Techniques in Aesthetic Plastic Surgery Series: Facial Rejuvenation with Fillers with DVD

7 
Volumetric use
of injectable fillers
in the face

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John M. Hilinski, Steven R. Cohen

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Key points
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• Non-surgical, minimally invasive alternative to • Establish a conservative approach with gradual

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surgery. reshaping over time.

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• Injectable fillers commonly used for skin wrinkles, • Utilize appropriate injection technique with
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deep creases, depressed scars and regional proper plane for filler deposition.
volume enhancement of the face.
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• Filler selection largely based on duration of

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enhancement and anatomic area of concern.

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Patient selection patients, injectable fillers can be used as a powerful

Over the last two decades, the concept of using inject-
able fillers for facial rejuvenation has become a well
accepted standard in the practice of plastic surgery. The
ideal patient for injectable filler use in the face is
one who desires a non-surgical, minimally invasive
approach for aesthetic soft tissue volumetric enhance-
ment. The best candidates tend to be younger, middle-
aged patients, as this population typically requires
only mild to moderate change for early signs of aging.
In those with more advanced aging changes requiring
more extensive volumetric enhancement, surgical
treatments options, such as facial implants or lifting,
may be more beneficial. Even in this population of
adjunct in augmenting or complementing a surgical
result.
Indications
As the number of injectable fillers has steadily increased
since their introduction decades ago, so has the array
of indications for their use in the face (Figure 7.1). For
many years now, one of the most popular indications
has been smoothing out unwanted facial wrinkles and
creases. As we age, the collagen framework that nor-
mally provides support to the dermal skin layer gradu-
ally begins to loosen. Over time, this results in dermal
thinning and focal reduction of soft tissue volume.

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Techniques in Aesthetic Plastic Surgery Series: Facial Rejuvenation with Fillers with DVD
7 Injectable fillers in the face

Tear trough
augmentation

Malar shading
augmentation

Nasal augmentation
Figure 7.1 Common indications
for injectable filler use
Nasal augmentation in the face. These
Lip augmentation include treatment of
wrinkles and creases,
Marionette augmentation depressed scars, and
regional volume

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Prejowl augmentation
deficiency (such as
the tear trough/malar

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region, nasolabial fold,

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nose, lips, marionette
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sulcus).

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Eventually this leads to formation of a fine wrinkle or An extension of wrinkle treatment is injectable
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crease within the skin. With further aging and gravita- filler use for depressed scars. Although unrelated to
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tional pull, fine wrinkles and creases can deepen into the aging process, depressed scars also demonstrate
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what are essentially skin folds. Glabellar frown lines marked thinning of the dermal collagen layer similar
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are a common example of this aging process. When to what is seen in wrinkles and creases. Such scars are
injectable fillers are used to treat a skin wrinkle or commonly seen in patients with a history of recurrent
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crease, the intention is to replenish the dermal colla- acne or prior traumatic injury that causes damage to
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gen that was lost as a result of the aging process. Thus, the dermis. This results in focal loss of dermal collagen
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the term dermal filler commonly used to describe this that leads to an unwanted depression along the skin
particular application. By volumetrically expanding, with unwanted shadowing. In an analogous fashion
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or plumping, the dermal layer, injectable fillers can for wrinkles or creases, injectable fillers are used to
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help decrease or even eliminate wrinkle depth to
restore a smooth skin surface.
Perhaps the most well-known example of a deep-
ened skin crease is the nasolabial fold. This represents
what happens when a naturally shallow crease in
youth deepens considerably with the aging process. It
should be pointed out that it is aesthetically acceptable
to have a fine line between the cheek and upper lip.
When this line begins to deepen and create an abnor-
mal shadow, injectable fillers may be indicated. The
goal of correction should be to restore a fine or shallow
line rather than completely erase any perception of
demarcation. In patients who have undergone prior
facelift surgery, soft tissue volume enhancement of the
nasolabial fold can be a powerful complementary pro-
cedure to further augment their results.
replace the lost collagen, which essentially raises the
depressed scar and smoothes out the skin surface.
Another widely popular indication for injectable
filler use in the face is regional volume deficiency. This
refers to broader aesthetic subunits, or regions, of the
face that are lacking in sufficient shape and contour.
Unlike wrinkles or creases, this type of contour abnor-
mality often results from volume deficiency below
the dermal plane. Depending on the area, this can
include deficiencies in subcutaneous fat, muscle and/
or mucosa. In some cases this involves patients who
are seeking to aesthetically enhance a certain area that
is naturally deficient in volume. In others, injectable
fillers are being used to rejuvenate or correct volume
deficiencies that are more related to the aging process
or iatrogenic causes.

