Dr Michael Aicken considers quantities of filler in the treatment of nasolabial and marionette lines
With treatments such as botulinum toxin, there are standard injection doses that most practitioners use as their starting point and that are recommended according to the type of product.1
Noting the top-up dose required makes botulinum toxin dosing relatively straightforward. But with dermal filler, we don’t tend to have ‘standard’ doses as both the desired outcome of treatment and the volume of filler required to achieve that desired outcome can vary greatly between patients. Because of this, in the training courses I run, I often suggest that botulinum toxin administration is more ‘scientific’, whereas dermal filler treatments are more of an ‘artform’.
So, how do I answer the common question, ‘how much filler should I use?’ In this article, I will address this very question regarding nasolabial folds and marionette lines, discussing one of many techniques for both, based upon my own clinical experience.
The ‘nasolabial’ or ‘nose-to-mouth’ lines and folds (Figure 1) are similar in many ways to the ‘marionette’ lines and folds (Figure 2). They are both formed when, through the natural ageing process, the central part of the face loses soft-tissue volume whilst the fat pads (Figure 3) from the lateral parts of the face, thin and drop downwards due to changes in the adipose tissue and a loss of elasticity in the demis.2
So, back to the original question: ‘how much filler should we use?’ Firstly, there is a facetious answer; ‘how long is a piece of string?’ There is also the more subtle, counter-question; ‘how deep are the lines?’ There is no point in helping a patient achieve the nasolabial lines of a 20-year-old if the rest of their face looks like that of a 50-year-old; balance is important when considering beautifying the face. There are many factors to consider and the decision as to how much filler to use usually needs to be made before the treatment has begun because it typically involves a complex balance between patient expectations, practitioner experience and patient budget.
There are a few issues to deal with when treating the nasolabial and marionette lines with dermal filler. The first is volume loss and the second is folds. Here, we’ll discuss each in turn.
The shadow cast by the step down from the more elevated lateral face, to the relatively less elevated medial face, causes the dark line that we notice whenever someone has nasolabial or marionette lines.2 Reduction of these ‘steps’ with dermal filler will reduce the shadow and therefore the appearance of the lines themselves. The process is virtually the same with nasolabials and with marionettes.
There are two possible techniques: bolus injections – best given at the proximal end where there tends to be the greatest volume loss – and linear injections – given either deeply or superficially along the lines themselves.5
When injecting, always ensure that filler is not injected above or lateral to the lines, as doing so would potentially increase this shadowing effect by increasing the size of the step indicated in Figure 4.
Think of the nasolabial or marionette line as a comet (Figure 1), with the top end, where we administer bolus injections as the ‘head’ of the comet and the rest of the lines, where we use linear injections, as the ‘tail’ of the comet. When deciding upon how much filler to use, as a rule-of-thumb, I start by giving around half of the total volume into the head and then seeing how much of an improvement is achieved before deciding how to use the remainder. So, if we have decided to use 1ml in total for both the nasolabial folds, I’d begin with injecting 0.2ml into each ‘comet head’ for starters.
The remainder will be administered during the same procedure, using any combination of deep linear, superficial linear, cross-hatching (see below) or further bolus injections into the comet head.6
Figure 4: The role of dermal filler in reducing the shadow that light casts as it shines across from the lateral to the medial face
‘Folds’ are the overhanging part of the nasolabials and marionettes. Not everyone who has lines has folds and potentially, someone might have folds and not an underlying line, but generally, folds come after the development of lines. I use the ‘cross-hatching’ technique – this is when filler is injected perpendicular to the direction of the fold.6 It’s a principle borrowed from engineering, known as ‘bracing’.7
Lines of filler can hold and support the tissue they are injected into, reducing the amount of unwanted movement in that tissue. Cross-hatching therefore, can also be used for lines elsewhere on the face, which are more pronounced with movement, such as perioral lines and lateral forehead lines. Obviously we don’t want to see lines of filler through the skin, so these injections are generally given a little deeper within the dermis than those of the linear injections mentioned above.
If we can see the lines however, I have found that it is easy to remedy this by applying gentle pressure to the lines at the time of treatment. My general rule is that as each line of cross-hatching increases, the larger the volume in each line and the closer together the lines become. Also, the thicker the product, the stronger the cross-hatching will be at withholding the pressures applied to it, such as gravity of facial muscle movement.
I recommend using a firmer/thicker cross-linked hyaluronic acid gel filler for marionettes/nasolabial lines, where it is important to withstand the effects of gravity. Some examples of fillers you could use include Dermal Revolution DEEP, Belotero Plus Intense, Restylane Perlane or Juvéderm Ultra 4. Although product should last nine to 12 months according to most manufacturers, in my experience, they seem to last much longer when injected into the nasolabial folds and almost as long in the marionette folds area. Often I find that whilst someone may require 2-4ml for deep nasolabial lines the first time around, when they return a year or more later, they might only require 1-2ml to keep the lines at bay. I believe that this could possibly be because the nasolabial folds are well protected by the zygomatic arch, chin and the nose from pressure applied inadvertently to the face, for example, whilst sleeping.8
Of course, no treatment is without risk. Bolus injections particularly should be administered slowly and only after aspirating the syringe. Anytime the needle tip is moved, the injector should aspirate again. This technique of regular aspiration should, in theory, reduce the risk of serious complications of dermal filler use, such as blindness and skin ischaemia.3 Although, there are some who dispute this because of the inability of some practitioners to accurately control the location of the needle tip or due to the collapsibility of some blood vessels whenever aspiration pressure is applied.3
So, what’s the answer? How much filler should you use when treating nasolabial and marionette lines? Here’s my thought process:
It can be awkward discussing budgets and treatment priorities, especially when some patients will expect you to perform miracles with tiny budgets, but it’s far more uncomfortable to end up with an unhappy patient who has spent several months saving for a treatment, which they don’t see as giving any significant benefit.
As we all know, we don’t always have a budget in mind when we enquire about a service, so it can be a sensitive question to be asked outright. Most of us will be prepared to pay more for a better quality product or service, but we would need to have some confidence that it will be worth it.
For addressing budgets, my suggestion is that if the patient states outright that they have only X amount to spend (e.g the cost of 1ml dermal filler), and they would like both their nasolabial and marionettes areas treated, I recommend that you focus on the area that bothers them the most and consider what you can realistically expect to achieve with a certain amount of filler. For example, you might say, ‘I’m not sure that you’ll see a significant result with just 1ml but with 2ml you should see a real difference – but I do recommend that we use the full amount I‘ve quoted so that you can see the best results possible.’
I urge them to choose between the nasolabials and marionettes and we decide together to treat that area within their budget. It is far better for them and for your repeat business that you do a good job on a focused area rather than doing a minimally impressive job on many areas.
Of course, we have to be careful that in advising this, we don’t cause an unnatural imbalance in the facial features – but for many patients, there will be a single problem area, which if corrected effectively, will give an excellent overall improvement in their appearance.
It is important to consider technique(s), line depths and patient budget when determining filler dosage. Practitioners should focus on areas of primary concern first to ensure maximum results. It’s the ‘wow-factor’ that brings patients back and entices them to tell their friends what they’ve had done and it is this same factor that makes patients satisfied that they made a wise decision in choosing you as their practitioner.
Disclosure: Dermal Revolution is owned by Visage Aesthetics UK LTD, of which Dr Aicken is the managing director.