Injectable Case Studies

Whether you’re a seasoned injector or just starting out in your aesthetics career, a great way to develop and build on your knowledge of these areas is to learn from others. At the forthcoming Aesthetics Conference and Exhibition (ACE) 2020 on March 13-14, there will be numerous chances to do just that, in our free educational sessions and live demonstrations. Among this year’s speakers are representatives from top injectable manufacturers Galderma, Allergan and Teoxane.

Ahead of the event, three ACE speakers share their experience of injectables through a case study of a patient they have each successfully treated, giving a sneak preview of what you can expect to learn on the day.

Female Periorbital Rejuvenation

Miss Rachna Murthy, consultant ophthalmologist, oculoplastic, aesthetic and reconstructive surgeon

This 48-year-old patient presented to clinic because she felt she looked sad and tired, and that she had a saggy appearance. Her concerns were focused particularly around the eyes, but she’d had acne when she was younger, leaving some scarring and enlarged pores. During the consultation, we discussed the patient’s medical and aesthetic history before exploring the different options available to her. I always take a group of dynamic photos showing a range of facial expressions, including front-on, in profile, at an oblique angle, and with the chin tilted downwards with the eyes looking upwards, allowing for a better assessment, particularly of the tear trough and periocular area. This patient opted for a combination of toxin and hyaluronic acid injectables to address her concerns: Voluma to lift the cheeks and zygomatic arch; Volift to address volume loss in the sub-orbicularis oculi fat (SOOF) and tear trough; Volite to the whole face to improve the quality of her skin; and Botox around the glabellar and lateral canthal lines to lift the brows and soften the frown lines and wrinkles. Initially, I performed periocular Botox injections with a 30 gauge needle to the glabella, suprabrow and lateral orbicularis oculi (a total of 48 units). Two weeks later, I reviewed the need for further additional toxin and proceeded to treat with filler.

I frequently use Dr Mauricio de Maio’s MD Codes system to determine my injection sites,¹ with a few variations. For this patient, in the first instance I used a 27 gauge needle to apply Voluma to site CK1 – the outer part of the zygomatic arch – injecting straight down to the periosteum of the bone. I used a total of 0.3ml on each side, divided into three boluses – posterior, central and anterior – to lift and support the cheek laterally.

I find that if you start off injecting the outer parts of the zygomatic arch, you need less product in the anterior parts of the cheek. So, after injecting CK1, I switched to a 25 gauge cannula to inject 0.2ml of Voluma deep to the SOOF at CK3 on each side, before moving on to the anterior cheek, where I used 0.3ml of Volift with a 25 gauge cannula into the SOOF, again at CK3, on each side.

I also used a 25 gauge cannula to treat the tear trough at TT1-3, going down to the orbital rim and depositing 0.02ml, while projecting the globe with the index finger of my non-injecting hand. I find this approach ensures safety and prevents the Tyndall effect.² This blueish tinge can occur when very hydrophilic fillers are injected in large volumes too superficially to the eyelid area, where the skin is thinnest.³ I reviewed my patient after three weeks, and re-treated the SOOF at CK3 and the tear trough with Volift, using a further 0.5ml on each side with a 25 gauge cannula.

To address this patient’s skin concerns, I treated her intradermally with a 32 gauge needle using 2ml of Volite, which I find very effective in making the skin appear hydrated and plump.³

Using a combination of a needle and a cannula means I can direct each product to the desired plane. I used a needle onto the bone in the lateral aspect of the cheek; because it’s a safe area and injected at a shallow angle, one can reach the periosteum more easily and achieve more projection with a needle than with a cannula.⁴

On the other hand, injecting through a cannula in certain areas allowed me to minimise complications due to its blunt tip, the most common being damage to blood vessels and bruising, particularly around the perioral and periocular areas.⁵

Whether I’m using a needle or a cannula, I always aspirate for at least five seconds before injecting because it can help to reduce the risk of bruising and vascular occlusion.6 Another crucial step to minimise bleeding and bruising is to make sure patients aren’t on blood-thinning medication, while arnica can be good to ease post-treatment bruising.⁶

The environment you work in is also important in considering the risk of complications, so I use aseptic techniques: I dress in surgical clothing, use sterile packs and wear sterile gloves, as if I’m performing a surgical procedure.⁷ I use Clinisept+ hypochlorous acid to reduce contamination risk, which is safe to use around the eyes.⁸

To other practitioners, I would say it’s essential only to treat areas according to your experience and competency. The periocular region is a high-risk area that requires a certain degree of expertise. If you have limited experience in this specific area you can make great changes to the way someone looks and feels, while achieving very good outcomes by treating the lower two thirds of the face or focusing on the skin.

