Các Kỹ Thuật Tiêm Thẩm Mỹ (Cosmetic Injection Techniques)

136
SECTlON IV • Filler Injection Techniques
Location of
sentinel v.
Fig. 44.1 Filler is placed along the periosteum of the lateral orbital rim to produce a lateral browlift.
• Additional Reading
CarruthersjD, Carruthers A Facial sculpting
and tissue augmentation. Dermatol Surg
2005;31(11 Pt2):1604-1612 PubMed

45
-------···-------
Filler Injection for Sunken Temples
Difficulty: • •
Patient Satisfaction: • • •
Risk: ••
• Indications
Hollowing of the temporal fossa can
lead to a sunken or gaunt look that ages
the upper half of the face. Though fat
loss can occur from trauma or disease
states, the most common cause is natu-
ral aging. Other causes include surgical
deformities, HIV-associated lipoatrophy,
or thin patients with little body fat.
• Anatomic Considerations
The anatomic boundaries of the temple
are the temporal line superiorly, the tail
of the brow and lateral orbital rim medi-
ally, the hairline posteriorly, and the
zygomatic arch inferiorly. Several large
veins and arteries run superficially in
this region. The temporalis muscle fills
the temporal fossa. Injections are placed
through the muscle, down to the peri-
osteum of the temporal fossa.
• Injection Technique
Hyaluronic Acid
The superior and medial aspects of the
temporal area provide the most benefit
aesthetically, and should be filled first.
Injection of hyaluronic acid {HA) re-
quires use of a l-inch (2.5-cm) needle to
inject deep onto the periosteum in the
upper half of the fossa and then deep
onto or below the temporalis fascia more
inferiorly. Depot injections must be
used in this region to minimize contour
irregularities. Placing the product deep
137

138
SECTlON IV • Filler Injection Techniques
and then massaging it into place will them. If a vessel is traumatized, firm
ensure uniform volumization of the tern-
pressure for several minutes will mini-
poral fossa. It would not be unusual to mize bruising.
use 1 cc of product in each temple in
moderately to severely sunken temples.
Calcium Hydroxylapatite
Calcium hydroxylapatite (CaHA) may be
injected into the temporal fossa and
gives a more firm feel to the temples.
The injection technique is similar to that
used for HAs.
Poly-L Lactic Acid
The depot technique similarly is used,
laying product onto the periosteum.
A 25-gauge needle of at least 1 to 1.5
inches (2.5 to 3.8 em) in length is pref-
erable to ensure deep placement. To
evenly spread the product, massage is
performed by the injector just after
placement and by the patient for 5 days
posttreatment (for 5 minutes, five times
a day). With a 6- to 8-cc dilution of poly-L
lactic acid (PLLA), 1 to 2 cc of product is
administered to each temporal fossa,
depending on the amount of atrophy.
Two or three treatment sessions may be
required. An interval of 4 to 8 weeks
between injections is recommended, and
increased improvement continues for 3
to 6 months after the final injection.
• Precautions
There are many surface vessels in the
temple, and care should be taken to per-
form depot injections between or below
• Post-Injection Instructions
Massage is helpful for the HA patients,
and mandatory for the PLLA patients.
Cold compresses can help prevent both
soreness of the temporalis muscle and
discomfort while chewing.
• Risks
Bruising is possible; apply firm pressure
should a vessel be violated. Filling too
dose to the surface can result in an un-
even or lumpy appearance. Trismus may
be noted in some patients for 1 to 2 days
posttreatment and will resolve without
treatment.
• Pearls of Injection
The end point of treatment usually oc-
curs when the area is still slightly con-
cave to flat but not overcorrected to
bordering on convex. Proper depth of
placement is the key to smooth results.
It is hard to overfill this area. It is valu-
able to look at both sides of the patient
to compare after completing the first
side. It helps to show the patient the dif-
ference in the two sides, as it is often
dramatic. This will give the patient an
idea of the treatment end point as well.
Because of the high vascularity in this
region, it is often helpful to perform a

OIAPTER 45 • Filler Injection for SUnken Temples
139
Temporalis m.
Filler placed
pre-periosteaE!y
Zygomatic arch
Fig. 45.1
Filler is placed deep to the temporalis muscle onto the periosteum to volumize the tem-
ples. Care is taken to avoid injury to the numerous vessels in this region.
reflux maneuver on the syringe before
injecting the product to prevent intra-
vascular injection.
Some patients will notice an elevation
of the lateral brow with improvement of
the temporal hollowing.
• Additional Reading
Fitzgerald R, Vleggaar D. Facial volume
restoration of the aging face with poly-1-
lactic add. Dermatol Ther 2011 ;24:2-27
PubMed
Lambros V. A technique for filling the tem-
ples with highly diluted hyaluronic acid:
the ''dilution solution". Aesthet Surg j
2011 ;31 :89-94 PubMed

46
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Filler Injection for Nonsurgical
Rhinoplasty
Difficulty: • • • •
Patient Satisfaction: • • •
Risk: ••
• Indications
Because the nose occupies the center of
the face, mild asymmetries can be quite
striking. Rhinoplasty surgery is not al-
ways a perfect procedure, and postsur-
gical defects can be difficult to correct.
As a result, the use of fillers in small
quantities to treat specific nasal defor-
mities has become a way to fine-tune
postsurgical noses. In addition, in some
patients who refuse surgery or who are
not surgical candidates, a nonsurgical
approach to their nasal concerns may
be possible by the use of filling agents.
140
• Anatomic Considerations
Knowledge of the ideal proportions of
an attractive nose will be necessary as
well as knowledge of the basic anatomy
of the bony, cartilaginous, and soft tis-
sue structures involved. It is also im-
portant from a safety standpoint to be
aware of the key vascular channels to
avoid intravascular injections.
• Injection Technique
When injecting a hollow or void in the
nose, it is best to start deep on the bone
or cartilage and perform a retrograde
injection with a threading movement
so as to avoid a direct depot injection
that could possibly flow into a blood
vessel.

