I n jecta ble Filler s

Panel Discussion, Controversies, and

Techniques
Theda C. Kontis, MDa,b,*, Lisa Bunin, MDc,
Rebecca Fitzgerald, MDd

KEYWORDS

Injectable fillers
Cannula
Tear trough
Injectable complications

KEY POINTS

New fillers have been developed for circumoral lip lines and these are now incorporated into lip defi-
nition and volumization techniques.

Injectors must be facile with both cannula and needle techniques for the accurate and safe place-
ment of fillers.

Facial rejuvenation techniques have advanced with the improved understanding of facial volume
loss with aging and with the development of newer products designed for the midface.

Panel discussion
With the introduction of Restylane in 2003, the
filler revolution began. This hyaluronic acid (HA)
1. What is your approach to the perioral area filler was proved dramatically superior to the
and lips and has it changed with the intro- then gold standard, collagen. Over the past
duction of new Food and Drug Administra- 15 years, new products have been developed
tion (FDA)–approved fillers? to meet the needs of the injectors and combined
2. How do you evaluate and treat the lower with improved understanding of facial aging,
lid/midface and how aggressive are you in previously neglected areas of the face can now
filling those regions? be targeted with fillers.
3. What is your opinion of cannulas versus In this article, specialists have been invited from
needles? oculoplastic surgery and dermatology to discuss
4. What complications with fillers have you their techniques and opinions for injections into the
seen and how do you avoid them? lower lids, midface, and lips. Cosmetic injectors
will find the differing viewpoints from physicians in
5. What role do fillers play in off-face treat-
ment in your practice?
different academic fields will not only highlight differ-
ences in personal techniques and philosophies, but
6. How have your techniques changed over the also reinforce that there are multiple approaches to
past 5 years?
analyzing and treating the aging face.

Disclosure: R. Fitzgerald acts as a speaker, trainer, and member of the advisory boards for Allergan, Galderma,
facialplastic.theclinics.com

and Merz. L. Bunin has nothing to disclose. T.C. Kontis is a member of the Speaker Bureau and injector trainer
for Galderma and Allergan.
a
Department of Otolaryngology-Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery,
Johns Hopkins Medical Institutions, Baltimore, MD, USA; b Facial Plastic Surgicenter, LLC, 1838 Greene Tree
Road, Suite 370, Baltimore, MD 21208, USA; c Private Practice, 1611 Pond Road #403, Allentown, PA 18104,
USA; d Private Practice, 321 N Larchmont Boulevard #906, Los Angeles, CA 90004, USA
* Corresponding author. Facial Plastic Surgicenter, LLC, 1838 Greene Tree Road, Suite 370, Baltimore, MD
21208.
E-mail address: tckontis@aol.com

Facial Plast Surg Clin N Am 26 (2018) 225–236

https://doi.org/10.1016/j.fsc.2017.12.008
1064-7406/18/Ó 2017 Elsevier Inc. All rights reserved.
226 Kontis et al