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Techniques in Aesthetic Plastic Surgery Series: Facial Rejuvenation with Fillers with DVD
A common example of regional volume deficiency
is the tear trough/malar region. In younger patients
who present with this type of volume deficiency, it
usually reflects a congenital predisposition to hollow-
ing below the lower eyelid. In the more aged popula-
tion, this scenario is due to infraorbital fat pads that
appear to herniate forward in combination with
descent and flattening of the malar fat pad. The end
result is disruption of the naturally youthful convexity
that normally extends from the lower eyelid to the
malar region. The clinical manifestation of this is an
excessively tired look due to puffy lower eyelids and
unmasking of the tear trough. Most patients complain
of unwanted shadowing and hollowing involving this
area that contributes to a prematurely aged appear-
ance. Injectable fillers can be quite beneficial in this
setting by volumetrically expanding the tear trough
with or without augmentation of the malar eminence.
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This helps to restore an uninterrupted convexity by
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blending the lower eyelid and malar region resulting
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in a more rested look.
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The perioral region is another area frequently
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treated with injectable fillers. This region, which
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includes the lips, marionette lines and prejowl sulcus,
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is considered the predominant aesthetic unit of the
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lower third of the face. Central to this region is the
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appearance of the lips, which includes the philtral
columns. In today’s society, fuller shapely lips are syn-
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onymous with a more feminine and sensual appear-
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ance. Younger patients presenting for lip augmentation
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typically only require additional volume. This usually
involves injection of the mucosal lip, vermillion
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border and philtral columns in combination to achieve
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an enhanced shape. This also includes increased defi-
nition of Cupid’s bow in the upper lip. In the more
senescent population, several other factors must also
be considered due to age-related submucosal atrophy.
These patients demonstrate further degrees of volume
deficiency giving the appearance of even more deflated
lips. In addition, these changes are accompanied by
formation of perioral vertical lip lines. Therefore, the
senescent lip demands not only volume enhancement
but also management of vertical lip lines to help
restore a more youthful definition.
When assessing candidacy for lip augmentation, it
is critical to evaluate the other components of the
perioral region, such as the marionette lines and
prejowl sulcus. Combined treatment of these areas is
commonly indicated to achieve optimal lower face
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Injectable fillers in the face 7
rejuvenation. Marionette lines refer to the soft tissue
fold that develops at the lateral oral commissure.
Often seen in conjunction with atrophic lip changes,
these lines descend in a downward direction from the
corner of the mouth. This often contributes to a sad
and prematurely aged appearance. Injectable fillers
work by effacing these lines, which helps give the
appearance of elevating the corner of the mouth. In
patients with hyperdynamic movement of the under-
lying depressor anguli oris (DAO) muscle, concurrent
use of Botulinum toxin can further enhance the results
of an injectable filler.
With aging, sagging skin and underlying bone
resorption contribute to formation of the jowl. This is
an abnormal soft tissue contour that disrupts the
normally youthful jawline. As a result, an abnormal
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oblique shadow is created between the jowl and chin
corresponding to the prejowl sulcus. In an attempt to
eliminate this shadow facelift surgery and chin
implants are frequently employed to suspend the jowl
and fill in the soft tissue void, respectively. As a non-
surgical alternative, injectable fillers can be used quite
effectively to volumetrically expand the prejowl sulcus.
By elevating this soft tissue depression a smoother,
more youthful transition can be restored from the chin
to the posterior jawline.
A recent and growing indication for injectable filler
use is an undesirable nasal appearance. In patients
who would otherwise undergo augmentation rhino-
plasty, perinasal injectable fillers can be used as an
alternative to elevate or project certain areas of the
nose, such as the radix, bridge and tip. This method
has gained increasing popularity and is often referred
to as injection rhinoplasty. Injectable fillers are also
quite useful in patients who have already undergone
rhinoplasty and note persistent postoperative contour
irregularities or depressions. Instead of undergoing a
complex and risky secondary rhinoplasty procedure,
injectable fillers can be used as a minimally invasive
option to achieve the anticipated result.
Fillers may also be used in cases where an alloplas-
tic implant would have, otherwise, been placed. The
malar regions, perinasal skeleton, mandibular angles
and chin are all amendable to volume augmentation
by fillers. Fillers may be used as a prelude to placement
of permanent implants or on a periodic basis in
patients desiring temporary improvement. Augmenta-
tion of the facial skeleton by fillers is one of the most
subtle, but powerful non-surgical treatments that can
Techniques in Aesthetic Plastic Surgery Series: Facial Rejuvenation with Fillers with DVD
7 Injectable fillers in the face
be offered and may yield at times dramatic improve-
ment in soft tissue drape.
Injectable filler selection
Over the last decade there has been a dramatic increase
in the number of fillers available for volumetric
enhancement of the face. This reflects the fact that the
ideal injectable filler has yet to be introduced. The
ideal filler would be a material that is biocompatible,
non-allergenic, easy to administer, long lasting, non-
migratory, economical, and predictable in terms of
results. Most fillers currently available possess at least
several of these desired properties. A majority are bio-
engineered materials that can be used interchangeably
for many different applications. With such a vast
number of fillers to choose from, a helpful approach
for many surgeons is to categorize them based on
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duration of enhancement – temporary, long lasting
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and permanent. Individual selection can then be
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further tailored depending on the anatomic area of
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concern and what works best in your hands.
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Temporary injectable filler
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Temporary injectable fillers are products that provide
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clinical enhancement on average between 6–9 months
in duration. Hyaluronic acid (HA) based materials
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comprise a majority of the temporary fillers currently
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used. These fillers are predominantly synthetic prod-
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ucts derived from non-animal stabilized hyaluronic
acid (NASHA). Thus, they do not require allergy skin
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testing prior to injection. Hyaluronic acid products are
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ideally suited for use as injectable fillers because HA
is natively present in the extracellular matrix of the
human body. Hyaluronic acid is a linear polysaccha-
ride with hydrophilic properties. With a high affinity
for binding water molecules, HA plays a key role in
hydrating the skin. This results in natural plumping
and cushioning of the soft tissue layer. This effect is
precisely why injectable HA can be used quite success-
fully in volume enhancement of the skin.
The primary difference between individual syn-
thetic HA fillers available today is related to the various
degree of cross-linking within each product. Chemical
cross-linking alters the solubility of HA to create a
more viscous, water insoluble gel form. This translates
into a more stabilized product that can be properly
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stored as well as readily injected through a syringe.
Higher degrees of cross-linking result in increased vis-
cosity, which can influence inject technique and use
for the various fillers. For example, less viscous gels
allow for smoother injection and, thus, are better
suited for superficial dermal injection. Products con-
taining a higher viscosity gel are less forgiving and
more prone to clumping. Therefore, these products
should be injected along a mid to deep dermal plane
to avoid superficial contour irregularities. Following
placement, the HA undergoes gradual digestion with
eventual clinical disappearance of the aesthetic effects
by six to nine months. In most patients this duration
of enhancement and need for repeat treatment is
acceptable given the versatility and safety profile of HA
fillers. In others, HA is considered more of a prelude
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to what a longer lasting or permanent filler may
provide them in the future.
Prior to the introduction of HA based products,
human derived collagen was considered the first choice
in temporary filler use. Today, HA based products have
largely supplanted these products. This is predomi-
nantly due to the fact that collagen products simply
do not provide an adequate duration of enhancement.
Clinical experience has demonstrated that collagen
lasts only a number of weeks or several months at best.
This would necessitate repeat treatment too frequently
for most patients seeking injectable filler augmenta-
tion. One of the only remaining advantages of colla-
gen use is for correction of very superficial fine lines,
such as vertical lip lines. In this instance, collagen can
be placed within the upper dermis to efface or smooth
out individual lines. Because of its low viscosity, col-
lagen can augment these fine lines with less risk of
visibility or palpability compared with other fillers,
such as hyaluronic acid.
Long lasting injectable fillers
Long lasting injectable fillers provide volume enhance-
ment on average between 12 months and several years
in duration. These fillers are largely composed of
polymer microspheres suspended in a resorbable
solution that slowly degrade over time. One of the
most widely used fillers is comprised of thirty percent
calcium hydroxylapatite microspheres (25–45 µm)
suspended in an aqueous carrier gel. Like HA based
products, calcium hydroxylapatite is relatively inert,
Techniques in Aesthetic Plastic Surgery Series: Facial Rejuvenation with Fillers with DVD
Injectable fillers in the face 7

