In my experience, women in their 20s and 30s frequently request ‘tweaks’ or ‘tweakments’. It has become increasingly apparent through my detailed consultations that ‘tweakment’ is being used to mean ‘natural’ results, with patients considering unnatural results to be caused by ‘too much’ filler. Although many undesirable results seen on television and social media are partly a product of over-administration of dermal fillers, the volume of filler is not the sole cause.1 Personally, as practitioners we should always seek to administer the minimum level of treatment to achieve the maximum results, but we must also educate patients about the fact that 1ml of the wrong filler placed poorly may give a more unnatural result than 8ml of appropriate filler placed effectively.2
In my opinion, it is therefore our responsibility to educate ourselves about detailed facial anatomy as well as physical and chemical properties of the fillers on the market.
Through a detailed assessment and collaborative treatment planning, I believe that patients may understand the multifactorial cause of their concerns and the value of a holistic treatment strategy. I have found that a patient-led consultation, jargon free discussion and mirror-aided visual education improves patient understanding of the treatment process.
A 32-year-old Caucasian female presented with concerns about deepening nasolabial folds and wrinkles between her eyebrows. She felt she looked tired and older than she would like with makeup no longer concealing the lines and shadows on her face. Using a handheld mirror, I asked her to clarify the areas of concern. She had never had any aesthetic treatments before and there was no previous medical history. I agreed that her concerns were valid and reassured her that these were common concerns I treated amongst her age demographic. Assessment
A detailed physical assessment was carried out on the patient at rest and animated. She was assessed upright in a frontal, oblique and sagittal view to gain full appreciation of the facial structures under gravity. She presented with fine lines across the forehead as well as faint ‘11’ lines in the glabellar region. Upon animation, these lines deepened and did not fully resolve upon relaxing. She also had heavy lateral eyebrows which did not elevate markedly on engaging frontalis. She was very slim, with significant loss of volume in the lateral and medial cheek, with the appearance of nasojugal and mid-cheek grooves bilaterally (Figure 1).
There was fullness and descension of nasolabial fat compartments creating undesirable light reflection lines, and emphasis on the nasolabial fold. The fold consisted of loss of volume in the pyriform fossa creating shadow at the alar base, as well as folding skin due to poor support from the mid-face. The skin of the nasolabial fold carried a deep rhytid from the nasolabial to the marionette and mental crease which did not resolve when stretching the skin. I informed the patient that these lines were unlikely to resolve completely from filler alone, and a combination of treatments may be required such as chemical peels and microneedling.
Her chin was retrognathic on a skeletal class II base, with high mentalis activity causing chin dimpling when speaking. In general, her facial structures were set marginally superiorly on her left and she had stronger muscle pull on her left oral commissure. She also had an ‘M’ shaped upper lip with a convex upper cutaneous lip and philtrum flattening. Her nasolabial angle was reduced at 90 degrees where a more open angle up to 115 degrees would appear more feminine.3 The nose had a mild dorsal hump and supratip break with broad light reflection on the alar cartilages. I showed the patient any significant findings pertinent to her concerns in the mirror and demonstrated by gently manipulating her tissues how the depleted mid-face impacted the heaviness, shadows and wrinkles of her lower face.
I explained the nature of dermal fillers and botulinum toxin and their roles in treating the signs of ageing and disproportions. I advised that she would likely need multiple millilitres of dermal filler to restore the loss of volume in her face. I reassured her that I would only administer as much filler as necessary, with natural results in mind. I explained the risks associated with treatments, for example, brow ptosis from toxin, and bruising, infection, vascular occlusion and blindness from dermal filler.4
The aim was to restore youthful proportions and light reflection points to the face, whilst maintaining her natural character. Mid-face restoration and chin contouring with a multi-layered approach would give maximal indirect support for the nasolabial fold/mental crease complex and allow little volume. I recommended subtle enhancement of the nose to create the illusion of a more lifted nasal tip with narrower light reflection points which would add to a youthful appearance.5
I suggested lip and perioral filler to help evert the upper lip and shorten the philtrum whilst providing definition, however she opted against this treatment as she liked how her lips looked. Botulinum toxin of the upper face would be administered last, including treatment of frontalis, glabellar complex and lateral eyebrows. I did this last, so the bumps left immediately after injection and didn’t distort the appearance before adding volume. I advised the patient that my estimated volume of filler would range between 8-10ml of varying viscosity gels to achieve significant resolution of her concerns, as well as harmonise the full-face. I reassured her that should the tissues respond more to filler, we would use less volume. Skincare recommendations, such as vitamin C, retinol and SPF30-50, were given to enhance the results and reduce the appearance of ageing.
