Dermal Fillers for Facial Harmony

Altamiro Flávio

• Publisher: Quintessence Publishing Co, Inc
• Year: 2020
• eBook ISBN: 9781647240073
• Edition: 1
• Topic: Medicine
• Subtopic: Dentistry

In our esthetics-obsessed culture, patients are becoming more aware and demanding of dermal filler treatments. Yet all too often we hear news stories of botched procedures or anesthesia gone wrong. This book walks you through how to incorporate dermal fillers into your clinical armamentarium, starting with the basic characteristics of the materials and advancing to the injection techniques and clinical indications for their use. The author includes such fine detail as whether to use a needle versus a cannula and why you must understand the precise tissue layers of the face in order to effectively deliver this nuanced treatment. In step with its sister volume, Botulinum Toxin for Facial Harmony, the book focuses on facial analysis as a crucial step in determining appropriate treatment, a philosophy that is carried through the entire book. An entire chapter is devoted to clinical cases illustrating the various facial regions and their appropriate filler applications, clearly demonstrating how to use the techniques presented to optimize esthetics and facial harmony. Supplemental material and videos are available via QR code for additional learning.

C H A P T E R

07

Facial Regions and Possible Filler Therapies

Swelling

The application of a good-quality hyaluronic acid (HA) filler is very safe because of its biocompatibility. However, swelling can be a problem and is associated with all fillers, especially in the tear trough area. Swelling occurs because of the hydrophilic nature of the gels and also the inherent disruption of normal vascular and lymphatic dynamics.1

The risk of persistent swelling can be minimized in a variety of ways. Firstly, careful thought must be applied when considering the type of filler material to be used around the eyes. There is a range of products available, and the choice of filler should match the location being injected. If you are using the same filler for all parts of the face, you are likely doing something wrong. Highly cross-linked HA gels are excellent for larger-volume and deeper fills such as the nasolabial folds or lateral cheeks. However, these gels are more prone to swelling and should be avoided around the eyes in favor of less cross-linked preparations or blends.2 In addition, remember that when treating the tear troughs, small volumes are the key. If you are used to treating areas where large injection volumes are used, you will find the volume requirements around the tear trough very different, as often 0.05 to 0.2 mL is more than sufficient for each tear trough deformity.

Injection Location

Figures 7-1 to 7-18 show the approximate location of the injected product for various regions of the face. The recommended products, as well as the instruments to be used during injection, are described in order of priority (first, second, third choice). Please note that the first choice is preferred but the other choices are acceptable. The volumes to be used might also vary in each case. The suggested route of administration is subcutaneous, that is, approximately 3 mm below the epidermis, except for the tear trough and palpebromalar groove, where the juxtaperiosteal injection is recommended. The skin is very thin in these two regions, which helps to visualize the volume of filler right below it, and thus small amounts of the filler should be injected. Large quantities can still partially block the lymphatic system, leading to recurrent swelling. The use of very hydrophilic fillers in this area should be avoided. Additionally, it is important to observe that at the tear trough and palpebromalar groove, juxtaperiosteal injections should be made so that the fibers of the orbicularis oculi muscle can hide undesirable volumes.

Fig 7-1 Injection location for orbit structuring.

• The filament should have a bone background, but this procedure does not require juxtaperiosteal injection.

• Inject to a 3-mm depth.

• Massage the area, curving the lateral part of the filament.

• This therapy projects the lateral of the orbit in a horizontal plane.

Fig 7-2 Injection location for eversion of the lip vermilion.

• Use a needle to make short filaments and a 25G cannula for long filaments.

• The filaments should be more superficial so they will become evident.

• Always inject at the vermilion.

• For better definition, do not massage the area.

• This therapy rejuvenates the mouth.

Fig 7-3 Injection location for the lip tubercle.

• The needle should stop at 3 mm.

• The injection should follow the midline.

Fig 7-4 Injection location for volumization of the lip vermilion.