very safe and requires no skin testing prior to injec- Permanent injectable fillers
tion. In comparison to HA based fillers, however,
Permanent injectable fillers refer to products that are
calcium hydroxylapatite is not recommended for treat-
non-degradable and, thus, provide a durable aesthetic
ment of more superficial wrinkles and creases. It is also
enhancement after placement. Currently, the most
not suggested for use in lip augmentation. The carrier
promising permanent filler available (Artefill) is a
gel typically absorbs soon after injection, leading to
product comprised of twenty percent non-degradable
some degree of calcium hydroxylapatite precipitation.
polymethylmethacrylate (PMMA) microspheres (30–
When injected superficially or into the lip, clumping
50 µm) suspended in a resorbable gel. The gel con-
can manifest as visible and palpable white nodules. It
tains bovine collagen that is derived from a restricted
is worth noting these nodules are not the same as
closed herd but still warrants allergy skin testing prior
granuloma formation. When placed in the mid to
to use. The size of the PMMA microspheres combined
deep dermis or subcutaneous tissue space, there is
with their smooth, round surface allows them to resist
ample soft tissue coverage to minimize visibility of the
phagocytosis and, hence, absorption, by the body.
opaque filler. For this reason, calcium hydroxylapatite
These qualities also help reduce the risk of granuloma-
is more commonly used to augment moderate to deep
tous response, which was the main criticism of similar
creases and folds as well as regional volume deficiency.

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predecessor products. It should be pointed out that
Around nine months after injection, calcium hydro­
PMMA microspheres are marketed under different
xylapatite begins to undergo gradual enzymatic

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names in different countries around the world. ArteFill

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digestion with full disappearance of the aesthetic effect

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is the only FDA approved permanent filler available in
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between twelve and eighteen months following
the United States. Other competitor fillers (including

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placement.
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Artecoll, Metacrill, and Newplastic) are comprised of
Another popular long lasting filler is composed of
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different PMMA material and under scanning electron

polylactic acid microspheres (1–63 µm). Polylactic
microscopy appear to have less uniform sphere diam-
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acid is a biosynthetic material that has been used

eters. In addition, these other products contain more
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safely for decades in the form of absorbable sutures,

nanoparticles. Combined, these inherent differences
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surgical plates and screws. With minimal antigenicity,

may be associated with higher rates of complications
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no skin testing is required prior to injection. The

when compared to Artefill®.
product is packaged as a freeze-dried powder that is
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Clinical experience has shown that PMMA fillers

reconstituted using sterile water to produce a sus­
work best when injected in the deep dermis or subcu-
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pension of polylactic acid microspheres. Originally

taneous layer so as to avoid unwanted ridging or
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intended for treatment of human immunodeficiency

papules in the skin. With proper level of placement,
virus drug-induced lipoatrophy, polylactic acid fillers
there is minimal inflammatory response elicited. The
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are now considered to have a similar profile to calcium

individual PMMA microspheres are eventually encap-
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hydroxylapatite in terms of use. They are injected in

sulated by the patient’s own collagen as the bovine
the deep dermis or subcutaneous space to restore full-
collagen disappears completely. The end result is a
ness to the face and reduce appearance of moderately
layer of biologically stabilized PMMA that resists
deep wrinkles and folds. Once placed, the filler stimu-
migration and provides enduring soft tissue volume
lates an inflammatory response from the body as it is
enhancement.
metabolized to carbon dioxide and water. After several
weeks, collagen deposition by the body begins to
replace the volume occupied by the filler. Because this Procedural technique
replacement process does not necessarily occur in a
one to one volume ratio, three to five treatment ses-
Pre-procedure preparation
sions are required over a twelve to eighteen month
period to gradually reach the desired level of augmen- An essential key to success with injectable fillers is
tation. Such a lengthy period of time has been one of establishing a conservative approach with their use.
the biggest deterrents from more widespread accep- This often translates into avoiding overcorrection. This
tance of polylactic acid filler use. is particularly important for the inexperienced surgeon