The patient was numbed topically with ice packs and advised of stop signals which could be used anytime during treatment if the patient wished to pause. Skin was disinfected with hypochlorous acid and relevant markings drawn on the face (Figure 2).
The mid-face was approached first with deep supraperiosteal boluses using a vector bisecting the alar-tragal and lateral canthus-oral commissure line. I used Teosyal Ultra Deep with a 27 gauge needle as a high G’ filler was required for structure.6 Other brands/products are available to use. Slow aspiration was employed to help assess for inadvertent intravascular needle placement.7-9 Augmentation of the SOOF and deep medial cheek fat compartments created support for subsequent superficial cheek augmentation with Teosyal RHA 4.10 A 38mm 25 gauge cannula was used to fan retrograde linear threads, enhancing the anteromedial and lateral superficial cheek without inadvertent augmentation of the nasolabial fat compartment. Care was taken to avoid inadvertent intravascular injection into the infraorbital, zygomaticofacial, transverse facial or angular artery by keeping injections lateral to medial limbal lines and administering all injections in appropriate planes.11 Although volumes of filler were not administered prescriptively, and decided by their physical effects on the tissues, no boluses larger than 0.3ml were delivered at a time.
The pyriform fossa was approached by deep supraperiosteal bolus with Teosyal Ultra Deep. Boluses were deposited supraperiosteally under mentalis in the midline and two paramedian points to aid in profiloplasty, lower face frontal contour and myomodulation.12 The superficial aspect of the nasolabial fold was approached in two ways:
- Superficial fanning of Teosyal RHA 4 with a 25 gauge cannula in the crest of the nasolabial fold at the level of the subcutaneous fat. A linear thread injection technique of no more than 0.05-0.1ml were placed conservatively to help avoid vascular occlusion.13,14
- Placing small linear threads of Teosyal RHA 3 over the rhytid in the descending portion of the nasolabial folds. The filler provided moderate G’ and elastic modulus to support but still integrate with the nasolabial fold naturally.15 The orientation of the threads was perpendicular to the course of the rhytid topographically, rather than the traditional approach where filler is placed in threads parallel to the fold.16 The technique used was a slight variation of the already established Fern technique.17
Intermittently, the patient was asked to smile in order to assess the improvement in dynamism as well as static position.18 A combination of Teosyal RHA 4 and RHA 3 was used to place retrograde linear threads in a subcutaneous fat plane, from an entry point just lateral to the pre-jowl sulcus. Fanned threads extended to the chin, mental crease, marionette area and oral commissure. Although the patient did not suffer with sagging in the marionette area, adding structural support in an angle crossing the dynamic smile lines at approximately 90 degrees helped support the skin from creasing in both a static and dynamic mode. Non-surgical rhinoplasty with 0.15ml of Teosyal Ultra Deep was performed with a 30 gauge needle. Deep supraperiosteal and supraperichondrial microbolus technique was employed in the radix and supratip respectively, and subdermal microboluses in the nasal tip midline. Injections were kept in the midline to reduce the risk of vascular occlusion of the lateral and dorsal nasal arteries.19 A total of 9.6ml of varying fillers was used. Toxin (Botox) was administered to the glabellar complex (22.5u) and frontalis (12.5u), avoiding treatment of the inactive lateral parts of frontalis. The tail of the brows was also treated (1.25u per side) to prevent brow ptosis, appearing to open the eyes. Post-procedure instructions were provided, and support given in the form of a 24-hour online review and communication via phone.
