Filler injection


General assessment


I would now like to introduce you to Reena. Reena is currently 29, and I asked her what areas of her face she was concerned with, and she mentioned that she had 3 main concerns. The first was that she would ideally like to have some treatment to the chin to make it more dominant, the second was her lips, and finally, she has an interesting issue with her nose. Let’s begin by just having a look at her face overall, we can immediately see that Reena is young and beautiful, she has a beautiful face shape – her face is overall an oval or heart shape, due to good lateral projection of her cheeks coming down into a delicate chin. We can also see that Reena has very beautiful skin, and this is even toned from the hairline to the chin. Clearly, her most beautiful feature is her eyes, they are large and dominant. Accordingly, when we treat a young, beautiful model like Reena, we have to be very careful to embellish her pre-existing features.


Lower third assessment


We are going to focus on the assessment of Reena’s lower face. We can see that there is at rest a short distance between the base of the nose and the beginning of the lip. On activation of smile or speaking, this distance shortens even more. We can also see that although her lip has an overall reasonable volume and ratio between the upper and lower lip, there is some pre-existing asymmetry. She appears to have a more full lip on her right side compared to her left side. If we cause a gentle eversion and projection of the left, we can see that she has a better symmetry and balance on both sides. Finally, if we look at the lower lip, you will notice that in the region between the lower lip and the chin there is a deep crease, the labiomental sulcus, and this is exacerbated by the mentalis rotating anteriorly.


Let’s have a look at Reena from the side profile. If I turn her to the side and we begin the assess, we can see that the chin has a retrusive position, appearing to be retrognathic. She has reasonable projection of her lips, and if I take a Rickett’s line from the chin to the nose, we can see the lower lip touches the stick, however, this is not due to over projection of the lower lip but because the chin is retrognathic. If I project the chin anteriorly then we can see the same Rickett’s line analysis puts the lower lip in a more favourable position. Accordingly, it is important that we do an analysis to figure out where the deficiency is. In her case, it is due to a retrusive or retrognathic chin. If I get her to bite, we can see that she has actually good occlusion of the upper and lower dental arcade so she just needs isolated treatment to the chin in the labiomental crease and then also additional treatment in the inferior pole of the chin to give inferior and anterior projection. We must treat the labiomental crease, otherwise we would get an unfavourable inferior projection, which would leave her with the appearance of a ‘witch’s chin.’


Chin markings and treatment


We will proceed to treat Reena in the chin area. I begin by treating the labiomental crease, inserting a 23 gauge needle to make an entry hole for a 25 gauge 38 mm cannula. My product here will be Juvederm Voluma. The depth here is critical – we don’t want to be too superficial otherwise we may get visible presence of product, but we cannot be too deep otherwise we will end up in the gingival sulcus. Accordingly, our depth is mid-level. I am injecting the product in anterograde linear threads, the idea being that the product helps open up the tissue plane, allowing the cannula to pass more easily. This can be tender, especially in the midline, so we allow the Lidocaine that is contained within the product to start giving some anaesthesia in this region. It is worth explaining to the patient that they will experience a little bit of discomfort here. We are treating the labiomental crease to get a better transition from the lip down to the chin, and this will also begin the process of elongation. In Reena’s case, if we had not treated in the labiomental crease before treating the lower part of the chin, we may have caused excessive anterior projection and the appearance of a ‘witch’s chin.’


After we have treated in the labiomental crease, we can then begin the process of treating the lower part of the chin to get some anterior and inferior projection. To do this, we can simply angle the cannula and syringe to a different orientation and then moving the cannula we can proceed to directing the tip towards the inferior pole of the chin. In this region, we can now inject 0.2 mls of product just anterior to the bone. We inject 0.3 mls of Voluma in the labiomental crease and we will inject a total of 0.2 mls in the inferior pole of the chin just anterior to the menton. After we treat the right side, we can just a give a little bit of massage and moulding to ensure that we have injected the product in an even way without any obvious bumps.


We now begin to treat Reena on the other side. It is important when treating both sides of a patient to ensure that we are as symmetrical as possible with the injection of the product. To do this, it is useful to mark the patient and also to make sure that we keep a careful track of the quantity injected. We injected 0.3 mls in the labiomental crease on the right and 0.2 mls in the inferoior pole. Accordingly, we will do exactly the same on the left side. If after this we notice any irregularities, we can then simply correct.


