Các Kỹ Thuật Tiêm Thẩm Mỹ (Cosmetic Injection Techniques)

86
SECilON II • Neurotoxin InJection Techniques
•
•
-
a
b
Fig. 29.1 a, b Trigger points identified by the patient are injected with BoNTA. These may indude
the trapezius. occipitofrontalis. and temporalis muscles.

CHAPTER 29 • Neurotoxin Injection for Migraines
87
• Additional Reading
Binder WJ, Blitzer A. Treatment of migraine
headache with botulinum toxin type A.
Facial Plast Surg Clin North Am 2003;11:
465-4 75 PubMed
Blumenfeld A, Evans RW. Onabotulinumtox-
inA for chronic migraine. Headache 2012;
52:142-148 PubMed
Mathew NT, Frishberg BM, Gawel M, Dimi-
trova R, Gibson J, Turkel C; BOTOX CDH
Study Group. Botulinum toxin type A
(BOTOX) for the prophylactic treatment
of chronic daily headache: a randomized,
double-blind, placebo-controlled trial.
Headache 2005;45:293-307 PubMed

30
-------···-------
Management of Neurotoxin
Injection Complications
The key to managing complications of
neurotoxins is their prevention. Accu-
rate assessment and planning of injec-
tion sites will minimize the chances of
unsatisfactory results. Because of the
duration of clinical effect of only ap-
proximately 12 weeks, most side effects
are self-limiting and mild.
•Headache
Although BoNTA can be used to treat
migraine, some patients complain of
headache following injection. Some prac-
titioners feel this is due to "bumping"
the periosteum with the needle before
injection. These headaches usually do
not require treatment.
planning. These asymmetries may be
remedied with a small "touch-up" injec-
tion into the mobile muscle.
• Brow Ptosis
Usually this occurs from overtreatment
of the forehead in an already ptotic brow.
The key to treating this is prevention.
• Eyelid Ptosis
Due to the diffusion of BoNTA into the
levator palpebrae superioris muscle. This
complication is usually self-limited and
may last 2 to 3 weeks. Make sure the
correct diagnosis is made: evaluate the
patient to assess if the complication is
brow ptosis or lid ptosis.
• Asymmetries
Treatment of Eyelid Ptosis
Occasionally BoNTA results are not Often supportive measures are all that is
symmetric, usually due to poor injection necessary. Stimulation of Muller's mus-
88

OIAPTER 30 • Management of Neurotoxin InJection Complications
89
Fig. 30.1 Right upper lid ptosis developed 1 week after BoNTA injection to the glabella.
de with an a-adrenergic agonist can be
done in patients who are uncomfortable
with the appearance of the ptosis. These
medications indude the following:
• Naphcon A (naphazoline and pheni-
ramine ): a nonprescription over-the-
counter allergy ophthalmic drop
used for allergic ocular symptoms
(Alcon Inc., Fort Worth, TX).
• Iopidine 0.5% (apradonidine): a pre-
scription drop used to treat glau-
coma (Alcon Inc.).
Dosing of these drops is titrated by ef-
fect; usually 1 to 2 drops can be used 2
to 3 times a day. Side effects may indude
blurred vision, dry eye, tearing, and lid
edema.

(Trang không có chữ)

•SECTION Ill•
Introduction to Fillers

31
-------···-------
Fillers Overview
The use of injectable fillers has become
one of the most requested minimally in-
vasive treatment options to re-volumize
the aging face. Bovine collagen use was
limited both by its short duration of
effect and its potential for allergic reac-
tion. In 2003, the introduction of hyal-
uronic acid {HA) as a facial filling agent
revolutionized the world of fillers. Cur-
rently the U.S. Food and Drug Adminis-
tration {IDA) has approved various
types of HAs, biostimulatory products
like calcium hydroxylapatite and poly-L
lactic acid, as well as polymethylmeth-
acrylate, a permanent filler. Although
these fillers are FDA approved only for
certain indications, their .. off-label" use
has become the mainstay for facial reju-
venation in the United States.
92
• Hyaluronic Acid
Composition
Hyaluronic acid is a polysaccharide nor-
mally found in the connective tissues
of the body. Original HA products were
made from animals (e.g., rooster combs);
however, newer products are synthetic.
Injection
Some of these products are premixed
with lidocaine. Injection is performed
using 27- or 30-gauge needles. Cannulas
may be used, but usually needles are
preferred for accurate placement of this
product. Topical anesthetics or regional
blocks may be required.

Uses
This class of fillers is used to improve
mild to moderate folds and wrinkles.
These fillers may be used anywhere on
the face, including the lips, nose, and
around the mouth.
Precautions
These products should be placed in the
deep dermis, superficial subcutaneous
tissue, or pre-periosteal planes. When
injected too superficially, the product
can be seen through the skin and has a
blue appearance. This is due to the par-
ticles scattering blue light, referred to
in physics as the Tyndall effect. Because
of more uniform particle size, Belotero
may be placed more superficially and
is less likely to produce a Tyndall effect.
When injecting HAs, care must be taken
not to cause vascular injury by occlusion
or compression.
• Calcium Hydroxylapatite
Composition
Calcium hydroxylapatite (CaHA) is a
biostimulatory filler of CaHA spheres
suspended in an aqueous gel.
Injection
The FDA has approved mixing this prod-
uct with 2% lidocaine (0.2 cc) prior to
injection. Injection is performed using
a 27-gauge needle. Cannulas can also be
CHAPTER 31 • Fillers Overview
93
used to inject this product, and may
decrease the chances of vascular injury.
Topical anesthetics or regional blocks
may be required.
Uses
This thicker paste is used to improve
moderate to severe folds and wrinkles.
It should not be used around the eyes
or in the lips.
Precautions
This product should be placed in the sub-
dermal or preperiosteal plane. When in-
jecting this product, care must be taken
not to cause vascular injury by occlusion
or compression. This product is radi-
opaque and can be seen on X-rays and
computed tomography ( CT) scans.
• Polymethylmethacrylate
Composition
Polymethylmethacrylate (PMMA) is a
permanent filler composed ofPMMA mi-
crospheres (20%) suspended in a bovine
collagen gel.
Properties
This thick gel must be kept refrigerated.
Allow the syringe to come to room tem-
perature prior to injection. A 26-gauge
needle or cannula may be used for in-
jection. Topical anesthetics or regional
blocks may be required.

