Filler injection

 

Assessment

 

I would like to introduce our next model here, I have Tony with me who is currently 41 years old. When I spoke to her about what she wants treated, she mentioned that she has three priorities. Priority number one is the infraorbital hollowing, number two is a dorsal hump she has which can’t be seen from the front but I will show it later from the side, and priority number three is her lips, as she would prefer that they were fuller. Now, let’s do a full assessment of her face so we can plan her treatment.

 

We can see that the upper third is smooth, and this is due to her having some botulinum toxin injected by her usual practitioner. We can see that the face shape is very long, and she also has a degree of hollowing in the temple, which acts to accentuate this long face shape. If I look at her brow, we see that the shape of the brow is, generally speaking, okay, but if I just give her some gentle brow elevation it serves to open up the orbital aperture, and this is something that we can target by treating both the temple and the brow. If I look at the lateral part of her face, we can see that the cheekbone is poorly projected, and again this is also adding to the long face shape that she has. Accordingly, some degree of cheekbone projection would be useful, not only to change the facial shape but also to start adding support to treat the under eye area. When I look at the under eye area, you will notice that although she has bilateral eye bags, it is considerably more severe on the right side compared to the left side, and if I turn her to side you will notice that one of the reasons for this is that she is very deflated in the anterior cheek just below the infraorbital hollowing.

 

Now, we can move on to the lips. You can see that the lips have a reasonable shape, but they are thin, and especially with her long face, they look too thin for her particular face. However, she never had particularly full lips when she was younger, so we must keep this in mind when we treat her lips and aim for just a very mild to modest augmentation. I also want to examine her dentition; if I get her to smile you will notice that she has a prominent upper dental arcade, but if I turn her to the side you will notice that she has a quite significant Class 2 dental occlusion, with the upper teeth considerably anterior to the lower dental arcade. However, she has an excellent chin position, therefore I am happy to treat her lips directly without the need to augment her chin. Finally, in this position we can also see the dorsal hump that concerns her, and we can treat this by injecting filler above the hump and disguising the appearance.

 

Temple injection strategy

 

Let’s now review the temple injection strategy for Tony. There are two main reasons we might inject in the temple; one is if there is true hollowing, but also if we want to add support for the lateral tail of the brow. You can see in Tony’s case, if I tilt her down, there is definitely some temple recession, but we can also see that the right brow is a little bit lower than the left brow, and the tail of the brow is lower than the head. Ideally, we want to try and raise the tail and open up the aperture of the eye. We can do this first by injecting the temple and then injecting the brow directly. In previous videos I have had some feedback that I may have confused some subscribers as to actual markings of the temple, therefore I am just going to go through that area again. If I turn her to the side, I have marked off the temporal fusion line and also the lateral orbital rim. To find our injection point, we simply go along the temporal fusion line 1 cm up and then 1 cm down at 90 degrees, and this will be the point that we inject.

 

Brow injection strategy

 

Let’s now review the brow injection strategy for Tony. If we look at the underlying shape of the brow, we can see that from the head of the brow we go along approximately two thirds of the length to the apex,and then we have one third of the brow as the tail. We see that there is a gentle angulation of about 20 degrees up to the apex, and the apex sits somewhere between the lateral canthus and the lateral limbus. Ideally, we want a little bit of brow raise, and therefore we will inject in this region, into a deep fat pad called the retroorbicularis oculi fat.

 

Nose injection strategy

 

Let’s review the injection strategy to treat Tony’s nose. Remember, we are treating her for the appearance of a dorsal hump, and therefore we will concentrate in the area above the hump. If I turn Tony to the side you will see that the rest of the nose, from the hump below, actually already has a good contour and angle. Therefore, we can concentrate on the area above. The idea will be to inject the product deep, which will then give us some projection. If we look at the radix break point, you will currently see that the existing radix break point is in line with her lower lash line. Ideally, we want to increase this to her upper lash line, and in doing so what we will have is effectively a straighter line from the radix down to the tip. This will have the effect of disguising the hump and making the nose appear smaller. As she has great convexity of the forehead, there is no danger in making the nose to forehead angle too wide.