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Techniques in Aesthetic Plastic Surgery Series: Facial Rejuvenation with Fillers with DVD
7 Injectable fillers in the face
using longer lasting and permanent fillers. Unfortu-
nately, injectable filler use has been mischaracterized
in the past as being a single session enhancement
procedure. Instead, patients should be prepared by
emphasizing their use as a gradual reshaping process
that extends beyond the first treatment session. Patients
should be counselled that the first treatment is
intended to achieve a notable improvement in the area
of concern. For optimal results, however, a follow-up
appointment is routinely scheduled several weeks later
for further augmentation and refinement.
Pre-procedure preparation for all injectable fillers
also includes a detailed consultation to establish real-
istic patient expectations for the chosen product and
planned area of treatment. Obtaining a medical history
will help ensure absence of known hypersensitivity or
allergic response to the material being placed. Other
contraindications, such as pregnancy, lactation and a
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history of keloid or hypertrophic scar in cases of long
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lasting or permanent filler placement, should also be
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ruled out. Skin testing is recommended several weeks
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in advance of planned placement of any product con-
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taining bovine collagen.
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Starting 10–14 days prior to treatment, patients
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should be restricted from using medications that
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would predispose to excess bleeding and swelling. Use
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of homeopathic supplements, such as Arnica, before
and after treatment has also proven successful in
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helping to minimize bleeding and swelling. Photo­
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documentation using adequate lighting and standard
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views is recommended to more accurately assess treat-
ment outcomes. Written informed consent is also a
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prerequisite for injectable filler use.
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Aesthetic analysis and determination of the volume
deficient areas is accomplished with a thorough physi-
cal examination. This should also include notation of
any preexisting asymmetries, contour irregularities,
and skin blemishes that may alter the proposed treat-
ment outcome. Some injectable fillers require a pre­
paratory lead-time before actual use. For instance,
polylactic acid fillers are packaged in a powdered form
and require reconstitution with sterile water prior to
injection. It is recommended this be done 2–24 h
prior to use to ensure complete hydration of the
product. Others, such as PMMA fillers require storage
in a refrigerator and, therefore, need to be thawed for
20–30 mins prior to use.
Assessment of the required level of anesthesia is
another important consideration prior to injection. It
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should be emphasized that a more comfortable patient
will be less prone to procedural-related hypertension
and, hence, ecchymosis and swelling. The simplest
form of anesthesia involves use of a cold compress
applied directly to the planned site of injection imme-
diately prior to and after treatment. This is mostly
commonly used when treating isolated wrinkles and
creases. Another popular method is to apply a
topical anesthetic to the skin 45–60 mins prior to
treatment. This should be done only after thoroughly
cleansing the skin surface of all makeup and oil. For
perioral injections, a cotton tip applicator can be used
to swab the upper and lower labial sulcus. Due to a
higher mucosal absorption rate, this method of
anesthesia requires only a few minutes prior to filler
placement.
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In cases where topical anesthesia is thought to be
insufficient, local or regional nerve blocks can be used
for added patient comfort. After applying the topical
anesthetic, 1–2% Lidocaine with 1 : 100 000 Epineph-
rine buffered with sodium bicarbonate is infiltrated in
strategic sites depending on the area being treated.
Careful attention must be paid to avoid excess infiltra-
tion as this may distort soft tissue contour and decrease
accuracy of filler placement. For the tear trough or
nasolabial fold, an infraorbital nerve block may be
used to anesthetize the midface region. This is done
by infiltrating approximately 0.25 ml at the exit site of
the infraorbital nerve (V2) via transcutaneous or sub-
labial delivery. For lip augmentation, a regional block
of the upper and lower lip can be quite effective. This
involves distribution of approximately 0.5 ml across
4–5 sites along the upper or lower gingival sulcus. If
more widespread perioral anesthesia is indicated for
marionette lines and/or the prejowl sulcus, a mental
nerve block may be performed. This is done by infil-
trating approximately 0.25 ml at the exit site of the
mental nerve (V3), which provides adequate anesthe-
sia for augmentation of the lower lip and chin.
Technique
All soft tissue fillers are injected through a sharp needle
that is typically packaged with the syringe. Needles are
sized relative to the viscosity of the filler. Lower vis­
cosity fillers, such as HA based products, can be
injected relatively easy through smaller bore needles
(30 gauge). Whereas higher viscosity products require
Techniques in Aesthetic Plastic Surgery Series: Facial Rejuvenation with Fillers with DVD
Injectable fillers in the face 7

larger bore needles (26–27 gauge) to accommodate a Cross-hatching

higher resistance to flow.
Cross-hatching is a technically a variation of linear
Using the non-dominant hand, the surrounding
threading (Figure 7.2D). This involves use of linear
soft tissue can be stretched to help stabilize the skin
threading technique to create several parallel lines of
surface for needle insertion. After insertion through
filler across the treatment area. Perpendicular to these
the skin, the bevel should be positioned downward so
lines, this process is repeated to create a cross hatching
as to minimize unwanted deposition of the filler in a
of filler placement. It is often helpful to draw out a
more superficial plane. Based on the area being treated,
patterned grid using a surgical skin marker to ensure
one or more of several different techniques can be
uniform spacing of the lines and minimize potential
employed for proper placement of injectable filler. The
contour irregularities. This technique is commonly
most common techniques include linear threading,
used in augmentation of broader areas, such as the
serial puncture, radial fanning, and cross-hatching
marionette lines and prejowl sulcus.
(Figure 7.2).

Linear threading Technical details

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Linear threading is a technique in which the needle is
inserted into the skin and the filler is deposited in a Glabella injection

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linear fashion along the track as the needle is slowly

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Treatment of deepened glabellar lines is typically

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withdrawn (Figure 7.2A). Because this creates essen-
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tially a tunnel of filler, this is also commonly referred
accomplished with linear threading or serial puncture

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technique. Although injectable fillers alone can help
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to as the tunnelling technique. This is the most fre-
soften these lines, the best results in this area are
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quently used technique for correction of isolated

achieved when done in combination with Botulinum
wrinkles and creases, including the nasolabial folds.
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toxin injection. The Botulinum toxin is first placed

In cases where a particularly deep fold is present, layer-
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in the procerus and corrugator muscles to address

ing the parallel lines can be quite helpful in achieving
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unwanted creases resulting from hyperdynamic move-

the desired results.
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ment. After the paralysis has taken effect, approxi-

mately 0.25–0.5 ml of injectable filler can be used to
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Serial puncture smooth out residual skin creases. Temporary fillers

