The Academy for the

Advancement of Aesthetics

Module 2: Collagen-stimulating Fillers

Course B:
Practical Guide to Collagen-stimulating Fillers
Module 2: Collagen-stimulating Fillers
► This on-demand course will provide an overview of the range of products
available and their use in aesthetic medicine, including the key
characteristics and mechanisms of action of collagen-stimulating (CS) fillers
► Mapping areas of the face relevant for injection with CS fillers will also be
covered, including the use of scales and managing patient expectations
with regard to treatment with CS fillers
► Optimal management of possible adverse events will also be explored
► This module consists of the 3 courses below
► Course A: The science behind collagen-stimulating fillers
► Course B: A practical guide to collagen-stimulating fillers
► Course C: Avoiding and managing complications associated with collagen-
stimulating fillers
2
Module 2: Learning Objectives
► Describe the mechanism of action of collagen-stimulating fillers in facial
aesthetic medicine, including the dual action of dermal filling and
neocollagenesis
► Explain the aesthetic evaluation process as it relates to assessing and
restoring volume to the aging face, including the patient consultation
process, managing patient expectations, individualized treatment, and use of
aesthetic scales
► Review safe and effective use of collagen-stimulating fillers, including
appropriate facial treatment areas, variations in injection technique, injection
plane, and product selection
► Identify the possible adverse events associated with collagen-stimulating
fillers, including strategies to avoid and to manage them
3
Steering Committee Disclosures
Sabrina G. Fabi, MD, FAAD, FAACS
Grants/research support: Alastin Skincare, Inc; Allergan, Inc.; Ampersand Aesthetics; Bayer HealthCare;
Colorescience, Inc.; Galderma Laboratories, L.P.; Merz North America Inc.; Revance Therapeutics, Inc
Honoraria or consultation fees: Alastin Skincare, Inc; Allergan, Inc.; Colorescience, Inc.; Galderma Laboratories,
L.P.; Merz North America, Inc.; Revance Therapeutics, Inc
Speaker’s Bureau: Alastin Skincare, Inc; Allergan, Inc.; Galderma Laboratories, L.P.; Merz North America, Inc.

Tatjana Pavicic, MD
Grants/research support: Ipsen; Merz Pharmaceuticals
Honoraria or consultation fees: Beiersdorf Inc; Cynosure, Inc; Galderma S.A.; Lutronic; Merz Pharmaceuticals

Jani van Loghem, MD

Consultation/speaker fees: Merz Pharmaceuticals

4
 Course B:
Practical Guide to
Collagen-stimulating Fillers
Introduction: A Practical Guide to CS Fillers
► Optimizing outcomes and minimizing complications with CS fillers
requires knowledge of, and attention to, specific and evolved
injection methodology in addition to careful facial analysis prior to
treatment
► This on-demand course will provide practical advice on using CS
fillers including the patient consultation, equipment needed, and
injection techniques

6
Facial Rejuvenation:
A 3-dimensional (3D) Approach
► Historically, facial rejuvenation focused on a 2-dimensional
(2D) approach aimed at filling lines and wrinkles
► With our increased understanding of facial anatomy, the
focus has moved to a 3D approach based on volume
restoration and contouring1

1. van Loghem J et al. J Clin Aesthet Dermatol. 2015;8(1):38-49. 7

Facial Rejuvenation:
A 3D Approach (continued)
► Central to this 3D paradigm is:
► Volumizing capacity: giving additional volume via 3D projection of skin tissue
► Lifting capacity: working against gravity by pulling up tissue vertically
► Contouring capacity: defining facial contours accurately

Lifting Contouring Volumizing

8
Facial Rejuvenation:
A 3D Approach (continued)
► It is useful to first evaluate the upper,
middle, and lower regions of the face
► Importantly, any treatment should be
carried out in the context of how it will
integrate with the rest of the face
► There needs to be harmonious flow
from one part of the face to the next
and from one contour to the next

9
Facial Rejuvenation:
A 3D Approach (continued)
► The ideal aesthetic outcome is the result of line filling, skin tightening,
lifting, contouring, and volumizing1
► Some of the CS fillers are well-suited to this approach
► You can learn more about the different types of CS fillers and their
properties in Course A: The Science Behind Collagen-stimulating Fillers

1. van Loghem J et al. J Clin Aesthet Dermatol. 2015;8(1):38-49. 10

3D Vectoring: What Is It?
► Changes in the face due to aging can be
denoted as the negative vectors of aging
► A vector is a quantity with a certain (negative)
direction and magnitude
► It can be visualized by a line or an arrow pointing
downwards and inwards to show the direction of
the facial changes
► Because they have an anatomic basis, they are predictable and common
to all individuals
► Since volume loss contributes to the aging process, we speak about 3D
negative vectors:
► Lateral tissue ptosis
► Vertical tissue ptosis
► Volume loss
11
3D Vectoring: What Is It? (continued)
► The correction of these vectors in reverse direction (positive
vectors) is known as the 3D vectoring technique and requires from
the practitioner a comprehensive vector and volume analysis
► Just augmenting lines or folds does not address the underlying issues of fat
displacement
► Treatment objective should be to restore each fat compartment to its original
position, providing lateral and vertical lift; and providing 3D correction by
restoring lost volume
► The displacement of soft tissue (negative vector) that occurs under the influence of gravity
is conditional on laxity being present
► Correction of laxity in the vector of displacement (positive vector) nullifies the effect of
gravity

12
3D Vectoring: What Is It? (continued)
► The most appropriate dermal fillers to use for this technique
are biodegradable, highly viscous, and elastic materials, with a strong
collagen-stimulating potential, such as calcium hydroxylapatite
(CaHA)1
► You can learn more about the 3D vectoring technique in the
following article:
► Zenker S et al. Mid-facial augmentation with a volume filler.
Prime-journal.com. October 2012:40-47.

1. Zenker S. Prime-journal.com. October 2012:40-47. 13

The Aging Face
► Careful facial assessment of an individual allows the appropriate
treatment to be planned
► This includes evaluating the signs of aging as well as the proportions,
harmony, and balance of the face
► A sound knowledge of facial anatomy and the changes that occur
with age will enable you to assess patient suitability and determine
the choice of product that will ultimately provide the optimal
aesthetic outcome for each individual patient

14
The Aging Face (continued)
► Facial aging is a dynamic process
involving soft tissue and bony
structures
► Dermal thinning and the decrease in
collagen and elastin with age cause
skin to lose its strength and elasticity
► Redistribution of adipose tissue, loss of
skeletal support, and skin laxity,
coupled with gravity and muscle pull,
contribute to the formation of lines,
and loss of facial contours1
Cohen AJ. Mid Face Facelift. Medscape. October 30, 2015. http://emedicine.medscape.com/article/1818907-overview. Accessed January 4, 2018.
Figures from Coleman SR et al. The anatomy of the aging face: volume loss and changes in 3-dimensional topography. Aesthet Surg J. 2006;26(1S):S4-S9.
By permission of Oxford University Press. 15
The Aging Face (continued)
► Consequently, a young face has been described as having a ‘V’ shape
and with aging this ‘V’ becomes inverted:
Youthful appearance: Signs of the time:
optimum volume distribution increasing volume shift

Aging process Aging process

Figure from Coleman SR et al. The anatomy of the aging face: volume loss and changes in 3-dimensional topography. Aesthet Surg J. 2006;26(1S):S4-S9.
By permission of Oxford University Press. 16
The Aging Face (continued)
► The decline of dermal collagen and elastin significantly contributes to
the age-related loss of skin volume and degeneration of skin quality
► CS fillers are well suited to the correction of volume loss, and
wrinkles and folds that are associated with aging

17
Patient Assessment:
Individualized Treatments
► Age-related anatomic changes are unique to every individual and
influenced by several factors, including sex, race, and skin type
► Treatment goals and the approach to aesthetic procedures must take
into account these influences and be tailored to each individual
► It is useful to first evaluate your patient’s face in terms of the
integrity of each structural tissue—skin, fat, muscle, bone
► Then, look at what those changes are doing to the face in terms of
morphologic changes—the shape, proportions, and topography of
the face1

