Cosmetic Facial Surgery

Chapter 13  •  Neurotoxins in Cosmetic Facial Surgery
633
B
A
FIGURE 13-69.  This 53-year-old female is shown before (A) and 2 weeks after (B) 15 units of Botox to the platysma band,
showing incomplete improvement. An additional 10 units of Botox were injected in the superior portion of the band for better
resolution. Treating patients with multiple small treatments is favorable to a single overtreatment. Patients are reminded that
neurotoxin treatment is a sculpting process and may require multiple treatments for safety.
FIGURE 13-70.  The author received this fax several years ago advertising
“bargain” neurotoxin. Shortly after, the headlines were reporting numerous
patients on life support from this product, and several physicians had their
licenses revoked and received jail time. There are no bargains in the
serious science of neurotoxins!
unit or by the area. I have done it both ways and can testify that
charging by the unit is the most straightforward and also easier
for conflict resolution. It is $X per unit for treatments and
touchups.
Although it seems unnecessary to warn competent physicians
to not purchase neurotoxin from questionable sources, many
have fallen prey to penny pinching. When purchasing neuro-
toxins in the United States (at the time of this publication),
the three official and reputable sources are Allergan, Medicis,
and Elan, with several more companies in the FDA pipeline.
The science of neurotoxins is a very serious and potential lethal
business, and attempting to purchase from an alternative source
in the name of cost savings can be disastrous for the surgeon
and patient (Figure 13-70). The fiasco of “research-grade” neu-
rotoxin almost cost several patients their lives and landed several
physicians in jail and without a medical license. There are no
bargains in the serious science of neurotoxins.
Although not a complication, it is important to inform
patients they will have skin wheals immediately postinjection.
Size will vary depending on the injector’s dilution, and they
usually resolve within 20 to 30 minutes. For the uniformed
first-time patient who may be on a lunch break, they may be
unhappy they cannot go directly back to work (or play) due to
skin wheals. This sequela is a good reason to use low-volume
dilutions (Figure 13-71).
Ecchymosis is probably the most common annoying com-
plication associated with neurotoxin injection (Figure 13-72).
Patients seek Botox treatment to look better, and an obvious
facial bruise that lasts for several weeks is problematic inasmuch
as it may raise unexpected, unwanted attention and questions
(including financial questions) from the patient’s family and
friends. Bruising will occasionally happen to the best injectors.
Close observation to surface vascularity, especially in the lateral
canthal region, is requisite for prevention of ecchymosis.
Wearing loupes may assist the injector. If a patient does bruise,
it is recorded in the chart, and future treatments are performed
very superficially. Controlling patient medications that affect
platelet function is helpful, as is icing before and after treatment.

634
Chapter 13  •  Neurotoxins in Cosmetic Facial Surgery
FIGURE 13-71.  Skin wheals are produced after injection and will be less
severe with smaller dilutions. First-time patients must be made aware of
this situation so they can appropriately plan their immediate postinjection
activities.
A
B
FIGURE 13-72.  Ecchymosis is an unwanted sequela that can lead to a loss of confidence with the injector. Close observation
of superficial vasculature and control of platelet-altering medications assist prevention.
Patients who are subject to repeated bruising may be treated
preinjection with Arnica montana.
The most feared complication of neurotoxin treatment is
unwanted muscle paralysis. Neurotoxin diffusion to the levator
palpebrae superioris can produce temporary but emotionally
catastrophic upper-lid ptosis (Figures 13-73 to 13-75). This
complication is best avoided by adhering to the rule of injecting
no closer than 10 mm from the orbit (see Figure 13-15, A). If
upper-lid ptosis does occur, some temporary resolution can be
obtained by using an alpha-adrenergic agonist medication (Iopi-
dine [apraclonidine hydrochloride]), to stimulate Mueller’s
muscle (see Figure 13-75). This muscle has autonomic innerva-
tions and is responsible for several millimeters of lid opening.
Several drops are placed in the eye, and the effects of the
medication last under an hour; it can be used prior to social
situations. Neo-Synephrine 2.5% can also be used. Fortunately,
the ptosis usually resolves spontaneously and does not last as
long as the intended treatment. Besides lid ptosis, extraocular
muscle dysfunction and diplopia have occurred from diffusion
to the extraocular musculature.
It is interesting what different injectors tell their patients to
do or not to do after botulinum toxin A treatment. When the
treatments first became popular, practitioners were telling
patients not to fly in a plane for 24 hours, to stay upright for 4
hours, and so forth. The airplane rumor is unfounded, and I
routinely treat flight attendants. The reason given for asking
patients not to lie down for 4 hours was to “keep the toxin from
diffusing to the levator palpebrae superioris.” If one thinks
about this, it makes no sense because if gravity affects toxin
diffusion, remaining upright would actually contribute to
downward diffusion of toxin to the upper lid. Lying flat would
not. In any event, I tell my patients they can do whatever they
desire after their neurotoxin treatment. This includes lying
down, going to the gym, and exercising.
There is some evidence that flexing the treated musculature
can increase toxin binding at the cholinergic receptors at the
presynaptic motor end plates for a faster onset,43 so it is reason-
able to ask patients to mimic the movements they are trying to
prevent (raising the brows, frowning, and squinting) for the first
60 minutes after injection. Stimulating the respective muscles
several times over the hour may assist the treatment.
Although true upper-lid ptosis is a feared and usually avoid-
able complication, upper-lid “pseudoptosis” is a much more
common sequela. Pseudoptosis of the upper lid occurs from
overtreatment of the frontalis muscles, usually in patients with
excess upper lid skin. If the frontalis is overtreated, they can no
longer perform subconscious eyebrow elevation, and the once
stretched upper-lid skin is now relaxed and more redundant. In
reality, although this may resemble true levator ptosis, their
upper lids are not ptotic, and levator function is normal. It has
to be thoroughly explained to the patient that this is not a result

Chapter 13  •  Neurotoxins in Cosmetic Facial Surgery
635
FIGURE 13-76.  This patient was treated with the brow-sparing pattern and
despite total frontalis and glabellar treatment, she is still able to raise her
brows.
With Iopodine drops
10 days post injection
B
A
FIGURE 13-75.  A, This patient is shown with true levator ptosis of the right
lid after Botox injection too close to the brow. B, The patient 15 minutes
after placing Iopidine drops in the right eye. This case shows much more
opening than is produced in some patients. Certain patients may not
respond at all.
FIGURE 13-73.  Patient is shown 9 weeks after treatment at another office.
She was unresponsive to Iopidine and Neo-Synephrine and unfortunately
had to wait out the complication.
FIGURE 13-74.  This patient was treated by an experienced injector and
developed a temporary ptosis of the right upper lid. Fortunately the condi-
tion improved over a 3-week period.
of misplaced injection but rather a result of not being able to
lift their brows as before. The best practical interventions for
avoiding this problem are (1) inform all patients of this possible
sequela and (2) avoid treating the lateral frontalis in patients
with dermatochalasis (see Figure 13-26). The question marks in
Figure 13-26 show areas to avoid in older patients who may be
a setup for pseudoptosis. Not treating the question mark areas
or treating them very conservatively (1 unit) allows lateral brow
elevation with central frontalis paralysis (Figure 13-76). In addi-
tion, it is a good idea to avoid simultaneous glabella and fron-
talis treatment in this patient group; the effects can be too
efficient. I have intentionally discussed this sequela twice in this
chapter, because it can produce very unhappy patients. They
should know that they are blepharoplasty or brow lift
candidates.
One shortcoming of the brow-sparing injection pattern, or
selective frontalis treatment, is the production of unnatural
unilateral or bilateral brow elevation. This is sometimes called
the “Spock brow” for the V-shaped brows of Leonard Nimoy’s
character, Mr. Spock, in the TV series Star Trek. Deactivation
of the central frontalis with incomplete treatment of the lateral
frontalis region is responsible. When the patient raises their
brows, the lateral brow elevates, while the medial brow does not
(Figures 13-77 to 13-79). This is easily treated by injecting a
few units of neurotoxin at the active lateral brow on the affected
side(s).
When treating the frontalis, it is important to pay attention
to the most superior region of wrinkling (Figure 13-80), other-
wise patients may present with residual wrinkles at or about the
hairline (Figure 13-81).
Second to eyelid dysfunction, dysanimation from overly
aggressive perioral treatment can be very inconvenient and
problematic in aesthetics and function. Figures 13-82 and
13-83 show complications from excessive perioral dosing.
Perioral dysfunction presents an aesthetic problem if smiling,
puckering, and other expressions are compromised. Adding
to the problem are functional deficits such as inability to

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Chapter 13  •  Neurotoxins in Cosmetic Facial Surgery
A
B
FIGURE 13-77.  These patients show asymmetric animation when elevating
their frontalis. A quick touchup of several units in the active lateral frontalis
will correct this embarrassing sequela in several days.
B
A
FIGURE 13-78.  A, Patient before frontalis treatment. B, One week after treatment, with the right brow treated and the left brow
hyperfunctional. The affected side was treated by injecting 4 units of Botox into the lateral frontalis region.
B
A
FIGURE 13-79.  This case became double trouble in terms of complications after Botox. Since this patient had preinjection
dermatochalasis, the lateral frontalis was not treated and caused overly arched brows upon animation (A). Additional lateral
frontalis injections were then performed and cured the brow overarching but created the appearance of excess eyelid skin,
making the patient even more unhappy (B). A blepharoplasty was performed, and the patient was once again content.
FIGURE 13-80.  It is important to pay attention to the most superior region
of active frontalis wrinkling when injecting, especially in patients with a high
hairline or hairline recession.

Chapter 13  •  Neurotoxins in Cosmetic Facial Surgery
637
A
B
FIGURE 13-81.  These two patients presented 1 week after injection complaining of residual and isolated superior frontalis wrin-
kling. Several units were injected at the active muscle for improvement.
B
A
FIGURE 13-82.  Female patient shown immediately before receiving 8 units of Botox across the upper lip (A). Although I com-
monly use this dose, it produced asymmetric animation (B), but did not affect function. The effect lasted about 4 weeks and
gradually improved to normal.
B
A
FIGURE 13-83.  This patient was injected for mentalis wrinkling (A) and the treatment affected her lip depressors (probably a
combination of mentalis and depressor labii inferioris). Although her mentalis dimpling was improved, when she smiled, her
lower lip curled over her lower teeth because the depressor activity was suppressed (B).

638
Chapter 13  •  Neurotoxins in Cosmetic Facial Surgery
B
A
FIGURE 13-84.  This patient had Bell’s palsy on the right side with loss of depressor action (A). Her asymmetry was treated by
injecting the normal left side depressor anguli oris (DAO) with 4 units of Botox and the depressor labii with 2 units. This lessened
the asymmetry (B), and when the palsy resolved, the Botox had worn off the treated side.
pronounce certain words, drooling, and inability to keep liquids
in the mouth. A close look at these images can keep the injector
conservative. The periorbital and perioral regions demand
conservative treatment. This can work to advantage in the
case of patients with temporary or permanent unilateral nerve
damage in many areas. The patient shown in Figure 13-84
has Bell’s palsy on the right side, which produced asymmetric
smiling and animation because the marginal mandibular
nerve was not active on the right side, hence the lip depressors
were inactive. The normal side was treated to even out the
asymmetry.
Conclusion
Neurotoxins are one of the most exciting and useful cosmetic
treatments of the 21st century. Although we have a multitude
of cosmetic and functional uses for neurotoxins, we are just
scratching the surface of their total potential. As we understand
more and more about this exciting science, we will surely capi-
talize on a new horizon of positive effects as well as new classes
and preparations of the drug. Hopefully a means of reversal will
also come in the near future, making the use of neurotoxins for
cosmetic enhancement even more safe and predictable.
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  3. Klein AW: Cosmetic therapy with botulinum toxin: anecdotal memoirs.
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57:1228–1233, 1999.
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lofac Surg 12:1–22, 2004.
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North Am 21:13–21, 2009.
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num toxin type A reconstituted up to six consecutive weeks before applica-
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Med Surg 2(Suppl 4):S4–S9, 1999.
24. Polo M: Botulinum toxin type A (Botox) for the neuromuscular correction
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Dentofacial Orthop 133:195–203, 2008.
25. Hillebrand HA: Botox for excessive gingival display. Am J Orthod
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26. Polo M: Botulinum toxin type A in the treatment of excessive gingival
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Bartleby.com, 2000.
29. Brandt FS, Bellman B: Cosmetic use of botulinum A exotoxin for the aging
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31. Venancio Rde A, Alencar FG Jr, Zamperini C: Botulinum toxin, lidocaine,
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L, Rios-Madariaga C: Subcutaneous histamine versus botulinum toxin type
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ment of occipital neuralgia: a pilot study. Headache 48:1476–1481, 2008.
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headache. Headache 48:1379, 2008.
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40. Talarico-Filho S, Mendonça DO Nascimento M, Sperandeo DE, Macedo
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hidrosis. Dermatol Surg 33(1 Spec No.):S44–50, 2007.
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Epub 2008 Feb 21, 2008.
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S110, 2007.
43. Hsu TS, Dover JS, Kaminer MS, Arndt KA, Tan MH: Why make patients
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Dermatol 139:948, 2003.