CHAPIER 46 • Filler Injection for Nonsurgical Rhinoplasty
141
Dorsal Hump
To straighten a dorsal hump, inject both
above and below it as needed to
straighten the dorsal profile. This tech-
nique can also be used on a wide nose
to give the illusion of a higher and nar-
rower nasal profile.
Saddle Nose Deformity
In these cases, there is little to no sup-
porting cartilage at the base of the con-
cavity; therefore, it is necessary to inject
into the immediate dermal/subdermal
plane to thicken the skin layer to allow
improved bridging from the bony dor-
sum to the cartilaginous tip. Secondary
injection to the deeper plane below will
help to further support and elevate the
concave area and augment the bridge
contour.
Twisted/Crooked Nose
When dealing with the twisted nose, it
is possible to imagine a single line that
passes through the midline. Usually there
are portions of the twisted nose that
will wind in a Cor S shape onto either
side of the midline. By filling the con-
cavities the nose will appear straighter.
Drooping Tip
better define the tip, and can also in-
crease the tip projection and increase
tip rotation. The thickness of the skin
and the amount of scar tissue in the area
will determine whether and to what ex-
tent this technique will be successful.
Risks
Nasal injections must be placed in an
avascular plane, either preperiosteal or
pre-perichondral. Care should be taken
not to inject into the dermis to avoid the
dermal vascular plexus.
• Precautions
Often if there are large pores in the area
being injected, the needle may need to
be passed at a deeper or different angle
if product begins to extrude through
one of the dilated pore tracts. Over-
injection of a given area can lead to
blanching or even intravascular ocdu-
sion. Restylane is the preferred hyal-
uronic acid (HA) for the nose, because
the hydrophilic nature of juvederm ac-
centuates edema in this region. Calcium
hydroxylapatite (CaHA) may be used;
however, because of its permanence, the
injector should proceed with extreme
caution.
When there is little tip definition and • Post-Injection Instructions
a droopy tip, a new, more rotated and
defined tip can be .. created" by placing Ice and pressure are helpful to prevent
filler depot injections into appropriate bruising. The product will swell some
anatomic locations. The injections can with an HA and feel firmer to palpation
mimic a tip graft that will augment and the first week and then blend in more

142
SECTlON IV • Filler Injection Techniques
a
b
Fig. 46.1 a-d (a) Dorsal hump. Filler can be placed above and below a dorsal hump to straighten
the dorsal profile. (b) Saddle nose. The concavity of the dorsum seen in the saddle nose deformity
can be improved nonsurgically by using filler.

CHAPIER 46 • Filler Injection for Nonsurgical Rhinoplasty
143
c
Fig. 46.1 (Continued) (c) Crooked nose. Filler is placed along the periosteum or perichondrium in
the concave aspect of the nasal sidewall to give the illusion of a straight dorsum. Pre-(left upper and
lower panels) and post-(right upper and lower panels) injections along the right nasal sidewall improve
a mildly crooked nose in a patient with a persistent deformity after closed reduction of a nasal frat:-
ture. (continued on next page)

144
SECTlON IV • Filler Injection Techniques
d
Fig. 46.1 (Continued) (d) Droopy tip. Filler can be used as a •tip graft• to define and elevate a ptotic
tip.
a
b
Fig. 46.2a, b (a) Mild right lateral nasal sidewall depression post rhinoplasty. (observe the light re-
flexes) (b) Improvement of right sidewall depression by placing filler in the defect.

CHAPIER 46 • Filler Injection for Nonsurgical Rhinoplasty
145
naturally. The patient should expect that
the areas injected will look raised and
welted at first. Swelling should improve
within about 2 to 4 days.
• Risks
The most significant risks involve injec-
so as not to inject into a vessel and cre-
ate an occlusion or embolic situation.
Proceed with caution in post-rhinoplasty
patients because prior surgery may com-
promise the blood supply to the nasal
skin, which may increase the chance of
skin necrosis.
tion into a vessel that could lead to vas-
• Additional Reading
cular necrosis. Retrograde injections and
avoiding high pressure on, or blanching
of, the skin during treatments can help
prevent this devastating complication.
Because ofthe highriskofvascularcom-
promise in these areas, consider using
only HAs in this region.
• Pearls of Injection
Undercorrection is recommended in this
region. Also, keep the needle in motion
Andre P. New trends in face rejuvenation by
hyaluronic acid injections. 1 Cosmet Der-
matol2008;7:251-258 PubMed
Humphrey CD, Arkins 1P, Dayan SH. Soft tis-
sue fillers in the nose. Aesthet Surg 1
2009;29:477-484 PubMed
Redaelli A. Medical rhinoplasty with hyal-
uronic acid and botulinum toxin A: a
very simple and quite effective technique.
1 Cosmet Dermatol 2008;7:210-220
PubMed

47
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Filler Injection for Nasal
Valve Stenting
Difficulty: • • • •
Patient Satisfaction: • •
Risk: •
• Indications
Collapse of the internal and external
nasal valves is generally treated surgi-
cally. In patients who have not had ad-
equate improvement after surgery, or
those who refuse surgery, filler can be
used to stent the valve and prevent col-
lapse with inspiration.
• Anatomic Considerations
The internal nasal valve is the acute
angle formed by the junction of the
146
septum and the lateral crus of the lower
lateral cartilage. The external nasal valve
refers to the area created by the ala, col-
umella, and nasal floor.
• Injection Technique
Topical anesthetics or intranasal 4% Xy-
locaine is adequate anesthesia for this
procedure. Avoid using injected local
anesthesia as it will change the shape of
the valve and negate the filler effect.
Internal Nasal Valve
Very small amounts of filler are depos-
ited intranasally in the area of the lateral
crus or scroll region until the patient
notices improvement in the airway. Be-
fore injection, ask the patient to rate
the nasal patency on a scale of 1 to 10.

a
OIAPTER 47 • Filler InJection far Nasal Vllw Stentlng
147
Inject a small amount of filler and ask
the patient to rate the airway patency
again. Inject until the nasal patency is
acceptable.
External Nasal Valve
Very small amounts of filler are placed
along the alar rim until there is im-
provement of collapse during deep
inspiration.
• Precautions
Lumpiness may be seen externally if
over-injected.
:::Oilapsed
~ntcrnal
:usa! valve
• Post-Injection Instructions
None. Bruising is unlikely.
• Risks
Over-injection can weigh down the ala
and worsen collapse.
• Pearls of Injection
Optimal results are obtained with
thicker fillers like calcium hydroxylapa-
tite or more concentrated hyaluronic
acid fillers.
Collapsed
ala
Srtnced external
n.asal val,·<
Fig. 47.1a, b (a) Filler is injected intranasally atthe scroll region to stiffen the internal nasal valve.
(b) Filler can be used to strengthen a collapsed ala and improve the external nasal valve.
b