1. Fitzgerald R, Vleggaar D. Dermatol Ther. 2011;24(1):2-27. 18

Attributes of Volume Loss

In the aged faces here, you should be able to

identify the following attributes of aging relevant to
volume loss:
• Less brow support (bone and fat)
• Temporal concavity (bone, fat)
• Less lateral projection of the cheekbone (bone)
• Nasojugal and nasolabial folds are visible (bone and fat)
• Oral commissures and marionette lines are visible (bone and fat)
• Jowling (fat)
• Mental fold (fat)

Top image courtesy of Kyle Koo-Il Seo, MD, PhD. All rights reserved.
Bottom image from Coleman SR et al. The anatomy of the aging face: volume loss and changes
in 3-dimensional topography. Aesthet Surg J. 2006;26(1S):S4-S9. By permission of Oxford University Press. 19
Patient Assessment:
the Patient Consultation Process
► The initial consultation with a patient considering any
aesthetic treatment should include a full clinical history and
examination, as well as a complete discussion of the realistic
potential benefits, adverse effects, and possible complications
► You should always be satisfied of the indication for the proposed
treatment, the patient’s medical suitability for the treatment, and
that full and informed consent has been obtained

20
Patient Assessment:
the Patient Consultation Process (continued)
► Expert tip: Understanding your patient’s desires and
preferences at the outset enables you to set realistic
treatment goals and manage their expectations1,2
► It is important that patients fully understand what is and what
isn’t possible from treatment

1. Carruthers J et al. Dermatol Surg. 2013;39(3 Pt 2):510-525.

2. Inglefield C et al. Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment. Aesthetic Medicine Expert Group, 2014. 21
 Patient Assessment:
the Initial Consultation
The key steps to a successful first consultation include:
Your patient’s treatment goals
DISCUSS • Ensure patient expectations are in balance with realistic aesthetic outcomes
• Identify patients who may not be suitable candidates for treatment

Facial anatomy, including the shape, contours, topography, and proportions of the face
ASSESS • Obtain the patient’s medical history and identify any contraindications or previous treatments

Your patients about the planned treatment(s) and provide them with detailed information
INFORM • Include potential adverse events, contraindications, and precautions specific to the indication
• Address any questions and alleviate anxieties

The indications to be treated

PLAN • Decide on the most appropriate treatments including product, placement, and volumes

Patient information and the agreed treatment plan

DOCUMENT • Use patient photography and visual scales to record baseline status
• Obtain patient’s informed consent (in writing)

22
Top Tips for Successful Patient
Consultations
► Discussions should be clearly recorded in patients’ notes,
including the information and advice provided and how patients
responded
► You should provide patients with written information to take
away and read—and encourage patients to ask questions
► Once a patient has consented to treatment, include
photographs in patients’ notes so it is clear what treatment is to
be performed

23
Patient Evaluation:
Aesthetic Assessment Scales
► Assessing a patient’s characteristics accurately, and deciphering the
attributes of aging, can be challenging due to the inherently personal
nature of an individual’s facial features and the variations in facial
characteristics that occur between sexes and ethnicities
► Furthermore, standardizing this evaluation before and after a procedure can
be crucial in the accurate assessment of treatment outcome1
► Aesthetic assessment scales that visually and objectively document
the signs of aging enable features to be consistently appraised,
providing an important tool for standardized evaluation of patients
pre- and posttreatment1

1. Carruthers J et al. Dermatol Surg. 2013;39(3 Pt 2):510-525. 24

The Merz Aesthetic Scales
► The Merz Aesthetics Scales have been developed and
validated by an international team of aesthetic physicians to
provide a robust tool for evaluating patients pre- and
posttreatment
► They can also be used as a communication tool for managing
patient expectations and can assist with the documentation of
treatment outcomes
► Each scale was created as a 5-point rating scale based on
computerised, photonumeric images to assess a range of facial
features1

1. Carruthers J et al. Dermatol Surg. 2013;39(3 Pt 2):510-525. 25

The Merz Aesthetic Scales (continued)
► These features include

Forehead lines
Glabellar lines
Brow positioning
Periorbital lines
Infraorbital hollow
Upper cheek fullness
Nasolabial folds
Lower cheek fullness
Lip wrinkles
Marionette lines
Oral commissures
Lip fullness
Jawline

26
The Merz Aesthetic Scales (continued)
► The Merz aesthetic scales can be used to assess the degree of
volume loss before performing any CS filler treatments
► For example, cheek fullness can be assessed in both the upper and lower cheeks
Upper Cheek Assessment

Full upper cheek Mildly sunken Moderately sunken Severely sunken Very severely
upper cheek upper cheek upper cheek sunken upper cheek
Before treatment After treatment

27
The Merz Aesthetic Scales (continued)
► The Merz aesthetic scales can be used to assess the degree of
volume loss before performing any CS filler treatments
► For example, cheek fullness can be assessed in both the upper and lower cheeks
Lower Cheek Assessment

Full lower cheek Mildly sunken Moderately sunken Severely sunken Very severely
lower cheek lower cheek lower cheek sunken lower cheek
Before treatment After treatment

28
The Merz Aesthetic Scales (continued)
► Using a combination of images taken from the
Available Merz
front, side, and above, this example patient would Aesthetic Scales
be rated as a 3 (upper) and 3 (lower) pretreatment, Brow position1
and 2 (upper) and 2 (lower) posttreatment Forehead lines2
Lip fullness3
► Expert tip: Individual differences, and those due to Marionette lines4
race, should be considered when using the Merz Crow’s feet5
Aesthetics Scales Global face6
► For example, in cultures where a ‘baby face’ look is Upper face7
desirable, it is important to assess and grade the Midface8
buccal area Lower face9
Neck volume10

1. Carruthers A et al. Dermatol Surg. 2008;34(Suppl 2):S150-S154. 2. Carruthers A et al. Dermatol Surg. 2008;34(Suppl 2):S155-S160. 3. Carruthers A et al. Dermatol
Surg. 2008;34(Suppl 2):S161-S166. 4. Carruthers A et al. Dermatol Surg. 2008;34(Suppl 2):S167-S172. 5. Carruthers A et al. Dermatol Surg. 2008;34(Suppl 2): S173-
S178. 6. Rzany B et al. Dermatol Surg. 2012;38(2 Spec No.):294-308. 7. Flynn TC et al. Dermatol Surg. 2012;38(2 Spec No.):309-319. 8. Carruthers J et al. Dermatol
Surg. 2012;38(2 Spec No.):320-332. 9. Narins RS et al. Dermatol Surg. 2012;38(2 Spec No.):333-342. 10. Sattler G et al. Dermatol Surg. 2012;38(2 Spec No.):343-350. 29
Preparing Your Equipment
and the Product for Use
As with all aesthetic procedures, it is important that
aseptic techniques are used when administering CS fillers
to prevent infection and related adverse events

Step 1: A clean work environment1

• Keep all work surfaces clean and tidy
• Use disinfectant wipes between patients
• Discard used materials immediately after a procedure
• If using cold packs, ensure they are cleaned with antiseptic
wipes and wrapped in gauze awaiting use

1. Inglefield C et al. Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment. Aesthetic Medicine Expert Group, 2014. 30
Preparing Your Equipment
and the Product for Use (continued)
► When conducting aesthetic treatments, it is important to have
the right equipment to hand
► You should have an emergency bag containing various items that
you might need to manage any adverse events
► The emergency bag should contain:1
1. Intravenous (IV) antihistamines
2. IV steroids for allergic/anaphylactic reactions
3. Adrenaline
4. Aspirin
for vascular compromise associated with filler treatment
5. Hyaluronidase

Check products regularly to ensure they are within expiry dates

1. Inglefield C et al. Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment. Aesthetic Medicine Expert Group, 2014. 31
Reconstitution of CS Fillers
► CaHA fillers come reconstituted, so no further action is required
before use1
► PLLA fillers require reconstitution with sterile water at least 2 hours
(preferably overnight) before use2
Check the product information for the particular filler
you are using for specific guidance on reconstitution
► All CS fillers are packaged and sterilized for single use
► Therefore, do not attempt to resterilize after use and dispose of any unused
product as biohazardous waste
► In cases when the needle cannot be safely detached from the syringe,
everything should be placed in a sharps bin
1. Radiesse Injectable Implant [Instructions for Use]. Franksville, WI: Merz North America, Inc; January 2016.
2. Sculptra Aesthetic [Instructions for Use]. Fort Worth, TX: Galderma Laboratories, LP; July 2016. 32
Preparing the Face
for Treatment with CS Fillers
 Aseptic techniques are important for more than just the environment and
equipment you use
 The area of injection and the surrounding skin should also be cleaned properly
with antiseptics before treating your patient with CS fillers
 Step 1: Clean your patient’s face1
• Review the patient’s history and check for any signs of local or systemic infection
• Remove all makeup
• Clean the skin with antiseptic wipes, solution, or spray
 Do not allow patients to touch areas after cleaning