I would also advise opting for a staged programme, rather than trying to treat all the patient’s concerns at once. You can achieve better, safer results that are kinder to the patient’s budget by spacing out your recommended treatments.

Overall, using the right tools and products in the right planes allows you to be as safe as you can be and achieve a really good aesthetic outcome, as well as a happy patient.

I would advise opting for a staged programme, rather than trying to treat all the patient’s concerns at once
Miss Rachna Murthy

Female Perioral Rejuvenation

Dr Raul Cetto, aesthetic practitioner

This 48-year-old female patient sought improvement and rejuvenation to her overall appearance. During our initial consultation we discussed the specific areas that were troubling her.

She highlighted the area around her lips as a key concern. Although her lips had always been well-defined, she had lost volume and developed lines in recent years, and she particularly noted elongation and loss of anterior projection of the upper lip, while her lower lip had also inverted. The patient didn’t want her lips to be large and overly inflated, so I explained to her that in order to address the areas of concern, I would restore volume around the mouth and lips to restore their previously natural shape. In a female Caucasian patient, the lower third of the face should be proportioned such that the bottom of the nose to the top of the lower lip, with the mouth closed, occupies one-third of the vertical height, and the top of the bottom lip to the bottom of the chin, two-thirds.⁹ This patient had an elongated upper lip and almost appeared to have a 1:1 lower face ratio, so I proposed a lip and chin treatment to create balance.

I always start from the top because the treatment will have an indirect impact on the areas below. So, I began by treating the lips before moving on to the chin.

Initially, I injected Teosyal RHA Kiss into the lips. I employed an anterograde injection technique, using a 30 gauge 4mm needle to the vermillion border and four small boluses into the body of the lip. I used 0.2cc to the upper lip and 0.2cc to the lower lip at the vermillion borders, followed by two boluses of 0.05cc to the upper lip and two boluses of 0.1cc to the lower lip. This everted the lips without them appearing inflated or unnatural.

One of the main advantages of RHA Kiss is that it has the strength required to restore volume and shape to the lips while still being stretchable and soft. The product is strong enough to evert the lip, yet malleable enough to appear and feel immediately natural, so the patient is unlikely to feel a solid implant in the lip.

I then proceeded to treat the chin, to elongate it and create anterior projection. For this, I used two different products at two different layers, due to the different characteristics in each tissue plane.

I always start from the top because the treatment will have an indirect impact on the areas below
Dr Raul Cetto

First, I injected a bolus of 0.3cc of Teosyal Ultra Deep to the pogonium of the chin to project it anteriorly. This product is very cohesive and has similar characteristics to the bone itself; it’s strong enough to displace the overlying structures, restoring bone volume and projection.

Then I looked to restore the superficial fat of the chin. Due to the loss of superficial fat and the bony projection, some of the muscles around the mouth and chin had become hyperactive. The depressor anguli oris (DAO) muscle was pulling the corners of the mouth down. The mentalis muscle was rotating upwards and creating what we call the labio-mental crease – a deep line between the lower lip and the chin – shortening the lower third of the face. To address this and to restore the length of the chin, I injected Teosyal RHA 4 between the skin and the muscle to provide structure and support for the skin overlying the muscle, thereby reducing the effect of the muscle pull.

I used a 25 gauge 38mm cannula, and through a single-entry point on each side of the chin, I deposited 0.4cc of the product at the superficial fat level, and 0.2cc into the labio-mental crease.

Teosyal RHA 4 is a unique product because its high strength and malleability makes it able to adapt to the movement around that area of the face.

