Technical Considerations for Filler and Neuromodulator Refinements

Abstract

Background: The toolbox for cosmetic practitioners is growing at an unprecedented rate. There are novel products every year and expanding off-label indications for neurotoxin and soft-tissue filler applications. Consequently, aesthetic physicians are increasingly challenged by the task of selecting the most appropriate products and techniques to achieve optimal patient outcomes. Methods: We employed a PubMed literature search of facial injectables from the past 10 years (2005-2015), with emphasis on those articles embracing evidence-based medicine. We evaluated the scientific background of every product and the physicochemical properties that make each one ideal for specific indications. The 2 senior authors provide commentary regarding their clinical experience with specific technical refinements of neuromodulators and soft-tissue fillers. Results: Neurotoxins and fillers are characterized by unique physical characteristics that distinguish each product. This results in subtle but important differences in their clinical applications. Specific indications and recommendations for the use of the various neurotoxins and soft-tissue fillers are reviewed. The discussion highlights refinements in combination treatments and product physical modifications, according to specific treatment zones. Conclusions: The field of facial aesthetics has evolved dramatically, mostly secondary to our increased understanding of 3-dimensional structural volume restoration. Our work reviews Food and Drug Administration-approved injectables. In addition, we describe how to modify products to fulfill specific indications such as treatment of the mid face, décolletage, hands, and periorbital regions. Although we cannot directly evaluate the duration or exact physical properties of blended products, we argue that "product customization" is safe and provides natural results with excellent patient outcomes.

Fig. 1.

Patient to “fill”: a young patient, 33 years old with little to no fat shown and clear demarcation line. Restylane-L 0.5 mL blended with 0.2 mL lidocaine 1%; 0.3 mL was injected on each side with a 27-G × 1 in. cannula. A, Before, (B) marks, (C) tear trough injection with blended Restylane-L and Botox upper face and masseteric muscles.

Video Graphic 1.

See video, Supplemental Digital Content 2, which demonstrates lower face neurotoxin injection, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRSGO/A334.

Video Graphic 2.

See video, Supplemental Digital Content 5, which demonstrates the assessment and injections to the tear trough, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRSGO/A337.

Video Graphic 3.

See video, Supplemental Digital Content 6, which demonstrates upper eyelid, eyebrow (ROOF), and temporal fossa injections, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRSGO/A338.

Video Graphic 4.

See video, Supplemental Digital Content 11, which demonstrates Radiesse cannula injection into the hands, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRSGO/A343.

Fig. 2.

Palpate: A, Green line marks palpable infraorbital rim, and red line highlights the skin color change between eyelid and cheek. Tear trough deformity lines between green and red line. B, Infraorbital foramen marking.

Fig. 3.

Juvéderm’s lasting effect after 3 years of treatment, 0.50 mL per side of Juvederm Ultra XC supraperiosteal needle, retrograde injection along orbitomalar groove.

Fig. 4.

Patient’s pupil: “GPS for safety.” IO, infraorbital; SO, supraorbital vessels; ST, supratrochlear.

Fig. 5.

Periocular deflation unmasked after surgery. A, 32 years old; (B) after upper and lower blepharoplasty with endobrow lifting; (C) after upper eyelid and roof filler.

Fig. 6.

Congenital deep upper eyelid sulcus: a 49-year-old male athlete. Restylane-L 1 mL blended with 0.2 mL lidocaine 1%; 0.6 mL of blended product injected on each upper eyelid with 27 × 1 in. cannula. A, Before, (B) after.

Fig. 7.

Sculptra peanut face patient: 45-year-old patient, 4.5 mL on each side, 1 vial per session. Second session 3 months after and third session a year after the first session. A, Injection depth; (B) amount injected per zone (C) before treatment; (D) 1 year after first injection session. SC, subcutaneous; SP, supraperiosteal.

Fig. 8.

Left chest volume restoration after implant removal. Three sessions, 1 vial per session, reconstitution 7 mL sterile water, 2 mL Xilocaine 1% with epinephrine plus 2 mL Bupivacaine 0.05% (total vial volume, 11 mL). A, before first session; (B) after second session.