1. Inglefield C et al. Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment. Aesthetic Medicine Expert Group, 2014. 33
Preparing the Face for Treatment
with CS Fillers
► Step 2: Clean your hands1
► Position the patient and lighting before cleaning your hands
► Disinfect your hands prior to using clean gloves
► Do not touch surfaces, lights, or other non-clean areas
before starting treatment and during the procedure

► With these steps, you will be able to minimize the risk

of infection in your patients

1. Inglefield C et al. Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment. Aesthetic Medicine Expert Group, 2014. 34
Signs and Symptoms of Infection
► Should infection occur, the signs and symptoms of acute
infection—including redness, pain, swelling, and heat—typically
occur within 2 weeks of treatment1
► The signs and symptoms of delayed infection and hypersensitivity
reactions typically occur later than 2 weeks after treatment and
may occur months after treatment1
► They also include redness, pain, swelling and heat1
► A detailed assessment of signs, symptoms, patient history, and
laboratory tests should be carried out and treatment carefully
tailored based on the results1

1. Inglefield C et al. Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment. Aesthetic Medicine Expert Group, 2014. 35
Assessing and Marking the Face
for CS Filler Treatment: Key Points
► Different types of CS fillers are available; these are described
in Course A: The Science Behind Collagen-stimulating Fillers
► Their main uses are restoring facial volume; however, the individual properties
of each filler may influence where they can be safely and effectively placed in
the face to achieve optimal aesthetic outcomes1
Check the product information for the particular filler you are using
for specific guidance on treatments indications and product placement
► You will need to have a sound understanding of each product you use,
and know how to assess and mark your patient’s face accordingly

1. Funt D, Pavicic T. Clin Cosmet Investig Dermatol. 2013;6:295-316. 36

Assessing and Marking the Face
for CS Filler Treatment: Key Points (continued)
► For any aesthetic procedure, careful mapping and treatment
planning are important to avoid complications and treatment-induced
asymmetries
► Top tips to help you in your everyday practice:
► Assess the face for proportion and asymmetry
► Mark the area to be injected using a makeup pencil
► Review the patient’s anatomy and mark danger zones
► You can locate vessels such as the superficial temporal and facial arteries by
palpating for a pulse
► The supraorbital foramen can be found by palpating the medial orbital rim
► The infraorbital and mental foramen can be found under the tissue using a cotton-
tipped applicator; your patient will feel and verbalize nerve irritation
► Mark bony landmarks such as the lateral orbital rim and superior zygomatic arch
37
Anesthesia
► Before any aesthetic treatment, you should assess the patient’s
need for pain relief
► A wide range of anesthetic procedures can be used
► They can be categorized as:1
► Topical anesthesia: applied to mucous surfaces and to skin; acts on nerve
endings
► Infiltration anesthesia: applied by subcutaneous injection; also acts on nerve
endings
► Regional anesthesia: the anesthetic is injected at different levels; affects
several nerves
► Nerve block anesthesia: the anesthetic is applied directly to a specific nerve

1. Suller AC et al. Minimally Invasive Procedures for Facial Rejuvenation. Eds. Giuseppe C, Antonio R. Foster City, CA; OMICS Group eBooks: 2014. 38
Anesthesia (continued)
► Local anesthetics temporarily block nerve conduction by affecting
the flow of sodium ions through sodium channels in the nerves
► The rate of membrane depolarization is reduced and this inhibits the
propagation of the axon potential through the nerve axon, with
sensitivity being lost in the corresponding area of the body1
► Some products are manufactured with lidocaine and some clinicians
prefer to add lidocaine or lidocaine/epinephrine just prior to
injection
► This allows the treatment site to be anesthetized as the injection
process progresses

1. Suller AC et al. Minimally Invasive Procedures for Facial Rejuvenation. Eds. Giuseppe C, Antonio R. Foster City, CA; OMICS Group eBooks: 2014. 39
Anesthesia (continued)
► When you add lidocaine, with or without epinephrine, or saline,
you are changing the filler’s physical properties
► For example, CaHA with 0.3% lidocaine is easier to extrude from the needle
than CaHA alone, and you are also diluting the products1
► Awareness of the sensory branches of the face allows the use of
nerve blocks, which provide effective anesthesia with minimal
discomfort

1. van Loghem et al. J Clin Aesthet Dermatol. 2015;8(1):38-49. 40

Anesthesia (continued)
► The most important sensory nerves are the supraorbital, infraorbital,
and mental nerves; blocks are achieved after the identification of their
respective foramina, which lie in the mid-pupillary plane1

1. Suller AC et al. Minimally Invasive Procedures for Facial Rejuvenation. Eds. Giuseppe C, Antonio R. Foster City, CA; OMICS Group eBooks: 2014. 41
Using CS Fillers in the Face:
Indications and Injection Guidelines
► A good understanding of facial anatomy, appropriate patient
selection, and safe injection technique is essential before injecting
any CS filler1,2
► Major complications are generally avoidable with good preparation
and injection technique1,3

► Read on to learn about the anatomic landmarks you should be

familiar with and injection techniques and patterns for each area of
the face

1. Radiesse Injectable Implant [Instructions for Use]. Franksville, WI: Merz North America, Inc; January 2016. 2. Bailey SH et al. Aesthet Surg J. 2011;31(1):110-121.
3. Ozturk CN et al. Aesthet Surg J. 2013;33(6):862-877. 42
Indications for Using CS Fillers in the Face

Brow lift
Medial/
Temporal
lateral
hollows
Submalar cheek
cheek Midface
hollows Mental Nasolabial
crease folds
Marionette Mandibular
lines angle/
Prejowl jawline
Chin
sulcus
Hands*

*Some CaHA fillers may be used to correct excessive volume deficits that occur due to age-related volume loss of the hands 43
Using CS Fillers in the Upper Face:
Temporal Hollows
► In the upper face, volume restoration of the temporal hollows with
some CS fillers can return a youthful appearance to the area
► Loss of volume in the temporal fossa occurs due to resorption of
temporal bone, atrophy of temporal fat pads, and a reduction in
frontalis muscle mass
► Use of dermal fillers in this area can restore the smooth transition from the
forehead to the temple and cheek1
► This is an advanced procedure requiring experience and specialist training
Check the product information for the particular filler you are using
for specific guidance on treatment indications and product placement

1. Pessa JE, Rohrich RJ. Facial Topography. Clinical Anatomy of the Face. St Louis, Mo: Quality Medical Publishing Inc; 2012. 44
Using CS Fillers in the Upper Face: 2

Temporal Hollows—Anatomy 3

1
► When using CS fillers to restore volume in the temples, it is
important to mark the key anatomic sites before carrying out
any injections
► Palpate and mark the superficial temporal artery and other
vessels to avoid
1. Orbital rim Palpate and mark the infraorbital rim on both sides of the face
• Use the tip of a makeup pencil to lightly palpate and mark out the boundary of this rim
• Mark out the contralateral side; never assume the opposite rim is at the same level as the
side you marked
• If the level of the 2 rims differs, lower the line of the higher rim to match the level of the
lower rim
2. Lateral bony orbit Palpate and mark the lateral bony orbit on both sides of the face
3. Superior border of Palpate and mark the superior border of the zygomatic arch
the zygomatic arch

45
Using CS Fillers in the Upper Face:
Temporal Hollows—Technique
Injection Bolus or linear threading
technique
Needle CaHA: 27G needle, 0.5″ (13 mm); 25G cannula, 1.5″ (38 mm) or 2″ (50 mm)
size PLLA: 26G needle Epidermis

Injection CaHA: under the superficial/temporoparietal fascia and into the interfacial
plane space OR under the temporalis muscle/deep fascia and on the periosteum Dermis

