Operative Technique in Plastic Surgery – Kevin C.Chung

FIG 2 • Patient photo before (A) and after (B) Botox
treatment for gummy smile.
POSTOPERATIVE CARE
■ Patients are sent home with small pack of ice and may apply as needed for
swelling and/or bruising.
OUTCOME
■ Excellent outcomes are achievable as demonstrated in FIG 2 with
improvement in the gummy smile with animation.
COMPLICATIONS
■ Patients should be counseled on possible risks of procedure including
bleeding, bruising, lip ptosis, facial asymmetry, and weakness of the orbicularis
oris.
REFERENCE
1. Mazzuco R, Hexsel D. Gummy smile and botulinum toxin: a new approach
based on the gingival exposure area. J Am Acad Dermatol. 2010;63:1042-
1051.

5
CHAPTER
Injection of Botulinum Toxin
for Treatment of Perioral
Rhytids
Z. Paul Lorenc and Johnson C. Lee
DEFINITION
■ The orbicularis oris (OO) and depressor anguli oris (DAO) muscles produce
raylike perioral lines and pull downward on the angle of the mouth,
respectively.
■ Small doses of botulinum toxin type A injection directly into the OO prevent
perioral rhytids.
■ Botulinum toxin injections into the DAO soften marionette lines and raise the
corners of the mouth.
ANATOMY
■ The OO muscles originate from both the maxilla and mandible, creating a ring
with insertions into the upper lip, lower lip, and modiolus.
■ The OO is innervated by both the buccal and the marginal mandibular
branches of the facial nerve.
■ Contraction of this ring of muscles closes the lips and creates a competent seal
against intraoral pressure.
■ The DAO is the most superficial muscle in the chin originating from the lower
edge of the mandible and inserting into the modiolus at the angle of the mouth.
■ The DAO is innervated by the marginal mandibular branch of the facial nerve
and contraction pulls the corners of the mouth downward with assistance from
the platysma, accentuating the marionette lines (FIG 1).
PATHOGENESIS
■ Dermal atrophy due to aging, bony resorption, and environmental factors

reveals vertical lines around the lips from OO contraction.
■ Marionette lines start from the corners of the mouth to the chin and are a
combination of tissue descent, age-related volume loss, and DAO activity.
FIG 1 • The orbicularis oris (white arrow) creates a ring
around the lips and contraction of this muscle creates a
competent seal against intraoral pressure while
producing vertical rhytids around the mouth. The
depressor anguli oris (black arrow) inserts into the
angle of the mouth, creating a downward pull, and
accentuating the marionette lines.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patients may report static or dynamic rhytids around the lips as well as
prominent marionette lines or a “frownlike” appearance.

T E C H N I Q U E S
■ The perioral and chin area is sterilely prepped with an alcohol pad.
■ Vertical Rhytids
■ The patient is instructed to purse or tightly pucker the lips.
■ Visible rhytids are injected along the base of each line at the vermillion
border in the subcutaneous plane (TECH FIG 1).
■ Inject 0.5 to 1 unit of Botox per site. A total of 2 units maximum are placed
onto each side in the upper lip and 2 units into the lower lip for a total dose of
6 units (100 units/4 cc NaCl).
■ For patients with significant dermal atrophy, a combination of hyaluronic
acid filler can be combined with botulinum toxin type A for maximal effect.
■ After extruding 0.2 cc of material from a 1.0-cc syringe (Restylane
Refyne), 0.2-cc solution of botulinum toxin type A containing 5 units(100
u/4 cc NaCl) is mixed using an accessory kit.
■ This homogenous HA/BTX material is then injected along the vermillion
border in the potential space using a 27G 25-mm blunt tip cannula.
■ For deep static rhytids, additional hyaluronic acid filler such as Restylane
Refyne, Belotero, or Juvederm Volbella XC can be injected vertically or
horizontally along each line for direct increase in volume.

TECH FIG 1 • While the patient is pursing the lips,
botulinum toxin is injected along at vermillion border in
the subcutaneous plane (dots). For severe rhytids, this
can be combined with hyaluronic acid filler injection
(arrows) injected alone or perpendicular to the rhytids’
direction.
■ Marionette Lines
■ The patient is instructed to frown and pull the corners of the mouth
downward.
■ The injection point is marked with the patient animating and in the upright
position.
■ The marking is halfway between the oral commissure and the jawline.
■ Because the DAO is a vertically oriented pyramidal muscle, injection in its
midportion, where the DAO muscle mass is minimal, will have a more
pronounced and longer lasting effect.
■ The marking is made lateral to the Marionette line.
■ Inject 2.5 units of Botox into each DAO to elevate the corners of the mouth
and reduce the shadowing of the Marionette lines (TECH FIG 2).

■ Pronounced Marionette lines should also undergo concurrent augmentation
with a hyaluronic acid filler such as Restylane Lyft, Juvederm Ultra Plus, or
Juvederm VOLUMA or a CaHA agent such as Radiesse.
TECH FIG 2 • The DAO should be injected with 2.5
units of Botox, halfway between the oral commissure
and the jawline where the DAO muscle mass is
thinnest. Injection should be performed laterally to the
marionette line to avoid weakening of the depressor
labii inferioris muscle.
PEARLS AND PITFALLS
Equipment
■ Use a 27G 25-mm cannula, 32G ½ in. needle.
Choice of
botulinum
toxin
■ Botox and Xeomin—4–5 units the upper lip, 2 units the lower lip.
■ Dysport—10–20 units the upper lip, 10 units the lower lip.
Technique
■ Injection of the OO should occur closer to the midline/philtrum to

reduce risk of oral incompetence from laterally placed injections.
■ Maximum limit of 4 units of Botox each in the upper and lower lip to
minimize risk of incompetence.
■ Injection into the thinnest area of the DAO will allow for maximal
effect with the lowest dose.
■ Care must be taken to inject the lateral aspect of the DAO to avoid
injection into the depressor labii inferioris.
■ Marionette lines should also undergo concurrent augmentation, when
appropriate, with a hyaluronic acid filler such as Restylane Lyft,
Juvederm Ultra Plus, or Juvederm VOLUMA or CaHA agent such as
Radiesse.
POSTPROCEDURAL CARE
■ Patients ice the area immediately after the procedure (15 minutes).
■ Avoid pressure, sweating, and alcohol for the remainder of the day to
minimize swelling.
OUTCOMES
■ Patient should expect additional treatments every 3 to 4 months (FIG 2).
■ Because of use of conservative dosages to avoid oral incompetence, perioral
retreatments may be needed even sooner.
COMPLICATIONS
■ Slight bleeding, discomfort, or ecchymosis can occur after injection.
■ Excessive injection of botulinum (8 units or greater) into the OO can result in
oral incompetence, which can last for several weeks.
■ Incorrect injection medial to the DAO will result in weakening or paralysis of
the depressor labii inferioris and an asymmetric smile.