Question 1: What is your approach to the The newest HA fillers, Restylane Defyne and
perioral area and lips and has it changed Restylane Refyne, with XpresHAn Technology,
with the introduction of new Food and Drug have been wonderful additions for this area. There
Administration–approved fillers? is much less swelling with these products, less
bunching up of material and reportedly more
BUNIN natural-looking expressions with muscle move-
ment. I find these new products are most useful
Knowledge of the effects of aging on the perioral in the perioral, marionette, and chin areas, where
area anatomy has greatly changed the way I fill unconscious contraction of the perioral mimetic
this area. It is not just about filling the lip but also muscles can cause irregular lines and folds. These
about understanding the anatomy of the area areas can be harder to treat without the use of
and the effects of aging on each layer. I have a neurotoxin, but some patients are either
large percentage of older patients (60–80 years) neurotoxin-phobic or are unhappy with loss of
and really see the effect of bone loss in this area. movement in this area. I have found the newer
Patients come in complaining of the Popeye look fillers more forgiving with added fill here.
after dental surgery, and I prefer to wait until they When doing a consultation for lip enhancement,
are done with their dental procedures before I I evaluate each of the fat compartments, the lip
inject these patients with filler, because the under- lines, the vermillion border, the symmetry of the
lying anatomy can change. Understanding the su- lip resting and smiling, and the shape of the lip
perficial and deeper fat pockets around the mouth and take baseline photographs in each position.
has also changed my approach considerably. Many patients do not realize they have asymme-
Although my younger patients (<40 years) often tries or that they look different when they smile
desire very full lips, even overinflated lips, my older or have an uneven amount of tooth showing in
patients have always come in scared of having a different positions. I discuss their concerns and
duck lip look. Often by just filling the fat pockets desires, and I make recommendations based on
around the lip, without even touching the lip itself, all these. If they want a very full, inflated lip, I pre-
the lip appears fuller and less deflated because it is fer Juvéderm and Restylane-L, filling the border
lifted into a more youthful position. My favorite and substance of the lip, taking care to reshape
fillers for the immediate perioral area and fine the lip as needed. I also like how I can use the
witches’ lines around the mouth are the thinner newer softer fillers (Restylane Silk and Belotero)
fillers like Restylane Silk and Belotero. I use the to smooth out the wrinkles in the lip itself without
thicker more cross-linked hyaluronic acid (HA) overinflating the lip.
fillers and calcium hydroxyapatite for the oral com- I always give patients a hand mirror and ask
missures and the marionette lines and if I need them for feedback. I reserve a little filler at the
more perioral lift in an older patient (although I end to use in case they think they want a little
may layer the thinner fillers over these for the fine more in an area; otherwise, I place it where I think
lines and skin side of the vermillion border). In it is needed. They appreciate the artistry and the
my older patients with more bone loss, I often concern for symmetry. But if someone comes in
end up reinforcing their jaw line with calcium hy- wanting an overly inflated lip, I talk to them about
droxyapatite for more support. And softening the facial balance and proportion and often show
muscular pull with a small amount of neurotoxin them how adding a bit of volume in the cheek
in the depressor anguli oris muscles (DAO), the may allow them to attain more beautiful balance
mentalis, and some of the deeper perioral lines with a larger lip.
helps soften as well as prolong the effect of the
fillers. My favorite fillers in each area are as follows:
With my older patients, I often add filler or neuro-
Perioral fine lines and volume loss just above
toxin in stages, gradually building up the area. This and below lip: Restylane Silk, Restylane Re-
accomplishes several things: it causes less fyne, and Belotero
swelling and faster return to normal and a gradual
Vermillion border and for lip substance: Resty-
adjustment to their new baseline, with an appreci- lane-L, Juvederm Ultra, and Restylane Refyne
ation of each level of improvement. These patients
Smoothing lip surface wrinkling: Restylane
tend to be surgery-avoiding, more private (“I don’t Silk
want anyone to know”) and want to look rested
Oral commissres: Restylane-L and Juvederm
and refreshed, not different. Yet, when they see Ultra, or Ultra Plus
the change in each stage, they are more inclined
Marionette lines and jugal grooves: Restylane
to try a little more on subsequent visits, including Lyft, Restylane Defyne, Juvéderm Ultra Plus,
lifting the midface with filler. and Radiesse
 Injectable Fillers 227

FITZGERALD the chin) appears to pull up on the chin shortening

this area.
The evolution of my approach to the perioral area Treatment in these areas that support the lips,
has been to be as mindful of the supportive rather than just the lips alone, results in a more
structures in that area as of the lips themselves. natural-looking result.
Advances in understanding of the anatomy of ag- Additionally, newer soft fillers, such as Resty-
ing in this area have provided more site-specific lane Silk and Volbella, allow the ability to add
targets to achieve more natural-looking results. natural-appearing contour and shape to the lips.
These targets include bony support in the ante-
rior maxilla and pyriform aperture as well as
the superficial and deep fat compartments of KONTIS
the lip and chin. Newer FDA–approved fillers
give the ability to use more robust agents where When I assess patients for lip injections, I place
a good deal of support is needed and softer them in 1 of 2 categories: lip volume enhancement
smoother agents in the lips and oral commis- or no volume enhancement with or without
sures themselves. smoker’s lines. These categories allow under-
The hallmarks of a youthful perioral region standing the desires of a patient and help me
include a smooth transition from the cheek to select the ideal product.
chin, devoid of shadowing, and a phi ratio in the For a patient who wants volume enhancement, I
lower third of the face and the lips as well as the choose Restylane-L or Juvéderm Ultra or Juvé-
anterior projection and eversion seen in younger derm Ultra Plus. I find these products give good
lips. In young faces with early aging, changes volume to the lips and, by injection of the vermil-
addressing the lips alone, as an isolated entity, lion, I can achieve nice definition and augment
often yield good results. In those further along in the lip roll. If these patients also have smoker’s
the aging process, however, this approach may lines, I treat the vermillion and cross-hatch injec-
yield suboptimal results by taking this area of the tions (with very small amounts of product to avoid
face out of harmony with its adjacent surrounding a chimpanzee look or produce visible filler lines). In
area. In the perioral area, the labiomental hollow these patients, I also may consider Restylane Silk
(from loss of labiomental fat in compartments or Volbella to treat the fine lines. I like to elevate the
that have now been identified and visualized in oral commissures with filler, when necessary and I
CT images of cadaveric specimens treated with find I can achieve a nice lift with the Juvéderm Ul-
radiopaque dye) creates an upside-down U- tra, Juvéderm Ultra Plus, and Restylane-L prod-
shaped shadow that separates the lower lip from ucts. I often add 2 units of onabotulinumtoxinA
the chin and results in a labiomental fold, which (Botox) to the DAO for severely downturned oral
creates a distinct shadow that typifies the frown. commissures.
Treating just along the vermillion border of the lip Poorly injected Hollywood stars have given lip
exacerbates this separation (as well as effacing filler a bad name and I find many patients fear
the sharp definition of this border). Targeted treat- the overinjected lip look. For these patients who
ment in this fat compartment with fillers, such as just want some smoothing out of their lips, Resty-
Restylane Defyne or Vollure, re-establishes this lane Silk and Volbella are typically my next go-to
support. Also, just as there is suborbicularis fat products. I have issues with each, however—
around the eye, there is suborbicularis fat of the excessive swelling with Silk and only 0.55 mL of
perioral region, and the volume of this deep lip Volbella in the syringe.
fat contributes significantly to the appearance of Question 2: How do you evaluate and treat
anterior projection and eversion seen in the youth- the lower lid/midface and how aggressive are
ful lip. I have found that Restylane Refyne, Juvé- you in filling those regions?
derm, and Vollure work well here. Loss of bony
and soft tissue support contribute to deviation
from the ideal phi proportions often seen with ag- BUNIN
ing in the perioral area. Bony remodeling in the The midface is the key to facial rejuvenation. A
anterior maxilla and pyriform aperture may in- young face has the triangle of youth: heart shaped,
crease the nasolabial angle, decreasing the con- widest at the cheeks, and narrower at the chin. As
vexity of the midface and resulting in the bone, fat, and tissue are lost, the midface loses
appearance of a longer upper lip. Additionally, as support and starts to sag and deflate, slowly trans-
labiomental fat as well as fat deep to the mentalis forming into an inverted triangle, which is heavier
wanes, the mentalis muscle (which originates on at the base. The lower lid elongates and may
the bone and inserts into the skin at the base of even pull away from the eye, there is a split in
228 Kontis et al