Note: When using a cannula, inject the filler more superficially (on top of
the temporalis fascia)
PLLA: Deeply under temporalis fascia, close to the bone Temporoparietal fascia
Loose areolar tissue
Subcutaneous fat
Deep temporal fascia
Temporalis muscle
Periosteum
Bone

46
Using CS Fillers in the Upper Face:
Temporal Hollows—Technique
Safety considerations
 Inject above the deep fascia to prevent migration below the zygomatic
area and into the malar area
 With submuscular injection, slow bolus injection minimizes the risk of
retrograde arterial migration of product and low volume of bolus minimizes the
risk of necrosis
 With subdermal injection it is important to avoid vessels such as the superficial
temporal artery and superficialis temporalis nerve; blunt cannulas may be used

47
 Bolus 2 (opt)
Using CS Fillers in the Upper Face:

Bolus 1
Temporal Hollows—Needle Technique
► Insert the needle superior to the zygomatic arch, ≈1 cm inferior to the temporal
crest and ≈5 mm lateral to the orbital rim at ≈90° angle to the skin
► Insert the needle slowly to feel the initial resistance of piercing through the skin
► Once the needle is inserted through the skin, advance the needle slowly until
you feel the light resistance of the superficial/intermediate temporalis fascial layer
► Gently push through this resistance (about 1–2 mm)
► This likely indicates the needle tip is in the temple fat pad, if the fat pad has not had significant atrophy
► Push the needle forward until it contacts the bone (ensure that the needle is long enough to
perform this procedure)
► Inject a bolus carefully and slowly while keeping the needle stationary to avoid injection into
deep fascial layer or temporalis muscle
► To reduce risk of accidental intravascular injection in an area of high anatomic vascular anatomy,
maximize each individual injection bolus to 0.1 mL; place multiple boluses without exiting the
needle from the skin until desired outcome1

1. van Loghem et al. J Clin Aesthet Dermatol. 2015;8(1):38-49. 48

 Cannula 1

Using CS Fillers in the Upper Face:

Temporal Hollows—Cannula Technique
► Insert the cannula into the skin at either:
1. The distal end of the eye brow immediately lateral to the hair line
Cannula 2
2. About 2–3 cm diagonally below the lateral canthus at a 30°–45° angle
► Inject linear threads of filler retrogradely in a fanning pattern on
top of the temporalis fascia
► Keep your non-dominant finger by the tip of the cannula and
disperse the filler as it is being injected
► Slightly mold the product to the desired correction

49
Using CS Fillers in the Upper Face:
Temporal Hollows—Cannula Technique (continued)
Interfacial cannula technique
► Insert the cannula into the skin at either
1. The temporal crest, ≈1 cm superior to the orbital rim
2. At the superior border of the zygomatic arch, ≈1 cm in front of the hair line
► Advance the cannula through the skin and through the resistance of
the temporoparietal fascia (from the frontal bone, the anatomical
layer continues into the deep temporal fascia placing the cannula in
the interfacial space)
► Keep your non-dominant finger by the tip of the cannula and disperse
the filler as it is being injected
► Slightly mold the product to the desired correction

50
Using CS Fillers in the Upper Face:
Brows
► With age, drooping of the outer edge of the eyebrows sometime
occurs
► A small amount of CaHA filler injected into this area to restore
volume to a very small fat pad located directly underneath the
eyebrow can provide a very subtle lift to the eyebrow
► Expert tip: Using botulinum toxin to relax the muscles that pull the
brow down (lateral brow depressors) can increase the effectiveness
of the above technique1

1. van Loghem et al. J Clin Aesthet Dermatol. 2015;8(1):38-49. 51

Using CS Fillers in the Upper Face:
Brows—Technique
Injection Linear threading or fanning
technique
Needle size 27G or 28G needle; 27G or 25G cannula
Injection plane Supraperiosteal (and subcutaneous) plane
Safety • Stay lateral to the supraorbital foramen to avoid
considerations the supraorbital artery and nerve
• Avoid injecting filler into the supraorbital foramen
• Avoid injecting filler into the orbicularis oculi to prevent the development of nodules
• Limit injection volume into subdermal layer at lateral brow to 0.05–0.1 mL to improve light
reflection
• Avoid overcorrection as this may cause brow ptosis, lateral hooding, and masculinization

52
 Supraorbital

Using CS Fillers in the Upper Face: foramen

Brows—Needle Technique
► Palpate the superior orbital rim and place a finger from the
nondominant hand along the rim as a barricade
► Insert the needle at a 90° angle at the level of the brow at the
lateral end down to the supraperiosteal plane
► Progress the needle tip vertical into the lateral 1/3 of the brow
(supraperiosteally)
► Be sure to stay lateral to the supraorbital notch (mid-pupillary)
► Inject retrograde linear threads; usually in the pattern of 3 strands in the shape
of a “W”
► Mold the product until it is smooth and even

► The danger zone, the supraorbital foramen, is marked in red

53
 Supraorbital

Using CS Fillers in the Upper Face: foramen

Brows—Cannula Technique
► Make the insertion point with a needle 1G larger than the
cannula; insert the needle at a 90° angle into the skin,
penetrate the dermis and retract
► Insert the cannula; stretching the opening in the skin with the non-dominant
index finger and thumb makes it easier to advance the cannula through the
insertion point and skin
► The insertion point should be ≈0.5 cm lateral to the tail of the brow
► Inject multiple strands of filler using fanning technique in a retrograde manner
► Maintain depth to inject at the supraperiosteal level
► Gently shape and mold the material to the desired cosmetic effect

► The danger zone, the supraorbital foramen, is marked in red

54
Using CS Fillers in the Midface:
Upper and Lower Cheeks
► Some CS fillers can be used to restore volume to the upper and
lower cheeks
► In the midface, restoring volume to the cheekbone and the sunken
area beneath the cheekbone (submalar hollowing) can restore the
V-shape of the face by lifting sagging tissues in the cheek and jowls,
reducing lower eyelid lag, and without treating the tear trough area
this can be reduced1
► Expert tip: Augmentation with fillers is influenced by ethnicity
► In Asian patients, facial anatomic landmarks differ from those described
here; in Asian patients, more volume is generally needed in the anterior
midface and less in the lateral midface

1. van Loghem et al. J Clin Aesthet Dermatol. 2015;8(1):38-49. 55

Using CS Fillers in the Midface:
Upper and Lower Cheeks (continued)
► The cheeks are a very mobile area of the face and the risk of
product displacement is higher here than in other areas
► This risk can be reduced by using a high viscosity filler
► You should ask your patient to avoid applying pressure to or
massaging the treated area for several hours after injection1
► Complications can include tissue necrosis, malar edema, and, at
worst, blindness
► This area is covered in detail in Course C: Avoiding and Managing
Complications Associated with Soft Tissue Fillers

1. Inglefield C et al. Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment. London: Aesthetic Medicine Expert Group, 2014. 56
Using CS Fillers in the Midface:
Upper and Lower Cheeks (continued)
► It is vital that you know the location and importance of
anatomic landmarks relevant to CS fillers
► Next, we will consider the key anatomic sites to mark when
using CS fillers to restore volume in the upper and lower
cheeks

57
Using CS Fillers in the Midface:
Upper and Lower Cheeks—Anatomy
► Infraorbital rim
► Palpate and mark the infraorbital rim on both sides
of the face
► Use the tip of your makeup pencil to lightly palpate
and mark out the boundary of this rim
► Mark out the contralateral side (never assume the
opposite rim is at the same level as the side you
marked)
► If the level of the 2 rims differs, lower the line of the
higher rim to match the level of the lower rim

58
Using CS Fillers in the Midface:
Upper and Lower Cheeks—Anatomy (continued)
► Infraorbital foramen
► Palpate and mark the infraorbital foramen () on
both sides of the face
► This is usually located 6–9 mm below the inferior
orbital rim and just medial to a vertical line with the
patient’s mid-pupillary gaze (green dotted line) 

59
Using CS Fillers in the Midface:
Upper and Lower Cheeks—Anatomy (continued)
► Lateral bony orbit
► Draw a vertical line from the lateral bony orbit in an
inferior direction parallel to the mid-pupillary line