 

Cheek undereye strategy

 

In this video I want to discuss the injection strategy for treating Tony in the cheek and undereye area, and this is because we can’t really treat the undereye area unless we give her lateral support. What I propose to do is give her some structure along the zygomatic arch, because this will already tend to give her a lift and start improving the undereye area, and then I can focus on the anterior cheek itself. If we now zoom in to her eye area, you will notice that I have marked off two lines. If I exert gentle pressure on her globe you will see the herniation of the infraorbital fat through the orbital septum, and I have marked out the inferior aspect of this with the black dotted line. As she opens her eyes, you will see a white line, which denotes the height of the inferior orbital rim. Accordingly, I want to make sure that I don’t put any product close to the rim, otherwise I run the risk of inadvertently injecting through the septum and into the infraorbital fat. I will therefore stay inferior to the black dotted line and get my maximum benefit in this region.

 

Lip injection strategy

 

In planning Tony’s lip treatment, we can see that the lips are relatively thin, and they also have downturned oral commissures, which gives a sad effect. We can further see that if we can get a gentle eversion and a greater show of the red lip, then this significantly improves the dynamic. Therefore, when we treat her we have to ensure that we keep the shape and definition, but at the same time we improve the upper lip to lower lip, this will involve some central injections to the lower lip and finally we have to see if we can improve the oral commissures, both directly and indirectly with cheek lift injections.

 

Cheek treatment

 

I will now demonstrate the treatment of the cheekbone for Tony. Because I want a relatively high degree of impact, projection, and lift, I am opting to use a cannula. I am using a sterile towel to cover her hairline to prevent contamination of the cannula, and I am going to use a 25 gauge cannula, therefore I have made a prehole with a 23 gauge needle. I am pinching the skin to make sure that I can enter in the deep plane, as ideally I want to place the product along the periosteum. I hold the cannula like a pen to make sure that I can get it in, and I can adjust my grip to inject. You will notice that you cannot see the shape or outline of the cannula, which shows that it is at the correct depth. I am laying a series of linear threads, however, when I inject I am putting more product at the distal end and injecting less as I withdraw. Essentially, I am trying to replicate the shape of the cheekbone, which is a little bit like a comet, with a head and then a tail which tapers out. If we do not do this, we will end up with a very linear or narrow shaped cheekbone, which will not look correct from an aesthetic point of view. I am continuing to inject in the deep plane, and my target tissue here is the lateral SOOF, or the suborbicularis oculi fat. The whole time that I am injecting, I am using the fingers of my non-injecting hand to make sure that my product placement is both symmetrical and also even. Because I want relatively high impact, I am going to use the full 1 ml of Juvederm Voluma in this region. This could also be done with a needle technique, however, using a cannula allows us to distribute the product more evenly, and will reduce the likelihood of there being gaps or boluses of product which then have little deficiencies in between them.

 

After injecting, I can then apply reasonable pressure to ensure that the product is conforming to a very even projection. If I sit her up, one of the first things I notice is not only a greater projection of the cheekbone, but look at the right oral commissure, which has gone up considerably compared to the left one, and this has already started to improve the lip. If I turn her to her side, we will notice that on the untreated side she remains flat with poor cheekbone projection, but on the treated side we can see a much better OG curve, which is a youthful trait. I can now go on to treating her anterior cheek, which will help give us a better continuation from the projected cheekbone to the under eye area. I will therefore mark out the maximum degree of deficiency and then we can proceed to treatment. I am going to move on to Juvederm Volift to treat the anterior cheek, and I will use a needle.