• If you notice that the lips are flat, evaluate a possible decrease of the occlusal vertical dimension as a possible cause.

• For better definition, do not massage the area and make a deeper injection (3 mm).

• The lower filaments can be interrupted in the width of the philtrum sulcus in order to cause a depression at the midline to fit the upper lip tubercle.

Fig 7-5 Injection location for philtrum columns.

• The injection should be performed close to the dermis (never in the dermis but more superficial).

• The bevel should be turned downward.

• Inject the filler in the philtrum before the eversion filament in the Cupid’s bow, because the philtrum already contributes to that. Only then analyze if there is still a need to create the Cupid’s bow near the midline.

Fig 7-6 Injection location for the subnasale point.

• The injection should be made 3 mm deep.

• Do not inject inside the columella.

• Do not inject at the anterior nasal spine. Deeper injections of fillers demand larger amounts of material and are dangerous because the blood vessels are larger than in the more superficial layers.

Fig 7-7 Injection location at the supratip.

• Caution should be taken in patients who previously underwent rhinoplasty because of necrosis concerns.

• This therapy is contraindicated for Asian patients because they do not show enough skin elasticity in this area.

• The length of the filament is equal to the height of the alar cartilage plus 1 mm.

• Redness in the tip of the nose for more than 7 days can mean an excess of the product was used. In that case, future injections should have a reduced amount of filler.

Fig 7-8 Injection location at the mentolabial sulcus.

• The depth of the cannula should be 3 mm.

• This therapy increases the length of the lower lip. It also corrects the inclined lip (Class II).

• This therapy makes the person’s face more dolichofacial and balances the ratio between the measurement of the upper lip and lower lip.

• This therapy lifts the lower lip and helps with passive sealing of the lips.

• It also promotes the chin-face integration.

Fig 7-9 Injection location for malar deficiency.

• Draw a triangle. The injection should be 3 to 4 mm deep.

• Avoid a deep plane because of the infraorbital foramen and the risk of internal bleeding.

• This therapy may worsen the infraorbital depressions. Thus, inform the patient that these depressions might also need filler injections.

Fig 7-10 Injection location for the prejowl sulcus.

• The cannula should be 3 mm deep.

• Extraoral access is recommended.

• This therapy promotes the chin-face integration.

• Inform the patient that at the end of the therapy, the filling will be noticeable to the touch and that this is normal.

Fig 7-11 Injection location for infraorbital depressions.

• CAUTION: Dark circles are a result of darkening of the skin and should not be treated with facial fillers. Fillers should only be injected in case of infrapalpebral depression.

• This is the only filling procedure that should be done using a juxtaperiosteal injection.

• Maintain a distance of 5 mm from the plica semilunaris.

Fig 7-12 Injection location at the nasolabial folds.

• After using the cannula to make the filament, use the needle to make a filling just like the shape of a zipper (only in a more pronounced sulcus). Do not extend it to the ala nasi.

• This is the preferred site for beginners, although it is less important than other sites such as the marionette lines, except in cases of maxillary deficiency.

• The marionette lines are the priority.

• Before injecting, enter and remove the cannula at least four times against the dermis, following the sulcus. It will make the subcutaneous tissue thinner in order to achieve a better result.

• Inject a uniform amount of the filler, but do not inject a larger volume in the superior border of the groove to avoid blocking the vessels.

Fig 7-13 Injection location for marionette lines.

• In some cases, the drawing in this area will be a filament, in others a filament with small perpendicular dashes (similar to the shape of a zipper), and in ...

Table of contents

• Cover
• Half Title
• Copyright Page
• Title Page
• Contents
• Foreword by Paulo Vinícius Soares
• Preface
• 01 Facial Anatomy
• 02 History, Classification, and Characteristics of Fillers
• 03 Injection Planes and Techniques
• 04 Complications
• 05 Facial Analysis for Dermal Filler Injections
• 06 Facial Anesthesia for Filling Procedures
• 07 Facial Regions and Possible Filler Therapies
• Index