The botulinum toxin effects were very satisfactory, requiring no further dosage. Assessment showed natural movement of the glabellar complex and frontalis, with her lateral brows being slightly elevated revealing a fresher appearance.
The filler results had settled well with no tenderness, bruising or significant swelling. There was some residual swelling on palpation in the nasolabial area which I advised was normal and may take a few weeks to settle. The nasolabial folds had less shadow at the crest, and rhytids of the descending fold appeared smooth at rest, with minimal folding when smiling. The mid-face light reflection, volume and contour was improved. Her profile was harmonised in terms of nasolabial angle and the relationship of pogonion to subnasale.20 The convexity of the philtrum and the slightly deficient lip volume and contour was still present, however, in relation to the appearance of the surrounding features, the perioral area did not concern the patient.
It is an encouraging trend to see that natural results are becoming more desirable amongst younger cohorts, however, expectations should be managed with regards to filler volume and placement. It is important that patient selection, bespoke assessment and patient education is employed. Observation of the tissues perioperatively will influence the volume delivered in a single sitting, but when in doubt of the tissue capacity, caution is advised.
1. Harris S, ‘Alienization’, Plast Reconstr Surg Glob Open, 2022.
2. Cotofana S, Gotkin RH, et al., ‘Anatomy Behind the Facial Overfilled Syndrome: The Transverse Facial Septum’, Dermatologic Surgery, 2020.
3. Walker L, Cetto R, Facial Ageing and Injection Anatomy, UK Book Publishing, 2021, p.120.
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5. Uzun A, Ozdemir F, ‘Morphometric analysis of nasal shapes and angles in young adults’, Brazilian Journal of Otorhinolaryngology, 2014, p.397-402.
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8. Sclafani AP, Fagien S, ‘Treatment of injectable soft tissue filler complications’, Dermatol Surg, 2009.
9. Ozturk CN, Li Y, Tung R, et al., ‘Complications following injection of soft tissue fillers’, Aesthet Surg J, 2013.
10. Fagien S, Bertucci V, et al., ‘Rheologic and Physiochemical Properties used to differentiate injectable hyaluronic acid filler products’, Plast Reconstr Surg, 2019.
11. Hufschmidt K, Bronsard N, et al., ‘The infraorbital artery: Clinical relevance in aesthetic medicine and identification of danger zones of the mid-face’, Journal of Plastic, Reconstructive and Aesthetic Surgery, 2019.
12. De Maio M, ‘Myomodulation with Injectable Fillers: An Update’, Aesthetic Plast Surg, 2020.
13. DeLorenzi C, ‘Complications of injectable fillers, part two: vascular complications’, Aesthet Surg J, 2014.
14. Glaich AS, Cohen JL, Goldberg LH, ‘Injection necrosis of the glabella: protocol for prevention and treatment after use of dermal fillers’, Dermatol Surg, 2006.
15. Faivre J, Gallet M, et al., ‘Advanced Concepts in Rheology for the Evaluation of Hyaluronic Acid-Based Soft Tissue Fillers’, Dermatol Surg, 2021.
16. Peng JH, Peng PH, ‘HA Filler Injection and Skin Quality – Literature Mini Review and Injection Techniques’, Indian J Plast Surg, 2020.
17. Van Ejjk T, Braun M, ‘A novel method to inject hyaluronic acid: the Fern Pattern Technique’, J Drugs Dermatol, 2007.
18. Trevidic P, Trevidic T, et al., ‘Mid-face Multilayering Filler Injection Technique: Understanding of the Dynamic Facial Anatomy through a “Smiling Cadavers” Anatomical Study’, Plast Reconstr Surg, 2022.
19. Jung SG, ‘Filler rhinoplasty based on anatomy: The dual plane technique’, JPRAS Open, 2019.
20. Ricketts RM, ‘Esthetics, environment and the law of lip relation’, Am J Orthod, 1968, p.272-289.