94
SECTION Ill • Introduction to Fillers
Uses
Due to the permanence of this product,
it should be injected only for improve-
ment of the nasolabial folds, cheeks/
midface, and marionette lines. Fill to
80% correction at the first injection and
place 20% more at second treatment ap-
proximately 4 to 6 weeks later. Do not
overcorrect with this product (see also
Chapter 35).
Precautions
A skin test is required 1 month prior
to injection of this product to rule out
allergy to bovine collagen. This product
is a permanent filler and should not be
used around the eyes and lips. Injection
should be placed in the subdermal or
pre-periosteal plane. When injecting
this product, care must be taken not
to cause vascular injury by occlusion or
compression.
• Poly-L Lactic Acid
Composition
Poly-L lactic acid {PLLA) is a biostimula-
tory filler composed of lyophilized crys-
tals of PLLA resuspended in water.
Injection
Poly-L lactic acid must be resuspended
with water prior to use. We recommend
using 5 to 8 cc preserved water. At the
time of injection, 1 to 2 cc of lidocaine
{1 or 2%) is added to the vial. Avoid shak-
ing this product in the vial because foam
in the bottle increases needle clogging.
Multiple treatments are needed at 4- to
8-week intervals until sufficient colla-
gen has been produced. The patient may
require three to five treatment sessions
for adequate correction. A maintenance
"boost" of one to two vials will be re-
quired every 1 to 3 years. Injection may
be performed with 25- or 26-gauge nee-
dles or cannulas. Topical anesthetics or
regional blocks may be required.
Uses
This product is used to restore volume
to faces that have developed lipoatrophy
from aging or HIV medications. It also
can be used to improve deep folds and
lines (see also Chapter 57).
Precautions
This product should be injected in the
subdermal or pre-periosteal planes. Nod-
ules or granulomas can form if the prod-
uct is injected too superficially (dermis)
or if too concentrated. The patient should
be advised to massage the injected areas
for 5 minutes, five times a day, for 5
days. When injecting this product, care
must be taken not to cause vascular in-
jury by occlusion or compression.

CHAPTER 31 • Fillers Overview
95
Table 31.1
Facial Fillers Currently FDA Approved in the United States
Year .FDA
Approved
Product Name
Composition
1981
Zyderm® 1
Bovine collagen
1983
Zyderm®2
Bovine collagen
1985
Zyplast®
Bovine collagen
2003
CosmoDerm® 1
Human collagen
CosmoPiast®
Human collagen
Restylane®
Hyaluronic acid (HA)
2004
Hylaform®
HA
Hylaform® Plus
HA
Captique™
HA
Sculptra® (HIV)
Poly-L lactic acid (PLLA)
2005
CosmoDerm® 2
Human collagen
2006
Juvederm® Ultra/Ultra Plus
HA
Artefill®
Polymethyl methacrylate (PMMA)
Radiesse®
Calcium hydroxylapatite (CaHA)
2007
Perlane®
HA
Elevess™
HA
2008
Prevelle® Silk
HA +lidocaine
Evolence®
Porcine collagen
2009
Hydrellen.t (formerly Elevessn.t)
HA
Sculptra® Aesthetic
PLLA
2010
Juvederm® XC products
HA +lidocaine
Restylane®-L
HA +lidocaine
Perlane®-L
HA +lidocaine
2011
Belotero
HA

32
-------···-------
Anesthesia Techniques
• Indications
Needle injections to the face are painful,
even more so in certain fadal areas. The
injector can shake the lip, use numbing
cream, or tap the cheek to "fool the
brain," but patients will tell you and ev-
eryone else that these injections hurtl
Although some injectables now have
lidocaine pre-added into the product or
can have lidocaine mixed into the prod-
uct at the time of injection, it is the nee-
dle that hurts. In addition, the lidocaine
does not take effect for several minutes
after injection. In sensitive areas like
the lip or when broad areas are being
treated, most patients will require some
form of anesthesia. Options include top-
ical anesthesia, ice, or regional blocks.
Even some of the most stoic patients
who dislike the feeling of regional
blocks have eventually succumbed to
the numbing block because, when done
correctly, it is much more comfortable
96
during the injection process. By using
these blocks, not only is the patient
more comfortable but the injector is
more at liberty to inject where neces-
sary to provide a better overall outcome.
The key to well-executed anesthesia is
knowledge of the anatomy, practice, and
having a routine.
• Anatomic Considerations
An intimate knowledge of the anatomy
of the trigeminal nerve (fifth cranial
nerve) is essential because its branches
(Vt, V2, and V3) provide cutaneous sen-
sory innervation to the face. The injector
should also understand how and why
anesthetics work to relieve pain. The
most commonly used blocks are the
infraorbital and mental blocks, though
mini-mucosal blocks have been de-
scribed and can be useful adjuncts for
treating areas around the mouth.

• Topical Anesthetics
Topical numbing creams are available
to lessen the feeling of the needle in-
sertion. These can be obtained as pre-
compounded products such as EMLA
(eutectic mixture of local anesthetics)
or Ela-Max (AstraZeneca, London, Eng-
land). EMLA contains 2.5% lidocaine
and 2.5% prilocaine. It is obtained only
by prescription and must be applied for
1 hour with or without occlusion. Oc-
clusion with plastic wrap can be used to
increase absorption, if desired. Ela-Max
(4% or 5% lidocaine) {AstraZeneca) is
available without a prescription, has a
30-minute onset of analgesia and can
be used with or without occlusion. In
addition, a cream can be compounded
by the physician's specifications, and
may include benzocaine {20%), lidocaine
(6%), and tetracaine (4%) {BLT; Bayview
Pharmacy, Baltimore, MD). BLT has a
quicker onset of action of approximately
20 minutes.
• Injection Technique
Regional or .. dental" blocks can be per-
formed for the midface {V2), lower face
(V3 ), or both. The injection technique
should be directed at the base of the
nerve as it exits the bone, which will
provide the most effective and broadest
area of anesthesia. This technique also
permits the least use of lidocaine (with
or without epinephrine) and the least
distortion of surrounding soft tissues.
As such, to adequately reach the desired
CHAPIER 32 • Anesthesia Techniques
97
target areas it is often necessary to use
at least a l-inch {2.5-cm) or longer nee-
dle. If a finger is placed over the infra-
orbital foramen, then the needle can be
directed percutaneously toward the fo-
ramen and approximately 0.5 cc of local
injection placed on the periosteum near
the nerve, but not in the opening. Simi-
larly, if the mental foramen can be pal-
pated in its position near the first molar,
then the needle can be angled to land
near its location on the face of the man-
dible. A second injection is done with the
needle in the submucosal plane along
the gingival-buccal sulcus. This is per-
formed in a retrograde fashion, as the
needle that has been passed from the
first premolar posteriorly to the back
molar is withdrawn.
Mini-blocks are a series of 0.1-cc ali-
quots of local anesthesia injected just
submucosally in the sulcus approxi-
mately 1 em apart to anesthetize the lips
and nasolabial folds. These blocks tend
to be more variable in effect and more
short acting in duration. One major ben-
efit is that they are very useful in getting
the center of the upper lip numb when
the regional blocks fail in this area.
Alternate Technique
Dental block may be performed intra-
orally only via a buccal sulcus injections
into the canine fossa and inferiorly at
the mental foramen. The areas not
anesthetized by these blocks are treated
with topical anesthetics, which may be
placed at the philtrum and lateral oral
commissures.