60
Using CS Fillers in the Midface:
Upper and Lower Cheeks—Anatomy (continued)
► Lateral bony orbit
► Draw a vertical line from the lateral bony orbit in an
inferior direction parallel to the mid-pupillary line
► Alar–helix line
► Draw a line from the ala of the nose in a diagonal
direction to the attachment of the helix 

61
Using CS Fillers in the Midface:
Upper and Lower Cheeks—Anatomy (continued)
► Lateral bony orbit
► Draw a vertical line from the lateral bony orbit in an
inferior direction parallel to the mid-pupillary line
► Alar–helix line
► Draw a line from the ala of the nose in a diagonal
direction to the attachment of the helix 

► Lateral canthal–mandibular angle line

► Draw a line from the lateral canthus in a diagonal
direction to the mandibular angle

62
Using CS Fillers in the Midface:
Upper and Lower Cheeks—Anatomy (continued)
► Lateral bony orbit
► Draw a vertical line from the lateral bony orbit in an
inferior direction parallel to the mid-pupillary line
► Alar–helix line
► Draw a line from the ala of the nose in a diagonal
direction to the attachment of the helix 

► Lateral canthal–mandibular angle line

► Draw a line from the lateral canthus in a diagonal
direction to the mandibular angle
► The apex of the cheek should fall within the triangle
created with these lines; mark both sides and check
for symmetry
63
Using CS Fillers in the Midface:
Upper and Lower Cheeks—Anatomy (continued)
 Generally, above the alar–trachal line, deep
periosteal placement is recommended in a
bolus technique (blue area) while avoiding the
danger zones (foramina and orbit)

64
Using CS Fillers in the Midface:
Upper and Lower Cheeks—Anatomy (continued)
 Below the alar–trachal line, subcutaneous
placement is recommended in retrograde
linear threads (orange)

65
Using CS Fillers in the Midface:
Upper and Lower Cheeks—Anatomy (continued)
 Alar–trachal line
 Mark a line from the ala to the tragus
 Infraorbital foramen
 Palpate and mark the infraorbital
foramen () on both sides of the face

 Infraorbital rim
 Mark a line over the infraorbital rim

66
 Using CS Fillers in the Midface:
Upper and Lower Cheeks—Anatomy (continued)
► Anatomic structures that
should be avoided when
treating medial/lateral cheeks

Infraorbital rim

Zygomaticofacial foramen
Infraorbital foramen

Angular artery

Facial artery

Park SW et al. Am J Ophthalmol. 2012;154:653-662. Image reprinted with permission from Lazzeri D et al.
Blindness following cosmetic injections of the face. Plast Reconstr Surg. 2012;129:995-1012. 67
Using CS Fillers in the Midface:
Upper and Lower Cheeks—Anatomy (continued)
► The malar septum, a band of connective tissue, divides the
suborbicularis oculi fat into a superficial and deep compartment
► The lymphatic drainage in the superficial suborbicularis oculi fat is
poor and injection of dermal fillers in this area may further impede
lymphatic drainage resulting in fluid accumulation and malar edema1

1. Inglefield C et al. Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment. London: Aesthetic Medicine Expert Group, 2014. 68
Using CS Fillers in the Midface:
Upper Cheeks—Needle Technique (I)
 Advance the sharp needle perpendicular to the
skin to the periosteum
 Inject 1 or 2 boluses of ≈0.1 mL at the apex of the
cheek
 Inject additional periosteal boluses around to the
apex to improve the contour of the upper cheek 

69
Using CS Fillers in the Midface:
Lower Cheeks—Needle Technique (I)
 With a new sharp needle, place multiple
retrograde linear threads in a fanning technique
at the dermal–subdermal junction
 Inject ≈0.05 mL per retrograde
 Consider (hyper)diluting the product to facilitate
smoothing out the result 
 Mold and massage the product to even out

70
Using CS Fillers in the Midface:
Lateral and Medial Cheeks—Cannula Technique (I)
Entry points Lateral and medial cheek
entry points
 Lateral cheek
 Mark the lateral cheek entry point just before
the hairline on the zygomatic arch
 Vector line 
 Draw a line from the entry point to the oral
commissure
 Medial cheek
 Mark the medial cheek entry point where the
alar–trachal line and the vector line cross

71
Using CS Fillers in the Midface:
Lateral Cheeks—Cannula Technique (I)
 Insert the cannula
Lateral cheek entry point
 Advance the cannula to the periosteum, parallel to the
alar–trachal line
 Place 1 or 2 boluses of ≈0.1 mL at the cheek apex
 Withdraw ≈1 cm, stop and place a smaller bolus; repeat
as needed towards entry point 

 Readvance the cannula in a direction between the

alar–trachal line and the vector line
 Repeat the multiple boluses
 Change depth to the superficial subcutis
 Inject multiple retrograde linear threads of ≈0.05–0.1 mL
72
Using CS Fillers in the Midface:
Medial Cheeks—Cannula Technique (I)
 Insert the cannula from the medial cheek entry
point and advance to the periosteum in the Medial cheek entry point
direction between the infraorbital rim and the
infraorbital foramen; stay lateral to the tear trough
 Place small boluses of ≈0.05 mL
 Readvance and place multiple small boluses 
inferior to the infraorbital foramen
 Change depth to the superficial subcutis
 Inject multiple retrograde linear threads of
≈0.05–0.1 mL

73
Using CS Fillers in the Midface:
Upper and Lower Cheeks—Technique (II)
Injection Bolus, linear threading, and fanning/cross-hatching
technique
Needle size CaHA: 27G needle, 1.0″ (25 mm); 27G needle, 0.5″ (13 mm)
25G or 27G cannula, 1.0″ (25 mm) or 1.5″ (38 mm)
PLLA: 26G needle
Injection Inject over bone (supraperiosteally) – zygomatic bone and malar/maxilla
plane Stay well below the infraorbital rim
Use subdermal injections only for lateral zygoma
enhancement when blending into surrounding area
Never inject subdermal in the medial aspect of
the midface to avoid injecting into (branches of) the
facial artery

74
Using CS Fillers in the Midface:
Medial Cheeks—Needle Technique (II)
Medial cheek (malar enhancement)
 Place microaliquots on the apex of the cheek first of ≈0.05–0.1 mL
 Then place microaliquots on the malar eminence, leaving the apex as the high point of the cheek
and tapering outward
 Deliver up to 0.1-mL aliquots
 Serial puncture, transcutaneous depot (90° angle) to the supraperiosteal plane
 Give due attention to the needle bevel direction, as it is wise to have the bevel opening facing
lateral or inferior to the infraorbital foramen
 Individual anatomy can vary; assess the patient for volume loss and appropriate product
placement
 Mold to the desired correction away from the infraorbital foramen and be careful not to force
pressure on the plunger, making a large aliquot
 You may use a finger from the non-dominant hand or a cotton tipped applicator as a barricade to
safeguard moving the product above the orbital rim when injecting and molding filler into place
75
Using CS Fillers in the Midface:
Lateral Cheeks—Needle Technique (II) (continued)
Lateral cheek (zygoma enhancement)
 To correct the appearance of a step-off possibly caused by the supraperiosteal aliquot injections
to the malar area or if performing cheek enhancement, additional augmentation of the
zygomatic–temporal zone may be needed
 Insertion point should be on the mid-zygomatic arch, or halfway between the superior and
inferior arch borders
 Injections of 0.1 mL retrograde linear threads may be placed in the subdermal plane
 If subdermal threads are used (versus aliquots or submuscular threading), these should only be
made lateral to the lateral canthus to avoid injecting superficial to the malar septum
 Mold to the desired correction
 You may use a finger from the non-dominant hand or a cotton tipped applicator as a barricade to
safeguard moving the product above the orbital rim when molding the filler into place

