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.
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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.