98
SECTION Ill • Introduction to Fillers
• Precautions
Especially with the use of epinephrine,
the patient may experience some mild
tachycardia and some rarer cases oflight-
headedness and occasional fainting. In
those patients who are particularly sen-
sitive, a note should be placed in the
chart noting epinephrine sensitivity. Al-
ternately, 1 or 2% plain lidocaine can be
utilized; however, the anesthesia result
may not be as dense or as long acting.
• Post-Injection Instructions
The duration of effect of the injection
typically is 1.5 to 2 hours.
• Risks
Minimal to none unless bupivacaine is
used. (Intravascular bupivacaine injec-
tions have been known to cause irre-
versible cardiac arrhythmias.) Lidocaine
can be toxic, and overdose may be fatal.
Patients should be observed when topi-
cal applications are used on large areas
of the body.
• Pearls of Injection
Caffeine intake, lack of sleep, hormonal
variations, and stress can all make a pain-
ful experience more so. Shaking the lip
when the needle enters the mucosa or
actually pulling the mucosa onto the tip
of the needle can minimize the discom-
fort of the initial numbing injection. Use
of topical intraoral lidocaine can also
make the entrance of the needle easier
in the most sensitive patients. In areas
where a regional or local block is not
possible, distraction using the gate the-
ory of pain can help to decrease dis-
comfort. Use of tapping or vibration at
the site or an adjacent site can flood
and then downregulate the perception
of painful stimuli felt by the central ner-
vous system.
• Additional Resources
Dentists can provide valuable assis-
tance when learning to perform regional
blocks. Ask a dentist to show you how to
provide regional anesthesia or "dental
blocks."

CHAPTER 12 • Anesthesia Tedlnlques
99
(
-----+----Mental n.
Fig. 32.1 Maxillary (V2) and mandibular (V3) divisions of the trigeminal nerve supply sensation to
the middle and lower face.
• Additional Reading
Dillane D, Finucane BT. Local anesthetic sys-
temictoxidty. Canj Anaesth 2010;57:368-
380 PubMed
Niamtu j Ill. Simple technique for lip and na-
solabial fold anesthesia for i(\jectable fill-
ers. Dermatol Surg 2005;31:1330-1332
PubMed

33
-------···-------
Filler Injection Methods
• Linear Threading
• Depot
Product is injected in a line or "thread" Small aliquots of product deposited in
as the needle is moving.
the desired plane.
Anterograde Injection
The needle is advanced as product is
being injected ahead of the needle. The
injector can usually visualize the prod-
uct tracking in front of the needle. This
technique may be used for the vermil-
lion border or the tear trough.
Retrograde Injection
The needle is fully advanced without
injection, and injection commences as
the needle is withdrawn, filling the tract
with product.
100
• Serial Puncture
Also called a "string of pearls" injection.
Multiple dosely spaced depot injections
are placed in a linear fashion along a
wrinkle or fold.
• Fanning
From a single entry point, the needle is
fanned in multiple directions, and prod-
uct is placed by retrograde injection. In
this technique, it is important to stop

CHAPTER 33 • Filler Injection Methods
1 01
injecting as the needle nears the inser-
The needle is then directed to each side
tion site to prevent buildup of product of the central tract, and product is placed
at the point of entry. In addition, the in small quantities, like the branches of
needle must be almost completely re-
a fern. This technique is useful when
moved from the patient before redirect-
treating fine lines with filler.
ing to create a new tunnel. Often fanning
tracts are overlapped by using several
sites of insertion.
• Cannulas
• Cross-Hatching
Multiple linear threads placed in an
X-shaped fashion.
• Grid
Linear threads intersecting at right
angles.
• Ferning
The needle is fully inserted and injection
is performed in a retrograde fashion.
The choice of needles or cannulas for
injection of fillers is based on the per-
sonal preference of the injector. Cannula
use lessens the chances of intravascular
injury and may diminish bruising; how-
ever, the trade-off is precise control of
the product. We have found that cannu-
las may be used for large-volume injec-
tions of product placed pre-periosteally
or subcutaneously, but we prefer nee-
dles for fine, controlled injections placed
more superficially.

1 02
SECTlON Ill • Introduction to Fillers
Anterograde
===-z:::::::=t
Retrograde
Fanning
Grid
Fig. 33.1
Injection techniques.
Depot
Serial
puncture
Crosshatching
Ferrung (recrograde)
•~Ll Ll
1 ' \ \ '

•SECTION IV•
Filler Injection Techniques

34
-------···-------
Filler Injection for Nasolabial Folds
Difficulty: •
Patient Satisfaction: • • •
Risk: ••
• Indications
The nasolabial fold (NLF). the groove
from the comer of the nose to the outer
comer of the mouth, is perhaps one of
the most maligned, studied, poked, filled,
and worried-about features in fadal
cosmetic surgery. It is present in youth,
deepens with the aging process, and is
not well addressed by facelift surgery. It
is the site of most "on-label" filler prod-
uct applications, it is easiest to study as
it has a built-in control (the opposite
side), and there are good grading scales
that have long been agreed upon to de-
scribe various severities of the notorious
104
fold. In the quest to eradicate this bane
of the aging face, it important to con-
sider that not all faces should be com-
pletely "nasolabial fold-free," and in fact
complete flattening or overfilling of the
fold produces quite an unnatural appear-
ance. Some NLFs are etched creases in
the skin, whereas others are deep struc-
tural folds transitioning from the lip to
full ••apple" cheeks.
• Anatomic Considerations
Volumetric loss of the malar mound and
descent of the cheek can contribute to
folding over of the skin lateral to the fold
Thinning of the upper lip and perioral
complex can lead to sinking of the me-
dial portion of the fold. Injection deep
into the area near the comer of the nasal
ala can be perilously close to the angular
artery, a branch of the facial artery.

CHAPTER 34 • Filler Injection for Nasolabial Folds
1 OS
• Injection Technique
Placement of product in this region
may be performed by using the cross-
hatching, fanning, linear threading, or
serial puncture techniques. The product
generally is placed at varying depths,
deeper for folds and more superficial
for wrinkles. The area injected should
be massaged into place after injection to
minimize lumpiness.
Technique
• Precautions
Injecting deeply onto bone at the corner
of the nasal ala, near the pyriform aper-
ture, can provide nice elevation of a deep
fold. However, extreme caution must be
used with proper placement and either
aspiration or perhaps the use of a blunt
cannula to avoid intravascular injection.
Superficial injections especially parallel
to the fold will increase the risk of the
Tyndall effect.
The injection technique should be mostly • Post-Injection Instructions
perpendicular to and medial to the fold,
just barely crossing or coming to the Ice and pressure are helpful to prevent
edge of the fold so as not to augment bruising in this region. The product will
lateral to the fold. It is best to imagine swell some with hyaluronic acid (HA)
a tall, thin, triangular deficit in front of and feel firmer to palpation the first
the fold that needs to be filled with fan-
week, and then blend in more naturally.
ning or threading injections rather than This is also true of CaHA injections which
large boluses or a fat sausage roll placed become firm, then soften over time.
parallel to and under the fold.
Alternate Technique
Injection can begin as described above
with filler placed in a deeper plane, per-
pendicular to the fold, to act as scaffold-
ing. A second layer is placed more su-
perficially parallel to and slightly medial
to the fold. A fanning technique can be
performed at the nasal-alar junction,
with care being taken not to inject the
angular artery.
• Risks
Minimal risks besides bruising and Tyn-
dall effect from too superficial injection
into the dermis.
• Pearls of Injection
Overcorrection of the nasolabial fold can
look unnatural and should not be overly
flattened.