the malar fat pad, hollows appear in the cheeks, inferior orbital rim between the palpebral and orbital
and jowls form. parts of the orbicularis muscle) and filling the orbito-
Early in my career as an oculoplastic surgeon malar groove and periocular area. The true tear
treating flaccid ectropions of the lower lids after trough area has anatomic landmarks that may be
strokes and Bell palsy, I discovered that lifting affected as much by congenital anatomy as by ag-
the cheek surgically restores the position of the ing. If photos of children’s faces are examined, a
eyelid. When I first started using Radiesse (it was visible tear trough is often found; if so, the, use of
Radiance then), I found that filling the midface fillers will not completely efface the tear trough.
immediately gave a more youthful look, despite The appearance of a tear trough deformity can
other wrinkles and deep lines, because it restored also be exacerbated by having allergies. It is impor-
the width and balance of the face. I presented the tant to ask patients about allergies and eyelid
Voluma-R Lift (R for Radiesse) in 2006 and have swelling and to ask about eye rubbing. Patients
filled the midface/cheek area with multiple fillers with these conditions may have much more
since then. The midface is really the starting point swelling after injections, more tendency for postin-
and focal point of true facial rejuvenation. Although flammatory hyperpigmentation and bruising, and
a patient may come in concerned about jowls and more fluctuation with sodium intake.
marionettes, lifting the midface through reinflation When filling the tear trough and periocular area, I
with fillers reduced the jowls and marionette lines, use only thinner HA fillers, such as Restylane,
allowing less filler to be needed in those areas. Restylane Silk, and Belotero. I have also used
Even nasolabial folds are less noticeable when the Restylane Refyne in this area in a few patients
cheek is no longer falling and pushing onto the fold known to have excessive swelling with HA’s and
area. Patients may come in complaining of promi- have been happy with the results. I prefer not to
nent nasolabial folds, but I explain to them how use Juvéderm because it is more hydrophilic and
the shifting anatomy created the fold and remind more likely to cause a Tyndall effect. (The Tyndall
them that even babies with chubby cheeks have effect occurs when HA is injected too superficially,
nasolabial folds. So, filling the cheek may minimize leading to a bluish discoloration under the skin
or negate the need for filling the nasolabial fold. caused by the way the colloid particles scatter
The midface, cheek, paranasal area, and naso- light.) I am less aggressive in these areas, preferring
labial fold are all a continuum, but special care to use less filler and adding more if needed on a
has to be taken when approaching the eye area. second visit. This area must be approached slowly,
The orbital area should not be viewed merely as with care, and it is best to avoid overfilling and the
an extension of filling the cheek. The skin here is resultant excessive swelling. HA fillers can last a
the thinnest skin in the body, the vessels are su- long time in this area, and this is the most common
perficial, and the tissues are delicate. place where I am consulted for hyaluronidase injec-
Volume loss, negative vector, extra skin, perioc- tions to correct overfilling and/or Tyndall effects. HA
ular pigment, postinflammatory hyperpigmenta- fillers should be injected deeply, onto the perios-
tion, and lid laxity all need to be considered. teum, in small aliquots, for the best results.
Overfilling this area in the presence of excessive If a patient requires or desires cheek or midface
skin can make the wrinkling appear worse. enhancement, I do that prior to filling the periocular
Pigment spots hidden in the shadow of a tear area, because elevating the cheek often reduces
trough can appear more prominent by inflating the amount of filler needed around the eye.
and stretching the area with filler. If the fat pockets
are too protuberant, then filling around them can FITZGERALD
make the cheek appear too heavy, and patients
are more likely to get a Tyndall effect in this area The manifestations of midfacial aging are largely
if some filler needs to be placed superficially to due to changes in facial volume that transition
cover the edges. It is wise to test what may the midface from a youthful convex platform domi-
happen in this area by manual elevation of the nated by highlights to an aged flattened platform
cheek to see what happens to the lower lid and segmented by shadows (concavities), as has
by stretching the skin in the tear trough area. If been eloquently described by Glasgold.1 The
there is lid laxity, excessive skin and/or fat, or a combination of volume loss and the effect of the
lot of periocular pigment, then patients may be underlying facial retaining ligaments contributes
better served by having eyelid surgery and skin to the hallmarks of midface aging. Volume loss at
rejuvenation with skin care and/or lasers. the inferior orbital rim creates a concavity and
Filling the area around the eye should be thought overlying shadow, separating the lower eyelid
of as divided into 2 areas: filling the true tear trough from the cheek. In the anterior cheek, volume
(defined as a depression centered over the medial loss unveils a central hollow with its base tethered
 Injectable Fillers 229