After treating the labiomental crease and the inferior pole, we can see that Reena’s chin appears longer, and when we look at her from the side we can also see there has been some inferior projection. To project the chin anteriorly, I have marked the area that I want to focus on. The ideal female chin will be the same width as the nasal flare, and accordingly when performing this treatment it is important to use the thumb and forefinger to lateralise the product and ensure we do not widen the chin. I have switched to using a needle as I want more precision here. There are a number of ways that you could do this, but I favour a particular technique here taught to be by Mauricio de Maio, and this region is known as C4 in the MD Codes. We proceed to inject the chin with a posterior approach and the needle is then angled forward, the idea being that the product will push the soft tissue envelope of the chin forward. The finger and thumb of the non-injecting hand are used to stop the product spreading laterally, which would cause excessive chin widening. If you watch closely, you will see that as the product is injected it is indeed projecting the chin anteriorly. After injecting a bolus of 0.3 mls of Juvederm Voluma, we stop, and even in this view we are aware that the chin is projected forward but has remained narrow. We can then use gentle pressure to mould and massage the chin as required.


Chin treatment outcome


Following treatment to Reena’s chin, we can see that there has been an apparent increase in the vertical dimension. At the same time, the width of the chin has stayed within the boundaries of the nasal, giving the ideal female chin width. From the lateral view, we can see that she has much better anterior and inferior projection of the chin, giving a better harmony of the mid and lower thirds. We can finally see the Rickett’s line analysis show that the chin is forward and the lips are in the ideal position in terms of projection.


Lips marking and treatment


We will treat Reena in the lip with a very subtle treatment. We are using Juvederm Volbella and I am injecting the red vermillion of her lip to give a very gentle augmentation. My depth is submucosal. I inject very small volumes of product with a retrograde linear thread and my location is just below the vermillion border. In each thread, I will inject 0.05 mls of product as she is slightly more full in her right than her left. After treating her I can see that the smile is starting to equalise. On her right side, as she has a greater fullness I will inject less product here. Again, my depth here is just submucosal. When we inject the Vycross range of products, it is important to massage the product after injecting. This is because the property of the product is that it is very spreadable. I will typically do this with a gauze covered in chlorhexidine, and at the end of the treatment we will use a little bit of petroleum jelly.


Having injected her upper lip, I will now move on to treating her lower lip. When I treat the lower lip, I want to maintain the ratio between upper and lower. I also want to keep the shape of the lower lip in keeping with an aesthetic lip. Accordingly, I will treat the central portion of the lower lip with more product and less towards the lateral sides of the lower lip. I enter from a cutaneous entry and I will inject a bolus of 0.1 ml in the lateral tubercle of the lower lip, before repeating this on her left side. This approach is less traumatic and less painful for the patient than injecting through the red vermillion. You will notice that as the tip of the needle is in the subcutaneous mucosal plane, we get an almost immediate projection and augmentation of this region. As I move laterally, I will now inject less product, so each bolus will be 0.05 mls, and this will maintain the natural shape of the lower lip. Following treatment, I will give Reena another massage and this time I will use a little petroleum jelly and a swab. It is important to notice that we have only used 0.4 mls of product, but already we have noticed that we have got enough of a result to stop treatment.


Immediate outcome


We now see Reena following treatment to her chin and also her lips. This is immediately following the injections, and you will notice that she is ever so slightly swollen in the lip region, however, we can already see much better balance between the mid and the lower thirds. In profile, we are aware of her lip having a better projection alongside a better anterior projection of her chin. Accordingly, we now have a better view of Reena in the lateral profile view, and if we do a Rickett’s analysis, we can see that the lips have a perfect projection.


Treatment outcome at 2 weeks


We have Reena here 2 weeks after treatment to the depressor septi nasi with botulinum toxin. You will notice that pretreatment, she had very excessive movement of the tip of the nose while talking. After treatment, although there is some movement, it is significantly reduced. Reena also underwent lip treatment to help an asymmetrical smile. If you look at her on the left, you will notice that she has more elevation of the right commissure than the left and the gap between the upper lip and the nose is very minimal. On the right, after the treatment to the depressor septi nasi with botulinum toxin and her lip with Juvederm Volbella, you can see that the smile is much more symmetrical.