical on both sides. Accordingly, this is a good place for us to stop our treatment now because we know that she will continue to get a clinical improvement. It would be interesting to see Phoebe from before we started today, and we can see that there has been a dramatic improvement in her face from baseline, with a much more youthful lower third of her face. There is a very pleasing improvement in the heaviness of the jowl at the jawline, and a nice lift from the treatment of her midface.


Treatment outcome at 6 weeks


We now see our patient, Phoebe, 6 weeks after her initial treatment. We treated her in the midface and perioral region to improve some jowling, and also to give her a better lip. We can see from baseline that this has had a significant improvement – she looks younger, refreshed, and certainly less saggy in the lower facial region. We can also see that from the side her jawline has improved substantially, with significantly less heaviness of the jowl region, and therefore a more youthful jawline in oblique profile. In this view you can also see significant improvement on her left side. Not only do we see a much more pleasing jawline in Phoebe’s face, we can also see that if we try and lift in the posterior vectors now, she gets very little further improvement. From the front, we can see that she would look slightly better with bigger lips. Now that we have given her the perioral support, we are in a great position to give her more lip treatment if she so desires.