106
SECTlON IV • Filler Injection Techniques
Many products have been approved for the superficial subcutaneous layers and
use in this region induding hyaluronic avoid more superficial injection. PMMA
add (HA1 calcium hydroxylapatite (CaHA),
is a permanent filler, and patients are
and polymethylmethacrylate (PMMA).
generally "under-filled" initially, with
All are injected similarly, with care being re-injection six weeks later.
taken to place CaHA and PMMA deep in
-
a
b
Fig. 34.1 a, b Possible techniques to treat the nasolabial fold are shown. The injector may choose to
perform a combination of these techniques to achieve maximum correction of the fold. (a) Filler may
be placed along the depth of the fold as well as horizontally to act as a scaffold for the filler. Fanning
technique can be performed at the nasal-alar crease. (b) Some patients will require the placement of
more filler medial to the fold as shown.

CHAPTER 34 • Filler Injection for Nasolabial Folds
1 07
• Additional Reading
Bass LS, SmithS, Busso M, McClaren M. Cal-
cium hydroxylapatite (Radiesse) for treat-
ment of nasolabial folds: long-term safety
and efficacy results. Aesthet Surg J 2010;
30:235-238 PubMed
Fedok FG. Advances in minimally invasive
facial rejuvenation. Curr Opin Otolaryngol
Head Neck Surg 2008;16:359-368 PubMed
Lemperle G, Knapp TR, Sadick NS, Lemperle
SM. ArteFill permanent injectable for soft
tissue augmentation: I. Mechanism of ac-
tion and injection techniques. Aesthetic
Plast Surg 2010;34:264-272 PubMed
Lupo MP, Smith SR, Thomas JA, Murphy DK,
Beddingfield FC III. Effectiveness of juve-
derm Ultra Plus dermal filler in the treat-
ment of severe nasolabial folds. Plast Re-
constr Surg 2008;121:289-297 PubMed
Narins RS, Dayan SH, Brandt FS, Baldwin EK
Persistence and improvement of nasolabial
fold correction with nonanimal-stabilized
hyaluronic acid 100,000 gel particlesjmL
filler on two retreatment schedules: re-
sults up to 18 months on two retreatment
schedules. Dermatol Surg 2008;34(Suppl
1 ):S2-S8, discussion 58 PubMed

35
-------···-------
Filler Injection with
Polymethylmethacrylate (Artefill)
Difficulty: • • • •
Patient Satisfaction: • •
Risk: •••
• Indications
Polymethylmethacrylate (PMMA) is used
as a permanent filler for improving the
nasolabial folds. This filler is most often
used in patients who have used absorb-
able fillers and desire a more permanent
correction. This is also a filler to con-
sider for men, who often do not want to
undergo multiple treatments.
• Anatomic Considerations
Because of its permanence, we prefer to
use this product only in the nasolabial
108
folds, cheeks, and marionette lines. It is
contraindicated for use in the lips.
• Precautions
The PMMA microspheres are suspended
in a bovine collagen matrix. A skin test is
required prior to injection to determine
if the patient has an allergy to bovine
collagen.
• Injection Technique
Injection should be placed in the sub-
dermal plane. The product is stored in
the refrigerator and must be allowed
to come to room temperature prior to
injection. Retrograde tunneling, cross-
hatching, or depot injection techniques
are appropriate.

OIAPTER 35 • Filler Injection with Polymethylmethaaylate (Arteflll)
109
• Post-Injection Instructions
• Pearls of Injection
Ice as needed.
Polymethylmethacrylate should be used
with caution in patients who are filler
naive. It may be preferable to inject pa-
• Risks
tients first with a reversible or semi-
permanent filler. The bovine collagen
Do not overcorrect with this product. matrix absorbs in 4 weeks, so a sec-
Fill to 80% correction with the first treat-
ond treatment should be performed at
ment and give 20% more at the second that time. Patients should be informed
treatment, usually 4 to 6 weeks later. that their results will actually improve
Nodules may form if the product is in-
over time as the body forms collagen
jected into the lips or around the eyes. around the PMMA partides; their 5-year
Because of the large partide size, care results may look better than their 1-year
must be taken to avoid intravascular in-
results.
jection and possible vessel ocdusion.
·-----Nasolabi.al
fold
a
Fig. 35.1 a, b (a) Polymethylmethacrylate (PMMA) is placed in the subcutaneous tissue to augment
the nasolabial fold. Injections can be placed along the fold as shown, or these techniques can be
combined as needed to optimize results. (continued on next page)

11 0
SECTlON IV • Aller Injection Tedlnlques
b
.,---------=-- Marionene
Jine
Flg. 35.1a, b (Continued) (b) The marionette lines can be treated similarly with either technique
shOINil or a combination of these techniques.
• Additional Reading
Cohen SR, Berner CF, Bussa M, et al. Five-year
safety and efficacy of a novel polymethyl-
methacrylate aesthetic soft tissue filler
for the correction of nasolabial folds. Der-
matol Surg 2007;33(Suppl 2):5222-5230
PubMed
Hilinski JM, Cohen SR. Soft tissue augmenta-
tion with ArteFill. Fadal Plast Surg 2009;
25:114-119 PubMed
Lemperle G, Knapp TR, Sadick NS, Lemperle
SM. ArteFill pennanent injectable for soft
tissue augmentation: I. Mechanism of ac-
tion and injection techniques. Aesthetic
Plast Surg 2010;34:264-272 PubMed

36
-------···-------
Filler Injection for Marionette Lines
Difficulty: •
Patient Satisfaction: • •
Risk: •
• Indications
groove and acts to deepen the groove.
Volumetric loss of the prejowl and chin
soft tissues can also lead to deepening
this region.
• Injection Technique
The injection technique should be per-
The groove that descends vertically from
pendicular to and medial to the fold so
the comer of the mouth toward the as not to augment lateral to the fold. It
mandible is known as the marionette can be helpful to pinch or squeeze the
line, drool line, or melolabial groove.
fold with the thumb and first finger on
These folds are prominent contributors either side of the line down onto the
to signs of fadal aging due to volume chin to accentuate the line and demon-
loss in the prejowl region, and may ere-
strate its extent. This technique will also
ate a sad, tired, and more aged facial demonstrate the accessory lines that
countenance.
are generally parallel to the marionette
lines, and other weakened areas of skin
and volume loss in the vicinity. Once
• Anatomic Considerations
those are determined, the appropriate
treatment can begin. Fill should occur
The action of the depressor anguli oris in the areas of concavity, avoiding thicker
(DAO) muscle underlies the melolabial areas of convexity.
111