FIG 2 • Before (A) and after (B) botulinum toxin injection
in the perioral area.

6
CHAPTER
Injection of Botulinum Toxin
to the Depressor Anguli Oris
Amir Allak, Sebastian Cotofana, and Jonathan Sykes
DEFINITION
■ Hyperfunction of the muscular depressor anguli oris (DAO) results in a
scowling, aged appearance, and marionette lines.
■ The position and orientation of the oral commissure is related to the relative
strength and contraction of the DAO (and to a lesser extent the depressor labii
inferioris [DLI]) vs the elevators of the oral commissure (levator anguli oris,
levator labii superioris).
■ Treatment with botulinum toxin can lessen the contraction of hyperdynamic
DAO muscles and can elevate the downturned oral commissure, resulting in a
more rejuvenated appearance.1
ANATOMY
■ The depressor DAO is a paired bilateral muscle that originates from the soft
tissue overlying the oblique line and the inferior border of the anterior body
and parasymphysis of the mandible. DAO inserts onto the lateral aspect of the
lower lip and oral modiolus (FIG 1).
■ The DAO is innervated by the marginal mandibular branch of the facial nerve,
and its activation moves the oral commissure inferolaterally.
■ The shape of the DAO is roughly a triangle with its base inferiorly at its origin
and its apex superiorly near the modiolus of the oral commissure.
■ At its origin, the DAO muscular body is continuous with the platysma muscle
inferiorly within the superficial musculoaponeurotic system.

FIG 1 • Cadaveric dissection of muscles acting at the
angle of the mouth. Mo, modiolus; DLI, depressor labii
inferioris; DAO, depressor anguli oris; OO, orbicularis
oculi; LAO, levator anguli oris; ZM, zygomaticus major;
LLS, levator labii superioris.
■ The DLI is a paired bilateral muscle that is directly medial to the DAO, which
also originates from the inferior border of the parasymphysis of the mandible
but inserts mostly on the body of the lower lip (see FIG 1). Its action, as its
name implies, depresses one side of the lower lip.
■ In the areas where the DAO and DLI overlap, the DLI lies deep to the DAO
(see FIG 1).
■ The facial artery runs superomedial from the mandibular notch, and the
inferior labial artery arises inferior to the modiolus. The inferior labial artery, a
branch of the facial artery, runs deep to the DAO fibers (FIG 2).
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Overactivation of the DAO contributes to an aged-appearing downturn of
overall lip shape and rhytids that follow from the oral commissure
inferolaterally (paralleling the course of the muscle), known commonly as
marionette lines.2

FIG 2 • Cadaveric dissection demonstrating the
relationship of the facial vasculature to the depressor
anguli oris. FA, facial artery; DAO, depressor anguli
oris; ILA, inferior labial artery.
■ There is often an associated soft tissue depression just inferior to the oral
commissure that is partially related to muscular activity and partially attributed
to descent of the cheek fat pad relative to the lower lip subunit.
IMAGING
■ No imaging is required for this procedure.
SURGICAL MANAGEMENT

Preoperative Planning
■ Patients should be screened for neuromuscular disorders including
amyotrophic lateral sclerosis, myasthenia gravis, and Eaton-Lambert syndrome
because these are contraindications for the use of the product.
■ Use in pregnant or nursing mothers is not advised, though no studies have
shown teratogenic damage to fetus or adverse affects to breast-feeding infants.
■ Patient medications should be screened for aminoglycoside antibiotics because
these affect the pharmacokinetics of the toxin and can potentiate the effects.
Positioning
■ The patient is examined in an upright position along with full facial analysis.
The treatment position is surgeon preference, upright, slightly recumbent, or
supine.
Approach
■ Delivery of the product is performed uniformly with percutaneous injection.
T E C H N I Q U E S
Video p1-c006
■ Injection of Botulinum Toxin Into the DAO
■ Topical anesthetic cream, commonly containing lidocaine, is applied and left
in place for a minimum of 15 to 20 minutes (and sometimes longer) for
00:00 / 00:00

maximal anesthetic effect.
■ Botox is reconstituted into sterile injectable saline to the concentration of 2.5
to 4 units/0.1 mL. This is drawn up into a 1-cc syringe, and a 30-gauge short
Luer Lock needle is prepared for injection.
■ The patient is asked to grimace to reveal the area of maximal activation of
the DAO and its distribution along the marionette line.
■ The mandibular groove is palpated at the junction of the posterior body and
angle on the inferior border of the mandible.
■ This is the area where the facial artery and vein course from the deep neck
to supply and drain the facial soft tissue.
■ Injection in this area should be avoided.
■ The product is typically injected in two to three locations, following the
shape of the inverted triangle of the DAO: two at the inferior aspect and one
superiorly for a total of 3 to 6 units per side.
■ Injection should be posterior to the oral commissure to avoid the DLI and
anterior to the mandibular groove to avoid the facial vascular structures.
■ Injection should be delivered in a relatively superficial plane to avoid the
DLI and the inferior labial artery running deep to the DAO.
PEARLS AND PITFALLS
Location
of
injection
■ Injection should be anterior to the mandibular notch to avoid vascular
structures and posterior to the oral commissure to avoid injection of the
DLI and subsequent smile asymmetry.
■ The plane of injection should be relatively superficial because the DAO
fibers run superficial to the DLI and inferior labial artery.
Dosing
■ 3–6 units are divided in 2–3 doses in a line or triangular orientation.
■ More product may be required in men.
POSTOPERATIVE CARE
■ Ice packs should be provided to the patient and placed immediately after
injection.
■ Some patients may bruise post procedure, especially if anticoagulated. This
can be expected to resolve in several days.