76
Using CS Fillers in the Midface:
Upper and Lower Cheeks—Cannula Technique (II)
Cannula technique (malar and zygomatic enhancement)
 Appropriate anesthesia procedure should be performed if necessary
 Make the insertion point with an appropriate needle; insert the needle, advance to the
periosteum and move the needle from left to right; lift the skin with needle (bevel up) and retract
from skin
 Insert the cannula at 30°–45° angle into the skin; pulling skin away with the non-dominant index
finger and thumb makes it easier to advance the cannula through the insertion point and skin
 The first insertion point should be midway along the zygoma
 Inject multiple strands of filler using the fanning technique in a retrograde manner
 Maintain depth to inject at the supraperiosteal level
 From a second insertion point, medial and at an oblique angle, cross-hatch the filler to further
augment the area and to define the highest point
 Gently shape and mould the material to the desired cosmetic effect
77
Using CS Fillers in the Midface:
Upper and Lower Cheeks—Technique (II) (continued)
Safety considerations
 Stay well below the infraorbital rim
 To avoid injecting near the infraorbital foramen or nerve, give due attention to the needle
bevel direction and preferably have the bevel opening facing lateral or inferior to the
infraorbital foremen
 To reduce risk of intravascular injection, place the filler supraperiosteally, below the region
of the suborbicularis oculi fat and medial cheek fat compartments
 Inject over bone to avoid the malar septum, which is located ≈3 cm inferior to the lateral
canthus

78
Using CS Fillers in the Midface:
Submalar Cheek Hollows
► Some CS fillers can be used to fill submalar cheek hollows
► Injection sites for CaHA fillers:
Needle Cannula

79
Using CS Fillers in the Midface:
Submalar Cheek Hollows

Injection Linear threading, fanning, and cross-hatching

technique
Needle size 27G needle, 0.5″ (13 mm)
25G or 27G cannula, 1.0″ (25 mm) or 1.5″ (38 mm)
Injection plane Subdermal and/or subcutaneous plane

80
Using CS Fillers in the Midface:
Submalar Cheek Hollows—Needle Technique
 Insert the needle at a 30°–45° angle into the skin until you feel an easy glide in
subdermal/subcutaneous plane
 Advance the needle and inject fine threads (0.05–0.10 mL each) while withdrawing the
needle in a retrograde manner
 Inject linear threading, fanning, and crosshatching techniques at oblique angles to
original threads correcting to visual endpoint
 Gently mold with thumb and forefinger as needed

81
Using CS Fillers in the Midface:
Submalar Cheek Hollows—Cannula Technique
 Make the insertion point with an appropriate needle
 Insert the needle into the skin until you feel an easy glide in the subdermal/subcutaneous
plane and move the needle from left to right; lift the skin with the needle (bevel up) and
retract it from the skin
 Insert the cannula at a 30°–45° angle into the skin; pulling the skin away with the non-
dominant index finger and thumb makes it easier to advance the cannula through the
insertion point
and skin
 Inject multiple strands of filler using the fanning technique in a retrograde manner
 From a second insertion point, lateral and at an oblique angle, cross-hatch the filler to
further augment the area
 Gently shape and mold the material to the desired cosmetic effect

82
Using CS Fillers in the Midface:
Submalar Cheek Hollows–Things to Avoid
 Avoid the parotid gland that is located sub-SMAS, overlying the mandibular
ramus and anterior and inferior the external ear; the gland extends irregularly
from the zygomatic arch to the angle of the mandible
 The parotid gland can be avoided by staying immediately subdermal or above, depending on
the product being used
 Be aware that the facial nerve and its branches pass through the parotid gland
 Avoid the orbicularis muscle

SMAS, superficial muscular aponeurotic system 83

Using CS Fillers in the Midface:
Nasolabial Folds
► Nasolabial folds typically arise due to loss of volume in the deep cheek fat pads
and a downward shift due to gravity
► Cadaver studies by Rohrich and colleagues have shown that infusing saline into
the deep medial cheek fat pad gives projection of the anterior cheek, as well as
effacement of the under-eyelid area and nasolabial fold1
► Similarly, placing localized soft tissue filler into the deep medial cheek
compartment can restore facial volume and reshape the soft tissues of the face
into an anatomically more youthful position1
► For this reason, it is important to carry out a careful assessment of your patient
to determine if the nasolabial folds are best treated by direct filling or filling and
lifting of the cheeks

1. Rohrich RJ et al. Plast Reconstr Surg. 2008;121(6):2107-2012. 84

Using CS Fillers in the Midface:
Nasolabial Folds—Injection Sites
Needle Cannula

1. insertion point
Insertion point

2. Insertion point

85
Using CS Fillers in the Midface:
Nasolabial Folds

Injection Linear threading and fanning

technique
Needle size CaHA: 27G needle, 0.5″ (13 mm); 25G or 27G cannula, 1.0″ (25 mm) or 1.5″ (38 mm)
PLLA: 26G needle
Injection Subdermal plane ≈30° subdermal injection

plane

86
Using CS Fillers in the Midface:
Nasolabial Folds—Needle Technique
 Insert needle at a 30° angle into the skin in the lower point of the nasolabial fold until you
feel it easily glide in the subdermal plane
 Gently lift the skin with the needle to check that you are in the correct plane
 Inject fine threads (0.05–0.10 mL each) of filler while withdrawing needle in a retrograde
fashion
 Inject parallel threads, linear threading and fanning in the medial direction
 If injecting a prominent crease, place the material in a deeper plane to support the fold,
ensuring you stay above the orbicularis oris muscle
 Mold gently with thumb and forefinger as needed

87
Using CS Fillers in the Midface:
Nasolabial Folds—Cannula Technique
 Appropriate anesthesia procedure should be performed if necessary
 Make the insertion point with an appropriate needle
 Insert the needle into the skin into the subdermal plane and move the needle from left to
right; lift the skin with the needle (bevel up) and retract it from the skin
 Insert the cannula at a 30° angle, pulling the skin away with the non-dominant index finger
and thumb makes it easier to advance the cannula through the insertion point
 The first insertion point should be at the distal end of the nasolabial fold
 Augment the area as described above using the needle; inject multiple strands of filler using
the fanning technique in a retrograde manner
 Gently shape and mold the material to the desired cosmetic effect

88
Using CS Fillers in the Midface:
Nasolabial Folds—Things to Avoid
 Take care not to place too much product in the alar triangle to avoid
compression of the angular artery
 Be aware that there is anastomosis between the ophthalmic artery and the
facial artery
 Avoid the orbicularis oris muscle as perimuscular injection anywhere on the face
can lead to product compaction/nodularity or even displacement (migration) of
product by mimic activity of the muscle affected

89
Using CS Fillers in the Lower Face:
Marionette Lines
► In the lower face, marionette lines form from the oral commissures
due to the actions of the depressor anguli oris1
► Some CS fillers can be used to correct marionette lines
► Injection sites for CaHA fillers:
Needle Cannula

1. Carruthers JD et al. Plast Reconstr Surg. 2008;1215(Suppl):5S-30S. 90

Using CS Fillers in the Lower Face:
Marionette Lines (continued)
 Patient selection is important
► Large amounts of filler can be used in this area without any
significant result, so it is important to establish what degree of
correction might be possible1

1. Inglefield C et al. Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment. London: Aesthetic Medicine Expert Group, 2014.
Using CS Fillers in the Lower Face:
Marionette Lines
Injection Linear threading and fanning
technique
Needle size 27G needle, 0.5″ (13 mm)
27G cannula, 1.0″ (25 mm) or 1.5″ (38 mm)
Injection Subdermal plane
≈30° subdermal injection
plane

92
Using CS Fillers in the Lower Face:
Marionette Lines—Needle Technique
 Insert needle at a 30° angle into skin just inferior to the lower lip vermilion border, at corner of the mouth
 Position the needle immediately to the subdermal plane; gently lift the skin with needle to check if you are
in the correct plane
 Advance needle running parallel to vermillion border in deep dermis and inject a first strand in a retrograde
manner; start at the marionette line and fan medially, towards the lateral end of the mental crease
 Without withdrawing the needle, place a further strand just below (inferiorly and laterally) to the first
strand using the fanning technique; continue this with a final strand of product just below the second
 This technique will place product in a triangular pattern inferior to the corner of the mouth and helps to
support the corners of the mouth
 At the same time, the technique augments the upper part of the marionette line
 A second insertion point may also be used at the base of marionette line, also using a fanning technique
 The first strand should be placed directly under marionette line with subsequent strands lying medial to
this strand
 Exercise caution in volume placement in the marionette lines; progressively bring the patient to an optimal
correction
 Avoid enhancing fuller tissue at the lateral edges of folds as this can deepen the appearance of folds
 Gently massage and mold the injected area
93
Using CS Fillers in the Lower Face:
Marionette Lines—Cannula Technique
 Any appropriate anesthesia procedure should be performed if necessary
 Make the insertion point with an appropriate needle; insert and move the needle in the correct
plane, from left to right; gently lift the skin with the needle (bevel up) and retract from skin
 Insert the cannula at a 30° angle into the skin; pulling the skin away with the non-dominant
index finger and thumb makes it easier to advance the cannula through the insertion point
 The first insertion point should be at the distal end of the nasolabial fold
 Augment the area as described above using the needle; inject multiple strands of filler using the
fanning technique in a retrograde manner
 Augment the area as described above using a needle