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14 
Use of Injectable Fillers in
Cosmetic Facial Surgery
O
ver the past decade, the average cosmetic facial surgery
practice has embraced the art and science of facial
fillers. With a long-standing appreciation for volume
loss in relation to facial aging and the advancement of filler
science, the contemporary cosmetic facial surgeon has new tools
to perform minimally invasive facial rejuvenation. Volume loss
is one of the prime factors that cause an aged look. Today’s
cosmetic surgery patients are extremely savvy on the pros and
cons of specific procedures. They want to look younger, not just
tighter. The past emphasis from surgeons was to look tighter,
and little attention was paid to volume restoration. With the
new era of cosmetic sophistication, fillers (and facial implants)
serve as the icing on the cosmetic cake. For younger patients,
fillers can serve as a sole procedure to disguise aging. For older
patients, they can be used with other rejuvenative procedures to
refine the treatment results.
Over the millennia, various substances have been injected
into the face, including wax, silicone, and animal products1,2
(Table 14-1). Contemporary cosmetic facial surgery includes
many options to augment lips, folds, and wrinkles. For decades,
bovine collagen has been the gold standard for facial filler aug-
mentation in the United States.3 Our European, Canadian, and
Australian neighbors have been more proactive in the use of
various fillers4; this technology is just reaching our shores and
is responsible in part for the enormous media coverage of inject-
able filler substances.
Recent Historical Overview of Facial
Fillers Available in the United States
An overview of injectable filler substances can be confusing.
There are over 120 filler products or devices available. This
chapter cannot cover all available fillers in depth but will con-
centrate on those commonly used or soon to be released for use.
As noted, bovine collagen (Zyplast, Zyderm; Inamed Corp.,
Santa Barbara, CA) dominated the U.S. market for over 2
decades. These fillers contained lidocaine, which mitigated the
discomfort of the injection process. Because they were of bovine
derivation, allergy testing was a prerequisite. Classically, patients
were inoculated in the forearm with the material, and if no local
allergic response was seen at 30 days, the material was assumed
safe. Some practitioners advocated two successive monthly neg-
ative allergy tests. The need for testing proved to be a great
drawback, because cosmetic consumers tend to be spontaneous
and desire treatment at their convenience and on demand.
There has been a foreign invasion of injectable fillers since
December 2003. At the end of 2003, Restylane (Q-Med Inc.,
Uppsala, Sweden), a hyaluronic acid (HA) filler that has been
used in many countries for over a decade, received U.S. Food
and Drug Administration (FDA) approval in the United States.
In June 2005, the FDA approved a new (to this country) HA-
based filler line, Juvederm. Even though such fillers as Restylane,
Juvederm (Allergan Inc., Irvine, CA.) and Artefill (Sunveva
Medical Inc., San Diego, CA.) were used overseas for decades,
it took many years for them to become approved and popular
in this country. On March 23, 2006, Inamed Corporation,
maker of CosmoDerm and CosmoPlast, was acquired by Aller-
gan and is now a wholly owned subsidiary of the Botox giant.
Consistent with the rapid changes in filler technology and
usage, Allergan will discontinue the production of its collagen
fillers in 2010.
The marketing release of Restylane brought an onslaught of
media attention that boosted interest among aging baby
boomers. It changed the paradigm in this country for injectable
Table 14-1  The History of Fillers*
Year
Developer
Description
1893
Neuberg
First to use autologous fat for tissue
augmentation
1899
Gersvny
First to use bioinjectable paraffin for cosmetic
deformities
1910
Lexor
First to use large block grafts to treat malar
depression
1911
Burnings
First to describe transfer of free fat employing
syringe technique
1953
Baronders
Use of liquid silicone in medicine
1959
Peer
Reported 50% survival of syringe-aspirated
transplanted fat for 1 year
1976
Fischer
Cellulosuctiontome extraction of fat
1978
Illouz
Liposuction as fat source
1981
FDA approval of Zyderm 1
1986
Fornier
Microliposuction
2003
FDA approval of Restylane, the first nonanimal
hyaluronic acid filler available in the United
States
2003
FDA approval of CosmoPlast and CosmoDerm
2004
FDA approval of Sculptra for facial lipoatrophy
2006
FDA approval of Juvederm
2006
FDA approval of Artefill
2006
FDA Approval of Radiesse
2007
FDA Approval of Perlane
2008
FDA Approval of Evolence
* A brief history of fillers. More activity has progressed at the lower end of the chart over a 7-year
period than in the entire previous century.

Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
641
introduction. These fillers have made a slight resurgence by
incorporating local anesthesia in the mix. Mentor Corp. (Santa
Barbara, CA) received FDA approval for Pevelle Silk in 2008.
I personally don’t feel that these fillers will occupy a dominant
spot in contemporary filler usage. The major filler companies
are in the process of incorporating local anesthesia into their
fillers. Juvederm XC, released in February 2010 by Allergan,
includes lidocaine mixed in with the Juvederm filler. In May
2009 Medicis released lidocaine containing fillers Restylane
Lidocaine and Perlane Lidocaine. Coapt Systems (Palo Alto,
CA) released Hydrelle, a hyaluronic acid filler that contains
lidocaine. Personally, I see no significant advantage, since all
practitioners should be masters of local anesthesia technique,
which would negate the advantage of filler/local anesthetic
combinations. My theory is that the needle and injection have
already caused pain by the time the local anesthetic is injected,
especially in multiple-injection techniques. In addition, these
filler/local anesthesia products are more expensive.
On February 28, 2003, the FDA’s General and Plastic
Surgery Devices Advisory Panel recommended that Artefill be
approved, with conditions for marketing in the United States.
Artefill is expected to become the first permanent aesthetic
injectable implant to gain FDA approval. It is a combination of
homogeneous precision-filtered microspheres suspended in a
solution of purified collagen gel and 0.3% lidocaine to alleviate
discomfort during injection. Artefill is designed with dual action
to correct facial wrinkles: 20% precision-filtered microspheres
made from polymethylmethacrylate (PMMA) and 80% puri-
fied bovine collagen. All microspheres have a defined size of 30
to 50 microns in diameter and have a smooth, round surface.
Aesthetic results are visible immediately after injection. PMMA
is not taken up by scavenger cells (macrophages) and cannot be
degraded by enzymes. Thus, the microspheres will remain intact
beneath the creases, providing a permanent structure to support
the wrinkle and prevent further wrinkling. As with all products
using bovine collagen, a skin sensitivity test must be performed
prior to use. Artes Medical declared bankruptcy in 2009 and
the product was purchased by Seneva Medical and it is back on
the market at the time of this writing. Oral and maxillofacial
surgeons have used hydroxyapatite products for augmentation
for the past 20 years. Radiesse (BioForm, Franksville, Wiscon-
sin) is an injectable filler that consists of hydroxyapatite micro-
spheres in a soluble gel vehicle10 (Figure 14-1). The author uses
Radiesse when requested by patients, primarily in the nasolabial
folds. The flow properties are different from other fillers. The
most noticeable property of Radiesse is that a little product goes
a long way. Because this product is hydroxyapatite based, the
longevity is increased. For this reason, overfill or asymmetry can
be a problem because it persists for a long time. The author does
not recommend this product for the novice injector. Because
Radiesse is opaque, lip injection is visible on radiographs;
patients and their dentists should be made aware of this (Figure
14-2).
Finally, a plethora of new products that have been used in
other countries are knocking at the doors of the FDA. In 2004,
Sculptra (Advantis Pharmaceuticals, Bridgewater, NJ), which
has been used abroad as Newfil, was FDA approved for the
treatment of human immunodeficiency virus (HIV)-associated
fillers for numerous reasons. First, it is a nonanimal product
synthesized from bacteria. Hyaluronic acid is a highly hydro-
philic polysaccharide found in all living cells; it attracts and
binds more than 1000 times its weight in water and is chemi-
cally, physically, and biologically similar in all species.4 There is
no reason for allergy testing, one of the biggest drawbacks of
bovine collagen products. Additionally, continental outbreaks
of swine flu, avian flu, and mad cow disease made fillers derived
from animal sources unattractive. Second, studies showed that
HA fillers last longer than Zyplast. The longevity of Zyplast has
long been a problem for patients and injectors. Although the
product was easy to use and produced acceptable results, it
lasted only several months in most patients, whereas some
studies show that HA fillers can last much longer.5,6 One of the
reasons for the extended longevity with the hyalurons (HA
fillers) is a process called isovolumic degradation. Normally, col-
lagen fillers are simply phagocytized and degraded, which causes
decrease in volume, but in this process, water is drawn into the
hydrophilic molecule as the filler degrades. The filler volume is
retained longer as more water is continually drawn into the
molecule.7
Multiple studies have shown HA to be a safe and effective
facial filler.8,9 The Medicis Pharmaceuticals (Scottsdale, AZ) and
Allergan HA products are available in various particle sizes.
These HA fillers come in larger particle sizes for less viscosity
and more robust consistencies.
In 2003, Inamed Aesthetics (Santa Barbara, CA) introduced
CosmoPlast and CosmoDerm, which are human collagen deriv-
atives produced from tissue-cultured human infant foreskin.
These dermal fillers are sterile devices composed of highly puri-
fied human-based collagen dispersed in phosphate-buffered
physiologic saline containing 0.3% lidocaine. CosmoDerm is a
non-cross-linked formulation used in the treatment of superfi-
cial lines, whereas CosmoPlast is cross-linked and is primarily
used in the treatment of more pronounced wrinkles. Cosmo-
Derm is a purified human-based collagen, 35 mg/mL, dispersed
in saline and indicated for treatment of fine lines, wrinkles, and
shallows scars. CosmoPlast is a purified human-based collagen,
35 mg/mL, cross-linked with glutaraldehyde dispersed in saline
and indicated for treatment of deep lines, furrows, and scars.
Again, because these products are of nonanimal origin, allergy
testing is not necessary. These products are very easy to inject
because they have excellent flow properties, and I have found
them to possess similar longevity as the bovine collagen prede-
cessors. It is rumored, however, that the company may cease
production of this filler line.
Hylaform (Inamed) gained FDA approval in 2004 and com-
peted with Restylane in the new filler arena. Hylaform is a
sterile, nonpyrogenic, viscoelastic, clear, colorless gel implant
composed of cross-linked molecules of hyaluronan. Hyaluro-
nan is a naturally occurring polysaccharide of the extracellular
matrix in human tissues, including skin. Differences lie in the
fact that this HA product is derived from animals (rooster
combs) and contains less HA per milliliter than Restylane.
Public awareness of avian flu has also caused some patients to
be concerned. Hylaform Plus and Captique were also intro-
duced by Inamed in 2004. These fillers took a relative back seat
to Restylane and Juvederm, which have led the pack since their

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Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
FIGURE 14-2.  Radiesse is radiopaque and sometimes visible on radio-
graphs. The patient should be aware of this situation.
FIGURE 14-3.  Sculptra (poly-l-lactic acid) must be reconstituted 24 hours
before injection and is intended as a subdermal filler.
is different from other fillers in that the response is not immedi-
ate, but rather the poly-l-lactic acid particles serve to initiate an
inflammatory reaction and induce the production of collagen
in the area. A typical treatment course for severe facial fat loss
involves three to six injection sessions, with the sessions sepa-
rated by two or more weeks. Full effects of the treatment course
are evident within weeks to months. The patient should be
reevaluated no sooner than 2 weeks after each injection session
to determine if additional correction is needed. Patients should
be advised that supplemental injection sessions may be required
to maintain an optimal treatment effect.
Injectable silicone is a filler of historic significance that has
been both praised and scorned over the past 50 years and will
be discussed separately in this chapter. I use silicone frequently
and feel that it is one of the most overlooked fillers by seasoned
injectors.
Autologous fat is another common filler technique and will
also be discussed later in this chapter.11,12
Evolence is the newest non-HA filler to hit the market and
was FDA approved in 2008 for filling nasolabial folds. Evolence
has been most popular in Israel and has been used with success
for over a decade, since it is a medical treatment considered
Kosher. This filler consists of porcine collagen with proprietary
cross-linking. The manufacturing process removes many of the
immunogenic substances, and therefore no allergy testing is
required, which is different from previous collagen fillers.
Porcine collagen is very close to human tissue and is used in
heart valves and skin grafts. Since this filler is a collagen deriva-
tive, it has hemostatic properties that are said to reduce bruising.
In addition, the substance is not as hydrophilic as HA fillers and
produces less swelling. At the time of this writing, Johnson and
Johnson has stopped the production and marketing of Evolence
in the United States, but like other fillers that have been dis-
continued, I anticipate another company reintroducing Evo-
lence in the near future. Older surgeons have seen a paradigm
shift from having a single filler product to having many choices,
and this will increase yearly as filler science continues. In my
early days of practice, I dictated the filler choice, but today’s
cosmetic consumers are much more informed and frequently
facial lipoatrophy. HIV patients are living longer and healthier
due to new antiretroviral drugs, but a side effect of these medica-
tions is lipoatrophy of the temporal and facial regions. This
stigmata makes HIV-positive patients stand out and has many
negative social implications. Although this condition is ame-
nable to treatment with multiple fillers, Sculptra has become a
popular option. Sculptra is an injectable implant that contains
microparticles of poly-l-lactic acid, a biocompatible, biodegrad-
able, synthetic polymer from the alpha hydroxy acid family.
Sculptra is reconstituted prior to use by the addition of sterile
water for injection to form a sterile nonpyrogenic suspension
(Figure 14-3). Since a large part of my practice consists of facial
implants, I have not used this filler much; however, many col-
leagues sing its praises, especially when used in the midface and
temporal regions for volume restoration.
Sculptra is intended for restoration and/or correction of the
signs of facial fat loss, but many practitioners use Sculptra off
label for filling lines and wrinkles. The mechanism of Sculptra
FIGURE 14-1.  Radiesse is a hydroxyapatite-based (calcium hydroxylapatite)
filler with the consistency of toothpaste. It is intended for deep dermal or
subdermal injection and is a popular filler for nasolabial fold and midface
augmentation.

Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
643
Most fillers are specifically designed to be placed at a certain
level (Figure 14-6). The exact level of filler placement is a debat-
able subject. Many fillers say their intended target is the
“dermis,” and some injectors describe injecting in the mid or
deep dermis. Obviously this is a histologic determination, and
in reality, the filler needs to be placed where its most optimum
action can be exerted, including the dermis and subcutaneous
planes. There is no doubt that this varies from patient to patient
and is affected by skin thickness, region to be injected, amount
of aging, and the specific filler composition. There are some
general rules that make sense and can serve as guidelines to
tissue placement. The less viscous fillers with smaller particle
sizes are intended for more superficial dermal placement. The
medium-particle fillers are meant for the mid-dermis, and the
more robust or particulate fillers are intended for deep dermal
or subcutaneous placement. Again, an experienced injector can
push these boundaries. Placing viscous or particulate filler too
superficially may produce contour irregularities or be visible
through the tissue. Conversely, placing a small-particle filler in
the deep tissue planes can result in premature resorption. A
common mistake of the novice injector is to place HA gel fillers
too deeply in the nasolabial fold region. This produces inade-
quate augmentation and dissolves faster. There is a “sweet spot”
on the skin where the placement of filler produces controlled
augmentation, and that differs from patient to patient. Experi-
enced injectors know where to put the filler for maximum
result, and this is a learned skill guided more by feel and visual
result than by science. In reality, histologic examination shows
that the injected filler occupies multiple planes, including
dermal and subcutaneous regions. Placing fillers such as sili-
cone, Radiesse, fat, and Sculptra in the superficial dermis can
produce contour irregularities. Placing fillers such as Restylane
or Juvederm Ultra in the subcutaneous tissues is a less judicious
choice than their more robust larger-particle counterparts.
Although confusing, the tenet of intradermal placement is a
good starting place for the novice injector. Injecting in the
dermis is an appreciated tactile situation with contributions
from the pressure of the needle entry and advancement and the
syringe pressure. Again, experienced injectors can sense the
correct plane. A pearl for novice injectors as to when the needle
request the type or brand of filler they prefer. The contemporary
filler injector is a “bartender” of sorts and must have expertise
in all commonly available injectable fillers (Figure 14-4). With
the older, faster-absorbing fillers, overcorrection was a necessity,
but with the newer fillers, the what-you-see-is-what-you-get
technique is employed.
Tissue Deposition of Injectable Fillers
It is far more important how the filler is used than which filler
is used. A competent injector can achieve aesthetic results from
any filler if he or she knows how to use it and where to put it.
Conversely, an inexperienced injector can use a premium filler
and get poor results. The key to success with all fillers is correct
placement in the skin, and various anatomic sites have specific
injection techniques. Figure 14-5 shows common areas of filler
injection.
FIGURE 14-4.  The contemporary cosmetic surgeon must be a “filler bar-
tender” in that many types of fillers are available and the choice is often
patient driven, requiring a broad inventory of product.
FIGURE 14-5.  Common areas of filler injection in the maxillofacial area.
Intradermal
Epidermis
DERMIS
Subcutaneous
FIGURE 14-6.  Most common fillers are placed intradermally. The approxi-
mate intended target. (Courtesy Surgiform Technology Ltd., Columbia SC.)

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Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
nasolabial folds are Juvederm, Restylane, and Radiesse in that
order. For lips, HA fillers (Juvederm and Restylane) and silicone
are most commonly used in my practice.
Due to the marketing hype, some patients confuse fillers
with Botox. In addition, some patients desire massive rhytid
injection, but because they have such a large amount of wrin-
kling, this would not be practical. These patients are informed
that they would be better treated with lifting or resurfacing
procedures. In theory, fillers can be injected anywhere on the
face; however, blindness has been reported with the periorbital
injection of Zyplast and fat due to intravascular injection.13-15
This rare but devastating complication calls attention to the care
that must be exercised in this area. The surgeon should always
inject very superficially, use the smallest-gauge needle possible,
and never use extreme plunger pressure on the syringe. Although
the injection of fillers is simple, many problems can result in
terms of patient expectations and satisfaction. The main consid-
eration is to accurately explain what can be realistically expected
as a treatment result. Showing patients a series of before-and-
after images for specific anatomic areas is one way to provide
a reasonable expectation. In addition, the injection of fillers
should not be presented as a one-time procedure but as a sculpt-
ing treatment sequence to approach a result. Especially for HA
fillers—which because of their hydrophilic properties cause
immediate swelling in the lips—judging the endpoint and sym-
metry can be difficult (Figure 14-7).
Having the patient return in 1 to 2 weeks gives both surgeon
and patient an opportunity to critique the result. Any areas
of underfill or asymmetry can be corrected and postinjection
images can be taken for marketing. The novice injector should
begin with “appetizer-sized” portions of filler; there is nothing
wrong with the treatment requiring multiple visits. Patients
must be educated on the advantages of sculpting over multiple
visits as opposed to the “wham-bam” mentality of a single treat-
ment session. This is especially true with fillers that cannot be
reversed.
Informed Consent Process
The communication that occurs before filler injection can be
paramount to a success or failure in the eyes of the patient. It
is the time to detail many other critical issues, including expected
longevity, what the filler will or won’t do, who will be respon-
sible for the cost of revision filler, and how much filler needs to
is in the dermis is observing the needle bevel upon skin entry.
When the bevel of the average injection needle enters the skin
and cannot be seen, this is an approximate indication that the
tip is in the dermal plane. All injectors must be aware of the
intended tissue plane target for various fillers. Experienced
injectors will frequently layer fillers in different tissue planes to
achieve results and sometimes use different fillers for the same
injection.
Injectable Fillers: Treatment
Considerations
“Doctor, how long will my filler last?” This is a question asked
by many patients and is not an easy one to answer. For sure, the
newer fillers outlast Zyplast and previous collagen fillers.
Although companies quote slightly optimistic lengths of time,
it is all variable. It depends upon the type of filler, the patient’s
metabolism, the area of the face the filler is placed, and other
variables. As a general rule, fillers placed in areas of extreme
motion such as the lips will not last as long as fillers placed in
a more immobile area such as the zygoma. Silicone will last
many years, and Radiesse or Sculptra can last over a year. This
author makes no guarantees to his patients but merely explains
that the new fillers last longer than the previous ones and hope-
fully will maintain result from 6 to 12 months. This estimate
has served accurately when using HA fillers and Evolence.
Although the industry is pushing permanent fillers, it must be
remembered that permanent fillers can cause permanent com-
plications! In the case where the filler is not to the patient’s or
surgeon’s liking, resorption is a good thing. One huge advantage
of using the HA fillers is that they can be reversed with hyal-
uronidase; this serves as an “insurance policy” for nervous
patients or surgeons. This technique will be discussed later in
the chapter.
Filler injection has grown to be a major portion of my prac-
tice, and I personally inject all filler and neurotoxin patients. I
believe my nurse would be a competent injector, but I enjoy
this treatment and find it an excellent one-on-one doctor/
patient bonding time. I have converted many filler patients to
eyelid and facelift patients.
Adhering to the “bartender” analogy, I stock all contempo-
rary fillers. My choice is guided by patient requests, area to be
treated, and personal experience. My most popular choices for
A
B
C
FIGURE 14-7.  Hyaluronic acid fillers cause immediate swelling that can make judging the endpoint difficult for the novice injector.
Patient preinjection (A), immediately after injection (B), and 14 days after injection (C). Follow-up appointments to judge results
are beneficial.

Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
645
be used. Many “parafiller” problems can be easily resolved by
showing the patient the consent if postinjection problems arise.
Prefiller photography can also be invaluable for situations
where the surgeon is blamed for an existing preinjection
problem. These photos not only serve to assist in adverse situa-
tions, they serve as a teaching and learning tool for the surgeon
and are invaluable for marketing.
The question of how much filler to use frequently arises. The
novice injector or the novice patient may be unaware of what
to expect in terms of how much area can be effectively treated
with a single syringe. Due to the high cost of a syringe of filler,
many new filler patients desire to test the waters by purchasing
a single syringe. For the nasolabial folds in adult patients, I
almost never use only a single syringe. The average adult could
tolerate three to four syringes and would have better results
when finance is not an issue. The problem is that a single syringe
is usually insufficient to augment bilateral nasolabial folds in the
older patient. Attempting this to save money will usually
produce an unhappy patient, because the result is minor. This
can reflect on the expertise and reputation of the surgeon. When
adults in the late 4th decade and beyond present for nasolabial
fold treatment and request a single syringe, I explain the pitfall
to them and ask them to save their funds until they can afford
the proper amount, which is usually at least two syringes.
When treating the lips, many patients are very nervous about
overcorrection. In these patients, a single syringe is usually suf-
ficient for augmentation of both lips. Patients who need volume
outline and lipstick-line treatment will require more than a
single syringe. It is important to advise patients to not expect
their nasolabial folds to be gone; they will be lessened. I explain
that the nasolabial fold is a valley, and the filler will make it
shallower, not reverse it. I also explain that although the naso-
labial fold (or other wrinkles) may look much better in repose,
they will still show upon smiling and animation.
To give the patient an idea of anticipated result, I use the
following method to demonstrate an approximate goal of naso-
labial and lip injections. For the nasolabial folds, I place my
index finger lateral to the patient’s nasolabial fold and gently
A
B
FIGURE 14-8.  By depressing the lateral nasolabial fold, the central region is elevated and can give the patient a preview of an
anticipated result.
push in on the skin. This elevates the nasolabial fold, simulating
an augmentation (Figure 14-8). I let them know that the fold
will improve but not disappear.
For the lips, I take both gloved index fingers and roll the
upper lip up and the lower lip down. This allows increased
vermilion show, similar to injecting filler, to increase pout and
volume (Figure 14-9).
Injection Techniques
Having taught hundreds of injectors over the years, I open my
lectures in jest by saying that if you can decorate a cake or caulk
a bathtub, you can become proficient in filler techniques (Figure
14-10). There is actually some truth in this, since there is a
distinct similarity of injection pressure and continual movement
with the cake and caulk examples. Push the plunger too hard
or fail to maintain a continuous motion, and you will get blobs
instead of controlled lines. It is this combination of tactile pres-
sure sensation and motion the novice injector needs to develop.
Diagnostic Decisions and
Patient Expectations
Although it sounds painfully simple, the surgeon has to (1) ask
the patient what changes they desire, (2) make an accurate
diagnosis of the problems that exist, and (3) decide how to
treat them (Figure 14-11). Patient input is extremely valuable.
There have been times when I was about to augment the
upper nasolabial fold, and the patient was not bothered by this
region but expected lower-fold augmentation. The price of the
treatment and the expected outcome warrant careful prefiller
conversation.
Some patients may want only a single lip (usually the upper)
treated, whereas most patients desire both. Specifics are impor-
tant. Do they want more defined lips? Do they want bigger lips?
Do they want to show more vermilion? Do they want their
“lipstick lines” improved? Many patients rely on the surgeon to
decide. I begin conservatively with patients who have never had
fillers and tell them before injecting them that when we are

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Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
A
B
FIGURE 14-9.  By rolling the upper lip border up and the lower lip border down, the patient can be shown an approximate goal
for volume augmentation.
FIGURE 14-10.  The injection of filler is comparable to “calking a bathtub” or
“decorating a cake”. The application of pressure while advancing or with-
drawing the injectable produces smooth and continuous filling.
FIGURE 14-11.  Accurate injectors will ask the patient exactly what they want
to correct and consider these expectations in the diagnosis and
treatment.
done, their lips are going to look overdone due to the local
anesthesia, the filler, and edema and will settle in usually by the
following day. I further explain that very infrequently a patient
may have unusual swelling that could last for days. Finally, I
explain that bruising is very hard to predict; most lip filler
patients do not bruise, but some will bruise significantly. I make
sure they do not have important social or work plans in the first
several days. It is not unusual for patients to procrastinate
getting filler before some event like a wedding or reunion, and
this is a slippery slope in terms of them possibly looking worse
(edema and ecchymosis) instead of better. Last minute filler
injections before and important function should be discouraged
and rescheduled. Sugar coating a recovery and causing the
patient distress, embarrassment, or lost work is not a practice
builder.
Treating young patients without significant photodamage is
usually straightforward. They may simply need a touch of
volume to plump the lips or some basic vermilion outline for
definition. Treating the senescent lip, on the other hand, can be
very challenging. The youthful lip is shorter, curvaceous, and
has volume (Figure 14-12, A). The aging lip lengthens for
numerous reasons, including volume loss from skin, muscle,
and fat changes (see Figure 14-12, B).
Marking the Patient
I am a big proponent of marking all filler patients with a fine-
tipped surgical marker. This includes lips, nasolabial folds, and
wrinkles. Degreasing the skin with alcohol prior to marking
helps the ink adhere. These ink lines must be made prior to local
anesthetic injection so they are accurate and not distorted.

Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
647
Anesthetic Considerations
Pain control is of utmost importance. Patient comfort and
easing apprehension should be kept in mind throughout the
entire procedure, similar to the painless dentistry model. I see
patients who were treated elsewhere, had a painful injection
experience, and switched to my practice because of their friends’
comments about how the procedure did not hurt. Never under-
estimate the power of marketing from painless procedures.
Some fillers contain inherent local anesthesia, but I strongly
recommend using topical and local anesthetics when treating
ultrasensitive areas like the lips and skin around the mouth.
Local anesthetic technique for pain control is covered in Chapter
4. I truly believe that many injectors are simply lazy and do not
invest the proper time and effort to make patients numb. Giving
a patient a ball squeeze is not competent anesthesia. Undoubt-
edly, anesthesia care takes time and lengthens filler procedures,
but this extra time spent will come back to the surgeon many
times over in happy, painless patients and referrals. I like to
supplement traditional anesthesia by having compassionate staff
hold the patient’s hand (“handesthesia”) and conduct a relaxed,
comforting conversation with the patient during the more
painful portions of the injection procedure (“talkesthesia”).
Pharmacologic anesthesia should begin with an application
of topical anesthesia on the skin if wrinkles or folds are to be
treated. If the lips are to be treated, the inside and outside are
covered with a thin coat of topical anesthetic, with care to
include the upper and lower sulcus (Figure 14-13). I prefer 20%
benzocaine, 6% lidocaine, and 4% tetracaine in a combination
cream formulation. This is left in place for at least 5 minutes.
The patient is then allowed to rinse their mouth; the anesthetic
stimulates saliva and also will cause numbness in the pharynx,
which is disconcerting for some patients (Figure 14-14).
A
B
FIGURE 14-13.  The lip vermilion, intraoral mucosa, and sulcus are coated
with a thin layer of topical anesthetic.
A
B
FIGURE 14-12.  The youthful lip (A) is curvaceous and volumized. The senescent lip (B) becomes elongated and loses volume
and form.

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Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
FIGURE 14-14.  Patients should rinse their mouths out after 5 minutes,
because saliva is stimulated and the pharynx can become numb, which
many patients don’t like.
lips,” and in that folder I keep pictures of beautiful lips on
various age groups. Some of these are actual patients, some are
taken from magazines. I studied these pictures in my learning
phase and now have them etched in my brain. A mental tem-
plate of what you are about to create and what proportions are
pleasing is vital to the end result.
A successful injector is a student of lip form and function
and needs to be cognizant of the differences between youthful
and senescent lips. In youth, the upper lip constitutes about a
third of the total lip volume, and the lower lip constitutes about
two-thirds of the mass. This varies among patients and ethnicity
(Figure 14-18). Another way of measuring the average ratio is
1 : 1.6 for the upper and lower lip, respectively. The youthful
perioral region is defined by numerous anatomic components
that undergo changes with aging. The astute injector is aware
of normal lip volume, outline, philtrum, and philtral columns
(Figure 14-19). Like any other body part, some patients exhibit
outstandingly aesthetic lips. This patients may exhibit three
distinct prominences or tubercles in the upper lip and two in
the lower lip. On the upper lip, these natural “pillows” lie in the
midline, one centrally and one on each lateral region. On the
lower lip, the two prominent tubercles lie on each side of the
midline. Some injectors strive to duplicate these prominent
regions. My experience is that this looks good on some patients,
but most patients feel that the discontinuous tubercles look less
aesthetic than simply having full, contiguous lips.
Every practitioner has his or her specific lip-enhancement
techniques. The two most popular are linear threading and serial
puncture (Figure 14-20). Linear threading involves inserting the
needle and injecting the filler in a straight line while continu-
ously moving in either a forward or backward direction. This
process would be analogous to placing a line of toothpaste on
one’s toothbrush, laying down a seam of calking, or decorating
a cake. Although I personally inject while withdrawing, other
injectors advocate injecting antegrade to push structures out of
the way. The other injection method is known as the serial
puncture technique. This involves placing small boluses of filler
with multiple punctures along the lip or wrinkle. In reality,
many instances call for a combination of both techniques.
Lip Outline
Each patient requires different filler techniques based upon their
specific needs. Some patients (young and old) lack the specific
outline of a “Cupid’s bow” or “white roll.” The Cupid’s bow of
Although many surgeons employ local anesthetic blocks,16 I
no longer use them, because they are more difficult and less
dependable than infiltration techniques.17 Blocks are more tech-
nique sensitive, can be difficult in some patients, and will affect
distant anatomy. Most patients do not like this. Using an infil-
tration I refer to as the “miniblock” technique, a series of injec-
tions is performed across the upper and/or lower sulcus. A 1-mL
syringe with a 32-gauge needle is used with 2% lidocaine and
1 : 100,000 epinephrine (which can be electively omitted). Lido-
caine in 0.2-mL aliquots is injected just above the upper sulcus
(Figure 14-15) and just below the lower sulcus (Figure 14-16).
This is generally performed in four to five areas from the canine
tooth on one side to the canine tooth on the other side. The
patient is then allowed 5 minutes for the anesthetic to take
action. The local anesthetic will affect lip animation, which may
become asymmetric, and this is another important reason for
marking the patient prior to local anesthesia so landmarks are
not lost. In addition, some of the wrinkles that existed with
animation may not be visible if the lip is not moving normally
(Figure 14-17).
Lip-Enhancement Techniques
Which areas to treat will have been decided before the patient
is actually injected. I have a folder on my computer called “great
A
B
C
FIGURE 14-15.  The upper miniblock technique is a series of four or five infiltrations across the mucosal surfaces of the upper
and/or lower lip. About 0.2 mL of 2% lidocaine with epinephrine are injected at each region between the cuspid teeth.

Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
649
A
B
C
D
E
FIGURE 14-19.  Important components to understand and duplicate when
necessary. A and E, Cupid’s bow and white roll. B, Philtrum, C, Philtral
column. D, Lip parenchyma or “volume.” The border of the upper lip is M
shaped, and the lower is curvilinear.
Linear Threading
Serial Puncture
FIGURE 14-20.  Linear threading involves laying down a controlled line of
filler with continuous motion and syringe pressure. Serial puncture involves
injecting small boluses or pillows of filler in a given area.
A
B
C
FIGURE 14-16.  Miniblock technique for the lower lip.
FIGURE 14-17.  When using infiltrative local anesthetic techniques, it is
important to mark injection landmarks before local injection. Anesthesia
can temporarily affect motor movement of the lip, and normal landmarks
such as wrinkles can be changed.
1/3
2/3
FIGURE 14-18.  The upper lip contributes less volume than the lower lip in
the average patient. The difference is frequently described as one-third for
the upper and two-thirds for the lower, or a ratio of 1 : 1.6.

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Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
A
B
C
FIGURE 14-21.  Each patient has different indications for lip enhancement and requires different treatment scenarios. A, This
patient needs only volume plumping, especially in the upper lip. B, Another patient is in need of both volume plumping and
vermilion border outline. C, A third patient needs volume, outline, and vertical rhytid filling.
the upper lip is a lazy-M shape, and the corresponding border
of the lower lip is curvilinear. In patients with well-defined lip
borders, a pleasing light reflex is visible and contributes to
maximum aesthetics. If a patient has adequate lip volume, they
may only need border outline, but some patients need both
volume and outline as well as vertical rhytid injection. Each
patient is different (Figure 14-21).
It is important to inject patients in a more upright position;
gravity will distort a supine patient’s normal anatomy (Figure
14-22).
When injecting the lip borders, needle placement is critical.
A potential space exists between the mucosa and orbicularis oris
muscle, and this space is the target of border outline (Figure
14-23). The guide for novice injectors is both visual and tactile.
When the needle is in the correct plane, the filler will visually
flow both antegrade and retrograde. This can be seen and also
palpated by the noninjecting hand. By pinching the border
between the noninjecting thumb and index finger, the injector
can feel the free-flowing filler as well as corral the filler to stay
within the border (Figure 14-24).
A
B
FIGURE 14-22.  Patients are more accurately treated sitting upright (A). Injecting in the supine position (B) can be inaccurate
because of gravitational influences.
FIGURE 14-23.  Using the noninjecting hand to pinch the lip border while
injecting serves to provide a “feel” for the filler flowing correctly and also
serves to corral the filler into the proper region.

Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
651
If the needle is in the correct plane (the described potential
space), the filler will flow freely with minor syringe pressure.
This is confirmed by observing the border being properly
created. If the needle is too deep, no distinct outline is seen. If
the needle is too superficial, the filler will not flow but instead
“ball up,” and the syringe pressure will increase. In this case,
the needle must be redirected into the proper potential space
(Figure 14-25).
Creating the Vermilion Outline
When augmenting the vermilion border for outline or white-
roll enhancement, I begin with the central V of the Cupid’s
bow. If the patient does not have a well-defined Cupid’s bow,
I draw it on during preinjection marking as a guide for
filling. Care is used to form crisp, angular contours in the
downward legs of the lazy M in the area of the central lip (Figure
14-26, A).
Deep
Outline
FIGURE 14-24.  Cadaveric dissection illustrating the plane of the potential
space in the lower lip, beneath the mucosa and above the orbicularis oris
muscle, marked “outline.”
A
B
FIGURE 14-25.  Injecting in the potential space between the mucosa and orbicularis oris muscle is the proper plane for vermilion
outline. A too superficial injection will be realized by the filler balling up and the syringe pressure increasing.
The next step is to continue the vermilion outline augmen-
tation laterally (see Figure 14-26, B). In the average patient,
the white roll only needs to be augmented in the central one-
to two-thirds of the upper lip that corresponds with the
“pucker area.” I rarely carry this out to the lateral commissure.
The needle is inserted all the way to the hub, and the filler is
injected with even syringe pressure upon withdrawal. Most
filler needles are 12 inch long, and the border is augmented
at 12-inch intervals, taking care to not leave a gap between
needle insertion points. The white roll is similarly created in
the lower lip, which is more curvilinear than in the upper lip
(see Figure 14-26, C).
A single syringe is usually more than adequate to outline the
vermilion on both lips. The lower-lip central vermilion outline
is a small but powerful augmentation. A little bit of filler goes
a long way here and creates a very pleasing light reflex, especially
in women who wear lip gloss.
Outlining the vermilion border in both lips as described is
sometimes all a patient needs for lip enhancement, especially
those who don’t desire larger lips.
Increasing Deep Lip Volume
Although vermilion border augmentation is a powerful means
of enhancing the lip, many patients have adequate outline and
a defined white roll or Cupid’s bow and do not require outline.
The most common presentation in my practice is the patient
who presents with the desire for more lip volume. These patients
request plumper, fuller, pouty, and more voluptuous lips. Many
are younger and already have adequate vermilion border. These
patients will benefit from deeper fill that will increase the general
lip volume and pout. By augmenting the deeper portion of the
lip, the actual lip will roll out and produce increased pout. The
target for deep lip augmentation is basically the center of the
lip. This is deep to the muscle and contains connective tissue,
minor salivary glands, and fat (see Figure 14-24, “deep”).
For deep augmentation, the needle is inserted at the wet/dry
line, deep into the central lip. The needle is inserted to the hub
and slowly withdrawn while continuous, steady injection is