148
IV • Filler Injection Tedmlques
• Additional Reading
Nyte CP. Hyaluronic acid spreader-graft in-
jection for internal nasal valve collapse. Ear
Nose Throatj 2007;86:272-273 PubMed
Nyte CP. Spreader graft injection with cal-
dum hydroxylapatite: a nonsurgical tech-
nique for internal nasal valve collapse. La-
ryngoscope 2006;116:1291-1292 PubMed

48
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Filler Injection for Medial
Midface Hollowing
Difficulty: •••
Patient Satisfaction: • •
Risk: ••
• Indications
Facial aging is a complex combination of
volume loss and tissue ptosis. However,
midface hollowing can be seen with
facial aging or occasionally in younger
individuals who present with an ana-
tomically flattened midface.
• Anatomic Considerations
The medial midface is the triangular
zone below the infraorbital rim, lateral
to the nasal sidewall and medial to the
infraorbital foramen adjacent to the sub-
malar region.
• Injection Technique
Hyaluronic acid (HA) or calcium hy-
droxylapatite (CaHA) may be injected
into this area for facial volume restora-
tion. Injection may be placed deeply
onto the periosteum or more superfi-
cially in the superficial subcutaneous
tissue. A fanning technique can ensure
even placement of the product. Massage
after placement helps to evenly distrib-
ute product and allows the injector to
palpate any areas that were not fully
injected.
• Precautions
Bruising is common in this area. The
angular artery runs lateral to the nose,
and care must be taken not to injure this
vessel, either by compression or embo-
lization. Avoid injecting into the infra-
orbital nerve foramen.
149

150
SECTlON IV • Filler Injection Techniques
Ask the patient to refrain from ap-
plying heavy pressure on the injected
cheeks (either from ice after treatment
or pressure from sleeping) to prevent
flattening the revolumized areas.
~"a:J
• Post-Injection Instructions
Ice and pressure are helpful to prevent
bruising. The product will swell some
with HA or CaHA and feel firmer to pal-
,
Jlliif.:---:, ... .,;...,;---Ameromed.ial
regjon
a
Angular a.
-
r r'lftaotbiral il.
Pre-periosteal
b
filler
Fig. 48.1 a, b (a) Anteromedial subdivision of the midface lies medial to the infraorbital nerve,
lateral to the angular artery and inferior to the infraorbital rim. (b) Filler may be placed along the
periosteum and massaged into place to improve a flattened midface.

CHAPTER 48 • Filler Injection for Medial Mldface Hollowing
151
pation the first week and then blend in superficial plane may require the use of
more naturally.
needles.
• Risks
There are minimal risks of injection in
this area. The most difficult aspect of
injection here is ensuring symmetry.
• Pearls of Injection
• Additional Reading
Funt DK. Avoiding malar edema during
midfacejcheek augmentation with dermal
fillers. 1 Clin Aesthet Dermatol 2011 ;4:32-
36 PubMed
Raspaldo H. Volumizing effect of a new hy-
aluronic acid sub-dermal facial filler: a
retrospective analysis based on 102 cases.
To reduce the risk of vascular injury,
1 Cosmet Laser Ther 2008;10:134-142
PubMed
consider the use of cannulas in this re-
Tansavatdi K, Mangat DS. calcium hydraxyl-
gion when performing deep injections.
apatite fillers. Facial Plast Surg 2011;27:
Fine-tuning of the injection in a more
510-516 PubMed

49
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Filler Injection for
Cheekbone Augmentation
Difficulty: ••
Patient Satisfaction: • • •
Risk: •
• Indications
Fillers may be used to augment the
cheekbones, or lateral malar prominence.
(Alternatively, permanent malar im-
plants may be inserted surgically or fat
augmentation can be performed.)
• Anatomic Considerations
The malar bone and overlying soft tis-
sue from the lateral malar prominence.
High cheekbones contribute to a youth-
ful arc seen in three-quarter view. Some
152
patients with aging of the midface dis-
play a fat pad of the lateral malar promi-
nence, referred to as the "malar mound."
This triangular prominence results from
the orbital retaining and zygomatico-
cutaneous ligaments.
• Injection Technique
Topical anesthesia may be used for this
procedure. Fillers with lidocaine may be
placed deeply at first injection to anes-
thetize the infraorbital nerve. Dental
blocks are discouraged and may actually
distort the anatomy. To volumize the
lateral malar prominence, fillers may be
placed through the intraoral or percuta-
neous route. Intraoral injection does not
predispose the patient to infection. Filler
can be placed deep in the subcutaneous
tissue and pre-periosteal planes.

CHAPTER 49 • Filler Injection for Cheekbone Augmentation
153
To camouflage the malar mound, hy-
few days to minimize flattening of the
aluronic acid (HA) fillers can be placed product.
more superficially (deep dermal or sub-
cutaneous) over the retaining ligaments.
• Risks
• Precautions
Bruising is possible. The greatest chal-
lenge with performing this procedure is
This is a very safe injection location; HA ensuring symmetry.
or calcium hydroxylapatite (CaHA) may
be used.
• Pearls of Injection
• Post-Injection Instructions
Lateral malar augmentation may be per-
formed through a single entry point on
Ice may be used as needed, but instruct each cheek. Cannulas may be used for
the patient not to press firmly on the the deep injections.
injected site or sleep on that side for a

154
SECTlON IV • Filler Injection Techniques
a
b
Zyg<)ma!i_co- ----'!:-...,....-
m alar reg10 n
Malar
prominence
lnfraorbiral n.
Pre-periosteal filler
along orbital rim
Subcutaneous filler
Fig. 49.1 a. b (a) The zygomaticomalar subdivision of the midface lies inferior to the infraorbital rim
and lateral to the infraorbital neiVe. (b) The prominence of the cheekbones is improved by augment-
ing the zygomaticomalar region. Injection may indude deep injection along the infraorbital rim and
zygomatic arch as well as a more superficial injection to camouflage the malar mound.