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Serial puncture involves multiple injections positioned placed in the upper to mid dermis are extremely effec-
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adjacently along the length of the wrinkle or crease tive for this purpose. Longer lasting or permanent
(Figure 7.2B). It is imperative these injections remain fillers can also be used to correct these lines. However,
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sufficiently close so as to form a relatively smooth, they require placement into the deeper dermis, which
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continuous line of augmentation. In cases where there
is a noticeable separation between injection sites, post
treatment massage may help blend the filler.
Radial fanning
Radial fanning is an extension of the linear threading
technique (Figure 7.2C). This involves insertion of the
needle at the periphery of the area to be treated.
Similar to the threading technique, the filler is depos-
ited in a linear line as the needle is withdrawn. Before
the needle is actually removed from the skin it is
redirected and advanced along a new radial line. Filler
deposition continues in this fashion until the desired
result is achieved. This is a popular technique utilized
for augmentation of the malar region.
theoretically increases the risk of intraluminal injec-
tion in this highly vascular region. This has reportedly
been linked to possible skin necrosis. Because of this
concern, some practitioners suggest compression of
the adjacent supratrochlear vessels during injection.
Still others have gone so far as to recommend only
unilateral glabellar injection at one session with the
contralateral side done on another day to minimize
this potentially disastrous complication.
Nasolabial fold injection
Enhancement of the nasolabial fold is done primarily
with linear threading or serial puncture technique. In
order to effectively efface this area, the needle should
be placed medial to the fold. If placed within the

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Techniques in Aesthetic Plastic Surgery Series: Facial Rejuvenation with Fillers with DVD
7 Injectable fillers in the face

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A B

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PL R
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D
C
Figure 7.2 Various injection techniques for filler placement. (A) Linear threading technique with deposition of
filler directly below the skin wrinkle or crease during needle withdrawal. Proper technique involves
placement within the dermis or at the dermal-epidermal junction with needle bevel facing down. (B)
Serial puncture technique with multiple filler deposits placed adjacent to one another along the length
of the skin wrinkle or crease. (C) Radial fanning technique involves linear threading to deposit the filler
below the area of concern. Prior to withdrawing the needle from the skin, it is redirected and advanced
along a new radial line. This process continues in a fanning distribution until the desired augmentation is
achieved. (D) Cross hatching technique is a variation of linear threading involving multiple parallel lines of
filler deposition. A cross hatching pattern is then created by repeating this process with injections made
in a perpendicular fashion.

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Techniques in Aesthetic Plastic Surgery Series: Facial Rejuvenation with Fillers with DVD
deepest aspect of the fold or more laterally, there is a
high likelihood of further deepening upon injection.
The needle is typically inserted at the inferior border
of the fold and advanced superiorly toward the alar-
facial junction. As in most other applications, tempo-
rary fillers are best placed in the mid dermis while long
lasting and permanent fillers should be placed in the
deep dermis. When properly placed, one should see
immediate plumping of the skin and noticeable
improvement as the needle is withdrawn. If this is not
the case, the needle should be repositioned until this
visual confirmation is noted. In many patients, the
superior aspect of the fold requires a layered injection
because of more volume deficiency in this area.
Approximately 0.5–2 ml are usually indicated to
achieve a clinically significant bilateral improvement.
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Tear trough–malar injection
O R
FI
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Management of the tear trough is usually done with
T
linear threading or serial puncture technique. Tempo-
T V
rary, long-lasting and permanent fillers can all be used
N SE
effectively to augment the underlying soft tissue and
TE L
smoothly transition the lower eyelid and cheek. In
N E
patients with thinner skin, however, it is considered
O F
more prudent to choose a temporary filler for this
C O
purpose. Given the higher chance of visible contour
irregularities, longer lasting and permanent fillers can
E TY
be significantly more challenging when placed under
PL R
the thin eyelid skin.
M PE
It is often helpful to keep the patient in an upright
position during injection. When placed supine, the
SA O
periorbital fat tends to retract under the eye, making
PR
it difficult to accurately visualize the ongoing correc-
tion process. The needle is inserted from lateral to
medial just inferior to the deepest margin of the tear
trough. Careful attention should be paid to maintain
a 2-4 mm distance from the lateral nasal wall as filler
placement in this area can widen the appearance of
the nose. Care should also be taken to avoid injection
above the level of the orbital rim to minimize risk of
damage to the eye. The plane of injection is supraperi-
osteal, which maximizes native soft tissue cushioning
of the filler. On average 0.5–1 ml of filler is placed on
each side, depending on the degree of rejuvenation
desired.
Treatment of the adjacent malar region is often
done in combination with tear trough augmentation.
Radial fanning is the preferred technique in this area
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Injectable fillers in the face 7
because of the broader region being enhanced. Like in
the tear trough, all categories of injectable filler can be
used for malar augmentation. The entry site for the
needle is several millimetres lateral and superior to the
bony malar eminence. Radial tunnels are then used to
deposit the filler along a supraperiosteal plane. As the
injections transition laterally and inferiorly away from
the thin skin of lower eyelid, placement can be safely
shifted to a more subcutaneous tissue plane. Approxi-
mately 1–2 ml are usually sufficient for each side to
create a more convex and defined appearance.
Lip injection
As mentioned earlier, lip enhancement in the younger
population involves straightforward volume enhance-
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ment. Currently, temporary fillers are the only category
that can be safely and effectively used in and immedi-
ately around the lip. Most of these patients require
volume enhancement only along the central three-
fifths of the lip (Figure 7.3A). Injection is typically
done with a linear threading or serial puncture tech-
nique, proceeding from medial to lateral. Along the
red lip, the targeted level for filler placement is within
the submucosa just above the orbicularis oris muscle.
In many cases, a layered distribution helps to provide
fuller, more uniform enhancement. For increased
vermillion definition, the needle is carefully inserted
within the potential space between the red and white
lip. When inserted properly, injection of the filler can
be seen to plump out the vermillion border even
without advancement of the needle. If this is not the
case, the needle should be repositioned until the low
resistance flow is easily appreciated. Many younger
patients will also benefit from volume enhancement
along the philtral columns. This usually involves mid-
dermis filler injection within the base of each column,
which helps to further outline and define the lips. A
total of 1–2 ml is usually sufficient volume to achieve
the desired size and shape.
Lip enhancement in the more senescent population
involves the same considerations as above. However,
the aging patient typically requires submucosal injec-
tion along the entire length of the lip rather than just
the central aspect (Figure 7.3B). In addition, older
patients typically present with more perioral vertical
lip lines. Some practitioners prefer to address these by
injecting the individual lines separately. However,
one must be careful when doing this with HA fillers.
Techniques in Aesthetic Plastic Surgery Series: Facial Rejuvenation with Fillers with DVD
7 Injectable fillers in the face