112
SECTlON IV • Filler Injection Techniques
• Precautions
• Risks
Undercorrection of this area will lead to Minimal risks besides bruising and TYn-
unsatisfactory results, and patients will dall effect from overly superfidal injec-
feel "that didn't make much of a differ-
tion into the dermis.
ence." It can often take 1 cc of product in
each marionette line to correct the en-
tire area and blend in on the chin and all
the way down toward the mandible, not
even induding the prejowl or along the
mandibular border, to achieve a proper
correction.
• Post-Injection lnstrudions
Ice and pressure is helpful to prevent
bruising. The product will swell some
with an HA and feel firmer to palpation
the first week and then blend in more
naturally. Massage of the area after in-
jection will help reduce lumpiness.
• Pearls of lnjedion
Overcorrection of this area is unlikely,
unless there are no lines to begin with
before injection. Bruising is quite com-
mon. As this area blends in with the oral
commissure, techniques to augment the
oral commissure will assist in improv-
ing the appearance of this fold (see
Chapter 38).
Superior and
inferior labial a.
Fig. 36.1 A combination of techniques may be necessary to improve this region, including injection
into the fold, horizontal filling across the fold, and fanning at the oral commissure. Combine tech-
niques as needed to obtain the desired clinical result.

CHAPTER 36 • Filler Injection for Marionette Lines
113
• Additional Reading
jansen DA, Graivier MH. Evaluation of a cal-
cium hydroxylapatite-based implant (Ra-
diesse) for facial soft -tissue augmentation.
Plast Reconstr 5urg 2006;118(3, 5uppl)
225-305, discussion 315-335 PubMed
Wise JB, Greco T. Injectable treatments for
the aging face. Facial Plast 5urg 2006;22:
140-146 PubMed

37
-------···-------
Filler Injection for Lip Augmentation
Difficulty: •
Patient Satisfaction: • •
Risk: ••
• Indications
One of the most requested filler treat-
ments is that of lip rejuvenation or
augmentation. Unfortunately, poor tech-
nique in performing this injection has
resulted in patients being fearful of un-
natural and overdone results.
• Anatomic Considerations
It is important when filling the lips to
dedde what area needs to be aug-
mented: the volume of the lip, the out-
line, or both. The lips can be accentuated
and shaped by filling the vermillion bor-
114
der. There is a potential space that. if en-
tered accurately, will allow the product
to track along the lip margin.
Volume can be placed in the body
(pink) of the lips for augmentation or
rejuvenation, or to improve symmetry.
Often overlooked are the philtral col-
umns, which flatten with aging. A small
amount of filler to accentuate the phil-
trum will give more definition to cupid's
bow and slightly evert the upper lip.
• Injection Technique
Filler injections into the lips can be quite
painful. A dental block or topical anes-
thetic may be placed prior to injection.
Some injectors believe that no anesthetic
is necessary when using fillers with
added lidocaine. A skillful injector will
inject slowly and enter the skin in areas
previously injected that have become
anesthetized. These injections are gen-

CHAPTER 37 • Filler Injection for Up Augmentation
115
erally placed in the superficial subcuta-
neous plane. Massage after injection
helps to evenly distribute the product.
Injection of the vermillion proceeds
from lateral to medial. Palpation is im-
portant to feel how far along the ver-
million the filler has traveled and to de-
tect untreated or skipped areas. Injection
may be performed in an anterograde
fashion as the filler can track along a
plane along the vermillion. Alterna-
tively filler may be placed in a retro-
grade fashion.
The body of the lips can be improved
by filling in the zones that require aug-
mentation. Do not think of the lip as one
long unit but rather as smaller subunits,
and fill appropriately. Overdone lips
are usually the result of overfilling the
lip without paying attention to aesthetic
units. Do not fill the lips like "filling a
sausage."
The philtra! columns can be redefined
using a small amount of filler. Pinch the
philtrum after injection to further de-
fine the ridges.
• Precautions
As a general rule, do not inject more
than 3 cc into the lips at one time. Avoid
over-injection of the upper lip, especially
in patients with very small lips. Rather
than over-filling small lips, consider the
adjunctive use of BoNTA to evert and lift
the lips (see Chapter 15).
• Post-Injection Instructions
Ice as needed. Bruising and edema are
likely. Advise patients that the edema
will subside in a few days.
• Risks
Injections into the lips can stimulate
recurrence of herpes simplex viral erup-
tions. Any patient receiving lip injec-
tions who has a history of fever blisters
should be placed on a short course of
antiviral medication.
• Pearls of Injection
Consider treating the oral commissures
when treating the lips (see Chapter 14).
Take photographs prior to performing
the dental block, as the block itself will
likely produce some asymmetries. Once
the injection is completed, persistent
asymmetries may be evident. Wait until
the effects of the local anesthetic have
worn off before assessing the final results.
Because of its hydrophilic properties and
syrup-like consistency,juvederm may be
preferable for use in the lips.

a
c
e
116
SECTlON IV • Filler Injection Techniques
---.. ---
-
-
-
-
Fig.37.1a-f (a) The philtra! columns can be augmented linearly along the fold. (b) Alternatively.
the philtra! columns can be augmented with small horizontal retrograde injections injected medial
to lateral. (c) Definition of the lips is accomplished by augmenting the vermillion border. injection
either retrograde or anterograde, from lateral to medial. (d) Small amounts of filler may need to be
placed outside the vermillion after augmentation to decrease shadowing. (e) Up fullness is achieved
by directed injection into the body of the lips. artistically filling in deficient areas. (f) A combination
of these techniques may be necessary to achieve the desired results.
b
d
f

CHAPTER 37 • Filler Injection for Up Augmentation
117
• Additional Reading
jacono AA. A new classification of lip zones
to customize injectable lip augmentation.
Arch Facial Plast Surg 2008;10:25-29
PubMed
Sarnoff DS, Saini R, Gotkin RH. Comparison
of filling agents for lip augmentation. Aes-
thet Surgj 2008;28:556-563 PubMed
Sclafani AP. Soft tissue fillers for manage-
ment of the aging perioral complex. Facial
Plast Surg 2005 ;21 :74-78 PubMed