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Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
A
B
C
FIGURE 14-26.  A, Central portion of the Cupid’s bow is filled first to make a distinct V in the central upper lip. B, Vermilion
border augmentation is carried laterally but generally not all the way to the lateral commissure. C, Vermilion border or white roll
is augmented in a similar manner, targeting the potential space described previously. As with the upper lip, border augmenta-
tion is limited to the central third or two-thirds and does not continue to the lateral commissure of the lip.
performed. In this area, the goal is to produce a “tube” of filler
for deep volume (Figure 14-27, A). As noted earlier, some injec-
tors attempt to reproduce the prominent lip tubercles seen in
some aesthetic lips, and instead of a continuous tube of filler,
the tubercles are reconstructed, three in the upper lip and two
in the lower lip (see Figure 14-27, B).
The center of the lip is generally a safe plane, because the
labial artery lies at the posterior third of the lip (Figure 14-28).
Generally a single syringe will treat the average patient requiring
deeper volume and is appropriately split between the upper and
lower lip based upon volumetric need.
A lumpy result with visible and palpable nodules of filler is
frequently the result of not massaging the filler after injection.
I strongly believe massaging the injected filler is a critical (and
oftentimes overlooked) step in obtaining natural and aesthetic
results. Most fillers have the consistency of soft gels or paste and
when injected will not always be homogenous. Massaging the
filler more evenly distributes and forms it and produces a
smoother, more homogenous result (Figure 14-29). In addition,
the injector can actually level out an area of excess by moving
the filler through the tissues. Since there is friction between the
skin and surgical gloves, massage is difficult and jerky without
a lubricant. My assistant keeps a small bolus of petroleum jelly
on the back of her glove during all filler injections, and I dab
this and coat the lip and skin just prior to massage. Again,
controlled massage is a critical part of filler injection.
Some injectors carry vermilion and deep volume injections
all the way to the corner of the mouth, but I generally do not
(Figure 14-30). In my opinion, one of the most common unna­
tural filler results is the “ducky” lip, due in part to an eversion
of the lateral lip reminiscent of the familiar rubber duck
bath toy, which is unfortunately visible on many female
celebrities.
Fat Injection Cannula Technique
Another convenient means of deep lip volume augmentation is
using a micro fat injection cannula instead of the standard 12-
inch needles.18 This cannula (Tulip Biomedical, San Diego, CA)
is a 20-gauge (0.9 mm) blunt cannula with the orifice set distal
to the tip (Figure 14-31). These cannulas are available in 4- and
5-cm lengths and are available in autoclavable or disposable
models. They have a standard Luer-Lok connection as well as a

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653
center than at the lateral border, the syringe pressure is increased
as the midline is approached to deposit more filler, and then
backed off as the cannula approaches the puncture insertion
point. This forms a natural taper from one side across the center
to the other side (Figure 14-34). The same procedure is per-
formed on the lower lip (Figure 14-35).
The final step is to massage the filler as earlier described.
As noted, having a dollop of petroleum jelly on the back of
the assistant’s hand is convenient for lubricating the mucosa
and skin for massage without interrupting the process
(Figure 14-36).
I find the cannula extremely useful for deep injection but
still use the standard needle technique for vermilion outline.
Perioral Filler Techniques
Philtral Columns
Although the lips are frequently the requested region of improve-
ment, there are numerous perioral indications that can make
patients look younger as well as enhance the result of the lip
augmentation. Philtral column enhancement is one of the most
overlooked aspects of lip rejuvenation. It may never occur to
many injectors to address this region, and others may be intimi-
dated. The philtrum is a subcolumellar depression with well-
defined columns on either side. In youth, this complex is defined
and contributes to youthful aesthetics. As we age, the architec-
ture of these structures frequently changes, and the central
upper lip becomes devoid of this pleasing topography. In treat-
ing this area, the injector can enhance existing philtral columns
or create them.
I personally employ two different techniques to augment
the philtral columns. A very simple technique is to conserve
the last bit of filler in the syringe and simply place a small
amount at the vermilion cutaneous junction at the base of the
existing column. This filler is injected in the dermis while the
other hand pinches the skin to allow a triangular deposition.
This technique does not extend superiorly up to the nostril,
but rather becomes a small peaked extension of the angular
tapered friction grip connection (Figure 14-32, A). For threaded
syringes, the cannula is simply attached to the syringe instead
of the needle. For syringes with attached Luer-Lok adapters, the
adapter is removed, and the friction grip connection is used (see
Figure 14-32, B). The cannula has numerous advantages over
needle injection. The tip is blunt and easily moves through the
lip without lacerating tissues and vascular structures and there-
fore produces less bruising and swelling. In addition, this tech-
nique only requires a single puncture. The cannula is passed
through the entirety of the lip, negating the need for multiple
needle sticks. The size of the cannula and orifice allow a larger
deposition of filler with minimal syringe pressure, making the
injection process much faster. Since the cannula is blunt, an
entry point is first made with an 18-gauge needle at the lateral
lip (Figure 14-33), and the cannula is inserted into the puncture
and threaded through the center of the entire lip. The filler is
then injected in a single smooth action while simultaneously
withdrawing the cannula. Since more filler is deposited in the
A
B
FIGURE 14-27.  Deeper parenchymal lip injection is performed to provide volume, pout, and increased vermilion show. Needle enters the lip at the wet/dry
line, and the target is the center of the lip. A, Author’s preferred means of deep lip augmentation. B, Alternate deposition technique to reconstruct tubercles
in both lips.
FIGURE 14-28.  Cadaveric specimen illustrating approximate position of the
labial artery (arrows) in the posterior third of the lower lip.

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Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
14-37, right). It is important to keep the column tapered to
appear natural, and pinching the upper portion of the skin
helps create the taper (Figure 14-38).
Vertical Lip Rhytids
Vertical lip rhytids (lipstick lines) bother women significantly.
This is one of the most commonly requested perioral procedures
and one of the more difficult conditions to remedy. These verti-
cal lines are problematic from the standpoint of aesthetics and
due to the fact that applied lipstick will leech out and follow
the lines onto the skin. These lines are perpendicular to the
Cupid’s bow (Figure 14-37, left). It only takes a small amount
of filler to create this peak and in younger patients gives the
semblance of normal anatomy without treating the entire
column. For older patients or those with no defined philtral
columns, a more complete reconstruction can be performed.
The goal is to replicate the normal conical-shaped philtral
column. This is merely a bigger version of the previously
described technique but more aggressive; it extends to the
nostril just lateral to the columella on both sides (see Figure
A
B
C
E
F
D
FIGURE 14-29.  Massaging the lips to evenly distribute and homogenize the filler immediately after injection is an important step
in achieving a smooth, natural result. On each lip, the central lip is grasped with both hands (A–B), and the filler is massaged
laterally (C–D). The same massage procedure is performed on each lateral lip (E–F). This is performed in both lips regardless
of what area is filled. Petroleum jelly is used to lubricate the lips and skin.
FIGURE 14-30.  Most lip augmentation is confined to the central third of the
lip to accent the “pucker” area when using outline and/or deep fill. There
are, however, patients who benefit from more lateral augmentation, and
this is based on the patient’s anatomy and preferences. Excessive filler in
this region produces a very unnatural result.
FIGURE 14-31.  The 20-gauge micro fat injection cannula attaches to the
standard filler syringe and provides a simple, expedient, and atraumatic
means of deep lip volume augmentation.

Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
655
A
B
FIGURE 14-32.  The micro cannula can attach to Luer-Lok or friction tip connections and replaces the needle when injecting
(A). Syringes that have Luer-Lok adapters over a tapered friction grip connector are adapted by pulling off the Luer-Lok adapter
and connecting the cannula via the friction grip (B).
A
B
FIGURE 14-33.  Since the cannulas have a blunt tip, an entry puncture is made at the lateral lip with an 18-gauge needle.
A
B
C
FIGURE 14-34.  The canula is inserted into the needle puncture and threaded across the entire lip. The filler is then injected as
the cannula is withdrawn, tapering both ends and with more filler in the center.

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Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
A
B
C
FIGURE 14-35.  The same technique is utilized for the lower lip injection.
2
1
A
B
FIGURE 14-36.  Small amount of petroleum jelly on the back of the assistant’s hand (A) is used to facilitate massage for the
mucosa and skin to homogenize the result and smooth any irregularities (B).
FIGURE 14-37.  Two techniques of augmenting the philtral columns. The left
column is treated with a minibolus of filler at the crest of each Cupid’s bow
and is used on younger patients. The right column shows total reconstruc-
tion that is more common in older patients or those without a distinct
column.
FIGURE 14-38.  The normal philtral column is a tapered cone. By pinching
the skin and injecting in the middle of the pinched region, more material
will fill the base than the apex, thus creating the taper. This is further
pinched and massaged to the desired form.

Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
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A
B
FIGURE 14-39.  Injecting individual lipstick lines can be effective if performed conservatively and massaged well so as not to
create ridges. It is preferable to augment lip volume and border in conjunction with individual line filling to achieve the best
results.
A
B
FIGURE 14-40.  Injecting 2 units of Botox at four sites across the lip(s) will decrease resting muscle tension and slightly reduce
muscular activity to slightly improve rhytids. It is important to remain conservative when using neurotoxins in the lip; there is a
fine line between minor improvement and dysfunctional animation from overdosage.
orbicularis oris muscle and are largely a result of this muscle’s
function over the years. Lip rhytids can be vertical, angular, and
radial. It is suggested that men are less affected because they
have more and denser hair follicles in the lips.
There are numerous means of addressing lip lines, and my
best results involve combination therapy with Botox, filler, and
laser resurfacing. Patients must understand that these lines will
not be eradicated, but rather mitigated. Although lines can be
individually injected, this procedure has the liability of creating
a series of “speed bumps” or ridges across the lip. Patients have
to understand that a filler is a type of implant and occupies a
space and therefore can frequently be seen or felt.
My preferred method for treating vertical lip rhytids is to
first volumize the lips with deep fill and outline. Virtually all
patients who have enough aging to have lipstick lines also have
volume and vermilion border loss. It is explained to the patient
that by restoring volume and border to the lip, the skin will
stretch and improve the appearance of perioral lines. After volu-
mization, I also conservatively augment the lines with small
lines of filler and massage it well to prevent visible and palpable
contour irregularities (Figure 14-39). One big problem is when
patients want the lines gone but don’t want larger lips. This
somewhat ties the surgeon’s hands and reduces treatment
options and therefore the result.
My routine treatment is to first administer 8 units of Botox
(four 2-unit sites across both lips) (Figure 14-40). I then add
border and/or outline as previously described and finish the
procedure by injecting the individual lines. To really make a
difference, I recommend full-face CO2 laser and treat the lip
rhytids aggressively. This is my optimum treatment approach,
but it is sometimes compromised by what the patient does or
does not want.
Some younger patients will present with depressions across
the lip instead of fine rhytids. These can be more aggressively

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Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
A
B
FIGURE 14-41.  Some younger patients may have larger depressions across the lip instead of individual rhytids. These depres-
sions respond well to filling with larger (but conservative) volumes of filler to plump them.
FIGURE 14-42.  A much less common pattern of lip wrinkles is horizontal
rhytids. These are similarly treated with Botox and conservative filler.
treated (but still conservatively) to plump the void (Figure
14-41). Less commonly seen are horizontal lip rhytids which
can be treated similarly (Figure 14-42).
Oral Commissure Injection
When addressing the perioral region for filler rejuvenation, the
corners of the mouth are a commonly requested treatment area.
This can be a difficult region to enhance and can be a “black
hole” for filler. Due to the numerous muscles merging at the
modiolus, this is a complex anatomic area. Many patients also
have a dimple in this region that is accentuated upon smiling.
It is important for these patients to realize that although the
commissure may be improved in repose, the dimple and hence
the depression will almost always be visible when smiling or
animating. Most young patients have crisp, tight, upward-turn-
ing oral commissures. As patients age, tooth structure is lost,
which decreases the vertical dimension of the jaw. Tooth attri-
tion also causes overclosure of the jaws, which increases the
perioral soft-tissue drape and in part results in turned-down oral
commissures (Figure 14-43). Also contributing to this aging is
muscle atrophy, loss of fat, and photoaging of the skin. Attempt-
ing to upturn the corners of the mouth has been advocated with
numerous surgical and nonsurgical treatments, none of which
are predictably successful and stable. I first approach this area
by educating the patient on options and the reality of the degree
of improvement. Patients with severe tooth wear or dentures
may need to have their vertical dimension increased by a restor-
ative dentist or have dentures remade to lengthen the intermax-
illary space.
My most successful cases (leading to minor to moderate
improvement) involve a combination of Botox treatment to the
depressor anguli oris muscle with simultaneous filling of the
commissures (Figure 14-44). When injecting the commissure,
it is important to control the flow of the filler. It can have a
tendency to flow laterally and can actually increase the defor-
mity by making a ridge lateral to the commissure which can
produce a “cashew nut” prominence lateral to the fold, worsen-
ing the problem.
Numerous injection techniques are used to treat the oral
commissures. I prefer to layer this area with some deep filler in
the depression and then add superficial filler in the dermis,
which plumps this region (Figure 14-45, A). Some practitioners
prefer to cross-hatch this region as shown in Figure 14-45, B. I
also inject filler in the very lateral upper and lower lip, because
this region contributes to the problem (yellow regions in Figure
14-45, A).
All lip injections—and for that matter, all filler injections—
are immediately treated with ice after augmentation, and the
patient is encouraged to ice the area for several hours (Figure
14-46).
Augmenting the Mentolabial Fold
The mentolabial fold represents the region below the lower lip
and above the chin. In youth this fold has a pleasing S curve
that deepens with aging. In addition, this fold is greatly affected
by the position of the jaw, chin, and teeth. In patients with
microgenia, retrognathia, or lower facial vertical-third height
deficiency, this fold can be very deep, with an overhanging lower

Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
659
A
B
C
FIGURE 14-44.  Botox and fillers can be synergistic in action. By reducing the downward pull of the DAO, the perioral aesthetics
can be improved in combination with lip and wrinkle fillers. A, The depressor anguli oris (DAO) is shown in blue. B, Asking
the patient to turn down the corners of the mouth can assist identification of the DAO. C, Botox, 2.5 to 5 units, is injected on
each side. (A, Adapted from Patton KA, Thibodeau GA: Anatomy and physiology, ed 7, St. Louis, Mosby, 2010.)
A
B
FIGURE 14-45.  The oral commissure region can be improved by injecting deep and superficially at the area of depression (A).
A cross-hatching technique is also used by some injectors in this region (B). Augmenting the lateral region of the lips also aids
in improving the commissures and turned-down smile (yellow regions in A).
A
B
C
FIGURE 14-43.  Common aging changes in a 20-year-old (A), a 40-year-old (B), and a 60-year-old (C).
lip (Figure 14-47). Some patients present with a simple deep-
ened fold from aging, and like any other facial fold or wrinkle,
the region is simply augmented with filler. For patients who
manifest severe mentolabial fold depth as a result of dental or
skeletal problems, this area can be impressively corrected by
layering deep and superficial filler (Figure 14-48). A deep fold
can take two or three syringes to correct or improve. The first
injections are placed in the deep dermis and subcutaneous
regions to buttress the augmentation, and the remaining injec-
tions are more superficial and can significantly improve the
depression, lift the ptotic lip, and give an appearance of increased
lower facial third vertical height.
Filler Augmentation of Nasolabial Folds
In my practice, the nasolabial folds are equally as popular as the
lips for filler injection. Treatment is faster and has fewer nuances
than the lips. The nasolabial folds are a complex anatomic
structure caused in part by the merging of various tissue planes;
they can even be influenced by maxillary skeletal substructure.
The repeated action of smiling results in deepening of the naso-

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Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
FIGURE 14-46.  Ice application before and immediately after filler injection is
important to minimize swelling.
FIGURE 14-47.  A deep mentolabial fold can result from dental or skeletal
influences and produces an unaesthetic cleft that can be accompanied
by a ptotic lip.
FIGURE 14-48.  Augmenting the mentolabial region is done in a biplanar
method using deep and superficial filler injection. The deep filler serves as
a buttress to reinforce and support the more superficially placed filler.
labial fold (NLF) at the point at which the superficial muscu-
loaponeurotic system (SMAS) inserts into the dermis.
Before treating this area, it is important to give the patient
an accurate idea of what to expect and an opportunity to provide
their own input as to how they want the fold changed. In most
adults, the fold extends from the lateral nasal region and can
merge with the geniomandibular folds (marionette lines). Other
patients exhibit anatomy where the NLF merges with the “smile
dimples” lateral to the oral commissures. Some patients desire
augmentation high on the fold to correct the deep paranasal
creases, whereas this region does not bother other patients,
whose desire may lie in augmentation lower on the fold or even
in the perioral region. I explain that the NLF will not “go away”;
our goal is to soften it. I further explain that the NLF is a valley,
and we want to blunt the fold, not eliminate it. Finally, I never
inject an adult with a single syringe. It takes a minimum of two
syringes to make a noticeable correction, and if they cannot
afford it, I ask them to save up and return when they can pur-
chase two syringes. In reality, most adults in their 5th decade
could easily accommodate three or four syringes. Trying to fill
larger areas with minimal filler is sure to lead to barely notice-
able differences and unsatisfied patients.
When treating the NLF, all makeup is wiped off with alcohol,
the folds are marked, and topical anesthesia is applied to the
skin. The anesthetic technique for the NLF is simple. A 1-mL
syringe with a 32-gauge needle (same set up as Botox) is used
with 2% lidocaine/1 : 100,000 epinephrine. We keep a con-
tainer of these filled syringes in each treatment room, since we
use them for many procedures. Again, when using local anes-
thesia for folds or wrinkles, it is important to inject it deep to
prevent distorting the anatomy of the fold or wrinkle, which
can affect the accuracy of the result. I generally inject 0.2 to
0.3 mL of local anesthetic at several points along the fold. The
first injection is in the area of the nasal ala (a painful region to
inject filler), another injection is placed in the midfold, and
frequently a third injection is placed at the inferior portion of
the fold (Figure 14-49). Wait 5 minutes for all these areas to
coalesce and numb the entire fold. Again, it is important to
inject the filler deep so as not to distort the fold.
As stated earlier, patients should not be positioned supine
for filler injections, especially the NLF, because gravity will
significantly affect the anatomy of the fold, making accurate
treatment difficult. I use a combination of the two methods of
linear threading and serial puncture described earlier for treating
the NLF. I begin with a linear threading technique (Figure

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661
deep volume as well as superficial injection, but it is the super-
ficial portion if the injection that really plumps the fold.
I generally begin in the middle of the NLF and place the
needle in the mid-dermis, which is a relatively superficial injec-
tion. When the bevel of the needle is no longer visible, the tip
is generally in the dermal plane. Using the linear threading
technique, I lay down lines of filler in the center of the fold,
14-50, left). When injecting the NLF, I bend the needle to about
a 30-degree angle, which provides a more natural injection
angle. If this is not done, the injector is frequently bending and
stooping (Figure 14-51).
One of the most common mistakes novice injectors make is
injecting the filler too deep. When this happens, the filler will
lateralize or be too deep to have much plumping effect on the
fold. A huge pearl to remember when treating the NLF is that
if you can’t see immediate improvement, your needle is in the
wrong place. The more superficial my injections became, the
better my NLF results (Figure 14-52). This is not to say that
there isn’t a place for deeper injection for patients who need
FIGURE 14-51.  Bending the needle about 30 degrees makes the syringe
more manageable when the patient is in the upright position.
FIGURE 14-52.  A common novice mistake when injecting the nasolabial
fold is placing the needle too deep in the tissue. Although deeper fill is
sometimes required, it is the superficial filler that noticeably plumps the
fold.
FIGURE 14-49.  The nasolabial fold is easily anesthetized with several small,
deep injections of local anesthesia. Although not used in this image, a
1-mL syringe with a 32-gauge needle produces less painful injection.
LT
SP
FIGURE 14-50.  Linear threading (LT) and serial puncture (SP) techniques
are used in combination to treat the nasolabial fold.

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Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
FIGURE 14-53.  Even when the needle is placed in the very center of the
nasolabial fold, it can follow tissue planes and migrate laterally, creating a
ridge and actually making the fold bigger. The injector must continually
monitor the flow of the filler throughout the injection.
FIGURE 14-54.  Placing the cheek and nasolabial fold on stretch with the
noninjecting hand will make the fold taut and can facilitate injection.
NLF, the markings are removed with an alcohol pad, and the
patient is handed a mirror and asked if they can tell the differ-
ence between the treated and nontreated side. They always see
the positive difference at this point; it gives them more confi-
dence in their investment, and they relax for the second injec-
tion (Figure 14-55).
Postinjection instructions are sometimes as important as the
actual procedure. The patient is asked to avoid excessive anima-
tion, because it is possible for the perioral musculature to push
the filler laterally. Immediate postinjection ice packs are also
important to minimize ecchymosis and edema. I routinely have
all filler patients return 2 weeks after treatment for a quick
examination to make sure they are happy and I am happy. Every
A
B
FIGURE 14-55.  Showing the patient the result after injecting the first fold and before injecting the second will enhance their ability
to appreciate the degree of change. Once both sides are filled, they oftentimes cannot appreciate the pre- and postinjection
difference.
carefully observing that the fold is actually filling. If immediate
noticeable improvement is not seen, I reposition the needle
more superficially. Due to the unique anatomic planes of the
NLF, even while injecting in the center of the crease, the filler
can migrate laterally and create a lateral ridge (Figure 14-53).
This can actually make the NLF bigger. If I see the filler migrat-
ing laterally, I redirect the needle more medially before continu-
ing the injection. Remember, what you see is what you get.
Another means of facilitating NLF filler is to put the cheek
on stretch with the noninjection hand. This makes the NLF taut
and straight and makes the injection easier (Figure 14-54).
It is important for the patient to appreciate the effect of the
augmentation. Even with excellent filling, it is more difficult to
appreciate the difference after both folds have been filled. The
patient can better see the difference if they are shown the result
after the first fold is filled. After injecting the first side of the

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Horizontal Forehead Lines
Although neurotoxin treatment is the frontline treatment for
horizontal forehead rhytids, some patients desire filler in this
region. I do not perform this frequently in my practice, but the
technique is the same as filling other wrinkles, and the injection
target is the mid-dermis (Figure 14-56). Treating the forehead
with neurotoxin followed by filler injection will decrease muscle
movement and therefore make the filler last longer. Figure
14-57 shows a before and immediate postinjection photo.
Periorbital Rhytids
Tear Trough (Nasojugal Groove)
All patients have a nasojugal groove. In the young patient it is
shallow, but with aging changes, it becomes more prominent
and deeper. As this region ages, fat prolapse occurs in the
lower lids, producing a convexity. The malar fat pad descends,
and fat and muscle atrophy over the inferior orbital rim. These
changes, along with dermatochalasis, produce a hollowing in
this region and a soft-tissue void over the inferior orbital rim
(Figure 14-58).
As injectors with at least a decade of experience know, it was
once pretty much unheard of for a patient to present to the
office asking for “tear trough” filling. I believe the popularity of
this procedure has stemmed from the advances in fat transfer
and its related technology, which was a spinoff of tumescent
liposuction. As the popularity of fat transfer grew, so did the
armamentaria, such as microinjection cannulas and preferred
sights of injection. Cosmetic surgeons have always realized the
aging contributions of the nasojugal fold. Although many of my
colleagues are advocates of fat transfer for soft-tissue filling,
many of us have abandoned fat transfer as the science and avail-
ability of new injectable fillers has progressed. The same tech-
niques employed for tear trough filling with fat soon became
popular using common fillers.
Personally, I feel that tear trough filling is one of the less
predictable filling procedures common today. I also feel that the
patient serves as marketing for the surgeon. If asymmetry or
underfill exists, the patient may not realize it, but their friends
may. Conversely, the patient may be unhappy with the result,
and this serves as a time to discuss and/or retreat. Finally, this
is an excellent opportunity to obtain “after” pictures to use for
patient education and marketing. I explain to all filler patients
that filler treatment is a sculpting process and not necessarily a
one-time treatment. When they understand this thought
process, they do not mind complying with follow-up treatment,
reinjection, or in some cases dissolving excess filler.
Alternate Injection Sites
Although the lips and nasolabial folds constitute the majority
of most filler treatments, many other facial areas have become
popular injection sites. For purposes of simplification, these
alternate injection sites will be discussed from the top of the
face to the lower face. In theory, any wrinkle or fold anywhere
on the body can be treated with injectable fillers. The same
principles are utilized when injecting.
A
B
FIGURE 14-57.  Patient desired filler injection of his horizontal forehead wrinkles. He was treated with 25 units of Botox 1 week
before the filler injection.
FIGURE 14-56.  Horizontal forehead rhytids are treated in the same manner
as other wrinkles and folds. Filler is injected into the mid-dermis.