Nasal base

Nasolabial fold Pritaal column

Vermillion border

Additional filler injection in the

more senescent lip
Distribution of filler injection in
A B
younger patients

Figure 7.3 Volume enhancement of the lip with use of injectable filler. (A) In the younger patient, linear threading or
serial puncture technique is used to deposit the filler along the central three-fifths of the upper and/or
lower red lip. Additional injections along the vermillion border and/or at the base of the philtral column

AL
can help provide further lip definition. (B) In the senescent patient, more contouring of the lip is required
due to more atrophic changes involving the lip. This usually involves filler distribution across the entire

N
upper and lower lip. In addition, the entire philtral column is augmented and not just the base. Individual

O R
FI
vertical lip lines can then be addressed by placement of human-based collagen, which is more
- N IE
appropriate for targeting finer wrinkles and creases such as these.

T
T V
N SE

Because they require mid to deep dermal injection, lateral margin based on the deepest marionette line. If
TE L

correction of these thin superficial lines is less precise. Botulinum toxin treatment is planned for the DAO
N E

Thus, their use can create unwanted vertical ridges or region, this is done after filler placement.
O F

beading due to inadvertent overcorrection of the Prejowl sulcus enhancement is often an adjunct to
C O

dermis. A better alternative is to simply add more marionette line correction that involves extending
E TY

volume during the vermillion injection, which tends filler injection down to the lower mandibular border.
to stretch the vertical lip lines as they extend from the Again, the proper plane of injection is combined deep
PL R

mucosal lip resulting in decreased visibility. Another dermal and subcutaneous. In thin-skinned patients,
M PE

option is to use only collagen-based temporary fillers longer lasting and permanent fillers can be placed over
for injection of the individual lines. Because collagen the periosteum with a higher safety margin. Due to
SA O

is better suited for superficial dermal placement, it can displacement of the jowl when supine, it is recom-
PR

be used more selectively to correct each line with less
likelihood of overcorrection.
Marionette lines: prejowl
sulcus injection
Volume enhancement of the marionette lines is usually
done with linear threading or serial puncture tech-
nique. Nearly all categories of filler can be safely used
for this purpose. The injection plane is combined deep
dermal and subcutaneous. In many cases, there is not
only a deep line extending from the commissure but
also loss of volume in the surrounding area. In these
cases, a cross-hatching technique can be used to add
more volume. Distribution of the filler often ends up
following the shape of an inverted triangle with the
mended to inject patients in the upright position for
more accurate correction. The filler is distributed along
the lower margin of the mandible and in some cases
just below the mandibular border if more jowling is
present. This injection extends from the anterior
margin of the jowl toward the midline of the chin to
help restore a more youthful transition between these
points. Between the marionette lines and prejowl
sulcus a total volume 2–3 ml of filler is commonly
used to achieve adequate correction.
Nasal injection
Nasal injection is done using either linear threading
or serial puncture technique. Essentially all categories
of filler can be used for nasal enhancement as long as

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Techniques in Aesthetic Plastic Surgery Series: Facial Rejuvenation with Fillers with DVD
Injectable fillers in the face 7

the subcutaneous plane is used for placement. As in
other areas, one must be more cautious when using
longer lasting and permanent fillers in the thinned-
skinned patient. It is sometimes beneficial to use the
non-dominant hand to pinch the bridge or tip of the
nose while injecting. This helps minimize chances of
inadvertent diffusion along the sides, which may give
the appearance of an undesirably wide nose. It is
uncommon to use more than 0.5 to 1 ml when per-
forming volume enhancement of the nose.
Procedure steps
• Maintain a conservative overall approach.
• Obtain thorough medical history and skin testing
when indicated.
• Provide appropriate method of anesthesia.
A gentle pinch and roll technique can be used for the
lip and nasolabial fold since there is access to the
posterior surface of the injection site. In other areas,
such as the tear trough, soft circular pressure can be
used to flatten and evenly distribute the filler. In rare
cases that do not respond immediately to this
corrective technique, a 22–25 gauge needle can be
used transcutaneously to decompress the focus of
overcorrection.
If additional contour irregularities arise after leaving
the office, we recommend abstaining from manipula-
tion of these areas for at least 12–24 h following treat-
ment. In most instances, these are irregularities due to
focal swelling at the needle entry site that will resolve
spontaneously. If such irregularities persist thereafter,
the above-mentioned techniques can be taught to the

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patient and self-administered until there is resolution
• Choose proper injection technique. of the contour.

N
• Injection plane dependent on filler choice and

O R
A cold compress is helpful during the first 48 h after

FI
treatment area.
- N IE treatment to minimize swelling and ecchymosis. Care

T
must be taken, however, to avoid undue pressure that
T V
Aftercare
would potentially cause unwanted displacement of
N SE

Light massage of the area can be done following injec- the filler. We recommend a follow-up appointment
TE L

tion. The surgeon should perform this immediately 2–4 weeks later so that any touch-up treatments can
N E

after injection if a visible contour irregularity is noted. be administered if necessary.