38
-------···-------
Filler Injection for Elevating the
Oral Commissures
Difficulty: ••
Patient Satisfaction: • •
Risk: ••
• Indications
The comer of the mouth, known as the
oral commissure, turns downward with
age, and often there is a genetic predis-
position to this downward tum. Filling
the oral commissure can significantly
alter the sad or angry appearance; it can
"turn the frown upside down."
• Anatomic Considerations
In childhood, the corner of the mouth
turns up in a slight smile. In the teens
to early twenties, the commissure be-
comes level to neutral in position. It is
118
not until later in life, when skin, soft tis-
sue, and volumetric loss in the lower
face and chin develop, that the oral com-
missure angle drops and may become
turned downward or negative in its vec-
tor. When this occurs, the overall effect
is one of a sad, tired, or stern fadal
countenance.
• Injection Technique
The most frequently used products in
this area are the hyaluronic adds (HAs).
The injection technique involves pladng
an X-like injection at the oral commis-
sure. A depot of product inferiorly also
can help tum the commissure upward.
Occasionally an injection of filler can
be placed perpendicular to the com-
missure. A slight immediate overcorrec-
tion, which takes a down-turned lip and
makes it into a slightly up-curved lip
at the comer, is necessary to achieve a

CHAPIER l8 • Filler InJection far Elevating the Oral Commlssures
119
good result when the swelling subsides.
Also, because this is such a highly mo-
bile area, it is necessary to use an ade-
quate amount of product in the space or
the effect will be relatively short lived.
• Precautions
It is important to advise patients that
they will experience an overcorrection
at first, and that they should not be
alarmed by a slight "joker-like" smile at
Opr-ion:tl
verticoal
injection
Oownw:ard h:tnging
41
9rnl Wmmi»ur~
b
..
~ J
~lrernati~
rechn:ique
Fig. 38.1 a, b (a) The oral commissure can be
elevated by injecting in an ><-shaped fashion as
shown. An optional vertical injection can also be
placed. A depot of filler will also act to support
the commissure. (b) Alternate fanning technique
may be used alone or in combination with other
procedures described.
first. This will resolve once the swelling
subsides.
• Post-Injection Instructions
Ice and pressure are helpful to prevent
bruising. Bruising and a sense of firm-
ness or hardness in the corner are not
uncommon.
• Risks
Minimal risks occur besides bruising and
the lYttdall effect from overly superfi-
dal injection into the dermis.
• Pearls of Injection
The action of the depressor anguli oris
(DAO) musde pulls the comers down. In
cases where fillers result in inadequate
upturning of the commissures, consider
also treating the DAO with BoNTA (see
Chapter 14).
• Additional Reading
Carruthers A, Carruthers J, Monheit GD,
Davis PG, Tardie G. Multicenter, random-
ized, parallel-group study of the safety
and effectiveness of onabotulinumtoxinA
and hyaluronic acid dermal fillers (24-mg/
ml smooth, cohesive gel) alone and in
combination for lower facial rejuvenation.
Dermatol Surg 2010;36{Suppl 4):2121-
2134 PubMed
Perkins SW. The comer of the mouth lift
and management of the oral commissure
grooves. Facial Plast Surg Clin North Am
2007;15:471-476, vii PubMed

39
-------···-------
Filler Injection for Vertical Lip Lines
Difficulty: •••
Patient Satisfaction: • •
Risk: ••
• Indications
Perioral wrinkles extend radially from
the lips due to the repeated puckering
motion from speaking or smoking. In
women, lipstick may "bleed" into these
lines. In nonsmokers, these lines can be
produced in patients who purse their lips
while talking.
• Anatomic Considerations
The orbicularis oris muscle is the sphinc-
ter that surrounds the mouth. Repeated
contraction of this muscle may result in
circumoral rhytids.
120
• Injection Technique
Because of the risk of visible product
ridges under the skin, this is a difficult
area to correct with fillers. Only low-
concentration hyaluronic acid (HA) fill-
ers and small volumes of product should
be used in this area. The initial injection
is placed along the vermillion border.
Subsequent injections are placed in the
skin of the lips; a combination of linear
threading and cross-hatching techniques
can be used Injection in the lips is pain-
ful. Patients may require topical anes-
thesia or a dental block.
• Precautions
Consider antiviral medication when in-
jecting patients with a history of fever
blisters (herpes simplex).

a
b
OIAPTER 39 • Filler lnjedlon for Vertical Up Unes
121
• Post-Injection Instructions
Ice as needed.
• Risks
Patients should be counseled that fillers
and neurotoxins cannot fully eradicate
lip lines. Risks indude asymmetry, in-
complete correction, and bruising.
~
• Pearls of Injection
I
I
Fig. 39.1a, b (a) The vennillion is treated first,
injecting from laterc~l to medial in an antero-
grc~de or retrograde fashion. (b) After the vermil-
lion is outlined. the lip lines are treated in a verti-
cal or a cross-hatch fashion and massaged after
injection to minimize lumpiness. A combination
of these techniques may be required to optimize
dinical results.
Do not over-inject this area. Massage
after injection to minimize lumpiness.
The concomitant use of neurotoxins in
this area can improve results (see also
Chapter 16).
Perioral lines can be quite resistant to
many forms of treatment. Consider laser
resurfadng. chemical pee~ dermabrasion,
or other adjunctive measures to treat
stubborn lines.
• Additional Reading
Ali MJ, Ende K, Maas CS. Perioral rejuvena-
tion and lip augmentation. Facial Plast
Surg Clio North Am 2007;15:491-500, vii
PubMed
Barton FEjr, Carruthers J, Coleman S, Graivier
M. The role of toxins and fillers in perioral
rejuvenation. Aesthet Surgj 2007;27:632-
640 PubMed

40
-------···-------
Filler Injection for Glabellar
Frown Lines
Difficulty: •••
Patient Satisfaction: • •
Risk: •••
• Indications
Neurotoxins are commonly used to treat
the vertical lines between the brows.
Fillers can be used in conjunction with
fillers, or as a primary mode if patients
are afraid of BoNTA injections. The hori-
zontal lines on the nasal dorsum can be
similarly treated.
• Anatomic Considerations
The vertical lines of the glabella are pro-
duced by contraction of the paired cor-
rugator superdlii muscles, and the hori-
122
zontallines are caused by contraction of
the centrally located procerus muscle.
Branches of the supraorbital and su-
pratrochlear vessels are located in the
glabella. The supratrochlear artery is a
distal branch of the ophthalmic artery.
• Precautions
Injection of fillers in this region should
be considered with some trepidation.
Warnings in the past about collagen
injections suggested that arterial embo-
lization and possible skin necrosis could
occur with injection in the glabella.
Additionally, particles can travel retro-
grade in the supratrochlear vessels and
embolize the ophthalmic artery. Be-
cause of the high risk in this area and
the potential for lumpiness, hyaluronic
acids (HAs) are the product of choice in
this region.

