Filler injection

Assessment

 

Hello. In this series of videos, I want to demonstrate a variety of techniques that we can use in the lower face for the chin and jawline. I am going to use a combination of cannula and needle techniques. Let me introduce you to my lovely patient, Kate, who is 59 years young, and I have previously treated her in the midface just to give her some support in the zygomatic arches, which gave her a nice lift. However, we are left with some appearance of jowling bilaterally, and the marionette line that we can see. To really appreciate how we are going to treat Kate, let’s have a look at her in profile, from the side. If we move her this way I think we can now appreciate all the various aspects of her treatment.

 

Starting posteriorly, we can see that there is certainly some degree of projection in the angle of the jaw, but it could do with a bit more definition. We have some degree of residual jowling but it has definitely improved since I first treated her after lifting in the cheek but it still remains prominent inferiorly and also in the marionette region. We can see a big deficiency in the pre-jowl region, and finally, we can see that the chin is retruded horizontally. The second thing to note is that the chin is not only retruded but it is also anteriorly rotated up, and because of this we have also got a very deep labiomental region. We have to take care in injecting the chin because if we inject in the incorrect plane, we will actually increase the anterior rotation, and although we may make the chin more prominent, we will also make it more anterior, which will give a worsening to the labiomental region. Ideally, we want to lengthen the chin by injecting in the labiomental. We then want to add support from the prejowl round to the tip of the chin and focus on the inferior projection. Having done that, we will then look at defining the jaw, which will also give us a posterior lift. I want to get the best transition I can from the angle of the jaw to the tip of the chin.

 

Labiomental Crease Treatment

 

I begin by treating the labiomental crease. I need to be in the subcutaneous depth here, and I am using a 23 gauge needle so that I can use a 25 gauge cannula to inject, and I’m using Juvederm Volux. Although this product is excellent for chin and jawline, we have to be careful when we use it in the subcutaneous region because it is powerful, it’s got a very high lift, and if we inject too much product we can get a lot of distension and firmness in this region, which needs to maintain some suppleness as it is so involved in animation. I can now see the tip of my cannula in the midline here, and so I will start injecting small amounts of product in the midline, and this will have the effect of numbing this region due to the Lidocaine that is contained in the product. I am using a series of linear threads just to open up this angle, and this will be useful in preventing excessive rotation of the chin, which will result in an unnatural and unpleasant appearance. This is a sensitive area, so it’s worth just injecting slowly and allowing the Lidocaine in the product to really numb the area up. If the mentalis muscle is very contracted, it can be very hard to inject, so I can just ask Kate to open her mouth slightly. I am using a combination of mini bolus and linear thread techniques to get the product evenly spread out. Where I feel a little resistance, I’m more likely to use a little bolus.

 

Some colleagues feel that the Volux should only be used deep on the periosteum, whereas others are comfortable with it being used in the subcutaneous. My personal view is that you should be experienced in treating this area with another product, such as Voluma, and I think if you can get good results with the Voluma, you can definitely move on to using the Volux in certain patients. I think patient selection, like so many things in aesthetic medicine, is key; we need to make sure the patient has good skin thickness and that the labiomental fold is very deep, otherwise we might find that the Volux is too strong and may give a very full appearance in this region. I have nearly finished the first side and then I stop there.

 

I am just going to use a sterile swab to remove the little bit of blood there, and I can carry on injecting. Just like the other side, I’ll get her to open her mouth, and as she does so I can get my cannula into the midline. You’ll notice that it’s more comfortable now because this area has started to numb due to the Lidocaine that we introduced from the first side. In the midline, where due to the tightness of the muscle I’m feeling more resistance, I’m using a series of mini boluses; not very much at all, just maybe 0.02 in each one and then I move on. I certainly don’t want any big boluses, because that will distort the rather delicate anatomy here. As it gets easier to pass the cannula, then I can use a few threads to link up the central area with the area more laterally. Again, it’s very important not to over inject the lateral area because otherwise, we will interfere with muscle function and animation. This is why the purpose of this is to open up the chin and stop that anterior rotation, or the upwards rotation, that she is exhibiting. As always with cannula treatments, we are constantly feeling. I can feel the treated side and I can see it’s nice and even. I’m feeling all the way along, and I’m very satisfied that we have got a very nice, very even fill. In patients with longstanding rotation, you sometimes find that there is almost a sense of scarring or fibrosis in this region, which makes passing the cannula very difficult, but if we are patient and we use the product to guide the cannula rather than forcing the cannula, we will find that at the end the result is exactly how we want it.

 

When we look at Kate after the treatment, from the front view it’s not easy to tell any change, although we are aware of a slight elongation. However, if I turn her shoulders and face to the side, now we can see that there is certainly a better positioning and less anterior rotation of the chin compared to pretreatment. Having given us the support, I am now confident that I can create a better chin shape when I start injecting the lower border.