O F
C O
E TY
PL R
M PE
SA O
PR

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Techniques in Aesthetic Plastic Surgery Series: Facial Rejuvenation with Fillers with DVD
7 Injectable fillers in the face

Results

Case 1

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N
O R
A B

FI
- N IE
T
T V
N SE
TE L
N E
O F
C O
E TY
PL R
M PE

C
SA O

Figure 7.4 Example of nasolabial fold augmentation. This elderly female patient desired non-surgical management
of rather deep nasolabial skin creasing. She underwent augmentation with nearly 3 ml of a calcium
PR

hydroxylapatite filler split between both sides. Notice dramatic improvement in the folds with an overall
softer, smoother appearance. (A) Frontal view. (B) Oblique view.

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Techniques in Aesthetic Plastic Surgery Series: Facial Rejuvenation with Fillers with DVD
Injectable fillers in the face 7

Case 2

A B C
Figure 7.5 Example of regional augmentation of the tear trough. This patient was bothered by an unusually deep

AL
tear trough that caused unwanted shadowing and hollowing of the region (see colored zone of
augmentation). Although she was considered a candidate for cheek implants, she instead elected to

N
undergo augmentation using nearly 1.0 ml of a hyaluronic acid filler on each side. Of note, this patient

O R
FI
also had 0.5 ml of filler on each side to soften the nasolabial fold. Following injection, notice much
- N IE
smoother lower eyelid contour and more rested, rejuvenated look. (A) Frontal. (B) Oblique.

T
T V
N SE
TE L
N E

Case 3
O F
C O
E TY
PL R
M PE
SA O
PR

A B
Figure 7.6 Example of regional augmentation of the tear trough. This patient was bothered by an unusually deep
tear trough that caused unwanted shadowing and an aged appearance. She underwent augmentation
of this region using nearly 1.5 ml of a hyaluronic acid filler. Following injection, notice less obvious
shadowing and a much smoother transition from the tear trough to the malar region.

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Techniques in Aesthetic Plastic Surgery Series: Facial Rejuvenation with Fillers with DVD
7 Injectable fillers in the face

Case 4

AL
Figure 7.7 Example of lip augmentation. This young woman did not like that her lips were flat with poor definition.
She underwent volume enhancement with nearly 1 ml of a temporary injectable filler used for both the
upper and lower lips. Following treatment, notice much shapelier lips with an overall more feminine

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appearance.

O R
FI
- N IE
T
T V
N SE

Case 5
TE L
N E
O F
C O
E TY
PL R
M PE
SA O
PR

A B
Figure 7.8 Example of injectable filler augmentation of marionette lines. This middle-aged woman disliked the
deep folds and shadowing of her marionette lines, which contributed to a saddened look. She
underwent augmentation using nearly 0.8 ml of a calcium hydroxylapatite filler. Following treatment note
nearly absent lines with a smoother skin contour and a less saddened appearance. (A) Frontal.
(B) Oblique.

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Techniques in Aesthetic Plastic Surgery Series: Facial Rejuvenation with Fillers with DVD
Injectable fillers in the face 7

Case 6

Figure 7.9 Example of combined augmentation of the prejowl sulcus and

marionette lines. This elderly woman was seeking a non-
surgical alternative to a facelift procedure that would address
unwanted volume loss in the perioral region. She elected to
undergo augmentation with approximately 4 ml of a calcium
hydroxylapatite filler used for both sides. Following injection,

AL
notice overall improvement in the prejowl sulcus and
marionette lines with a more rested, youthful appearance.

N
O R
FI
- N IE
T
T V
Pitfalls and how to correct Technique related complications primarily involve
N SE

undercorrection and overcorrection of the filler. One

TE L

Like everything in medicine, injectable dermal fillers of the most common pitfalls resulting in undercorrec-
N E

can have their pitfalls. Therefore, informed consent is tion involves injecting fillers too deep. This relates
O F

mandatory before injection of any filler and an open more to use of temporary fillers and suggested intra-
C O

discussion of both the advantages and disadvantages dermal placement. If the filler is incorrectly placed
of any agent should be carried out with the patient. deeper into the subcutaneous plane, there will not be
E TY

Fortunately, the complications resulting from inject- any noticeable volume enhancement of the line or
PL R

able fillers are rare and generally minor. All fillers can fold. In these cases, the filler is simply wasted without
M PE

have complications related to insertion of the needle any clinical improvement noted. Undercorrection also
and injection of the material. Complications from skin occurs when an insufficient amount of filler is placed
SA O

piercing include needle marking, swelling, persistent for the area of concern. Often times patients request
PR

ecchymosis, pain, and itching. Local reactions can also
occur to the topical anesthetic agent utilized. Fortu-
nately, these tend to be self-limiting and require no
further treatment.
In the majority of cases it is best to begin with a
temporary filler, preferably one that can be easily
reversed if the patient does not like the effect once
initial swelling has resolved. In some cases, injection
of saline or a lidocaine/epinephrine solution will
permit the clinician and patient to make an assess-
ment of what might occur with injection of the actual
filler. This might be particularly helpful in correcting
minor nasal deformities such as transitioning the
supratip-tip area of the nasal dorsum or showing the
effect of radix augmentation for a deep nasofrontal
angle.
use of only a single syringe of filler, primarily due to
economic considerations. Unfortunately, if the degree
of volume deficiency warrants use of multiple syringes,
there is a high probability the patient will perceive
their outcome as a treatment failure. Because of this,
patients should be made aware of the amount of filler
recommended beforehand and encouraged to make
the appropriate investment that will result in a notice-
able aesthetic enhancement.
Overcorrection occurs when excess injectable filler
is placed for the degree of volume deficiency present.
It is absolutely critical to avoid this when using a per-
manent filler, such as PMMA, but these complications
can arise with injection of any filler. This often mani-
fests as palpable and visible nodularities, and is espe-
cially common with HA injections around the tear