OUTCOMES
■ Onset of effect usually become apparent in 1 week.
■ Inactivation of the DAO should lead to less downturn of the oral commissures
and some relief and softening of marionette lines.3
■ The neuromodulation is commonly effective for 12 to 20 weeks wherein it
would need to be redosed for continued effect. This can vary from patient to
patient.
COMPLICATIONS
■ Injection of the DLI or migration of product so as to chemically denervate this
muscle will lead to asymmetry when smiling because the ipsilateral muscle will
not activate the lower lip to depress. The effect of the product should wane
over the normal metabolic period.
■ Intravascular injection, though exceedingly rare, can cause systemic effect
similar to botulism (generalized weakness, visual disturbance, dysarthria, etc.)
ACKNOWLEDGMENT
The authors thank Peter Palhazi, MBBS, for his contribution to the preparation
of this chapter.
REFERENCES
1. Wu DC, Fabi SG, Goldman MP. Neurotoxins: current concepts in cosmetic
use on the face and neck—lower face. Plast Reconstr Surg. 2015;136:76S-79S.
2. Choi YJ, Kim JS, Gil YC, et al. Anatomical considerations regarding the
location and boundary of the depressor anguli oris muscle with reference to
botulinum toxin injection. Plast Reconstr Surg. 2014;134(5):917-921.
3. Goldman A, Wollina U. Elevation of the corner of the mouth using botulinum
toxin type A. J Cutan Aesthet Surg. 2010;3(3):145-150.

7
CHAPTER
Injection of Botulinum Toxin
to Platysma Bands
Z. Paul Lorenc and Johnson C. Lee
DEFINITION
■ Platysma bands become more pronounced with age and activity.
■ Botulinum toxin injection directly into the muscular cords relaxes the muscle,
efface the vertical bands, and define the mandibular border.
■ Treatment of the platysma muscle is routinely combined with treatment of the
depressor anguli oris (DAO) to lessen the downward forces of the muscles of
the neck and face.
ANATOMY
■ The platysma originates along the fascia of the superior portions of the
pectoralis major and deltoid muscles. The muscle fibers run superiorly and
obliquely before inserting into the perioral muscles, dermis of the cheek and
chin, and inferior mandibular symphysis posterior to the DAO origin (FIG 1).
■ The platysma is innervated by the cervical branch of the cervicofacial trunk of
the facial nerve with some superior coinnervation by the mandibular branch.
■ Activation causes depression of the corners of the mouth and mandible,
tightening the anterior neck skin, and blunting of the mandibular border.
PATHOGENESIS
■ Contraction of the free anterior and posterior fibers in the submental and neck
regions creates both vertical platysma bands and horizontal neck lines.
■ Excess or lax skin can compound the appearance of platysma bands even at
rest.
■ With aging, loss of submental fat contributes to platysma bands prominence.
PATIENT HISTORY AND PHYSICAL FINDINGS

■ Patients may report the appearance of bands when speaking or making facial
expressions, which become more pronounced with age.
■ Patients with significant skin laxity component may have suboptimal results.
FIG 1 • The platysma originates along the pectoralis
major and deltoid muscles and inserts into the anterior
mandible and skin of the lower face. Activation causes
the formation of vertical bands.
T E C H N I Q U E S
■ Preparation
■ Choice of botulinum toxin

■ Botox (onabotulinum toxin type A)
■ Xeomin (incobotulinum toxin type A)
■ Dysport (abobotulinum toxin type A)
■ Suggested dilution
■ Onabotulinum toxin type A—100 units/2.5 cc NaCl
■ Incobotulinum toxin type A—100 units/2.5 cc NaCl
■ Abobotulinum toxin type A—300 units/1.5 cc NaCl
■ The neck area is sterilely prepped with an alcohol pad.
■ The patient is in an upright sitting position.
■ Botulinum Toxin Injection
■ The patient is instructed to voluntarily contract the platysma by grimacing or
pulling the corners of the mouth and lower lip downward and laterally while
tightening the skin of the neck.
■ Visible anterior and lateral platysma bands are marked using a marking pen
with 1-cm spacing.
■ Platysma injection points at the mandibular border as well as the depressor
anguli oris (DAO) injection sites are marked, if clinically necessary.
■ Visible cords are held between the thumb and index finger during the
injection (TECH FIG 1).
■ Injections are given directly into the vertical muscular cords with a 32-gauge
needle using a 1.0-cc Luer-Lok tip syringe.
■ Dosage total depends on the choice of botulinum toxin:
■ 25 to 50 units of onabotulinum toxin type A
■ 25 to 50 units of incobotulinum toxin type A
■ 100 to 150 units of abobotulinum toxin type A
■ Additional injections can be performed along the mandibular border, at the
posterior platysma bands, and the DAO injection points for improved
jawline.

TECH FIG 1 • Visible cords (A) are held between the
thumb and index finger (B), and botulinum toxin is
injected evenly spaced approximately 1 cm apart at
the level of the deep dermis.
PEARLS AND PITFALLS
Equipment
■ Use a 32-gauge needle, 1.0-cc Luer-Lok tip syringe.
Technique
■ Retract the individual cord away from the deeper muscles.
■ Inject into the deep dermal layer to avoid deeper structures or the
hypoglossal nerve.

FIG 2 • Before (A–C) and 60 days (D–F) after
treatment. Full animation, ¾ view, side view. A 62-year-
old female, total dose: 80 units incobotulinum toxin type
A (100 units/2.5 cc NaCl). Muscles injected: platysma,
medial, lateral, mandibular border, depressor anguli
oris.
POSTPROCEDURAL CARE
■ Patients place ice over the area immediately after the procedure.
■ Avoid pressure, sweating, alcohol for the remainder of the day to minimize
postinjection sequelae.
OUTCOMES (FIG 2)

■ Resolution of platysma banding may not occur for up to 3 to 5 days after
treatment.
■ Patient is seen 1 week post injection for additional therapy if necessary.
■ Patient should expect additional treatments every 3 to 4 months.
■ Horizontal banding, if necessary, may be addressed with injectable hyaluronic
acid filler with low G′ characteristics.
COMPLICATIONS
■ Slight bleeding, discomfort, or ecchymosis can occur after injection.
■ Accidental botulinum toxin injection into the strap muscles, deeper muscles of
the neck, or hypoglossal nerve injury can cause dysarthria, dysphagia,
dysphonia, or breathing difficulties.