CHAPTER 49 • Filler Injection for Cheekbone Augmentation
155
• Additional Reading
Carruthers JD, Carruthers A. Facial sculpting
and tissue augmentation. Dermatol Surg
2005;31{11 Pt 2):1604-1612 PubMed
Lowe NJ, Grover R Injectable hyaluronic acid
implant for malar and mental enhance-
ment. Dermatol Surg 2006;32:881-885,
discussion 885 PubMed
Mendelson BC, Muzaffar AR, Adams WP Jr.
Surgical anatomy of the midcheek and
malar mounds. Plast Reconstr Surg 2002;
110:885-896, discussion 897-911 PubMed

so
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Filler Injection for Sunken Cheeks
Difficulty: ••
Patient Satisfaction: • •
Risk: •
filling these regions may be performed
as an adjunct to rejuvenation surgery.
• Anatomic Considerations
The area under the zygomatic arch and
• Indications
lateral to the nasolabial fold and modio-
lus comprises the submalar and buccal
Hollowing of the cheeks can be seen in regions of the midface.
some patients who present with serious
volume deficits. The loss of malar and
buccal fat pads often can lead to a wind-
• Injection Technique
swept post-facelift appearance as well
as wrinkled cheeks, deepened naso-
Topical anesthesia is usually sufficient
labial folds, and the presence of jowls. for these injections. The injection tech-
In many cases, the hollow submalar nique should be a grid or fanning pat-
and buccal concavities are better suited tern, spreading the product in a medial
to augmentation than surgery; however, to lateral fashion. The plane of injection
156

CHAPIER 50 • Filler Injection for Sunken Cheeks
157
is usually at the dermal-subcutaneous A gentle post-injection kneading mas-
junction. Gentle massage after injection sage can be helpful.
helps to smooth irregularities.
• Risks
• Precautions
This is a low-risk procedure; however,
Injecting too superficially in this region if very large volumes of product are
can result in ridges or striping of mate-
necessary, the excess filler can "weigh
rial. Placing the product in deeper planes down" the cheek. In these excessively
will necessitate using more material. hollow patients, consider using poly-L
Lumpiness in this region is common after lactic acid (PLLA) or fat augmentation.
injection, and the injector should mas-
sage the area after injection to ensure
even placement of product. Placement of • Pearls of Injection
product too deeply will project some of
the volume into the oral cavity because Inject at different levels and massage to
the buccal area is not supported by bone. evenly disperse product. Large volumes
of product are necessary to properly
correct these areas. To best treat a pa-
• Post-Injection Instructions
tient on a modest budget, begin the in-
jection medially and near the inferior
Ice and pressure are helpful to prevent aspect of the zygomatic arch. The goal
bruising. The product will swell some is to ease the transition from the high
and will feel firmer to palpation the first to low regions and creates a less sharp
week, and then blend in more naturally, step-off transition.

158
SECTlON IV • Filler Injection Techniques
Submalar a.n d-
--'---
-----"<..
b·u«:al regiMS
a
Angular a.
Subm.Uar a11d ->r
buccal hollow
-~
(
Nasolabial
fold
b
Fig. 50.1 a, b (a) The submalar and buccal regions of the midface lie inferior to the zygomatico-
malar region and lateral to the infraorbital nerve. (b) Filler is placed at different depths in a crossed
fanning technique to elevate the submalar and buccal hollows.

CHAPIER 50 • Filler Injection for Sunken Cheeks
159
• Additional Reading
Cattin TA A single injection technique for
midface rejuvenation. 1 Cosmet Dermatol
2010;9:256-259 PubMed
Raspaldo H, Aziza R, Belhaouari L, et al. How
to achieve synergy between volume re-
placement and filling products for global
facial rejuvenation. 1 Cosmet Laser Ther
2011 ;13:77-86 PubMed

51
-------···-------
Filler Injection for Chin Augmentation
Difficulty: • •
Patient Satisfaction: • • •
Risk: •
wants a smooth contour across the cen-
ter of the chin.
• Anatomic Considerations
The bone structure of the mandible can
• Indications
be too "squared," "pointed," or "weak,"
and filler can be used creatively to shape
The weak chin is usually best addressed or augment the chin. During injection,
with a permanent surgical solution such be cognizant of the location of the men-
as an alloplastic implant. However, aug-
tal nerves and adjacent vessels exiting
mentation with a filler can be a good the mental foramen.
alternative in the following situations:
the patient needs only small amounts of
augmentation; the patient is elderly or • Injection Technique
a poor surgical candidate; the patient is
already scheduled to undergo lower fa-
There are two basic techniques that are
cial volume restoration; the patient is
useful for filling the chin: deep depot
looking for immediate results without injections onto the periosteum to truly
surgical downtime or great expense; the mimic a surgical implant; and fanning,
patient is considering a chin implant but threading-type injections in the sub-
is hesitant about receiving a permanent dermal plane that spread over a broad
implant; the patient has a deft chin and area. The more superficial injection tech-
160

CHAPTER 51 • Filler Injection for Chin Augmentation
161
niques should be at the dermal subcuta-
neous junction so as to add volume as
well as to firm the overlying skin, which
is often less firm than it once was. With
the threading technique, a longer 1- to
1.5-inch (2.5- to 3.8-cm) needle and a
27- to 30-gauge work best. The depot
is easily placed along the border of the
mandible as long as the mental foramen
is avoided.
• Precautions
Determine where the mental foramen
and nerve are located, and stay away
from that region when injecting. If a chin
implant is already in place, use careful
sterile technique and avoid directly in-
jecting into or onto the implant to avoid
seeding the implant with bacteria.
• Post-Injection Instructions
Immediate pressure and then ice are
helpful to minimize bruises. The chin
initially will appear swollen and more
rounded than it will appear once the
edema subsides.
• Risks
Minimal risks occur, besides bruising,
with the superficial technique if the
injections are smooth and even. When
injecting deeply onto the bone, there are
more inherent risks for damage to the
mental nerve and possible intravascular
injection if a depot injection is used.
• Pearls of Injection
Evaluate the chin from all angles to
ensure that it looks proportionate and
balanced all over, as symmetry will be
important as well as challenging when
trying to fill a whole midline structure.
Massage of the area will aid in smooth-
ing any injection irregularities.

162
SECTlON IV • Filler Injection Techniques
a
Mental n.
and foramen
:-7-----Subcutaneous
Pt·e-periosteal
fiUer
filler
b
Clefc chin
Fig. 51.1 a, b (a) Filler is placed on the periosteum and/or in the subwtaneous tissue to increase
prominence of the chin. (b) Filler may be placed subcutaneously to camouflage a chin cleft.