94
Using CS Fillers in the Lower Face:
Prejowl Sulcus
► Some CS fillers can be used to correct the prejowl sulcus
► Injection sites for CaHA fillers:

Bolus Subdermal fanning/

deep dermal fanning

1. Carruthers JD et al. Plast Reconstr Surg. 2008;1215(Suppl):5S-30S. 95

Using CS Fillers in the Lower Face:
Prejowl Sulcus

Injection Linear threading and fanning, bolus

technique

Needle size 27G needle, 0.5″ (13 mm)

Injection Subdermal/supraperiosteal plane ≈30° deep dermal injection

plane
Epidermis

Dermis

Subcutis

Muscle
Periosteum
Bone

96
Using CS Fillers in the Lower Face:
Prejowl Sulcus—Needle Technique
 Palpate the edge of the mandible
 Position a finger under the edge of the mandible to prevent inadvertent tracking of the product
inferiorly upon injection
 Pick the prejowl sulcus insertion point (antero-superior to the mandibular edge, mid prejowl
sulcus defect)
 Advance the needle down to the periosteum
 Lift the needle slightly and inject multiple aliquots of the product (up to 0.1 mL per aliquot)
supraperiosteal
 Alternatively: insert the needle into the subdermal plane and inject linear threads of filler in a
fanning pattern along the jawline
 Gently pinch and mold to further contour the jawline
 Gently mold for correct placement and smooth contour of product

97
Using CS Fillers in the Lower Face:
Prejowl Sulcus—Safety Considerations
► Avoid the orbicularis oris muscle
► Vascular compromise can arise when filler is injected into the facial artery
► To avoid such complications, the facial artery should be located by palpating the
medial border of the masseter1
► The facial artery can be found lateral to the oral commissure, running lateral and
inferior

1. Inglefield C et al. Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment. London: Aesthetic Medicine Expert Group, 2014. 98
Using CS Fillers in the Lower Face:
Mental Crease
► Some CS fillers can be used to correct the mental crease
► Injection sites for CaHA fillers:
Needle Cannula

99
Using CS Fillers in the Lower Face:
Prejowl Sulcus

Injection Linear threading, fanning, and parallel lines

technique
Needle size 27G needle, 0.5″ (13 mm)
25G or 27G cannula, 1.0″ (25 mm) or 1.5″ (38 mm)
Injection Deep in the dermal plane ≈30° deep dermal injection

plane

100
Using CS Fillers in the Lower Face:
Mental Crease—Needle Technique
 Insert the needle at ≈30° into the skin immediately lateral to the end of the mental crease
 Insert the needle into the skin until you feel an easy glide in the deep dermal plane; lift the
skin with the needle to check if you are in the correct plane
 Advance and withdraw needle 3–4 times without injecting product; do not exit injection site
 Advance the needle under the mental crease in the deep dermis and inject fine threads
(0.05–0.10 mL each) while withdrawing the needle in a retrograde manner
 Inject parallel threads, linear threading, and fanning; the threads should be positioned
under the crease itself, in a linear and very narrow fan pattern
 Repeat the injection pattern on the other side
 Exercise caution in volume placement in the mental crease; progressively bring the patient
to an optimal correction
 Gently massage and mold the injected area with forefinger and thumb as needed

101
Using CS Fillers in the Lower Face:
Mental Crease—Cannula Technique
 Any appropriate anesthesia procedure should be performed if necessary
 Augmenting the mental crease with a cannula requires only 1 insertion point,
but a second insertion point might be necessary
 Make the insertion point with an appropriate needle; insert the needle and
move the needle in the correct plane from left to right; lift the skin with the
needle (bevel up) and retract it from the skin
 Insert the cannula at ≈30° angle into the skin; pulling the skin away with the
non-dominant index finger and thumb makes it easier to advance the cannula
through the insertion point and skin
 Augment the area as described above using a needle

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Using CS Fillers in the Lower Face:
Mental Crease—Things to Avoid
 The buccal sulcus is susceptible to product accumulation if the injection is placed
too deeply superior to the alveolar process
 Avoid the orbicularis oris muscle as this will reduce the risk of nodularity post
injection
 Be aware that pressure on the incisive and mental nerves may affect sensation
of the mandible and inferior teeth
 A mental crease can be adhered to underlying tissue and the needle must pass
easily into the area, otherwise the product may track around and reach an
unwanted location

103
Using CS Fillers in the Lower Face:
Jawline
► Some CS fillers can be used to contour the mandibular edge, which will improve jawline shape
► A set of consensus recommendations on use of CaHA for jawline rejuvenation is available1

► Injection sites for CaHA fillers:

Needle (periosteal bolus) Needle (subcutaneous) Cannula

1. Dallara JM et al. J Cosmet Dermatol. 2014;13(1):3-14 104

Using CS Fillers in the Lower Face:
Jawline

Injection Bolus, linear threading, and fanning

technique
Needle size 27G needle, 0.5″ (13 mm)
27G cannula, 1.0″ (25 mm) or 1.5″ (38 mm)
Injection Supraperiosteal (needle)
≈30° deep dermal injection
plane or subdermal plane (cannula)
Epidermis

Dermis

Subcutis

Muscle
Periosteum
Bone

105
Using CS Fillers in the Lower Face:
Jawline—Needle Technique (Subcutaneous)
 Insert the needle at ≈30° angle into the skin at the mandibular angle
 Insert the needle into the skin until you feel an easy glide in the deep dermal
plane; lift the skin with the needle to check if you are in the correct plane
 Advance the needle in the deep dermis and inject fine threads
(0.05–0.10 mL each) while withdrawing the needle in a retrograde fanning
technique
 Repeat the injection pattern along the jawline
 Gently massage and mold the injected area with forefinger and thumb as
needed

106
Using CS Fillers in the Lower Face:
Jawline—Cannula Technique
 Appropriate anesthesia procedure should be performed if necessary
 Make insertion point with an appropriate needle
 Insert needle into the skin into the subdermal plane and move the needle from left to right; lift
the skin with the needle (bevel up) and retract it from the skin
 Insert the cannula at a 30° angle into the skin; pulling the skin away with the non-dominant index
finger and thumb makes it easier to advance the cannula through the insertion point and skin
 Make an entry point at the mandibular angle
 Inject multiple linear threads of filler towards the earlobe and along the jawline using the fanning
technique in a retrograde manner
 Apply gentle pressure with your non-injecting hand along the jawline to avoid spreading of the
filler to distal regions
 If additional augmentation is desired, a second insertion point can be made at the prejowl sulcus
insertion point (antero-superior to the mandibular edge, mid prejowl sulcus defect)
 Retrogradely inject multiple linear threads in a fanning pattern
 Gently shape and mold the material to the desired cosmetic effect
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Using CS Fillers in the Lower Face:
Jawline—Things to Avoid
 Just lateral to the oral commissures, running lateral and inferior, is the
facial artery
 Avoid the facial nerve by not injecting too deeply
 Avoid placing aliquots of filler near the mental foramen and nerves
 Avoid the masseter muscle
 Avoid the parotid gland

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Using CS Fillers in the Lower Face:
Chin
► With age, loss of definition occurs around the mandible and the mentalis area
leading to a ‘cobblestone’ appearance
► This is the result of mentalis activity over time in conjunction with volume loss in the chin1
► Some CS fillers can be used to augment the chin
► Injection sites for CaHA fillers:
Needle Needle Cannula
1 = Aliquots at (1) shape the chin 2 = Bolus at (2) elongates the chin and face 3 = Bolus at (3) elongates the chin and face
4 = Retrogrades shape the chin