8
CHAPTER
Section II: Technique for
Injection of Fillers in the
Face
Injection of Fillers in the
Glabella, Forehead, and
Brow
David A. Sieber and Jeffrey M. Kenkel
DEFINITION
■ Hyaluronic acid: a naturally found glucosaminoglycan polymer found in
human tissue, which is reversible with hyaluronidase
■ Tyndall effect: bluish hue created in the skin from light scattering off
superficially injected particles of filler
ANATOMY
■ The supratrochlear artery lies approximately 2 cm lateral to midline between
the corrugator and frontalis/orbicularis, traversing the frontalis/orbicularis 1.5
to 2.5 cm above the orbital rim transitioning into the subcutaneous plane1 (FIG
1).
■ The supraorbital artery runs approximately 3 cm lateral to midline, piercing
the frontalis between 2 and 4 cm above the orbital rim also transitioning to a
subcutaneous plane.1,2
■ The supraorbital nerve originates 2.1 to 3.5 cm from midline and divides into
superficial and deep branches. The deep branch courses deep to the corrugator
supercilii and frontalis muscles, traveling between the periosteum and galea
superiorly and laterally toward the temporal fusion line.3,4

PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patients will often present complaining of static rhytids in the glabella and
forehead that persist after adequate treatment with neurotoxins.
■ Other patients will have hollowing of the inferior brow, complaining of an
aged and gaunt appearance of the eyes.
NONOPERATIVE MANAGEMENT
■ The senior author’s preference is to use hyaluronic acid fillers due to their
temporary nature and ability to be reversed through the use of hyaluronidase.
Positioning
■ The patient should be comfortably seated in an upright position.
Approach
■ The glabella, forehead, and brow may be injected from either side of the
patient.
■ It is the author’s preferred approach to inject standing to the side of the patient.

FIG 1 • Location of the supratrochlear and supraorbital
arteries. Notice the transition to a more superficial plane
as they ascend in the forehead.
T E C H N I Q U E S
■ For most hyaluronic acid products, the authors add 0.2 cc of 0.5% lidocaine
with epinephrine using a Luer-lock to Luer-lock connector to help constrict
local blood vessels, reducing the risk of postprocedural ecchymosis.
■ When superficial/dermal injections are performed, the authors follow Dr.
Fagien’s recommendations regarding dilution, which reconstitutes the
product 1:1 with 1% lidocaine.5
■ Although injections may be performed with a 30-gauge needle, 27-gauge
needle, 25-gauge cannula, or 27-gauge cannula, the authors’ preference is to

use a cannula for injections of the inferior brow along the orbital rim and a
30-gauge needle for treatment of superficial rhytids of the forehead.
■ Skin is always prepped using a swab containing 4% chlorhexidine gluconate
prior to injection.
■ Injection of Fillers in the Glabella and Forehead
■ A 30-gauge needle is advanced into an intradermal plane parallel to the
rhytids being treated.
■ The filler is then deposited in a serial retrograde fashion along the course of
the rhytid.
■ This area is slightly overcorrected and then massaged to produce an even
result.
■ Additional cross-hatching may be necessary for complete correction of the
rhytid, especially in treating deep vertical lines of the glabella.
■ Care is taken to stay very superficial (intradermal) so as to not cannulate or
injure the supratrochlear or supraorbital vessels.
■ Injection of Fillers in the Brow
■ A common portal is made in the lateral tail of the brow with a needle.
■ The cannula is advanced medially along the brow periosteum to just past the
area needing correction. This is below the inferior border of the brow.
■ Filler is gently injected along the inferior border of the superior orbital rim
as the cannula is withdrawn laterally.
■ Multiple passes may be necessary to achieve the desired effect.
■ An additional portal may be needed medially to reach the more medial
aspects of the orbital rim.
■ After placement, the product is massaged into place along the orbital rim to
produce an even, natural result.
PEARLS AND PITFALLS

Technique
■ The supratrochlear and supraorbital arteries lie in the subcutaneous
plane starting 2 cm above the orbital rim; care must be taken to not
cannulate or injure these during injection.
■ When injecting the glabella and upper forehead, filler should be placed
into a superficial/dermal plane to avoid injury to the supratrochlear and
supraorbital vessels.
■ Filler placed along the superior orbital rim can produce a subtle brow
lift in patients with pre-existing brow ptosis.
■ Filler placed along the superior orbital rim helps with orbital
hollowing and correction of “A” frame deformities.
POSTOPERATIVE CARE
■ Patients are sent home with small packs of ice and may apply as needed for
swelling and/or bruising.
■ Patients should keep their heads elevated for a few hours after injection and
should abstain from exercise for 4 hours.
OUTCOMES
■ Excellent outcomes are achievable as demonstrated in FIG 2 with correction
of the brow hollowing (see FIG 2) and superficial rhytids of the forehead (FIG
3).
FIG 2 • A 66-year-old female pre (A) and post (B)
injection of 0.5 cc Restylane Lyft into each temporal
region/lateral brow, 1 cc total of Restylane Silk into the
lips/perioral region, and 0.4 cc Restylane Lyft into each
sub-brow region. Notice the more youthful appearance
of the brow/periocular region (C,D).
COMPLICATIONS
■ Patients should be counseled on possible risks of procedure including

bleeding, bruising, facial asymmetry, and intravascular injection leading to skin
necrosis and/or blindness.
FIG 3 • A 50-year-old female pre (A) and post (B)
treatment with a total of 2 cc Restylane Silk placed into
static forehead rhytids as well as perioral lines.
REFERENCES
1. Kleintjes WG. Forehead anatomy: arterial variations and venous link of the
midline forehead flap. J Plast Reconstr Aesthet Surg. 2007;60:593-606.
2. Erdogmus S, Govsa F. Anatomy of the supraorbital region and the evaluation
of it for the reconstruction of facial defects. J Craniofac Surg. 2007;18:104-
112.
3. Christensen KN, Lachman N, Pawlina W, Baum CL. Cutaneous depth of the
supraorbital nerve: a cadaveric anatomic study with clinical applications to
dermatology. Dermatol Surg. 2014;40:1342-1348.
4. Knize DM. A study of the supraorbital nerve. Plast Reconstr Surg.
1995;96:564-569.
5. Fagien S. Variable reconstitution of injectable hyaluronic acid with local
anesthetic for expanded applications in facial aesthetic enhancement. Dermatol
Surg. 2010;36:815-821.