 

After recleansing the skin, I will use my Juvederm Volift, and I am approaching from the lateral aspect just at the junction at the area I treated. I aspirate, and having ensured that I am onto the periosteum, I will inject a slow bolus of product. Again, I am now in the suborbicularis oculi fat, and I will inject a total of 0.2 ml of product. After the first injection, I can then move more medially towards the tear trough. I will first just mould the injection, and after recleansing the skin I can then proceed with another bolus of Juvederm Volift. It is important to remember that every time we touch the patient we must take care to cleanse the skin. Again, I am aspirating, and after I aspirate I am injecting a slow bolus deep onto the periosteum in the deep cheek fat. I need to get reasonable projection here so I am going for another bolus of 0.2 ml of product, and after withdrawing the needle I just use a very gentle mould to ensure that the product is smooth. I want to see what impact these injections have had on her face so far, and what I can see is that there is now much better continuity from the projected cheekbone to the anterior cheek, especially if I compare it to the untreated side. However, this has now accentuated the deficiency of the tear trough, both medially and at the lateral lid-cheek junction, so we will now proceed to treatment of this area.

 

I am going to do this in two stages; I will start by treating the lateral lid-cheek junction, and to do this I am going to use Juvederm Volbella, but I will use a needle approach because I can get better precision with my injections. I am going to decant the Juvederm Volbella into a 0.3 ml, 32 gauge needle syringes, and I have a video in another section of the website that shows the technique for doing this. I insert the needle deep, and I go straight into the lateral orbital rim, and I will inject a total of 0.05 cc of product. Often, when you inject in this area you may find that you have created an unsightly bolus, however, because this is Volbella, which is a Vycross product, it is easy to massage and mould straight away using just finger pressure. I then come more medially, and I will stop just before I get to the mid-pupillary line, because I will prefer to treat the medial part of the tear trough with a cannula. The whole time I am injecting I am constantly massaging and moulding the product to make sure that I have even deposition of the product. I use one final injection in an area I have identified as still being deficient, and I will continue just to mould this. Now I can see that there has been a subtle but effective improvement of the lateral lid-cheek junction which is more in keeping with the left side, which was less severely affected.

 

I can now proceed to treating the medial part. For this, again, I am going to use Juvederm Volbella, and I will use a 27 gauge cannula, so I make an entry hole with a 25 gauge needle. You will note that I am holding the cannula like I would hold a pen, just to ensure that I can get to the correct depth, which is deep. Having satisfied myself that I am at the correct depth, I can adjust my grip, and I am using the finger of my non-injecting hand to ensure that I know where the tip of my cannula is. I start by injecting the deep plane in the middle part of the tear trough. As I get more medial, I may need to change my depth to inject the product more superficially. This is because the orbicularis retaining ligament is very tightly tethered to the bone at this level, and it is impossible to get below it, so we end up having to inject within the muscle rather than under it. It is important when treating the infraorbital region not to over inject product; it is better to leave the area underfilled because we can always top up, but it we overfill the area we can get problems with swelling and visible product. I am also going laterally to blend the medial and lateral parts of my treatment. I finish off by injecting the medialmost part of the tear trough, in the superficial plane. Now, you can see the tip of the cannula through the skin to show that I am in the more superficial area. Do take care to ensure that you don’t leave visible traces of product in this very sensitive region.

 

Following treatment of the right cheekbone, anterior cheek, lateral tear trough, and medial tear trough, I can already see that compared to pretreatment there was a very obvious severity on the right more to the left, we have now at least managed to reduce the asymmetry between the eyes. I am happy to leave the treatment of her right eye at this stage and concentrate of treating the left side. We can always add more product either at this session or in a follow up session, if required, as undertreating the eye is quite important to avoid swelling.

 

Temple treatment

 

I would like to demonstrate the treatment of the temple region in Tony, and I will begin by retracting the skin. I have an injection point which is approximately 1 cm along the temporal fusion line, and 90 degrees perpendicularly down. I am going to aspirate to ensure that I am not intravascular, then I will use a slow, steady injection to deposit a bolus. Remember, the structures in this region are the skin, a scant degree of subcutaneous fat, superficial temporal fascia, deep temporal fascia, then the temporalis muscle, and finally the periosteum. The muscle is closely adherent to the periosteum that we cannot get underneath it, so in fact the product will track back up the needle path and fill up the muscle. I am going to use a total of approximately 0.5 cc of product, and the idea is that we want to get some support for the tail of the brow. After injection, I just check to ensure there is no bleeding or haemotoma formation, and then we can have a look at the impact this may have given to the eyebrow. If we look at Tony now, you may recall that before treatment her right brow was lower than her left brow. Now you may see that the two brows seem to be more equal in height. Secondly, if we look at the tail of the right brow, compared to the left side where it is lower than the head of the brow, we now see that the tail has risen up to a more favourable position. We can therefore see how treating the temple can impact the brow position, and we can proceed to filling the brow itself so we can improve this further.