CHAPTER 40 • Filler Injection for Glabellar Frown Lines
123
• Injection Technique
Topical anesthesia may be used; how-
ever, this injection usually can be toler-
ated without anesthesia.
Prior to injecting the patient, have the
patient frown the brow. Filler is placed
deep and parallel to the wrinkle with a
30-gauge needle. Filler is placed into the
superficial to mid-dermis and massaged
to prevent lumpiness.
• Post-Injection Instructions
Ice as needed.
• Risks
When treating the vertical lines of the
glabella, reflux on the syringe prior to
injecting to minimize the risk of arterial
injury, and do not inject deeply in this
area. Do not overfill in this area to mini-
mize lumpiness and the risk of vascular
compression. However, injection of the
horizontal lines over the nasal bridge is
much safer and can be injected into the
subdermal plane. Massage is also neces-
sary to prevent lumpiness.
• Pearls of Injection
Patients who have persistent glabellar
lines after BoNTA treatment may benefit
from injection of fillers into the residual
creases. Patients find that the combi-
nation of fillers and neurotoxins in this
region produces a longer lasting result.

124
SECTlON IV • Filler Injection Techniques
Supratrochlear a. and n .
Supraorbital a. and n.
Orbital rim
Fig. 40.1 Hyaluronic acid is placed deep to and parallel to the gla bellar creases. Stay very superficial
in this region to avoid injury to the supraorbital and supratrochlear vessels.
• Additional Reading
Carruthers J, carruthers A. Volumizing the
glabella and forehead. Dermatol Surg 201 0;
36(Suppl3):1905-1909 PubMed
Glaich AS, Cohen JL, Goldberg LH. Injection
necrosis of the glabella: protocol for pre-
vention and treatment after use of dermal
fillers. Dermatol Surg 2006;32:276-281
PubMed

41
-------···-------
Filler Injection for Forehead Wrinkles
Difficulty: • •
Patient Satisfaction: • •
Risk: ••
• Indications
Transverse wrinkles of the forehead in
patients who have had insufficient re-
sponse from BoNTA injections, or who
are not candidates for BoNTA injection
of the forehead.
• Anatomic Considerations
Transverse wrinkles of the brow gener-
ally respond to neurotoxin injection;
however, even with BoNTA, some rhytids
may not fully improve. Also, some pa-
tients are opposed to BoNTA injections.
Patients with ptotic brows may not be
candidates for BoNTA because the ptosis
can be accentuated (and constantly rais-
ing a ptotic brow is likely the reason
they have rhytids in the first place!). In
certain cases, the injector may elect to
augment deep transverse folds of the
forehead with filler.
• Injection Technique
Multiple injections are required in this
area, so topical anesthetic is recom-
mended. Small depot injections are
placed along the line of the wrinkle in
the immediate subdermal plane. The
filler is marched along the fold along its
entire length. Mter several injections, the
product should be massaged to evenly
distribute the filler into the wrinkle. Hold
firm pressure over areas that bleed.
125

126
SECTlON IV • Filler Injection Techniques
• Precautions
Care must be taken to smooth the prod-
uct well and to place very small amounts
directly into the fold to elevate the
crease. Inject only the amount of prod-
uct necessary to improve the wrinkle, or
an elevated ridge of product will be seen
horizontally across the forehead.
• Post-Injection Instructions
None. Ice may be used for bruising.
• Risks
Although this is an easy technique,
vascular interruption of the subdermal
vessels can occasionally occur. If
blanching of a wide area is seen during
injection, usually massage and warm
compresses will restore the circulation
to the region.
• Pearls of Injection
Use a small needle (30 or 32 gauge) and
inject only enough filler to elevate the
wrinkle. Do not over-injectl Because of
the chance of lumpiness, we prefer hy-
aluronic adds in this area. Combining
fillers with BoNTA can also improve
results.
o.OO""V""o•gO-O.O.Oc;:l;g
Gg.
vcro•v•oo• G-GG Oc;;•
Fig. 41.1
Filler is placed like a string of pearls along the forehead crease. The serial puncture (depot)
technique is used and the product is smoothed by gentle massage of the treated areas.

CHAPTER 41 • Filler Injection for Forehead Wrinkles
127
• Additional Reading
Carruthers JDA, Glogau RG, Blitzer A; Facial
Aesthetics Consensus Group Faculty. Ad-
vances in facial rejuvenation: botulinum
toxin type a, hyaluronic acid dermal fill-
ers, and combination therapies-consensus
recommendations. Plast Reconstr Surg
2008;121(5, Suppl)5S-30S, quiz 31S-36S
PubMed
Coleman KR, Carruthers J. Combination
therapy with BOTOX and fillers: the new
rejuvnation paradigm. Dermatol Ther
2006;19:177-188 PubMed

42
-------···-------
Filler Injection for Tear
Trough Deformity
Difficulty: ••••
Patient Satisfaction: • • •
Risk: ••
• Indications
The semicircular depression under the
eyes may be filled with hyaluronic acid
(HA) fillers to lessen the shadowing in
this area. Fillers may be used to delay
blepharoplasty surgery in patients with
mild fat herniation.
• Anatomic Considerations
aassically the tear trough referred to the
most medial segment of the under-eye
crease; however, with aging the infra-
orbital rim becomes more skeletonized
and filler may be placed at the top of the
rim along its entirety.
128
• Injection Technique
This is not a painful area to inject, but
it is quite unsettling for many patients.
Options for anesthesia include topical
anesthetic cream, or an infraorbital
nerve block using a small amount of
lidocaine.
This is one of the most difficult areas
to inject well. Ideally a l-inch (2.5-cm ).
30-gauge needle should be used to allow
the point of entry to occur below the
thin skin of the lower eyelid. This will
greatly reduce the amount of bruising.
as most of the blood vessels are in the
orbicularis muscle. The needle is then
passed upward at an angle until it comes
to rest at the top of the orbital rim,
where the finger of the opposite hand
is positioned so as to direct the needle,
confirm the location, and protect the
contents of the orbit. Injection should
not proceed until the tip of the needle
has been place against the bone and its

CHAPTER 42 • Filler Injection for Tear Trough Deformity
129
precise location has been verified. Inject
very slowly and deeply onto the bone.
It is very important that the product be
precisely placed at the highest point
along the upper edge of the maxilla at
the top of the infraorbital rim. If out of
hesitation or fear the injection is placed
lower, one runs the risk of creating a
deeper trough by augmenting the cheek
while neglecting the deep valley. Mas-
sage the product as it is injected in small
0.1- to 0.2-cc depot boluses to fill in the
depressed areas. The patient should be
placed in a sitting position. Have the
patient vary the eye position, as this may
accentuate bulges and depressions and
aid in evaluating for symmetry.
• Precautions
Inject deeply onto the orbital rim perios-
teum. Superficial injections will increase
bruising and increase the risk of the
Tyndall effect.
• Post-Injection Instructions
Ice is necessary. Bruising is possible but
less common when injected as de-
scribed above. If injected through the
thin skin or superficially, then bruising
will be very common. Lumpiness and
unevenness of the lower lid should not
be seen if the injection has been done
properly, unless a hematoma occurs. If it
persists for more than 2 weeks, have the
patient place a warm compress over the
lid for 20 minutes while applying firm
pressure. This can help flatten lumps
and improve minor irregularities.
• Risks
Although there are no serious risks to
injecting the tear trough, the greatest
risk of injection is an unsatisfactory
result. Particularly with the HAs, the
Tyndall effect can be seen even if the HA
is deposited deeply. The HA can occa-
sionally increase fluid retention in the
entire periocular area in certain patients
and lead to prolonged swelling in the
malar area or a delayed bluish color in
the medial orbicularis muscle. If this oc-
curs, hyaluronidase injections into the
subcutaneous tissue can often disperse
the swelling and discoloration.
• Pearls of Injection
It is not uncommon for patients to be-
come vasovagal with cosmetic injections,
but this is particularly seen with tear
trough injections. Patients are often quite
anxious about being injected in this
area. They also complain of an unset-
tling feeling when the lower lid becomes
numb. At the completion of the proce-
dure, ensure that the patient does not
feellightheaded upon standing.
Hyaluronic acids are the products of
choice in this area. The uniform particle
size of Belotero allows for more super-
ficial injections and less chance of the
Tyndall effect.