9
CHAPTER
Filler Injection Into the
Upper Periorbital Area
Val Lambros
DEFINITION
■ The upper periorbital area refers to the superior orbital rim inferiorly to
roughly the height of the eyebrow, from the medial temple to medial-most
orbit.
■ The reason to fill the brows is that a certain population of patients looks better
with fuller upper periorbital than hollow.
ANATOMY
■ The anatomy of the brow is well known. The pertinent anatomy is aesthetic
and vascular.
■ The supraorbital and supratrochlear arteries arise from the bone and rise to the
level of the frontalis muscle.
■ The superior orbital rim in most young persons is characterized by skin that
most clinicians characterize as “tight” as well as generalized fullness of
subcutaneous fat. The overall look in many of these eyes is a full orbital rim
and upper lid, which describes a low and horizontal path across the orbit. These
young eyes tend to look longer from medial to lateral than the does old eye.
Part of this phenomenon is secondary to the stretch of the lateral canthal
tendon, and part is from the height versus width ratio: the visual height of the
orbit is low in relation to its length.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ In patients whose faces age by thinning, it is very common for the orbit to
hollow. Therefore, eyes that fit the description above become eyes that look
larger vertically (less fat volume) and round (greater height for width, as well

as a shorter lid aperture). This look when extreme is sometimes descriptively
called a nursing home eye (FIG 1).
■ Older eyes tend to have greater eyelid show and room for makeup. Some
patients like this look. In young eyes that have had surgery with a great deal of
fat removal, the loss of fat can in time accelerate the natural aging of the
eyelid.
■ The thesis of this chapter is simply that some upper lids and superior orbital
rims look better when fuller than not.
FIG 1 • Contrast of youthful (A) versus aged (B)
periorbita.
Preoperative Planning
■ Though the criteria above give a hint as to who may be good candidates for
filling the supraorbital area, some patients with configurations described above
may look better with fill and some not.
■ Though most patients would understand the effect of filling in a wrinkle,
filling certain areas of the face is not intuitive, for example, the temples, brows,
and anterior jawline, where a small amount of filler may make a huge change
visually.
■ Because cosmetic alterations of the face are visual by definition, there is an
easy way to show patients the visual alternatives before the final injections and
get their understanding and approval of the procedure before it is actually done.
Though one may use preoperative computer imaging, I prefer the use of a
small amount of local anesthesia to duplicate the effect of the filler.
Positioning
■ Injections are performed with the patient seated upright.
Approach
■ I prefer to block all filler injection with local anesthesia with epinephrine
before placing the filler. The primary reasons are for pain control and

vasoconstriction. The least common but most feared complication of filler
injections is intra-arterial injection of product. Injecting into a vasoconstricted
environment would logically be expected to reduce its incidence. If one is
going to inject local anesthetic anyway, one may as well get additional benefit
from doing so, and that is to show the patient the intended outcome of the final
result.
T E C H N I Q U E S
■ Filler Injection Into the Upper Periorbital Area
■ In my experience, patients uniformly like the idea of visualizing the result
before committing to the injection; it tilts the balance of power from the
doctor to the patients, and all patients are familiar with the idea of trying on
clothes before buying them.
■ Most patients like the preview with local anesthesia, and the filler injection
is performed immediately afterward.
■ The patients who do not like the preview do not have to find out after
spending money and experiencing a result that they do not like.
■ The extra 5 minutes that this takes is well worth the effort in my opinion.
No one has told me that they did not like an injection that was previewed
and approved.
■ Placing the local anesthetic is more difficult than doing the final injection. It
is all too easy to place a blob of fluid in the tissues that demonstrates nothing
but lack of injection ability; with some practice, one learns to place the local
anesthetic in even threads, which are quite convincing.
■ The local is massaged and the patient is shown the result, and the area is
now numb and vasoconstricted.
■ The presence of the local does not complicate the injection at all as one
knows both the dose and distribution already and the smoothness is
confirmed by feel.
■ Either a cannula or a needle is used for the final injection.
■ From long experience, I use a 30 G ½ in. needle.
■ The presence of the local helps with the distribution of the product.
■ Most commonly, the dose is ½ cc per side.

■ The injection of product itself begins laterally at about the tail of the brow. It
is in the middle level, below the orbicularis oculi, but not subdermal or
adjacent to the bone. There are two reasons not to be deep here:
■ In some patients, the globe is immediately adjacent to the bone, increasing
the possibility of injury.
■ The supraorbital and supratrochlear as well as other forehead arteries arise
from the bone or adjacent to it and may be more easily injured with the
needle (TECH FIG 1).
TECH FIG 1 • Injection into the upper periorbital.
■ The injection is done in a fanning manner with an injection headed
superiorly straight ahead and inferiorly to the injection path.
■ Usually about 5 needle placements are necessary, making a total of about
15 passes.
■ As the dose is typically ½ cc per side, that makes about 0.03 cc per pass.
PEARLS AND PITFALLS