 

Brow treatment

 

In this video, I would like to demonstrate the treatment of the brow with dermal filler. You will notice that we can improve the position of the apex, and therefore what I will do is use a needle technique with Juvederm Volift. I am going to take the apex and just retract the skin, and I am going to direct my needle into the fat pad below the brow called the retroorbicularis oculi fat. Accordingly, I inject deep until I hit the periosteum of the superior orbital rim, and then I will inject a small bolus of product, approximately 0.025 cc. I then retract and I will inject another bolus adjacent to the first one, and you can see that as the tissue elevates it will cause the hairs of the brow above just to ascend superiorly. After injecting in this region, we can just administer a very gentle mould, but do not want to apply too much force because we need the projection that the product gives us. If we now look at the impact of that treatment, we can certainly see that, compared to pretreatment, we now have a much more favourable position and also shape, if we track the brow from the head to the apex and then the tail of the brow, we can see that it now conforms to the perfect female eyebrow shape.

 

Nose treatment

 

In this video I would like to demonstrate a simple technique for treating the dorsal hump in Tony. You can see that I have marked out the area I want to inject, and I will use the fingers of my non-injecting hand to compartmentalise the product. I am using Juvederm Voluma, which I have decanted into a 30 gauge, 0.3 ml insulin syringe, then I insert the needle perpendicularly to the skin, and I am injecting in a deep plane. I will use a bolus of 0.15 cc, and I am injecting slowly, making sure that I am deep and in the midline. The idea is that I want to fill the hollow above the hump to try and bring the angle of the dorsum into one straight line. After injecting, the first thing I need to do is gently massage and mould the product to make sure that it is even, and I need to view this from both the foot of the bed and also both sides. We can use gentle pressure, but we do not want to overexert, because otherwise we can squash the product down and lose the projection that we have created. Having satisfied myself that the product is smooth, I can then sit her up to view.

 

Because it is a dorsal hump treatment, we cannot see much from the front view, but when I turn her to the side you will notice there has been a reasonable improvement in the dorsal hump already. I can see that the hump is not so evident, and we have a much more pleasing angle of the dorsum from the radix down to the tip. If I do want more correction, I can consider injecting at a future session, but before I make that choice I can put a flat object on the nose, and I am aware that although there has been a good improvement, there is still a little bit of hollow at the radix. Accordingly, I will inject a little bit more product. I use the same technique using some more Voluma, and this time I will inject in an area which is slightly superior to my previous injection point, and I will use less product, 0.05 cc. After I have moulded this, I will look to see the impact that this may have caused. As with all filler treatments, it is best to leave some degree of correction, because we do not want to create a lump or an asymmetry. Again, as I turn Tony to the side, I am much happier with the appearance of her nose. I can see that the hump is almost eradicated, and yet somehow the nose appears to look smaller and less dominant because we now have a straight contour.

 

Lip treatment

 

I will be demonstrating the treatment of the lip with a cannula for Tony. I am using a cannula because I want to get a very subtle augmentation, given that she has thin lips, and even as a younger lady she never had very full lips. I will use a 27 gauge cannula, so I am making the prehole with a 25 gauge needle, and I am using Juvederm Volbella. I enter just above the vermillion border, and I will place the cannula in a very superficial position. You will notice that when I reach the extent of the cannula you will see the tip of the cannula at the GK point of the peak of the Cupid’s bow. I will then lay a retrograde linear thread of approximately 0.1 cc, but I won’t inject all the way to the end, because I want a little bit more product in the central part of her lip, compared to the lateral aspect. After I finish the first linear thread, I will angle my needle so I am slightly inferior to the first thread, and I can therefore add some volume to the red vermillion body. I will inject a further 0.1 ml linear thread here. Finally, I will adjust my syringe and cannula to go slightly deeper than the first two threads, and this will have the effect of maintaining definition, but at the same time giving me the volume that I desire to give the upper lip. After treating the right upper lip, I will do exactly the same on the left side. Notice that I aiming for a very subtle impact with the augmentation, and it is important to bear in mind that if a patient has a very thin lip we must not overdistend it in one treatment, but actually build up over a series of sessions.