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Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
A
B
FIGURE 14-58  Periorbital region of a 35-year-old and an 80-year-old. The senescent changes in this region involve bone, muscle,
fat, and skin, which collectively produce a deep, defined nasojugal groove.
recent popularity of hyaluronidase to dissolve unwanted filler
has in part been driven by unhappy tear trough patients and
injectors. Treating the nasolabial folds or lips is relatively
straightforward, involves a moderate learning curve, and pro-
duces predicable results. The tear trough region on the other
hand is more variable. This may be in part because patients have
unrealistic expectations or because of the unique anatomy of the
region. It is important for patients to understand that similar
to nasolabial folds, the tear trough will not “go away” but rather
be made shallower (Figure 14-59).
Although some injectors do not use supplemental anesthesia
for tear trough filling, I always perform a transcutaneous infra-
orbital block. This is simply and painlessly performed with a
1-mL syringe of 2% lidocaine with a 32-gauge needle (preceded,
of course, by topical anesthesia). The infraorbital nerve lies in
line with the medial limbus about 5 to 8 mm inferior to the
infraorbital rim (Figure 14-60).
The actual filler injection for the tear trough is at the level
of the periosteum, or more specifically, just above the perios-
teum. Advanced injectors can place filler more superficially, but
A
B
FIGURE 14-59.  By depressing the lower portion of the nasojugal fold with the index finger, the volume will be repositioned and
thus “fill” the tear trough. This maneuver can done to show a prospective patient an anticipated result.
FIGURE 14-60.  To perform painless tear trough filling, topical anesthesia is
first applied, followed by an infraorbital nerve block using a 1-mL syringe
and a 32-gauge needle. The infraorbital nerve lies 5 to 8 mm below the
infraorbital rim on an imaginary line tangential to the medial limbus of the
pupil.

Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
665
medial. It bears repeating that the massage step is extremely
important to homogenize the filler and prevent lumping as well
as a smooth surface (Figure 14-63).
Additional filler can be placed more superficially if the needle
remains below the orbicularis oculi muscle. The thin nature of
the overlying skin is very unforgiving in terms of contour irregu-
larities, and lumps can be very visible. Filler placed too close to
the skin surface can result in a bluish tinge known as the Tyndall
effect.
Lateral Canthal Rhytids
Filling crow’s feet wrinkles is not a frequently requested proce-
dure in my practice, but it is requested from time to time. I
always treat these patients with lateral canthal neurotoxin before
injecting filler. It not only compliments the result, but the lack
of muscle movement will extend the longevity of the filler. Since
these wrinkles can be very fine, I sometimes dilute the filler with
0.2 mL of local anesthesia and inject through a 32-gauge needle
(Figure 14-64). This dilution and small-needle technique can
be used anywhere fine lines and wrinkles exist. Figure 14-65
shows a representation of lateral canthal rhytid filling.
The lateral brow is a region that is often overlooked as a site
for filler treatment. Injecting a modest amount of filler in the
dermis at the lateral third of the brow and under the brow tail
will fill out this region and can even provide slight brow eleva-
tion (Figure 14-66). This technique in conjunction with preci-
sion upper-facial neurotoxin injection can enhance the lateral
brow region.
Injection Rhinoplasty
With the growing popularity of fillers and techniques, virtually
all head and neck anatomy has some indication for augmenta-
tion. Filler techniques can be useful in the nose to mitigate a
dorsal nasal hump or provide a degree of tip elevation. They can
also be used to fill voids or soft-tissue depressions. The most
common nasal indication I encounter (although infrequently
requested) is filling superior or inferior dorsal hump deformi-
ties. The purpose of this technique is to fill the depression above
and below the actual bony prominence to give the illusion of a
smaller hump. I perform this by first injecting the filler deep,
over the bone or cartilage, to provide a base. Then I augment
this with a more superficial augmentation to plump the skin
it should never be placed above the orbicularis oculi muscle, the
reason being that the overlying orbital skin is so thin, the filler
material can show through. Depending upon the filler, this can
result in a whitish or bluish tinge and will be discussed in the
complications section of this chapter. The periorbital and lateral
nasal regions are very vascular, so patients should be warned
about possible swelling and bruising.
Filler injection is performed differently by various injectors.
Some prefer to inject across the rim in the same manner they
would inject any fold or wrinkle in a linear threading manner.
Others perform a serial puncture technique where they inject a
bolus of filler and massage it along the rim from lateral to
medial. My personal technique is a combination of both
methods. I generally begin by placing the needle (bevel up) at
the orbital rim in the medial canthal region and begin injecting
as I withdraw (Figure 14-61). Sometimes I place a single “tube”
of filler in the void, and other times I overlay several “ribbons”
of filler to augment the trough. I work my way from medial to
lateral and if necessary, fill any voids with a serial puncture
technique (Figure 14-62).
After injection (and frequently during injection), I apply
petroleum jelly to the skin and massage the filler from lateral to
A
B
FIGURE 14-61.  When injecting the tear trough, I begin at the level of the orbital rim in the medial nasojugal groove (A) and inject
the filler as I am withdrawing laterally. I frequently repeat this for several “passes” through the same puncture. I then reinsert
the needle more laterally and repeat the same sequence (B).
FIGURE 14-62.  Any voids that are apparent are filled with a serial puncture
technique.

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A
B
C
FIGURE 14-63.  Massage is very important in this region to homogenize the filler and prevent lumping.
A
B
FIGURE 14-64.  Diluting the viscosity of filler with 0.2 mL of local anesthesia can make injection of fine lines easier and provide
augmentive local anesthesia for pain control. A 1-mL syringe of 0.2 mL of 2% lidocaine with 1 : 100,000 epinephrine is attached
to the filler syringe via a female-to-female Luer-Lok adapter (an IV stopcock can also be used in the open direction), and the
liquids are mixed by pushing from syringe to syringe.
FIGURE 14-65.  Lateral canthal rhytids are filled in the same manner as other
winkles.
FIGURE 14-66.  The tail of the brow can be volumized and slightly lifted by
injecting filler at the lateral third of the brow and under the brow tail in the
subcutaneous and dermal planes.
(Figure 14-67). Care must be taken to not overfill these regions,
or the dorsal hump will appear worse.
Malar Augmentation With
Injectable Fillers
There are many means of augmenting the midface, including
silicone implants, fat injection, midface lift, and fillers. Although
I do perform midface injection, I prefer cheek implants; they
provide permanent three-dimensional augmentation. When
secured to the malar bone, they will never migrate and can be
easily removed or changed should the patient desire. Filler, on
the other hand, is not only temporary, but several rounds of
filler injection are more expensive than permanent cheek
implants. I do not like to place fat or permanent fillers in the

Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
667
FIGURE 14-67.  “Injection rhinoplasty” is an augmentation technique, shown
here augmenting the depression superior to the dorsal hump. By reducing
the concavities superior and inferior to the hump, the operator can blend
the area and make the dorsal nasal hump appear smaller.
soft tissues of the cheeks, because this augmented tissue will sag
with aging and can accentuate the aging process.
Aging produces changes in the midface manifested in volume
loss and hollowness. By augmenting the midface region, the
surgeon can restore youthful volume. Although this can be
performed freehand, I have published a technique of using sili-
cone cheek implants as a template to guide filler injection in a
precise manner.19 Silicone implants are available in many shapes
and sizes and are applicable to almost every aging pattern. The
submalar implants can be traced to provide submalar fill, the
malar shell implants can be traced to enhance lateral malar or
“high cheekbone” augmentation, and the combined submalar
shell implant can serve as a template for augmentation of both
these regions (Figure 14-68).
After the appropriate template is selected, it is placed in
position and traced. Asking the patient to smile will further
define the exact placement of the template, since smiling natu-
rally augments the midface by elevating ptotic tissues (Figure
14-69).
At this point, the filler is injected, keeping the actual implant
anatomy in mind to guide the specific deposition of filler in the
appropriate regions. The thickest portions of the implant cor-
respond to the largest areas of filler injection, and the thin
implant borders correspond to the filler feathering (Figure
14-70). The choice of filler for malar augmentation is variable,
but the more robust, longer-lasting fillers are preferable for
obvious reasons. In this thick region, the filler is placed in the
subcutaneous plane (Figure 14-71) as well as the dermis. The
20-gauge (0.9 mm) micro fat injection cannula is also very
convenient to use in the midface, because larger volumes of filler
can be easily and atraumatically injected (Figure 14-72). Figure
14-73 shows the patient’s right cheek immediately post injec-
tion and the left cheek untreated.
Filler Injection of the Earlobes
Earlobe aging manifests as volume loss and wrinkle formation.
It is very simple to plump the aging earlobe with fillers and
restore youthful volume in seconds. The fleshy subcutaneous
earlobe tissue will plump nicely (Figure 14-74).
Injecting the Prejowl Sulcus
Since I perform several facelifts per week, I rarely choose to
inject the jowl region, but this is a patient request from time to
time. The midfacial structures descend with aging, and this situ-
ation plus other soft-tissue and skin changes produce jowl for-
mation, with a defined prejowl sulcus between the jowl and
chin. The prejowl sulcus can be augmented with filler to dimin-
ish the concavity seen in this area and create a smoother man-
dibular border that lessens the deformity. This region can be
treated with standard filler needles or with the micro fat injec-
tion cannula (Figure 14-75).
Alternate Filler Techniques
I have attempted to not specifically discuss each currently avail-
able filler in depth; they come and go rapidly and can quickly
date a textbook. Although there are many available fillers, most
require very similar injection techniques, with the basic differ-
ence being the specific plane. Fat transfer and liquid silicone oil
injection, however, are so technically different that their use
warrants dedicated coverage in this chapter.
Liquid Silicone Oil Injection
This filler earned a separate section because it has been both
hailed and condemned over the past century. Proponents of
liquid injectable silicone call it the perfect filler for numerous
reasons:
• It is less expensive than other fillers.
• It is painless on injection.
• It easy to use.
• It is a “permanent” filler.
• It has minimal side effects when correctly injected.
• It is natural feeling.
• It is clear, tasteless, odorless, and stable at room
temperature.
These statements are true about injectable silicone in the
hands of an experienced injector. The problem lies in the prior
use of silicone. In the past, unscrupulous practitioners utilized
industrial-grade silicone (instead of medical grade) and injected
large volumes (lakes) into the tissues. It is a known fact that
silicone will migrate through tissue planes when injected in large
volumes. Overinjection of nonmedical-grade compounds with
contaminants and injection of large volumes created the mul-
tiple problems documented in the past.20 Reported treatment-
site reactions included pain, erythema, induration, pigmentation
ecchymosis, excessive elevation, migration to distant areas,
nodules, granulomas, and local lymph node enlargement. Fol-
lowing injection of large amounts, tissue destruction, pneumo-
nitis, and granulomatous hepatitis occurred. In 1975, the state
of Nevada even went so far as to make the injection of silicone
a felony, and it cannot legally be injected for aesthetic tissue
filling today. In 1992, breast-augmentation controversy led the
FDA to outlaw medical silicone for cosmetic purposes. In 1997,
Silikon 1000 (Alcon Laboratories, Ft. Worth, TX) was approved
by the FDA for intraocular use for the treatment of retinal
detachment. In 1997, the FDA Modernization Act afforded

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Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
B
E
C
A
D
F
FIGURE 14-68.  A–B, Submalar implant being traced. This implant provides fill in the submalar region. C–D, Malar shell implant
serves as a template for superolateral malar augmentation, which produces the high-cheekbone appearance. E–F, Combined
malar shell implant can serve as an injection template for both submalar and superolateral augmentation.
A
B
FIGURE 14-69.  A, The appropriate implant is placed on the patient’s midface and traced. B, Asking the patient to smile will
elevate the ptotic midface and assist confirmation of the proper template location.

Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
669
A
B
C
FIGURE 14-70.  Filler is injected into the tissues, using the template as a guide for the exact regions to augment. The original
implant thickness is also used to estimate filler thickness; thicker regions of the implant will correspond to areas of increased
filler injection.
FIGURE 14-71.  Treatment of the malar region with injectable fillers requires
multiplanar injection. It is important to provide deeper injection into the
subcutaneous plane to serve as a base and prevent too-rapid filler resorp-
tion. Dermal filling is then layered to further plump the area.
FIGURE 14-72.  The 20-gauge micro fat-injection fat cannula is convenient
for deeper injection of midface filler.
FIGURE 14-73.  The patient’s right cheek immediately after injection and the
left cheek untreated.
of the individual patient. Orentriech and others have published
on the success of injectable liquid silicone with an almost
50-year experience.20
Purified polydimethylsiloxane is a polymer of elemental sili-
cone (Si) that ranges from liquid to solid. The elastomer (solid
silicone) has many uses, from IV tubing to prosthetic devices.
Liquid silicone oil is clear, odorless, tasteless, stable, and can be
stored at room temperature for extended periods without growth
of bacteria. Centistoke (cS or cSt) refers to the viscosity of the
silicone oil and is related to the chain length of the repeating
dimethylsiloxane units. One cS has the viscosity of water;
1000 cS has the viscosity of honey and is the most commonly
injected product. A 5000 cS preparation is available but is too
viscous for convenient filler use.
I have a particularly comprehensive informed consent when
injecting silicone. It is important that patients understand the
characteristics of permanent filler and its irreversibility. It is also
important they understand that the result is not immediate and
will require multiple monthly visits. Finally, my consent explains
the past experiences of silicone misusage and the contemporary
techniques considered safe. I don’t use silicone (or any perma-
nent filler) in patients who have not first had treatment with a
resorbable filler. Permanent filler can sound like a great idea, but
every injector should remember that permanent fillers can cause
permanent complications.
Silikon 1000 comes in an 8.5-mL vial. The viscous oil is
drawn into a 1-mL Luer-Lok syringe with a 16-gauge needle
(Figure 14-76). Many practitioners use a 30-gauge MaxFlo
physicians the ability to use medical devices with the same off-
label provisions previously applicable to drugs. The FDA further
clarified that the off-label injection of FDA-approved liquid
silicone for soft-tissue augmentation is legal as long as the physi-
cian does not advertise and bases treatment on the unique needs

670
Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
needle (RJ Development, Peabody, MA) for injection, but
I have better results with a standard 25-gauge needle. I find
the flow much better, and I can inject with less syringe
pressure.
The single most important issue is that the silicone be
delivered in extremely small microdroplets. As stated earlier,
large amounts of injected silicone can potentially migrate
and cause problems. Microdroplet injection consists of the
administration of tiny “seeds” of silicone in 0.01-mL aliquots19
(Figure 14-77).
Silicone oil is a stimulatory filler. When the microdroplets
are injected into the tissue, they become encapsulated by col-
lagen because they are recognized as a foreign body. This process
takes about 4 weeks, but the delayed reaction amplifies the
actual result. For this reason, the injections are spaced at monthly
intervals until the final result is neared. Since there will be
continued growth due to the secondary collagen deposition, the
final augmentation sessions are spaced farther apart to prevent
overcorrection. Silicone oil is NEVER injected to a final result
at a single session. The continual microdrop filling in numerous
deep tissue planes provides an aesthetic and natural-feeling
result. Although the small-volume injection has been for years
described as “microdrop” technique, in reality, I see it as a “rice-
grain” technique because the term is more descriptive. My per-
sonal injection technique involves inserting the 25-gauge needle
to the hub and then injecting the small amounts while with-
drawing the needle, which produces a thin rice-grain shape as
opposed to a microdroplet (Figure 14-78). Silicone oil should
not be injected in the superficial dermis but rather the subcu-
taneous tissue or deep dermis. This is not a technique for novice
injectors, owing to related problems of overfill or large-volume
injection.
A small amount of this filler goes a long way. I rarely use
more than 0.2 mL of silicone per lip or nasolabial fold. This
volume is so small that the first treatment usually does not result
in noticeable augmentation. I explain to the patient that the use
of silicone is similar to planting seeds in a garden, and they will
grow between appointments. For this reason, there is never an
indication to overcorrect with silicone. Overcorrection with
filler injection was once the standard when the highly resorbable
A
B
FIGURE 14-74.  The aging earlobe is easily volumized by simple filler injection in the subcutaneous fatty tissue.
FIGURE 14-75.  A 20-gauge (0.9 mm) micro fat injection cannula is con­
venient for injecting filler into the prejowl sulcus.
FIGURE 14-76.  Silikon 1000 is a clear, viscous liquid silicone oil that is
drawn up with a 16-gauge needle just before injection. It is injected with
a 30-gauge or 25-gauge needle.

Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
671
Prior to fat transfer, patients are treated with cephalexin
500 mg every 6 hours starting the day before the procedure and
for the following week.
Fat can be extracted from areas where patients desire reduc-
tion, such as the lateral thighs in females or the flank region in
men, although generally not enough fat is removed for transfer
to make a bilateral difference. I prefer the periumbilical region;
there is generous fat in most patients, and it is easily accessible.
The umbilicus and abdomen are prepped and draped in the
usual surgical manner, and local anesthetic (2% lidocaine with
epinephrine) is injected at the proposed puncture site. Tumes-
cent anesthesia is made in the routine fashion by mixing 1 liter
of lactated Ringer solution (or normal saline) with 1 mg of
1 : 1000 epinephrine and 50 mg of 2% lidocaine. Some sur-
geons also add 12.5 mEq of sodium bicarbonate, but this is not
necessary for small-volume harvest.
collagens were used, but none of the contemporary filers require
overcorrection techniques.
In carefully selected patients, silicone is injected in almost
any region that is typically treated with contemporary fillers
(Figures 14-79 to 14-83).
Fat Transfer
The injection of fresh or frozen autologous fat is a very popular
option and could merit an entire textbook. Generally it involves
harvesting fat with a syringe technique and injecting it back into
a remote area. The less manipulation performed on the fat cells,
the better their survival rate. It is also generally accepted that
harvesting fat with low manual pressure with a syringe will
produce a high yield of adipocytes with an intact stromal cell
fraction.21
FIGURE 14-77.  Microdroplet silicone injection consists of tiny drops
(0.01 mL) which are “seeded” into the tissues. Large volumes (lakes) are
never injected.
FIGURE 14-78.  Although classically described as a “microdroplet” tech-
nique, I personally describe my technique as a “rice-grain” injection,
because the continual withdrawal of the needle while injecting small
volumes of silicone produces an elongated drop or thin “rice grain.”
FIGURE 14-79.  Patient has maxillary hypoplasia manifested by lack of
support of anterior lip projection. Four sessions of microdroplet injection
were performed to this area over a 4-month period.
FIGURE 14-80.  Patient is undergoing malar augmentation for a congenital
defect. Silicone is injected in multiple microdroplets in many areas over
the defect. These silicone “seeds” will become encapsulated with colla-
gen, which increases the augmentation and prevents migration.

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Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
FIGURE 14-81.  Patient was treated in two sessions with silicone oil micro-
drop injections to glabellar wrinkles.
A
B
C
FIGURE 14-82.  A, Patient was treated with silicone injection to the earlobe to correct inferior border lobe notching that occurred
from wound contraction. B, Before injection. C, Immediately after injection.
A stab incision is made with a #11 blade, a tumescent infil-
tration cannula (or 23-gauge spinal needle) is inserted, and the
region is infiltrated with tumescent anesthesia until the tissues
are firm (Figure 14-84, A). Waiting at least 20 minutes for the
tumescent anesthesia to take effect is preferable if performed
under local anesthesia.
The fat is harvested with low suction and a handheld syringe
and harvest cannula (see Figure 14-84, B). The plunger is
retracted while moving the syringe in reciprocal motions, which
sucks the fat into the syringe. When performed correctly, little
blood or aspirate accompanies the harvested fat.
At this point, the fat can be centrifuged or allowed to sepa-
rate by gravity, which is the technique I prefer. After settling,
the fat is transferred into smaller syringes (1 to 5 mL), via a
connector and the infranate is left behind (see Figure 14-84, C).
Attaching two syringes to a female-to-female Luer-Lok adapter
and pushing the fat from one syringe to another can emulsify
the fat for easier injection, although some surgeons feel that
such manipulation can affect the cell viability.
An appropriate Luer-Lok blunt-tipped injection cannula (18
to 20 gauge) is attached, and the syringes of fat are ready for
injection. The key to soft-tissue filling with fat is to distribute
small ribbons or pearls of fat into multiple tissue planes, which
increases the chance of neovascularization. The fat should be
injected at the bone level, the muscular level, the subcutaneous
level, and in the superficial fat (see Figure 14-84, D). It is rec-
ommended that fat not be injected into the dermis, because
fibrosis can occur.22,23
Fat is injected into the required sites and must be overcor-
rected; approximately two-thirds of the augmentation will
resorb over the next 90 days. An 18-gauge needle is used to
make skin puncture sites, and these entry sites are placed remote
to the intended target so the fat does not exit the injection
tunnel. The injection cannula is then inserted to the target, and
the fat ribbons or pearls are injected with gentle pressure as the
cannula is withdrawn. Numerous tunnels are made in various
directions (cross-hatching) around the area to be augmented. It
is preferable to seek virgin tunnels with each insertion and
withdrawal. Care must be taken to avoid intravascular injection,
because blindness and stroke have occurred with fat transfer.
This process is similar to injecting filler but involves multiple
tissue planes and overcorrection. Fat can be used in virtually any
region that is acceptable to injectable fillers.
The main problem with fat is that it is resorbed by the body,
oftentimes very fast. When fat is injected, about a third of the
adipocytes will survive and become viable, but the other two-
thirds of the injected volume will be resorbed. This means that
it will take multiple injection sessions to achieve a desired result
that may or may not be permanent. Some practitioners will
freeze harvested fat for up to a year to reinject, whereas others
use fresh harvest at each session.
Postoperative care includes ice to the treated areas for 48
hours and asking the patient to refrain from excessive animation
for several days. Figure 14-85 shows a before-and-after image of
a facial fat transfer patient.
Case Presentations
Figures 14-86 to 14-111 illustrate before-and-after cases of
various filler applications.
Complications of Injectable Fillers
Complications seen with injectable fillers are usually minor,24-33
although as mentioned earlier, blindness has been reported after
Text continued on page 685.

Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
673
A
B
FIGURE 14-83.  Patient with a deep wrinkle in the area of previous acne scars, which magnified the depth of the wrinkle. The
patient is shown before (A) and immediately after (B) the second injection of 0.1 mL of silicone oil into the wrinkle.
A
B
C
D
FIGURE 14-84.  A, Tumescent anesthesia is injected into the intended harvest area until the tissues are firm. B, Fat is harvested
via handheld syringe with an extraction cannula, using as low a pressure as possible. C, Syringes are allowed to sit for several
minutes until the fat separates from the aspirate and is ready for injection. Many injectors prefer 1-mL injection syringes, others
use larger syringes. D, Harvested fat is injected into the target tissue in multiple tissue planes in multiple directions.

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Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
A
B
FIGURE 14-85.  A, Patient treated for a right orbital rhabdomyosarcoma with radiation in infancy and has a developmental growth
deficiency on the right face. B, One month after a 100-mL fat transfer to the right face. Much of this volume was diminished
at 90 days.
A
B
FIGURE 14-86.  This young female patient was treated with a single syringe of hyaluronic acid filler to define her Cupid’s bow
and philtral columns.

Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
675
A
B
C
D
FIGURE 14-87.  A–B, Patient was treated with two syringes of hyaluronic acid filler to volumize the lips. A patient like this who
already has defined anatomy is easy to treat with simple deep filler injection in the center of each lip. C–D, Another view.
A
B
FIGURE 14-88.  Patient with a prognathic lip profile due to mandibular prognathia. This deformity was normalized by filling the
upper lip and subnasal region with a single syringe of hyaluronic acid filler.

676
Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
A
B
FIGURE 14-89.  Patient was treated with two syringes of hyaluronic acid filler for vermilion border definition and volume
enhancement.
A
B
FIGURE 14-90.  Deep lip injection to increase pout and volume using a single syringe of hyaluronic acid filler. There is slight
asymmetry in the lower left side.
A
B
FIGURE 14-91.  Patient was treated with a single syringe of hyaluronic acid filler to increase volume.

Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
677
A
B
FIGURE 14-92.  Patient was treated with a single syringe of hyaluronic acid split between both lips for volume enhancement.
A
B
FIGURE 14-93.  This young patient was treated with one syringe of hyaluronic acid filler in each lip, injected deep for volumization
and pout.

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Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
A
B
FIGURE 14-94.  An older patient before (A) and immediately after (B) two syringes of hyaluronic acid filler for vermilion outline
and deep volume augmentation. The senescent lip presents a greater challenge for the injector.
A
B
FIGURE 14-95.  Patient was treated with a single syringe of hyaluronic acid filler for volume enhancement and pout.

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A
B
C
D
FIGURE 14-96.  A–B, Patient with a deep mentolabial fold was treated with three syringes of hyaluronic acid filler. The first syringe
was injected deep for a base and the remainder injected more superficially. C–D, Oblique view. Note improvement of mento-
labial fold aesthetics.

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Chapter 14  •  Use of Injectable Fillers in Cosmetic Facial Surgery
A
D
C
B
FIGURE 14-97.  A–B, This patient was treated with three syringes of hyaluronic acid filler to augment her deep mentolabial fold
and improve lip and chin aesthetics. Note the degree of improvement of her chin profile. C–D, Oblique view.
A
B
FIGURE 14-98.  Young patients may be treated with a single syringe of hyaluronic acid filler, but most older adults require at least
two syringes. This patient had half a syringe on each nasolabial fold.

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A
B
FIGURE 14-99.  This patient was treated with 1.2 mL of Radiesse split between each nasolabial fold.
A
B
FIGURE 14-100.  Patient was treated with one syringe of hyaluronic acid filler in each nasolabial fold.
A
B
FIGURE 14-101.  Patient was treated with one syringe of hyaluronic acid filler in each nasolabial fold.