Patient
selection
■ The first and most important criterion for patient and doctor satisfaction
is patient selection.
■ In the currently popular volume-centric approach to facial cosmetic
surgery, patients may be treated by rote or by principle that faces should
be made fuller regardless of the face. Though some faces may deflate
with age, many do not in the American population. Volume treatments
across the face and specifically around the eye may look ridiculous and
be permanent.
■ When one is changing as visually important a part of the face as the
periorbital area, one wants to know that the patient will like it and that
complications can be treated.
Filler
selection
■ I invariably use HA fillers around the eyes. Fillers in this class, which,
at the time of this writing, include Restylane and Juvederm, have unique
properties that make them invaluable in the periorbital area.
■ The longevity in the periorbita (as well as the temple and tip of the
nose) is much greater than in the lips and nasolabial fold. I tell patients
that it will last 2 years, but it is common to see 3 or 4 years of
persistence. In addition, HA filers can be dissolved with hyaluronidase,
thus making it easy to erase lumps and most complications. These
luxuries are simply not available when using calcium- or lactic acid–
based fillers.
FIG 2 • Pre (A) and post (B) injection.
POSTOPERATIVE CARE
■ Postprocedure care is minimal. Ice usually suffices. Using a needle has a
higher incidence of bruising, which takes the usual course. Cannulas have less
bruising but are less maneuverable and precise.
OUTCOMES
■ FIGS 2 to 5 show before and after photos in four patients.
COMPLICATIONS
■ Complications specific to the periorbital area are similar to other parts of the

face. Occasional irregularities may be supplemented with more product or
sometimes dissolved with a low dose of hyaluronidase.
■ Arterial injection injuries are rare but most serious. It is thought that some
lesions from arterial injection are embolic by virtue of distal arterial flow,
whereas some occur from flow proximal to the injection point.
■ Severe injuries include duskiness of the skin to full-thickness necrosis of the
skin or even blindness. Suggestions for prevention include using a cannula,
vasoconstriction, and low-pressure injection with a moving needle.
■ Cannulas would be expected to generate less arterial perforations than needles
though arterial injections have been generated with cannulas as well.
Aspiration of the syringe before injection, though traditionally recommended,
does not seem to be reliable, as HA fillers injected through a small needle are
too viscous to allow product to backflow into the syringe. The only article that
characterized the incidence of “severe complications” gave an incidence of
close to 1 in 1 000 000,1 though the incidence is probably higher than that.
FIG 3 • Pre (A) and post (B) injection.
FIG 4 • Pre (A) and post (B) injection.
FIG 5 • Pre (A) and post (B) injection.
REFERENCE

1. Ozturk CN, Li Y, Tung R, et al. Complications following injection of soft-
tissue fillers. Aesthet Surg J. 2013;33(6):862-877.

10
CHAPTER
Tear Trough and the Lid-
Cheek Junction
Z. Paul Lorenc and Johnson C. Lee
DEFINITION
■ The tear trough and lid-cheek junction are natural anatomical structures that
become accentuated with time due to changes in the skin and periorbital
structures.
■ Proper placement of injectable fillers restores volume and support to these
structures for periorbital rejuvenation.
ANATOMY1,2
■ The tear trough or nasojugal groove is the natural depression 4 to 6 mm caudal
to the arcus marginalis at the orbital rim and extends inferolaterally from the
medial canthus to the midpupillary line.
■ The lid-cheek junction extends from the tear trough at the midpupillary line
and lies below and parallel to the infraorbital rim.
■ In the subcutaneous plane, both the tear trough and the lid-cheek junction
correlate with a junctional cleft between the palpebral and orbital portions of
the orbicularis muscle.
The lid-cheek junction has an additional deep submuscular plane at the
orbitomalar ligament (FIGS 1 and 2).
PATHOGENESIS
■ The tear trough and lid-cheek junction are normal anatomic features that can
be seen in many youthful individuals.

FIG 1 • The tear trough deformity (arrow) is the natural
groove extending inferolaterally from the medial
canthus to the midpupillary line. The lid-cheek junction
(white arrow) extends laterally.

FIG 2 • The underlying anatomy is shown with the malar
fat pad reflected. The tear trough deformity (black
arrow) lies at the junction of the palpebral and orbital
components of the orbicularis oculi muscle. This
continues laterally with the lid-cheek deformity (white
arrows).
■ With age, there is skin and fat atrophy and attenuation of the periorbital
structures allowing orbital fat herniation and increasing shadows.
■ The tear trough and lid-cheek junction become more visible and accentuated
by overlying pigment, texture, and shadow changes.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patients may report a “tired” or “aged” under-eye appearance which is not
relieved with rest, hydration, or topical therapies.

■ A depression can be seen starting at the medial canthus and parallel to the
orbital rim.
The tear trough and lid-cheek junction deformity can be accentuated by actively
increasing orbital fat herniation with upward gaze or globe pressure (FIG 3A).
FIG 3 • Patient photos before (A) and after (B) injection.
T E C H N I Q U E S
■ Preparation
■ The area is cleansed and sterilized with a sterile alcohol pad.
■ Marking of the areas for filler injection of the tear trough and the lid-cheek
junction is made with the patient in an upright position with the orbicularis
oculi muscle in a completely relaxed state. Cannula access port is marked in
the midpupillary line 0.5 cm inferior to the border of the orbital rim.
■ Topical anesthetic (benzocaine 20%, lidocaine 6%, tetracaine 4%) is
carefully applied to the area with cotton-tipped applicators for 30 to 45
minutes prior to injection.
■ Cannula access port is injected with 0.1 cc of 1% lidocaine solution and
epinephrine 1:100 000.
■ Just prior to cannula insertion, a 25G 5/8″ needle is used to puncture the skin
and create the cannula access port.
Tear Trough

■ Restylane-L (Galderma Laboratories, L.P.) is diluted with 2% lidocaine 1:1
(off-label use). When reconstituting an agent, make sure there is a
homogenous distribution of the material throughout the syringe.
■ After insertion of the cannula, injections begin medially to laterally with a
27G 25-mm cannula in a retrograde fashion at the supraperiosteal level.
■ Using the free hand, the orbital rim is palpated.
■ Care is made to inject below the orbital rim, deep to the muscle, and onto the
periosteum between the palpebral and orbital portions of the orbicularis oculi
muscle.
■ Injection of small aliquots (0.01–0.05 cc) is made in a retrograde fashion.
■ Average reconstituted volume delivered is 0.6 cc.
■ Minimal massage, if any, can be used to blend (TECH FIG 1).
Lid-Cheek Junction
■ The 27G 25-mm cannula is advanced from the access port laterally at the
supraperiosteal plane toward the lateral canthus.
■ Injections are made directly onto the periosteum with a 27G 25-mm cannula
in a retrograde fashion similar to the tear trough but now laterally to medially
stopping short of the access port.