2 4
2
3

1. Carruthers JD et al. Plast Reconstr Surg. 2008;1215(Suppl):5S-30S. 109

Using CS Fillers in the Lower Face:
Chin

Injection Bolus, linear threading, and fanning

technique
Needle size 27G needle, 0.5″ (13 mm)
25G cannula, 1.0″ (25 mm) or 1.5″ (38 mm)
Injection Supraperiosteal ≈30° deep dermal injection

plane or subdermal plane

Epidermis

Dermis

Subcutis

Muscle
Periosteum
Bone

110
Using CS Fillers in the Lower Face:
Chin—Cannula Technique
 Any appropriate anesthesia procedure should be performed if necessary
 Augmenting the mentum with a cannula requires only 1 insertion point per side
 Make the insertion point with an appropriate needle; insert the needle and move it in the
correct plane from left to right; lift the skin with the needle (bevel up) and retract it from the skin
 Insert the cannula at ≈30° angle into the skin; pulling the skin away with the non-dominant index
finger and thumb makes it easier to advance the cannula through the insertion point and skin
 Lift the mentalis muscle with the non-dominant hand
 Advance the cannula to the submuscular, supraperiosteal plane, just at the midline
 Inject 1 or more boluses of ≈0.1 mL of product
 Retract the cannula and readvance in the subcutaneous plane
 Using a fanning technique, inject multiple retrograde threads of ≈0.05–0.1 mL
 Gently mold the product into the desired shape

111
Using CS Fillers in the Lower Face:
Chin—Things to Avoid
 Avoid placing aliquots of fillers near the mental foreman and nerves
 Keep augmentation to the anterior side of the mandibular rim
 Avoid placement of filler in the mental crease as this could manifest as a gingival
sulcus nodule on the mucosal aspect

► Tip: Patients with a “square” or a “round” face may need more of a “pointed”
prominence of the chin to add definition to their profile, but drooping of the
chin or ‘witches chin’ can occur if you inject too low on the jawline1

1. Inglefield C et al. Expert Consensus on Complications of Botulinum Toxin and Dermal Filler Treatment. London: Aesthetic Medicine Expert Group, 2014. 112
CS Fillers:
Aftercare and Repeat Treatments
► The effective use of CS fillers does not end with the injection technique, as
aftercare is a vital part of successful treatment
► Also, many patients will request repeat treatments and the timing of
additional filler injections is important
► Once patients have left your clinic, they will need to know how to care for
the treatment area and who to contact if they have any concerns
► It is also important to see how a patient reacts to treatment before
considering further injections and a follow-up visit can be used to
evaluate this

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Patient-led Aftercare
► Patients should understand how they can care for their injected areas after treatment
► You can provide your patient with this short list of recommendations to help speed their
recovery
They may want to… They may want to avoid…
 Lightly and gently apply an ice pack or cold  Massaging, scrubbing, or rubbing the area after treatment
compress to the area to reduce swelling or redness
 If swelling or redness persists beyond 7 days  Extreme temperature after treatment; saunas or exposure to extreme cold
contact your clinician should be avoided until any redness, swelling or bruising have resolved
 Gently wash the area every day  Ultraviolet exposure such as sun and tanning beds until any redness,
swelling or bruising have resolved
 Once makeup can be applied, do so gently and  Applying makeup before the time specified by your clinician (dependent on
without strenuous rubbing what treatment you have had)
 Report any worsening of symptoms or concerns to  Strenuously exercise after treatment to allow treatment effects to settle
your clinician

► Don’t forget to provide your patients with the necessary contact details should they
have any concerns
Fitzgerald R, Vleggaar D. Dermatol Ther. 2011;24(1):2-27. 114
Follow-up Appointments and Repeat Treatments
► Follow-up visits are important for ensuring a patient has responded well
to their treatment and to check for any signs of complications, such as
infection
► The timing of these varies dependent on the extent of their treatment, but
2 to 4 weeks following the procedure is optimal1
► Providing a patient has responded well and shows no signs of an adverse
event, repeat treatments can be scheduled
► In line with the treatment guidance, a first treatment should be
conservative and touch-ups can then be performed at follow-up
appointments1,2

1. Radiesse Injectable Implant [Instructions for use]. Franksville, WI: Merz North America, Inc; January 2016.
2. Fitzgerald R et al. Dermatologic Ther. 2011;24(1):2-27. 115
Follow-up Appointments and Repeat Treatments
► Further treatments will then depend on the CS filler that was used; the
recommended strategy with PLLA-based fillers is gradual, progressive correction
over multiple treatment sessions with ≥4 weeks between treatments
► Treat, wait, assess. Do not overcorrect1
► For CaHA-based fillers, additional injections may be performed, but only after
sufficient time has passed to evaluate the patient
► The patient should not be re-injected sooner than 7 days after the previous treatment
► The duration of effect among products varies from 12–18 months for CaHA
based fillers to 25 months for PLLA based fillers1,2
► As long as there are no signs to cause concern at the initial follow-up visit, these
appointments can be scheduled appropriately

1. Bass LS et al. Aesthet Surg J. 2010;30(2):235-238. 2. Fitzgerald R et al. Dermatologic Ther. 2011;24(1):2-27. 116
Common Mistakes and How to Avoid Them
► In general, the mistakes associated with CS filler injections are due to overcorrection,
suboptimal product placement or incorrect product reconstitution (PLLA-based fillers),
and can therefore generally be avoided by adherence to the previously discussed
guidelines1
► Avoid placement in or through areas of hyperdynamic muscle movement
► Do not inject through the inferior portion of the orbicularis oculi muscle or into the modiolus or
proximal depressor anguli oris muscles
► Muscle movement in these areas will clump the product, leading to localized overcorrection1
► Depending on the area that is being injected, overcorrection or suboptimal product
placement can cause a range of complications and at worse lead to vascular occlusion
and necrosis
► Do not overcorrect the treatment site
► Use a 1:1 correction factor
► Mold or massage the injected implant periodically during the injection process to maintain a smooth
contour of the implant
1. Fitzgerald R, Vleggaar D. Dermatologic Ther. 2011;24(1):2-27. 117
Tips for Preventing Overcorrection or
Suboptimal Product Placement
► Locate the initial site for the implant
► Avoid, if at all possible, scar tissue and cartilage when advancing the injection needle
► Inject slowly and gently
► Do not inject into a blood vessel
► Tailor the depth of the injection and the amount injected to the site and extent of the
restoration or augmentation If in doubt, be conservative with the amount of filler you inject and
re-evaluate and re-treat later
► Massage the filler to distribute it appropriately
► Inject in the correct layer for the area you are treating
► Injections should be sufficiently deep so as to prevent nodular formation at the surface of the
skin or ischemia of the overlying tissue
► Check you are in the correct plane by gently lifting the skin with the needle
► Consider the treatment required for a natural appearance in line with the patient’s face
► Ensure the results will remain natural during expression

Radiesse Injectable Implant [Instructions for use]. Franksville, WI: Merz North America, Inc; January 2016. 118
Key Points to Document in Patient Records
► Patient information and medical history including any previous treatments and
their effects
► Patient goals, type/severity of lines, any asymmetry or natural ptosis, skin type, general skin health
► Discussion of product selection and alternative cosmetic procedures
► Signed informed consent
► Before and after photographs
► Mark areas to be treated on a picture in the treatment record form
► The quantities of product to be injected into the areas
► A record of all drugs and fillers used, doses/volumes and batch numbers
► Document both planned treatment and treatment actually carried out (you can use an indication-
specific treatment record form)
► Clinical and other outcomes
► The timing of follow-up

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CS Fillers: Summary
► You should now have an understanding of the following:
► The theory behind using the 3D vectoring technique to reverse signs of aging
► The aesthetic evaluation process as it relates to assessing and restoring volume to the aging
face including the patient consultation process, managing patient expectations, individualized
treatment, use of Merz Aesthetic Scales, patient aftercare, and repeat treatments
► Key considerations for patient treatment, including aseptic technique, taking before/after
photos, use of Merz scales, expected desired results, aftercare, and appropriate time intervals
between treatments
► Reconstitution and safe disposal requirements for CS fillers where relevant
► Facial mapping areas specific to facial volume depletion and how to map the face when
injecting with CS fillers
► Injection techniques for CS fillers and how they can be used to reverse signs of aging
► The value of documenting case histories and what should be included in a case history when
treating patients with soft tissue fillers

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