CHAPTER 51 • Filler Injection for Chin Augmentation
163
• Additional Reading
Andre P. New trends in face rejuvenation by
hyaluronic acid injections. J Cosmet Der-
matol2008;7:251-258 PubMed
Wise JB, Greco T. Injectable treatments for
the aging face. Facial Plast Surg 2006;22:
140-146 PubMed

52
-------···-------
Filler Injection for the Mental Crease
Difficulty: •
Patient Satisfaction: • •
Risk: •
• Indications
The mental crease (or chin crease) is the
horizontal crease between the lower lip
and chin. and it can be quite deep in
some individuals.
• Anatomic Considerations
The paired mentalis muscles originate
on the incisor fossa of the mandible and
insert directly onto the dermis of the
chin skin. Contraction of the mentalis
164
muscles elevates the lower lip and con-
tributes the mental crease.
• Injection Technique
This is a painful area to inject; a topical
or dental block may be utilized. Filler
is injected at multiple levels in the der-
mis and subdermal subcutaneous tissue
to elevate the crease. A combination of
linear threading both parallel and per-
pendicular to the crease can be used.
Deeper creases can be treated with depot
techniques.
• Precautions
Superficial injection of some hyaluronic
acids (HAs) will result in bluish blebs of

CHAPIER 52 • Filler InJection far the Mental crease
165
Fig. 52.1
The mental crease can be improved by injection of filler in the subcutaneous tissue be-
neath the concavity.
material. Do not over-inject this area.
Massage after injection to maximize
smoothness.
• Post-Injection Instructions
Ice as needed; bruising is possible.
• Risks
This is a very safe area to inject. Deep
creases may require a large amount of
filler.
• Pearls of Injection
Filler used alone in this area tends to last
for very short periods of time. However,
in conjunction with BoNTA injection to
the mentalis, the duration of any filler
in this area is significantly improved.
Neurotoxin may be injected into the
mentalis musdes as in treatment of the
peau d'orange chin (see Chapter 18),
which may also help to flatten the men-
tal crease.
• Additional Reading
Brandt FS, Cazzaniga A Hyaluronic acid
fillers: Restylane and Perlane. Facial Plast
Surg Clin North Am 2007;15:63-76, vii
PubMed
Romagnoli M, Belmontesi M. Hyaluronic
add-based fillers: theory and practice. Oin
Dermatol 2008;26:123-159 PubMed

53
-------···-------
Filler Injection for
jawline Rejuvenation
Difficulty: ••
Patient Satisfaction: • •
Risk: •
• Indications
Prejowl sulcus fat loss and descent of the
midface can accentuate the formation
of the jowls. By filling the concave area
just anterior to the jowl, a straighter,
more youthful jawline can be achieved.
However, the formation of jowls is mul-
tifactorial, and often a facelift is the only
treatment that can adequately lift or re-
move the jowl.
• Anatomic Considerations
Aging changes of the jawline are a re-
sult of draping of excess skin, sagging of
buccal fat, loss of prejowl fullness, and
166
changes in the submental platysma(
angle. Filling the prejowl area, both in
the area of the marionette lines as well
as in the area at and below the mandi-
ble, creates a much more pleasing ante-
rior mandibular contour. Augmentation
of the prejowl sulcus occasionally must
be addressed when surgical options are
planned, either by the use of filling
agents or by the use of prejowl surgical
implants.
• Injection Technique
Hyaluronic adds (HAs) are commonly
used in this area. They may be injected
at the dermal subcutaneous junction so
as to add volume as well as to finn the
overlying skin, which is often less firm
than it once was. A threading technique
with 1-or 1.5-inch (2.5- to 3.8-cm) nee-
dles and a 27- or 30-gauge needle works
best. The injection needs to bridge all
the way from the high point of the jowl

b
OIAPTER 51 • Aller Injection for J.wllne ReJuvenation
167
and blend forward to the firm level por-
• Precautions
tion of the chin.
-------------
Alternate Technique
Subdermal injections may be combined
with depot injections along the mandi-
ble. For these deep injections, HA, cal-
cium hydroxylapatite (CaHA), or poly-
methylmethacrylate (PMMA) can be
used safely, and these deep injections
can mimic a true prejowl implant. This
technique requires more product wl-
ume than do the more superficial injec-
tions to achieve a similar effect.
Subc\ltancous
Fig. 53.1a, b (a) Filler can be placed in the pre-
periosteal or subcutaneous planes to augment
the prejowl sulcus. (b) Filler can also be placed
subcutaneously in a linear fashion. A combina-
tion of these techniques may be required for op-
timal correction.
Bruising is very common with the sub-
dermal injection. Care needs to be taken
to avoid the mental foramen, as pares-
thesias could occur with a direct injec-
tion into the foramen.
• Post-Injection Instructions
Immediate pressure and then ice are
helpful to minimize bruising.
• Risks
Minimal risks occur, besides bruising,
with the superficial technique if the in-
jections are smooth and even.
• Pearls of Injection
Massage the product to shape it and re-
create the mandibular jawline. Include
injection along the inferior aspect of the
mandible to fill in the entire prejowl
concavity. Consider using a cannula for
injection into this region, as precision of
filler placement is not required in this
location.
• Additional Reading
Fedok FG. Advances in minimally invasive
facial rejuvenation. Curr Opin Otolaryngol
Head Neck Surg 2008;1 6:359-368 PubMed
Wise JB, Greco T. Injectable treatments for
the aging face. Facial Plast Surg 2006;22:
140-146 PubMed

54
-------···-------
Filler Injection for Earlobe
Rejuvenation
Difficulty: •
Patient Satisfaction: • • •
Risk: •
• Indications
The earlobes flatten with age and lose
their volume. This flattening combined
with elongated piercing holes can re-
sult in the downward hanging of stud
earrings. Re-volumization of the lobes
contributes to a more youthful look and
more attractive earring positioning.
• Anatomic Considerations
Fill the lower aspect of the earlobe to
• Injection Technique
Hyaluronic add (HA) should be placed
in the subcutaneous tissue in a u-shape
until adequate filling of the earlobe is
seen. Alternately, poly-L lactic add (PLLA)
may be used in a similar fashion, but the
results will take longer to achieve.
• Precautions
None.
• Post-Injection Instructions
Ice as needed
• Risks
provide structural support to the ear-
None; this is a very safe procedure to per-
ring and restore volume to the earlobe.
form, yielding high patient satisfaction.
168