TECH FIG 1 • Injection technique—The orbital rim is
palpated, and the cannula is inserted between the two
portions of orbicularis muscle of the tear trough and
onto the supraperiosteal plane. Filler is then injected
in a medial to lateral and retrograde fashion.
■ Average reconstituted volume delivered is 0.4 cc.
■ Minimal massage, if any, can be used to blend (TECH FIG 2).
Additional Agents
■ Belotero Balance (Merz, Inc. Frankfurt, Germany)—short-lived HA filler (6
months or more) can also be placed intra- or subdermally.
■ Juvederm Ultra XC (Allergan, Inc., Santa Barbara, Calif.)—hydrophilic HA
filler if used, should be injected conservatively.
■ Restylane Refyne (Galderma Laboratories, L.P.)—a flexible HA recently

cleared in the United States, as all agents, is recommended to be injected in
the supraperiosteal plane.
TECH FIG 2 • Injection technique—The lid-cheek
junction is injected in a similar fashion to the tear
trough in the supraperiosteal plane below the
orbicularis oculi muscle at the level of the orbitomalar
ligament from lateral to medial toward the cannula
insertion point located at the midpupillary line.
PEARLS AND PITFALLS

Equipment
■ A 30G 13-mm needle may be used. Multiple punctures routinely
result in increased ecchymosis. Injections are performed at 90 degrees
to the skin surface at the supraperiosteal plane.
Choice of
injectable
filler
■ Hydrophilic or fillers with higher lifting capacity should be used
conservatively and injected in the deepest plane possible to minimize
complications.
■ Fillers with a high elastic modulus (G′) and lifting capacity can be
more safely placed laterally along the lid-cheek junction with caution.
Technique
■ Be aware of the orbital rim at all times.
■ Inject conservative amounts in a retroactive manner, and avoid
overcorrection.
■ Slow injection should be performed at all times.
POSTPROCEDURAL CARE
■ Makeup and other under-eye products should not be used until the following
day.
■ Patients may ice the area immediately after the procedure and should remain
with their head elevated for the next 24 hours to minimize swelling.
■ Gentle digital pressure can be used to blend areas of edema or irregularity.
Massage is not recommended.
OUTCOMES
■ Patients may expect edema, ecchymosis, and injection site tenderness for the
first 24 to 48 hours lasting up to 7 to 10 days.
■ Patient should expect additional treatments every 6 to 12 months depending on
the filler used and or associated use of botulinum toxin type A in the periorbital
area.
■ See FIG 3 for before and after patient photos.
COMPLICATIONS
■ Irregularities and nodules occur rarely and are secondary to poor technique
and/or overcorrection.
■ A gray-bluish hue of the skin caused by the Tyndall effect can be seen if a
hyaluronic acid (HA) product is placed too superficially or undiluted.
■ Injection of material above the rim or posterior to the orbital septum can cause
prolonged edema or contour abnormalities.
■ Excessive volume, malposition of filler material, or contour abnormalities can

be resolved with hyaluronidase (10 units of hyaluronidase/0.1 cc of HA filler)
for HA products. Allow swelling to subside for evaluation prior to attempting
reversal.
REFERENCES
1. Flowers RS. Tear trough implants for correction of tear trough deformity. Clin
Plast Surg. 1993;20:403-415.
2. Haddock NT, Saadeh PB, Boutros S, Thorne CH. The tear trough and
lid/cheek junction: anatomy and implications for surgical correction. Plast
Reconstr Surg. 2009;123(4):1332-1340.

11
CHAPTER
Injection of Fillers in the
Malar Region
Benjamin T. Lemelman and Julius W. Few
DEFINITION
■ Injection of filler in the malar region addresses the aesthetic concerns of the
aging patient without the need for surgery.
■ The primary filler is hyaluronic acid (HA) gel due to its many properties and
U.S. Food and Drug Administration approval.1
■ Replaces lost midfacial soft tissue volume due to aging.
■ Increases tissue’s capacity to bind water.
■ The authors use a combination of U.S. Food and Drug Administration (FDA)–
approved fillers including Juvéderm Voluma XC (Allergan, Inc., Irvine, CA)
and Restylane Lyft (Galderma Laboratories, Fort Worth, TX).
■ Various rheologic properties contribute to the ability of the HA filler to
enhance volume and lift the midface:
■ One of these factors is the G′ (G-prime). This describes the firmness or
elasticity of the HA product. A product with higher G′ has an increased
firmness or density.
■ Restylane Lyft has a reported higher G′ than that of Voluma.
■ Despite the differences in G′, both are considered “high density” and have
shown success in midface rejuvenation.1–3
■ Cross-linking of the HA particles during production also contributes to the
product characteristics.
ANATOMY
■ The midface extends from the lower eyelid-cheek junction to the nasolabial
fold.
■ The three target regions for midface enhancement include (FIG 1A)1:

■ Zygomaticomalar region
■ Anteromedial cheek region
■ Submalar region
FIG 1 • A–D. Before and after results following a total of
3 mL of HA filler to the three regions of bilateral midface
of a 65-year-old woman with history of a facelift 5 years
prior to presentation. The results shown are after 12
months.
■ Additionally, the midface can be divided into four regions V1 to V4 (FIG
1B)4:
■ V1—zygomatic arch
■ V2—zygomatic eminence
■ V3—anteromedial cheek
■ V4—submalar
■ In the V3 region, knowledge of the location of the infraorbital nerve and
neuromuscular bundle is essential. The authors use a blunt cannula technique
to minimize risk of intravascular injection of HA, when injection is anywhere
other than on the periosteum.
PATHOGENESIS
■ Midface aging is a result of many contributing factors including volume loss
and tissue descent.
■ Changes in underlying bony anatomy, soft tissue volume, and skin thinning all
contribute to the aging mid face.1–3
PATIENT HISTORY AND PHYSICAL FINDINGS