 

Inferior Chin Treatment

 

Having treated the labiomental area subcutaneously with the cannula, I now want to move to the inferior part. In this region, I do have the support of the periosteum, so I like to inject deep onto the periosteum, and for precision, I am going to use a needle. I have made a marking from one prejowl sulcus to the other, and I have this area. This corresponds to the MD Code C6, C5, and C4. Essentially, what I want to do is treat in a ‘u’ shape, and I call this the ‘horseshoe technique’ and it’s a very nice way of getting an anterior projection of the chin. If you’ve ever seen what an anatomical chin implant looks like, it looks like a horseshoe and it’s a piece of silicon that fits just like this, and my idea here is that we are emulating the implant by injecting a series of boluses from one side to the other. I’ll begin by treating the lateral-most box, and to do this I am going to put my finger on the jowl area and I’ll put my thumb underneath. This is to stop the product going laterally and making the jowl more accentuated, or going inferiorly, and I want to localise the product. I go perpendicular and down onto the periosteum, I’m aspirating and I go ahead and inject 0.2 ccs in a bolus. I can feel the product against my fingers, which is perfect as that way I can ensure that it’s exactly where I want it to be, to ease the transition from the heaviness to the chin. When I look from above, I am very happy with the next region, which corresponds to C5. This area is often left out in female patients because it can cause an unnatural widening of the chin, so I will now treat the prejowl on the opposite side before moving on to treating the anterior part of the chin. To assess whether I need to treat in the next box, which would correspond to C5, I look from above and I notice there’s actually already a nice transition in this region, and I don’t see any deficiency, so I’m going to miss it out. This is not uncommon in female patients because if I inject this area it can widen the chin, which is a more male characteristic. Accordingly, I will just go ahead and treat on the other side. I use my thumb on the jowl area this time and my finger on the underside of the mandible. As before, I’m coming in perpendicular onto periosteum, I aspirate and inject another bolus on 0.2 ccs.

 

I find that the Volux here is very powerful in creating the structure we need, and it can be quite powerful even in small quantities, so in a face where you want very little augmentation, you can even use small quantities like 0.05 cc and actually get very visible and palpable results. In Kate, I used a bolus of 0.2 ccs and another bolus of 0.2 ccs in these lateral boxes. With the Volux, I find it has an incredible lifting capacity, so in a patient with a lesser indication, I may use 0.1 ccs or even 0.5 ccs.

 

To treat the central area, rather than going perpendicular, I prefer to approach this from an inferior aspect, because I find it gives us more projection, so I’m going to get Kate to bend her neck and put her chin up in the air for me like this. It’s always worth checking that patients don’t have any issues with the neck because we are hyperextending. After cleaning, my idea is to pass close to the bony border and angle towards the midline. I’m going to use my finger to stop any superior passage of the product, so I aspirate, and with a slight angulation to the midline and very firm pressure down, I will start injecting. I am already aware of a high degree of pressure against my fingers from this bolus that we are creating, which shows that if I hadn’t used the digital pressure I might find this product escaping more superiorly and worsening her rotation. I’m using a bolus of 0.3 ccs here.

 

I am going to do exactly the same from the other side but I’m going to give her a quick clean first. Again, I will aspirate and just like before I will use my finger and thumb just to hold the product. I don’t mind it travelling towards the midline, that’s what I want, but I don’t want it going laterally or superiorly. We’ve used one syringe of the Volux superficially in the subcutaneous layer in the labiomental region and another 1 cc of the Volux inferiorly to help the bone projection. You may have noticed that before I treated her in the chin, she had some fasciculations and some depressions in this region. After treatment, we can already see that there appears to be some improvement. Let’s sit Kate up.

 

From the front, we are aware that there appears to be a better transition from both cheeks into the chin, certainly, the marionette and the depression in the prejowl is considerably improved. If we turn her to the 45 degree, we are now seeing a better transition from chin to the jawline on both sides. From the profile, we can see that although the chin is in a better position and isn’t so retruded, it is still quite flat. Accordingly, I want to do a treatment that will take care of the depression here and give me inferior projection, and the best way to do that is by treating on the underside of the mandible. In terms of the MD Codes, this would be JW4 and JW5, which is what I will go ahead and do now.

 

Submental Treatment

 

This area needs to be treated at the subcutaneous depth, therefore I am going to use a cannula. I am using a 23 gauge needle and my cannula of choice here is 25 gauge and 40 mm long. After I introduce the cannula, I want to make sure that my depth is right, so I don’t want to be entirely subdermal because that’s too superficial, I want to be very firmly in the subcutaneous, so I lift the tissue, advance the cannula, and keep advancing until I get right to the tip of the chin. This is perfect, and I will start by injecting a small bolus of product in this region, then I can advance a little bit further and actually push along, and you can see where the tip of my cannula is. It’s giving me exactly what I’m seeking, which is an inferior and anterior projection without upward rotation. I am going to concentrate the product in this region initially and fanning it out. I’m not just going underneath, I am also slightly anterior to get a better shape, and this is something I can observe while I am injecting. Then, I will cautiously inject along this rectangle here. I can then make another passage to inject slightly more inferiorly, and each time I inject I am changing either the depth or inclination to ensure that I don’t have too much product in any one area, and I’ll begin by just using half a syringe on each side.