OIAPJ'ER 54 • Filler Injection for Earlobe ReJuvenation
169
Fig. 54.1 Hyaluronic acid may be placed in the
earlobe both to support a hanging pierced ear-
ring and to restore volume to the deflated aging
lobe.
• Pearls of Injection
This is a nice technique to offer patients,
especially when looking for an appro-
priate place for the last little bit of prod-
uct remaining in the syringe after treat-
ment of other facial areas.
• Additional Reading
Hotta T. Earlobe rejuvenation. Plast Surg Nurs
2011 ;31 :39-40 PubMed

55
-------···-------
Filler Injection for Acne Scars
Difficulty: • •
Patient Satisfaction: • •
Risk: •
• Indications
Severe cystic acne can lead to large
depressed facial scars. These scars can
include depressions in the dermis as
well as the subdermal fat. The shadow-
ing of these depressed scars can ac-
centuate their deep appearance, and
elevation with fillers will minimize the
shadowing and improve the overall
skin contour. Although some flattened
scars and concavities can be improved
with fillers, enlarged pores and ice-
pick scars will not improve with such
injections.
170
• Anatomic Considerations
Prior to injection of the scar, the injector
may perform a "stretch" test to deter-
mine if the scar will improve with filler
injection. If the scar flattens out with
skin stretching, the scar will likely elevate
and improve with filler. If it does not ele-
vate, it may require release of the dermal
attachments by subcision, or it may re-
quire direct excision. Most injections will
be placed intradermally or in the imme-
diate subdermal plane. To prevent lumpi-
ness in areas with thin skin such as the
temple and the lower eyelid, very small
amounts of filler should be injected.
• Injection Technique
Any filler may be used for these injec-
tions; however, we commonly use hyal-

uronic acids (HAs). The injection tech-
nique should start with a 30-gauge
needle so as to layer and cross-hatch the
intended area with multiple passes from
different angles. Part of the correction
requires subcision within the dermis
and subdermis to break up fibrosis and
scar tissue. The action of the needle
moving back and forth across the scar
will disrupt the fibrous attachments
deep to the scar and permit its eleva-
tion with filler. A significant amount of
force is necessary to introduce the prod-
uct into the scar area. If no resistance is
met, then the needle is probably too
deep. It is best to introduce the needle 4
to 5 mm away from the edge of the scar
area so that the product does not escape
out of the puncture site when the nee-
dle is withdrawn or when the next pass
is made from a different angle.
• Precautions
If there are large pores in the area being
injected, the needle may need to be
passed at a deeper or different angle if
product begins to extrude through one
of the dilated pore tracts. Over-injection
of a given area can lead to blanching or
even intravascular occlusion.
• Post-Injection Instructions
Ice and pressure are helpful to prevent
bruising and lumpiness. The product will
CHAPTER 55 • Filler Injection for Acne Scars
171
swell some with an HA and feel firmer to
palpation the first week and then blend
in more naturally. The patient should ex-
pect that the areas injected will look
raised initially.
• Risks
Minimal risks besides bruising and Tyn-
dall effect from overly superficial injec-
tion into the dermis.
• Pearls of Injection
The force of the injection and the pres-
ence of the product in the expanded
space of the scar can actually stimulate
neocollagenesis. Unless adequate release
of scar tissue is performed at the center
of a depressed scar, filling the area can
create a mound that will accentuate the
shadowing at the base of the scar.
Consider layering fillers, placing cal-
cium hydroxylapatite (CaHA) deeply in
the subcutaneous tissues and HA more
superficially in the deep to superficial
dermis. Restylane has more lifting qual-
ities than does juvederm and is pre-
ferred for acne scars. Collagen is also
an excellent scar elevator. Polymethyl-
methacrylate (PMMA) may be used as
well, usually several days after subcision
has been performed.

172
SECTlON IV • Filler Injection Techniques
-
lnj ec;:t froJTl
multiple
angles
Fig. 55.1 Some acne scars may be elevated by placing filler deep to tfle scars. Scars that do not el-
evate with filler alone may require subcision to release dermal attachments prior to injection.
• Additional Reading
Carvalho Costa IM, Salaro CP, Costa MC.
Polymethylmethacrylate facial implant: a
successful personal experience in Brazil for
more than 9 years. Dermatol Surg 2009;
35:1221-1227 PubMed
Goldberg DJ, Amin S, Hussain M. Acne scar
correction using calcium hydroxylapatite
in a carrier-based geL J Cosmet Laser Ther
2006;8:134-136 PubMed
Smith KC. Repair of acne scars with Dermi-
coi-P35. Aesthet Surg J 2009;29(3, Suppl)
S16- S18 PubMed

56
-------···-------
Filler Injection for Aging Hands
Difficulty: • • •
Patient Satisfaction: • • •
Risk: ••
• Indications
The back of the hand is an area that
often shows a person's age even while
the face and body are well maintained
and physically fit. The aging hands
manifest dyschromias, loss of fat, thin-
ning of the skin, and grooving of the
spaces between the extensor tendons of
the fingers.
• Anatomic Considerations
For superficial injections of the hand
dorsum, the anatomic concerns include
a superficial venous arcade and the long
extensor tendons. For deeper injections,
the injector must be aware of the loca-
tion of the interosseus muscles and the
five metacarpal bones of the hand.
• Injection Technique
Hyaluronic acid (HA) or calcium hy-
droxylapatite ( CaHA) can be used to aug-
ment this region. These fillers provide
instant gratification and a soft, even
fill in the space between the skin and
the interosseous muscles. The injections
should be performed as if there are
separate compartments between each
metacarpal. It is best to avoid injecting
directly over the tendons and bones, as
it is more likely to lead to surface irregu-
larities. As the area being injected is a
long narrow compartment with many
large veins throughout, it is best to us
a long needle (either 1- or 1.5-inch/2.5-
to 3.8-cm, 25- to 27-gauge) to inject
173

