Many injectors, especially when new to the industry, question which dermal filler is the best filler for the specific targeted area on the face. However, other considerations also come into play when making these decisions such as, the patient’s anatomy and age. It is important to realize that not all dermal fillers are created equal. The most common type of filler is one comprised of hyaluronic acid.
By as young as 30, or even before then in athletic or slim individuals, the fat pads start to shrink and descend down the face. There are some obvious dermal filler choices for certain anatomical areas. For example, for correction of age-related midface contour deficiencies you would want to pick a filler that is good for deep implantation into the facial tissue such as Restylane Lyft or Juvéderm Voluma. These fillers have a higher g-prime. Volume loss in the mid-face is a signature hallmark of the aging face. These fillers help replace the deep and superficial fat pads of the cheeks.
Typically, a patient will get at least two syringes in the cheeks. One for each side of the face. Most patients have some asymmetry, so generally there is a little more dermal filler placed on one side of the face versus the other. For instance, sometimes the left side of the face is asymmetrical due to sun damage from the driver’s side window. Perhaps the right side of the face is flatter because that is the side of the face that the patient generally sleeps on. Whatever the cause, take note of the asymmetries when evaluating patients.
Injections in the lips can boost volume to create plumper, younger looking lips. They can also create symmetry or provide contour for those with thinner lips. Lip filler does not have to have the appearance of “lip filler.” Lip injectables should be a dermal filler with more flexibility, or xStrain. There are many different lip fillers to choose from. Ultimately, the injector needs to pick not only the best filler for the patient’s goals, but also a filler that will work well with the patient’s given anatomy. Do not use a filler with too much g-prime or firmness, because that will look hard and bulky in the lips. If the patient has very thin lips and wishes to have a natural fullness, it is best to build up to that volume over a couple of sessions.
Many patients complain of their nasal labial folds or a “jowling” appearance in their lower face as they age. This appearance of the aging face is characterized by not only thinning skin and loss of collagen, but also the loss of deep fat pads in the face. Adding volume and contour to the cheeks should always be targeted first, because replacing volume in the mid-cheek can reduce the depth and severity of other mid-facial lines as the nasal labial folds.
Hyaluronic acid fillers for nasal labial folds and marionette lines depends greatly on the patient’s anatomy and skin structure. If the patient has very thin or aged skin, a filler with a high g-prime could appear heavy. Since these areas are anatomically around the mouth and in turn have more movement, a dermal filler placed here should have some flexibility. The fillers here are indicated for moderate to severe facial wrinkles and folds and injected into the mid to deep dermis.
Hyaluronic acid fillers pull water. Thus, when choosing a filler take this into consideration. For instance, placing filler in tear troughs should not have a filler that pulls a lot of water. No one wants swelling and puffiness under their eyes. Filler placed in the tear troughs should not be the first and only filler because that will give an unnatural convexity beneath the eye, causing one to look filled. Filler here is considered off label.
Ultimately, no matter where the filler is placed anatomically, take into consideration the depth of where the filler will be placed, patient anatomy and skin, the g-prime and flexibility of the dermal filler.
Safeguard Measures
The popularity of temporary dermal fillers continues to rise every year. That being said, there are more and more aesthetic injectors. Knowing the anatomy of the face is crucial to be a prudent aesthetic injector. There are necessary precautions that an injector must take because anatomic variation and vessel path can vary. Anatomy gives a general sense of important areas to be extra cautious in, but knowing anatomy is not the only safeguard.
Unintentional injection into a blood vessel can lead to complications such as necrosis, scarring and even blindness. One key safety measure is aspirating. By pulling back on the syringe pre-injection, and not getting blood return in the hub of the needle, it helps safeguard that it is not in a blood vessel. Thereby eliminating the risk of an intravascular injection or occlusion complication. That being said, the face is one of the most vascular areas of superficial anatomy, and aspirating is not a 100% guarantee that the injector is not in a blood vessel.
Other techniques can decrease the risk of intravascular injection such as injecting retrograde and anterograde. In doing this, it avoids depositing large amounts of filler into one area, including the intravascular space. Additionally, inject slowly. This allows the injector to observe reactions like sudden or extreme pain per the patient or blanching of the skin which could indicate intravascular injection. Also, minimize boluses as boluses could occlude a vessel due to external pressure.
Using cannulas is yet another safeguard that has become more popular. They are blunt tipped, so theoretically decreases the risk of intravascular injections because the cannula does not enter the lumen of a blood vessel. Another plus to using cannulas is they may decrease incidence of bruising due to less injection sites.
Know the anatomy of the face. In conjunction, distinguish how the face ages such as changes in the craniofacial skeletal structure and superficial and deep fat compartments. When injecting around an area of concern, use every safeguard measure to ensure that the injection will be safe. And most importantly, know how to recognize a complication and how to manage one if it arises.
In conclusion, many patients want a natural appearance when getting filler. In fact, sometimes they are even terrified of filler due to patients that look “overdone.” They want to turn back the clocks of time and appear as they did in their youth. While there are some patients that would prefer to appear more as a caricature of themselves, as practitioners we have to educate these patients that a natural look gives the appearance of a more youthful look.