 

If I look on the untreated side, we can still see the deficiency from the jowl to the chin. On the treated side, it appears that we’ve got a better transition now, and I think you can probably notice that we’re getting a better position of the inferior pole of the chin. We can also see that the level of jowling is starting to decrease and we’ve got a very nice transition certainly in the inferior aspect.

 

I’m treating the other side exactly the same, and it’s always important to remember when you do treat both sides of the face that symmetry is really important to maintain. One of the tricks is to try and keep a mental note of approximately how much product you’re injecting in each area, especially when it’s a wider area like this. To get my correct depth, I’m pinching the skin and advancing right to the tip here. Just like the other side, I’ll begin by a small bolus first which allows me to push my cannula even further. When I’m exactly where I need to be, I’m palpating to make sure I don’t have any little gaps in this region. I used about 0.2 ccs on the anterior part on the other side so I’ll do exactly the same here, coming up a bit more anteriorly and not staying inferiorly to ensure I get a nice curve in the chin. Again, I’m using a bit of manual pressure to stop the product from riding up. Because she’s got nice thick skin, the product is giving us quite an impactful lift already, then I’m very happy to start laying the product as a linear thread along and filling out this little rectangular box I’ve drawn, which corresponds to the lateral inferior border of the mandible in this region. Every time I make a pass, I’m changing my depth or inclination so I am not injecting too superficially and I am not accumulating the product in what is quite an obvious area.

 

Let’s sit her up so we can have a look. Already, I’m aware that there seems to be quite a nice improvement in the jowl areas on both sides. We have also got a very obvious lengthening of the chin, but it’s maintained its feminine, narrow dimensions. Looking at both the treated sides, we have a better harmony from jawline to the chin by filling out this area that was deplete, and it’s taking away the prominence of the jowl on both sides. We will now move onto treating the jawline to see if we can improve the definition by treating in the posterior border, the angle, and the ascending ramus. These correspond to codes JW3, JW1, and JW2.

 

Jaw Treatment

 

These are my markings for treating the jawline. I will put the product in linear threads along the posterior border, use a superficial bolus at the angle, and then a series of bolus as I go up the ascending ramus. I’m entering in the mid part of her jaw, and remember, this is an area where we do have structures like the facial artery and the facial vein. If we start by entering our cannula just above this region, then it’s safe because we are working away from it rather than moving towards it. My depth here is subcutaneous, I don’t want to be deep, and the first thing I’ll do is advance my cannula until I’m at the angle of the jaw and I want to put in a small bolus of 0.1 ccs to give some definition. After I’ve done that, I withdraw partially and go a little bit higher and inject some more product, then higher still. What I’m doing effectively is building up the ascending ramus, which will give us some definition, but it will also give us some good lift in a posterior vector. Each time, the boluses are not particularly large, maybe 0.05 ccs, but they’re very effective, and I’m using my finger to trap the product from going too far back. I then tunnel with the cannula to treat the lower posterior border, and as I’m injecting I’m constantly palpating to make sure that the whole treatment area is nice and uniform and smooth. I realise that she needs a little more up here so I’ll go back to that region. When I’m doing these threads I’m constantly changing my depth. I pause, just to give it a good assessment and palpation. I view it from the side, and with the jawline, we don’t want to overdo the projection in a female patient, and we certainly don’t want the jaw any wider than the width of the midface. Because of all the neurovascular structures in the part of the jaw, like the facial vein and facial artery, I don’t use a needle other than at the absolute angle, where I can put a deep bolus. She didn’t need any projection, so I have just used a cannula to define the jaw.

 

Now, if we compare the treated and untreated, we can see that on the untreated side we notice there is very little projection or definition, and the skin over the preauricular and the jawline almost blends into the neck. However, if you compare that with the treated side now, we have a very definitive jawline, certainly in the angle, and it blends in very nicely with the area we previously treated on the underside of the mandible. My idea now is to finish off the treatment here and then look to see if there are any areas that need further enhancement.

 

If you’re too deep here, the risk here is that we inject within the parotid gland, which can lead to cyst formation. It’s also painful, because the masseteric parotid fascia is very sensitive as it is richly innervated. Now, I’m concentrating the product along the lower posterior border of the mandible, but remaining in the subcutaneous plane. It’s always worth palpating to make sure that the product placement is both consistent and even, because in this region it’s very easy to leave little gaps, which are hard to correct at a later stage.

 

Now that we’ve finished the treatment of the lower face, let’s recap what we did; we started off by injecting Juvederm Volux into the labiomental region with a cannula. We then used the same product, the Volux, in the deeper part of the chin along the periosteum with a needle. We moved on, back to the cannula, to treat the under border of the mandible in zones JW4 and JW5. When we look from this side, we are aware of a very nice, harmonious impact in the jawline to the chin. If I also turn Kate all the way to profile, towards me, we can now see that not only does the chin occupy a more anterior position, but we also have a better connection from the jawline all the way through. We’ve managed to achieve that while preserving the rotation and avoiding deepening the labiomental region. All in all, a very enhancing lower facial treatment.