174
SECTlON IV • Filler Injection Techniques
product deep to veins and the skin into pation the first week and then blend in
the deep subcutaneous layers or right more naturally. The patient should ex-
above the muscle if necessary. All injec-
pect that the areas injected will look
tions should be performed as retrograde raised and welted at first. Swelling
threading or fanning to avoid vessel in-
should settle down within about 2 to
jection. Poly-L-lactic acid {PLLA) is also 4 days. Vigorous massaging is necessary
another excellent choice in this area and with the PLLA injections for the next 5
it should be diluted to approximately to 10 days.
10 cc per vial prior to injection. This high
dilution and injecting deeply prevents
the occurrence of nodule formation.
• Risks
The most significant risks involve in-
• Precautions
jection irregularity and the product not
feeling and looking smooth. It is impor-
With so many large and torturous ves-
tant to massage uneven areas soon after
sels in this area, hitting one or even a injection so as to avoid a longer term
couple is often inevitable. Ice ahead of problem, though an even injection tech-
time and quick firm pressure on the site nique is always more effective than any
of injection as soon as the needle is with-
amount of massage.
drawn can minimize hematomas or very
large bruises from forming.
• Pearls of Injection
• Post-Injection Instructions
Undercorrection is usually safest, as well
as injecting with the needle in motion
Ice and firm pressure are helpful to pre-
so as not to inject into a vessel and ere-
vent bruising. The product will swell ate an occlusion or embolic situation.
some with an HA and feel firmer to pal-

OIAPJ'ER 56 • Filler InJection far Aging Hands
175
Fig. 56.1
Filler is placed subrutaneously and massaged into place to improve the hollows of the
aging hand.
• Additional Reading
Brandt FS. Cazzaniga A Hyaluronic acid fill-
ers: Restylane and Perlane. Facial Plast Surg
Oin North Am 2007;15:63-76, vii PubMed
Edelson KL. Hand recontouring with calcium
hydroxylapatite (Radiesse).J Cosmet Der-
matol 2009;8:44-51 PubMed

57
-------···-------
Filler Injection with Poly-L Lactic Acid
for Facial Volumizing (Sculptra)
Difficulty: •••
Patient satisfaction: ••
Risk: •••
• Indications
The aging face undergoes lipoatrophy
and essentially "deflates" prior to suc-
cumbing to the effects of gravity. Fat
augmentation of the face is gaining in
popularity; however, poly-L lactic acid
(PLLA) may provide similar results with-
out the need for a surgical intervention.
In addition, many thin faces are part of a
body that is also depleted of fat, so with
no adequate donor site for fat augmen-
tation, PLLA may be a viable alternative.
PLLA is a biostimulatory filler, and mul-
tiple treatments are necessary.
176
• Anatomic Considerations
Prior to injecting this product, it is essen-
tial to have a thorough understanding of
the facial aging process to accurately re-
store volume to a more youthful shape.
PLLA is not intended to be injected into
the muscle. Therefore, the injections
should be directed either into the more
superficial subcutaneous planes in the
lower face or near the periosteum below
the muscles of the upper face.
• Injection Technique
Currently injectors are required to be
trained by an injector trainer prior to
use or purchase of this product in the
United States. Re-suspension of product
is performed preferably 48 hours prior
to injection, but may be reconstituted

CHAPIER 57 • Filler Injection for Facial Volumlzing
177
anywhere from 20 minutes to 3 days
prior to the procedure using preserved
water. Preserved water is preferred be-
cause it allows a longer shelf life after
rehydration. (If saline is inadvertently
used for re-suspension, the product
should not be used.) The volume of water
used should be 5 cc or more per vial. Xy-
locaine (1 or 2%) should be added to each
vial (1 to 3 cc) just prior to performing
the injections to increase patient com-
fort. Some injectors advocate using li-
docaine with epinephrine 1:100,000 to
theoretically minimize bruising. The
authors do not use this mixture and
have not found that its benefits have
outweighed its complications.
Targeted on-label areas for injection
include the temples, nasolabial folds,
cheeks, pre- and post-jowl regions, and
melolabial folds. Advanced areas that
lead to good results in experienced hands
include the brows, tear troughs, mid-
face, lateral orbital rim, and backs of
the hands. Injection is placed in the su-
perficial subcutaneous or pre-periosteal
planes, not intradermally or in the lips
or lip lines. Typically a patient will re-
ceive a single vial for the upper half of
the face and a single vial for the lower
half of the face at each treatment ses-
sion. A pan-facial volumization often
requires the use of at least six vials over
three sessions. In severe cases, much
more can be used.
Injection techniques include linear
threading in a grid pattern, which is an
on-label use, along the cheeks and the
whole lower face, or fanning, which is
not an on-label use. Depot onto the peri-
osteum is used for volumization of the
upper half of the face in all areas above
the inferior border of the orbicularis
oculi muscle. Due to the suspension par-
ticle size of the PLLA product, it is neces-
sary to use at least a 26-gauge needle
and preferably a 25-gauge needle to in-
ject. With both the depot and the fan-
ning and threading techniques, the use
of a 1.0- to 1.5-inch (2.5- to 3.8-cm)
needle makes for many fewer puncture
sites and more efficient placement of the
product.
• Post-Injection Instructions
The patients are instructed to perform a
deep tissue massage of the injected areas
for 5 minutes, five times a day, for the
next 5 days. Bruising can be quite sig-
nificant, and patients should be warned
that they may need to be camouflaged
for upward of a week or more because
of the volume of injection and the size of
the needles.
• Precautions
Nodule formation is the great fear for
those injecting this product and is due
in most case to faulty technique. Overly
concentrating the particles in one area
and not placing the injection at the right
plane are the most common reasons for
clumping of the product and subsequent
collagen overgrowth or granulomatous

178
SECTlON IV • Filler Injection Techniques
reaction. The occurrence of nodules • Pearls of Injection
and injection sequelae has diminished
greatly due to the higher dilutions used
and the injection training requirement
by the manufacturing company.
Do not inject this product in the circu-
lar muscles of the face-the orbicularis
oculi and oris-as there is increased in-
cidence of nodules in these areas.
• Risks
Intravascular injection is possible, espe-
cially along the nasal-alar junction. Per-
form a reflux maneuver on the syringe
prior to injections in this area. One
consolation, despite the blanching or
hematoma, is that the product is almost
entirely watery and that any embolic
event will be self-limiting compared
with a solid injectable substance.
Do not attempt this injection without
the proper training. Make sure patients
understand that it will take several treat-
ments at 4- to 6-week intervals to see
results. It is almost impossible to over-
inject a patient with PLLA.
To prevent the syringes or needles
from plugging, it is advisable to keep the
product warm at or above room temper-
ature when ready to inject. Also, after
adding the water reconstitute, allow the
product to sit for 48 hours without agi-
tating. When you are ready to add the
lidocaine, gently vibrate, stir, or agitate
for 5 to 10 minutes to fully suspend the
particles. Try to avoid shaking the vial
and causing the production of foam, as
this tends to increase clogging of the
needle.