 

Just like the right side, I am using the 25 gauge needle, and you will notice that I am placing it just superior to the vermillion border and just inside the oral commissure. I enter with just the bevel of the entry needle, and one I remove it I will use the cannula to enter in a very superficial plane along the vermillion border. As I pass the cannula along, just like on the right side, you will notice that the tip of the cannula is visible at the GK point of the Cupid’s bow. When treating the lips, it is vital to ensure that you inject exactly the same amount of product in both sides and in the same location, so I will put the first linear thread along the vermillion border. The second thread will be slightly inferior in the red vermillion of the lip, and my third thread will be at a slightly deeper plane to the first two. In total, I will have injected approximately 0.3 cc in each side of the upper lip. After injecting, especially with the Vycross products, it is important to mould and massage to ensure even distribution of the product.

 

I will now move to treating the lower lip, and I will demonstrate this on the left side only. I am going to choose a different entry point, and this will be just slightly lateral to the oral commissure. I am using the same 25 gauge needle and the same 27 gauge cannula. Having inserted the cannula, I am aiming to reach the centre part of the lower lip, and I will deposit more product in the anterior central part of the lower lip and very little product as I withdraw. I am going to inject a total of 0.3 cc of product in total in each half of the lower lip. After treating the left lower lip, I will move on to treating the Cupid’s bow. I like to use an instrument like a cotton swab in the philtrum to prevent the product from tracking into the centre of the cutaneous lip. This maintains the definition and ‘v’ shape that we get in the peak of the Cupid’s bow. I prefer to use a needle here, and I have decanted the product into a 32 gauge, 0.3 ml Botox syringe. I am injecting a total of 0.02 cc in each half of the peak of the Cupid’s bow. Following treatment, I will use a gentle mould and massage to ensure that the product is both symmetrical and smooth. I can see that the lower central lip requires a little bit more eversion and volume, so I will again use the product decanted into a Botox syringe, and this time I am injecting from the cutaneous part of the lip into the red vermillion. I am still superficial, and this means that I am under the mucosa but above the muscle, and I am using the finger and thumb of my non-injecting hand to keep the product localised. This will give me a nice lateral pillow on each side of the lower central lip. The total amount I am injecting is 0.1 cc of product. You can see, therefore, that in Tony we have used a combination of cannula and product decanted into a needle syringe.

 

Outcome

 

Let’s now review the impact of treatment on Tony. Just to recap, we treated her in the temple, the brow, the cheekbone, anterior cheek, infraorbital area, the lip, and the radix of the nose to reduce the dorsal hump. We can see that automatically there is quite significant impact when we compare her to pretreatment. We can see that there is a much better face shape due to the projection of the cheekbones, and this has the effect, alongside the temple filling, of giving the face a less long appearance and a slightly more oval or heart shaped appearance. She also seems to have more energy in the face, and look less tired because we have managed to significantly decrease the appearance of the eye bags. Finally, the treatment of the lip is also managing to make her look younger and less tired. If I turn her to the side, we can also see significant improvement. We notice not only an improvement in the angle of the shape of the nose, but let’s see how the treatment has affected her profile. We start by noticing that she already had a very nice convexity to her forehead, but she now also has a much better angle to the dorsum of her nose. The lip treatment has given her better projection of the upper and lower lip, and the chin was already in a good position but notice how the cheek treatment has improved the oral commissure marionette line and also improved the negative eye vector. Overall, the treatment has had the impact of making Tony look younger, more attractive, and less tired.