130
SECTlON IV • Filler Injection Techniques
a
Tear trough
Orbicularis
b
deformity
ocuH m.
Fig. 42.1 a, b (a) The intraorbital region of the midface. (b) Filler is placed along the infraorbital rim
periosteum to improve inferior orbital hollowing. If necessary, filler can be placed subcutaneously,
but this technique runs the risk of the Tyndall effect with some products.
• Additional Reading
Andre P. New trends in face rejuvenation by
hyaluronic add injections. j Cosmet Der-
matol2008;7:251-258 PubMed
CarruthersjD, Carruthers A Facial sculpting
and tissue augmentation. Dermatol Surg
2005;31{11 Pt2):1604-1612 PubMed
Donath AS, Glasgold RA. Meier J, Glasgold
Mj. Quantitative evaluation of volume
augmentation in the tear trough with
a hyaluronic add-based filler: a three-
dimensional analysis. Plast Reconstr Surg
2010;125:1515-1522 PubMed
Morley AM, Malhotra R. Use of hyaluronic
add filler for tear-trough rejuvenation as
an alternative to lower eyelid surgery.
Ophthal Plast Reconstr Surg 2011 ;27:69-
73 PubMed

43
----···----
Filler Injection for Sunken
Upper Eyelids
Difficulty: • • • •
Patient Satisfaction: • • •
Risk: •••
• Indications
The hollow or sunken upper eyelid can
be unattractive and an aging sign on the
face. Genetics, aging, illness, and overly
aggressive surgical fat resection can all
contribute to a skeletonized, bony ap-
pearance of the medial third to half of
the superior orbital rim as it blends into
the nasal bridge. Restoring the look of
lost soft tissue fullness in this area can
greatly improve the youthful aesthetic
of a hollow orbit.
• Anatomic Considerations
The upper lid skin is usually quite thin
in most individuals; there are sensory
nerves of the supraorbital and supra-
trochlear nerve branches, as well as vas-
cular bundles to avoid during the injec-
tion of this area. This is an area that
requires advanced knowledge and ex-
perience; it should be approached only
by the confident injector who is experi-
enced and comfortable with the perti-
nent anatomy and the management of all
aspects of complicated filler patient care.
• Injection Technique
We prefer hyaluronic acid (HA) for these
injections. The best injection plane is
131

132
SECTlON IV • Filler Injection Techniques
directly onto the periosteum on the placed along the bone rather than in the
lower to inferior aspect of the superior orbital hollow.
orbital rim. Whether performed as a se-
ries of depot pearl-like injections mas-
saged together or with a long retrograde • Post-Injection Instructions
injection, the goal is to coat the bone
with a uniform layer of product so as to Immediate pressure and then ice is
cushion and fill the space between the helpful to minimize bruises. The eyelid
bone and the skin/musde complex. The will swell and may need to be iced for
area is most safely approached from a several days.
lateral to medial direction, keeping the
injections lateral to the medial aspect of
the brow. The safest technique is to use • Risks
a 30- to 32-gauge, l-inch {2.5-cm) nee- -------------
die; place the tip of the needle firmly Risks for swelling and bruising are real,
on the bone and perform retrograde in-
but the catastrophic intravascular, peri-
jections. Careful observation will reveal ocular accidents that could arise are
where extra sculpting is necessary to enough to deter most novice and even
augment the deepest concavities of the experienced injectors from trying this
upper eyelid complex and improve the new area of volumetric correction.
upper lid contour.
• Pearls of Injection
• Precautions
Keep the injection volume low at first.
Injecting higher along the face of the Inject from the lateral toward the me-
frontal bone away from the free edge of dial upper eyelid, staying low and keep-
the orbit will create two potential prob-
ing the needle moving while introduc-
lems. The first would be a risk of injury ing product. Many times there is not a
to or injection into one of the neuro-
true foramen for the supraorbital nerve,
vascular bundles as it exits the bone so it can be expected to exit from the
or orbit. The second possible problem orbit and course superiorly over the bony
would be the potential for creating the rim. Consider dilution of the HA with
appearance of frontal bossing if filler is Xylocaine.

Medial orbital
hollow
OIAPJ'ER 43 • Filler Injection for Sunken Upper Eyelids
133
SupratrocMear
a. and n.
Filler placed
on peit'iosteum
Supraorbital
a. and n.
OrbiraJ rim
Fig. 43.1
Filler is placed along the superior orbital rim periosteum to camouflage a supraorbital
hollow. Care should be taken to avoid injury to the supraorbital and supratrochlear neurovascular
bundles.
• Additional Reading
Lambros V. Volumizing the brow with hyal-
uronic acid fillers. Aesthet Surg J 2009;
29:174-179 PubMed
Morley AM, Taban M, Malhotra R. Goldberg
RA. Use of hyaluronic Acid gel for upper
eyelid filling and contouring. Ophthal Plast
Reconstr Surg 2009;25:440-444 PubMed

44
-------···-------
Filler Injection for Lateral Brow Lift
Difficulty: •••
Patient Satisfaction: • •
Risk: •
• Indications
The brow becomes ptotic or droopy be-
cause of volume loss between the skin
and the bone, with hollowing of the
temple and skeletonization of the lateral
orbital rim. As a result, the position of
the brow hairs can be much lower than
desired. and the overall position of the
brow can cause a sad or even stern
appearance. Fillers can be used, when
placed properly, to restore fullness, vol-
ume, and actual lift to a flat or bony
brow.
134
• Anatomic Considerations
The skin is usually thin in individuals
who are candidates for lateral browlift
with volumetric filling, and there may
be a great deal of superficial vascularity.
Typically there is a single perforating
sentinel vein just superolateral to the or-
bital rim that is perpendicular to the sur-
face of the skin, whereas all the other
vessels spread out parallel with the
surface and can be avoided with deep
injection.
• Injection Technique
The best injection plane is deep to the
orbicularis and the aponeurotic fascia
and galea, but just above the periosteum.
It is often easiest if this plane is first en-