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7 Injectable fillers in the face
troughs and lower lid-cheek junction. If this is appreci-
ated at the time of injection, a 22 or 25 gauge needle
can be inserted into the prominence to allow drainage
of the excess deposit. In cases where this does not
resolve, digital massage of the area over several
days can result in a smoother contour. In more refrac-
tory cases, excess HA can be addressed by use of
hyaluronidase. This is an injectable enzyme that
causes selective degradation of the HA material within
hours and continues for several weeks following place-
ment. The end result is a marked diminution of the
unwanted volume. However, careful attention should
be paid to avoid overzealous use of hyaluronidase as
this could quickly reverse much of the desired
augmentation.
Nodularity resulting from polylactic acid injection
is also more likely to occur in thinner skin areas such
as the lower eyelid-cheek junction. Unfortunately,
N
O R
there is no antidote, such as hyaluronidase, currently
FI
- N IE
available for polylactic acid fillers. Instead, polylactic
T
acid nodules can be addressed with use of a 25 gauge
T V
needle to mechanically disrupt the material. Concur-
N SE
rent infiltration of anesthetic solution helps to dilute
TE L
and redistribute the disrupted filler fragments. Warm
N E
soaks may be of benefit as well since polylactic acid
O F
may remodel with heat.
C O
Nodularity resulting from PMMA may be a result
of too much material placed in a particular site or,
E TY
exuberant host scar tissue replacing the absorbable
PL R
bovine collagen component. Clustering of the micro-
M PE
spheres can occur as well resulting in nodularity. These
can generally be managed successfully with local
SA O
anesthetic injection and mechanical disruption with a
PR
needle. Steroid injections may be helpful if the nodule
is caused by scar encapsulation. In some cases excision
will be necessary. This can typically be accomplished
through an intraoral approach to the nasolabial folds,
corners of the mouth and marionette lines. For lumps
that occur on the lips with semi-permanent and per-
manent fillers, excision can be carried out with the
incision placed in the wet mucosa to avoid a visible
scar.
Other pitfalls include a bluish discoloration to the
skin that may develop if HA and calcium hydroxylapa-
tite fillers are injected too superficially. Vascular occlu-
sion can also occur with any filler and is usually treated
with hyaluronidase and nitropaste in combination
with warm compresses. It is important to withdraw the
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needle and verify that a small blood vessel has not
been inadvertently punctured in order to avoid this
potential pitfall.
All injectable fillers have been reported to create
granulomas. Fortunately, this occurrence is quite rare.
Most have a late onset and the majority occur in the
perioral area. Many patients trace onset to a preceding
systemic viral infection or facial trauma. Granuloma
formation may be asymptomatic or associated with
erythema and swelling. They may even occur years
later. Treatment is initiated with intralesional steroids
in association with antibiotics such as minocycline,
which target granulomas. In more severe cases oral
steroids may be helpful. Noninflammatory fibrotic
nodules can be treated using intralesional steroids and
5-fluorouracil. Excision may be necessary in some
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cases. Also, it is advisable to obtain a punch biopsy to
confirm the diagnosis as many nodules are referred
to as granulomas and granuloma is a histologic
diagnosis.
A rare but noted pitfall is reactivation of herpes
simplex virus following injectable filler use. If this
occurs, topical antimicrobial ointments are helpful
in minimizing secondary bacterial infection. Institut-
ing oral antiviral therapy may hasten the recovery
process, although this is controversial once the viral
outbreak has been noted. Instead, it is more prudent
to screen patients for a history of herpes simplex
and administer of prophylactic therapy prior to the
procedure.
Conclusion
Use of injectable fillers is a well-established non-surgi-
cal method for volumetric facial enhancement. As
the number of available injectable fillers has increased,
so has the array of indications for their use. Currently,
the most popular indications include effacement
of the nasolabial fold, perioral augmentation, tear
trough correction, malar contouring and perinasal
shaping. An essential key to success for all applications
is a conservative, gradual approach. When combined
with proper filler selection and appropriate injection
technique, one can achieve very powerful aesthetic
results that in some cases rival a surgical outcome.
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Injectable fillers in the face 7

Further reading
Biesman B. Soft tissue augmentation using restylane. Facial
Plast Surg 2004;20:171–177.
Broder KW, Cohen SR. An overview of permanent
and semi-permanent fillers. Plast Reconstr Surg
2006;118(Suppl):7S–14S.
Burgess CM, Quiroga RM. Assessment of the safety and
efficacy of poly-l-lactic acid for the treatment of HIV-
associated facial lipoatrophy. J Am Acad Dermatol
2005;52:233–239.
Cohen SR, Berner CF, Busso M et al. Five-year safety and
efficacy of a novel polymethylmethacrylate aesthetic soft
tissue filler for the correction of nasolabial folds.
Dermatologic Surgery 2007;33:S222–S230.
Duffy DM. Complications of fillers: Overview. Dermatol
Lemperle G, Holmes RE, Cohen SR, Lemperle SM. A
classification of facial wrinkles. Plast Reconstr Surg
2001;108:1735–1750.
Marmur ES, Phelps R, Goldberg DJ. Clinical, histologic and
electron microscopic findings after injection of a calcium
hydroxylapatite filler. J Cosmet Laser Ther 2004;
6:223–226.
Niamtu J. Accurate and anatomic midface filler injection by
using cheek implants as an injection template. Dermatol
Surg 2008;34:93–96.
Sadick NS, Katz BE, Roy D. A multicenter, 47-month study
of safety and efficacy of calcium hydroxylapatite for soft
tissue augmentation of nasolabial folds and other areas
of the face. Dermatologic Surgery 2007;33:S122–S127.

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Surg 2005;31:1626–1633. Vartanian AJ, Frankel AS, Rubin MG. Injected hyaluronidase
Humble G, Mest D. Soft tissue augmentation using sculptra. reduces restylane-mediated cutaneous augmentation.

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Facial Plast Surg 2004;20:157–163. Arch Facial Plast Surg 2005;7:231–237.

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