In treating this area, there is risk of several potential complications, and it’s important that we discuss them with the patient during the initial consultation. The most common are transitional redness, swelling and bruising, while rarer complications include infection and damage to the blood vessels.¹⁰

To minimise the risk of complication, I used a cannula to treat the chin.¹¹ Its blunt tip is less likely to injure a blood vessel and cause trauma and bleeding. In addition, when treating the lips, I used a very small needle – just 4mm – away from where the labial arteries are most commonly located, which lessens both the patient’s discomfort and the risk of any bleeding or bruising.¹² I also minimised the number of injection points and sterilised the area repeatedly to minimise the risk of infection.

This patient was able to see her before and after images in 3D immediately following the procedure, and she was delighted with the result. She could see the improvement in her lips and her lower face and, most importantly, she was relieved that her lips looked natural for her, and were not over-volumised. The results are expected to last more than a year.

Female Lower-third Restoration

Dr Christoph Martschin, senior consultant dermatologist, Sweden

This very healthy 53-year-old patient came to see me because she felt her face looked tired and gaunt. She is a passionate marathon runner, and this repetitive exercise left her face depleted of volume.

You could see the bony structure of the face through the skin because she had almost no subcutaneous fat left, which creates a very aged appearance. She wished to restore her face, and it was clear that this patient predominantly needed more volume in the lower third of her face, rather than lifting.

I started by addressing the pre-auricular area, injecting each side with 1.5ml of Restylane Volume superficially with a 25 gauge cannula. This gave some padding to the region, which had become very hollow. The second step was to treat the perioral region with Restylane Refyne. I find the soft gel texture of this product integrates very well, and it’s particularly suited to areas that are exposed to facial dynamics and high flexibility. In each side, I used 1ml of the product, again with a 25 gauge cannula.

To complement this, I suggested that I do a light volumising treatment on the patient’s lips as well. She neither had nor wanted big lips, but the ageing process had caused her lips to be quite flat and sad-looking. I chose to deposit a total of 0.8ml of Restylane Kysse to both lips using a 25 gauge cannula, which replenished the volume she’d previously had. The last area I treated during the patient’s first visit was her chin. The muscles in the chin region were cramping, giving the skin an orange peel-like appearance. This is caused by a lack of structural support. Here, I used Restylane Lyft – which is a precise, firm gel texture – injecting 1ml through a 29 gauge needle straight down to the bone. This gave support to the muscle and projected her chin nicely. Together, the treatments I performed to the lip, perioral and chin regions perfectly restored her Ricketts’ line, bringing balance to her face in profile.

When the patient came back a week later, I assessed the modiolus – the junction where the many muscles of the face join and pull on the corners of the mouth – which was creating a bulge because of volume depletion in the buccal fat pad. This means there was no support for the zygomatic major muscle. My approach to correcting this was to use a 25 gauge cannula to inject Restylane Volume deep into the buccal fat pad compartment. Because the volume was so depleted, I needed to inject quite a lot of product here – 1ml on each side – and in doing so, it restored the patient’s face shape.

It’s important to minimise the potential for complications; proper analysis and investigation of the treatment area, knowledge of anatomy, and the injection technique and plane all determine the risk profile. Due to its blunt tip, using a cannula to inject the lip, the perioral and pre-auricular regions lowers the risk of vascular complications. The same is true for the buccal fat pads, where there would be potential to cause an injury because the blood vessels go much deeper.¹³

In the chin, I use a needle down to the bone, because I find it gives better lift and projection than a cannula. So to avoid vascular damage, I aspirate for nine seconds before injecting very carefully while observing the area for signs of complications.⁶

In the chin, I use a needle down to the bone because I find it gives better lift and projection than a cannula
Dr Christoph Martschin

In aesthetics, we come across very volume-depleted individuals like this once in a while, and they make great candidates for injectable facial fillers. I would recommend, in patients where you see the modiolus bulging due to loss of volume, to examine the buccal fat pad area and consider injecting in this region. Patients like this often require a large amount of product depending on their individual needs. But, like my patient who was very pleased with the outcome, they are incredibly grateful because it makes such a difference. The results are expected to last 12 to 18 months. When you restore a patient’s facial shape, make them appear younger and healthier, it can have a significant impact on their quality of life.