■ A detailed history and physical examination is required prior to any
intervention.
■ The main reasons for patients to seek aesthetic procedures are to appear
younger and more attractive, and feel more confident.1
■ History of allergies, tobacco use, autoimmune disorders, connective tissue
diseases, anticoagulation therapy, and herbal therapies are important issues to
discuss with patients.
■ Note any prior surgeries on the midface or history of filler use; discuss the
type of filler and the number of previous treatments.
■ Examination of the face must be performed with the patient in the upright
position, as gravity is a major component of tissue descent.
■ Examine for facial symmetry, midface firmness, function, sensation and
presence of rhytids, skin lesions, or masses.
■ A standardized informed consent is obtained from each patient, ensuring they
understand the risks, benefits, and alternatives.
IMAGING
■ Use of photographic documentation is essential for both the patient and
surgeon to examine the effectiveness of the procedures.
■ Many computer programs and imaging modalities have the ability to create 3D
images to allow the surgeon to digitally modify the patient’s midface features,
showing the desired outcomes prior to injection.
■ Surgeons must obtain standardized before and after photographs for each
patient undergoing midface rejuvenation.
NONOPERATIVE MANAGEMENT
■ Injection of HA gel is a good option for patients desiring midface rejuvenation.
The technique is detailed in this chapter.
■ Off-label use of calcium hydroxyapatite is an effective filler substance for the
midface but lacks the reversibility seen with HA injection and is not currently
approved by the U.S. Food and Drug Administration.
SURGICAL MANAGEMENT
■ Autologous fat transfer to augment the aging midface is one surgical option.
■ One disadvantage of fat transfer is the requirement for a surgical procedure
and the associated donor-site morbidity.
■ Other surgical interventions to address the midface include the

transconjunctival midface lift or standard facelift.
T E C H N I Q U E S
■ Following informed consent, the patient is positioned in the upright position
to mark the midface zones and highlight the areas of concern (TECH FIG
1A).
■ No anesthesia is required for midface injections with Voluma XC or
Restylane Lyft, as each product contains lidocaine.
■ Optional topical lidocaine or related anesthetic gel may be used prior to
injection.
■ Clean the entry site on the midface with betadine or chlorhexidine prep.
■ Using a 25 (for a 27G cannula) gauge needle, make a hole in the skin at the
desired entry point.
■ Focus on targeting the three main regions of the midface: zygomaticomalar,
anteromedial cheek, and submalar regions (TECH FIG 1B).
■ Target the injection in the subcutaneous space.
■ The periosteal plane may also be targeted, and we prefer the use of included
27- or 30-gauge needles for the injection of Juvederm Voluma and Restylane
Lyft, respectively.
■ Thread the product in retrograde fashion to create the desired effect when
using the cannula technique; 0.2- to 0.3-mL sequential bolus injections are
preferred for needle-based periosteal placement.
■ Fanning or cross-hatching of the product may also be employed.
■ Take note to avoid the V2 neurovascular bundle in the anteromedial cheek
region.
■ Cross-hatching, with or without fanning, may be employed.
■ Massage of the injection sites can help manipulate the tissues to the desired
result.
■ Each therapy should be tailored to the patient’s desired effect.
■ When finished, reassess the patient in the upright position to evaluate any
areas needing further therapy.
■ On average, approximately 2.5 mL of HA filler is used per side during the
initial procedure for Voluma.1
■ About 1 month later, patients may undergo reinjection with an average of

approximately 1 mL per side, to achieve optimal correction.1
■ Patients with a history of oral herpes simplex virus are placed on
prophylactic antiviral therapy 2 days before and 5 days after injection.
TECH FIG 1 • A. Midface zones. B. Midface regions.
PEARLS AND PITFALLS
Techniques
■ The authors prefer a blunt cannula technique to avoid
intravascular injection.
■ Moderate manual massage by the surgeon helps to mold the filler.
■ Layering of the product in microaliquots can help achieve the
desired aesthetic result.
Complications
■ Hyaluronidase must be immediately available.
POSTOPERATIVE CARE
■ There are no activity restrictions for patients following the procedure.
■ Ice packs are provided for pain relief and/or edema.

■ Patients with history of bruising are provided Arnica Montana, a natural
remedy, and/or vascular-based nonablative laser.
FIG 2 • A–D. This 63-year-old woman underwent
injection of three syringes of HA filler to the three
regions of the midface.
OUTCOMES
■ Studies reveal results can last up to 2 years.
■ Most patients require an initial touch-up (approximately 1 mL per side) 1

month after the initial injection.
■ FIGS 1 and 2 are examples of patient results.
COMPLICATIONS
■ Potential complications are listed on all consent forms and must be discussed
prior to injection.
■ The most common complications include tenderness, swelling, firmness,
lumps, or bumps. Most issues resolve at 2 weeks.
■ Other complications include bruising, pain, redness, discoloration, and itching.
Most of these symptoms also resolve within 2 weeks.1
■ The most devastating complication is intravascular injection of HA filler,
which can result in tissue damage.
■ Hyaluronidase must be readily available in any office of clinical setting
providing HA fillers.
■ A standardized clinical protocol must exist for treatment of accidental intra-
arterial injection.
■ Idiopathic HA-based nodules have been reported and appear to respond to
anti-inflammatory agents combined with strategic hyaluronidase injection.
REFERENCES
1. Few J, Cox SE, Paradkar-Mitragotri D, Murphy DK. A multicenter, single-
blind randomized, controlled study of a volumizing hyaluronic acid filler for
midface volume deficit: patient-reported outcomes at 2 years. Aesthet Surg J.
2015;35(5):589-599.
2. Jones D, Murphy DK. Volumizing hyaluronic acid filler for midface volume
deficit: 2-year results from a pivotal single-blind randomized controlled study.
Dermatol Surg. 2013;39(11):1602-1612.
3. Weiss RA, Moradi A, Bank D, et al. Effectiveness and safety of large gel
particle hyaluronic acid with lidocaine for correction of midface volume deficit
or contour deficiency. Dermatol Surg. 2016;42(6):699-709.
4. Cotofana S, Schenck TL, Trevidic P, et al. Midface: clinical anatomy and
regional approaches with injectable fillers. Plast Reconstr Surg. 2015;136(5
suppl):219S-234S.