Temporal----
depots
Gridding/ ~
cross-hatching
·
technique
Post-jowl--__,
sulcus
Pre-jowl-------r
sulcus
OIAPJ'ER 57 • Filler InJection far Fadal Volumlzlng
179
~
Nasolabi.al
'c'
_ /
fold
~Fanning
technique
Fig. 57.1
Multiple techniques may be used to inject PLLA. The depot technique is generally used to
augment the temples. A grid technique may be used for the cheeks and pre- and post-jowl regions.
The injection also may be placed along the nasolabial fold. Alternatively. a fanning technique can be
used. A combination of these techniques is also acceptable.
• Additional Reading
lactic add. Dennatol Ther 2011;24:2-27
PubMed
Fitzgerald R, Vleggaar D. Facial volume res-
Lacombe V. Sculptra: a stimulatory filler. Fa-
toration of the aging face with poly-I-
dal Plast Surg 2009;25:95-99 PubMed

58
----···----
The ''Liquid Facelift"
Difficulty: • • •
Patient Satisfaction: • • •
Risk: ••
• What Is a Liquid Facelift?
A combination of fillers and neurotoxins
can be used to rejuvenate the face. This
technique can be offered to patients who
are not willing to undergo surgical treat-
ments. This technique can contour the
face and rejuvenate wrinkles and folds.
The results are temporary and repeated
treatments are usually necessary, but
overall, the patients note a fresher, more
youthful appearance.
"Liquid facelift" is somewhat of a mis-
nomer, as it is not truly a facelift. Used
180
correctly and artistically, the techniques
discussed in this book can be used alone
or in combination to improve a patient's
appearance and "set the clock of aging
back" 5 to 10 years.
• What a Liquid Facelift Is Not
The liquid facelift is not a replacement
for traditional facelift surgery. No amount
of fillers and toxins can reposition the
superficial musculoaponeurotic system
(SMAS), improve the jowls, and remove
fat and excess skin from the neck. It is
important to accurately counsel patients
about what fillers and neurotoxins can
and cannot do for them. Be sure that pa-
tients have the correct expectations prior
to treatment.

CHAPIER 58 • lhe •Liquid Facellft"
181
a
b
Fig. 58.1a, b Three-dimensional volume assessment of a patient before and after treatment with
1 0 cc Restylane and 50 units of Botox.
• Complementary Procedures
toxins (see Chapter 7) and augmenting
the lips with fillers (see Chapter 37) can
Fillers and neurotoxins can be used as be nice adjuvants to fadal rejuvenation
an adjunct to fadal surgical procedures. surgeries.
Treatment of the crow's feet with neuro-

59
-------···-------
Management of Filler
Injection Complications
Fortunately, the most common compli-
cations from filler injections are minor
and temporary, and may include swell-
ing, bruising, and lumpiness. Rarely,
more serious complications can occur,
even in the best trained hands. By hav-
ing thorough knowledge of facial anat-
omy and understanding the filler prop-
erties, most serious complications can
be avoided.
• Tyndall Effect
Some hyaluronic acids (HAs) will refract
blue light if placed too superficially or if
they migrate superficially.
Treatment
A 20-gauge needle is used to puncture
the pool of product, and the product is
expressed through this tract. This is the
preferred treatment for product in the
182
lower face. Treatment of the lower lids
with the puncture technique is difficult
and can cause excessive bruising while
trying to manipulate the product. In this
region, 20 to 50 units of hyaluronidase
(Vitrase, ISTA Pharmaceuticals, Irvine,
CA) can be used. Vitrase is sheep-derived
(Ovine) hyaluronidase supplied in 200
U/1 cc vials (20 units/0.1 mL).
• Herpetic Outbreak
When injections are placed in the lips,
patients who have experienced prior
herpetic outbreaks may have a flare-up
of symptoms. Valtrex (500 mg) is typi-
cally started 3 days before injection
and continued for 1 week afterward.
More aggressive therapy with higher
dosing and acyclovir creams is pre-
scribed if herpetic eruptions occur de-
spite prophylaxis.

CHAPTER 59 • Management of Aller Injection Complications
183
• Nodules/Lumpiness
Clumps of product may occur after
injections.
Treatment
Massaging the product at the time of
injection can lessen the occurrence of
these lumps and bumps. Warm com-
presses and massage often help improve
these lumps over time. Hyaluronidase
can be used if HA lumps are unaccept-
able to the patient.
that biofilms play a role in this
condition.
Treatment
Oral fluoroquinolones ( ciprofloxacin,
levofloxacin) or macrolides ( darithro-
mycin or azithromycin) may be used for
up to 6 weeks. Steroids and nonsteroidal
anti-inflammatory drugs (NSAIDs) may
encourage the formation of biofilms and
should be avoided in these conditions.
• Vascular Compromise
• Granulomas
Can be due to intravascular injection,
vasospasm, or external compression. 1m-
Granulomas are reactions to product mediate blanching of the skin is seen
that can be seen several months after during injection.
injection.
Treatment
Granulomas may be treated with Kena-
log injections, oral methylprednisolone,
and oral antibiotics. Some advocate using
5-fluorouracil ( 5-FU) for treatment. Ex-
cision is also an option.
• Delayed Hypersensitivity
Erythema of the skin surrounding the
injected product can be seen weeks to
months after injection. It is theorized
Treatment
• Stop injection immediately.
• Massage the area.
• Apply warm compresses.
• Consider use of hyaluronidase (even
if a calcium hydroxylapatite [ CaHA]
was used).
• Apply topical nitropaste.
• Prescribe aspirin PO.
• Follow the patient frequently;
photodocument the injury and its
progress.
• Consider consulting colleagues for
assistance/ advice.

a
b
184
SECTlON IV • Filler Injection Techniques
Fig. 59.1 a-f (a) Blanching seen awtely at the time of vascular occlusion. (b) Purpura noted after
facial artery occlusion.