by the zygomatico-cutaneous ligament. Loss of draping of the outer soft tissues. A recent study
deep cheek fat, which contributes to the anterior measuring changes in 7 patients with a mean age
projection of the cheek, may worsen the nasolabial of 61 years and CT scans on average 10.3 years
fold. Lateral cheek volume loss skeletonizes the apart showed that resorption was consistently pre-
zygomatic arch, creating a harsh submalar sent (100%) at the pyriform aperture and the ante-
shadow. Hollowing of the temples interrupts the rior wall of the maxilla. Resorption was also noted
oval facial frame seen from continuous light reflec- at the superocentral (71%), inferolateral (57%),
tion from the arc of the upper cheek and the and superomedial (57%) aspects of the orbital
temple. In the midface, augmentation of the medial rim.2 Voluma and Sculptra are my products of
aspect of the anterior cheek alone worsens the choice when treating deeply around the pyriform
separation from the eye, upper lip, buccal area, aperture because they do not cause much swelling.
and temple, often contributing to an unnatural I dilute 1 mL of Voluma with 0.5 mL of normal saline
appearance. Addressing the shadow group of and administer it with a 26-gauge needle to allow
the midface as a whole allows the creation of a uni- for aspiration prior to injection in this area (although
fied cheek highlight with no separation between the reliability of aspiration is controversial). Recent
the cheek, the eye, and the upper perioral unit. studies of this pyriform space (also known as Ris-
Adding volume in the inferior orbital rim reunifies tow space) reveal it to be a large area with the
the lower eyelid and cheek segments. Softer fillers, angular artery running along the roof of the space,
such as Vollure, Volbella, and Restylane Refyne, allowing for safe injections deeply along the bone.
work well in this area. A hydrophilic product like Radiesse, Juvéderm Ultra Plus, Vollure, Resty-
Juvéderm may cause an unwanted persistant lane, Restylane Defyne, or Restylane Refyne can
edema. More robust products like Voluma or be used in the nasolabial fold area if it is not
Restylane Lyft or Defyne may be visible through improved with the cheek injections alone.
the thin overlying skin. Particulate collagen–stimu- Filling around the zygomatic arch is important to
lating agents like Sculptra (poly-L-lactic acid) or eliminate harsh shadows and restore youthful soft
Radiesse (calcium hydroxylapatite) may clump in contours to the lateral cheek. The buccal region
the orbicularis muscle, leading to nodules and often needs to be addressed as it transitions the
should be avoided around the muscles of the lateral facial contour of the zygoma into the lateral
eyes and lips. Volumization of the medial and mandible. I have found that Sculptra or Vollure
lateral cheek should be addressed first, because both work well in these areas.
support in this area may decrease (or even elimi-
nate) the need for treatment in the tear troughs KONTIS
and nasojugal fold, especially in younger patients
with good skin elasticity. Too much filler directly In evaluating the midface, I separate the anatomy
in the tear trough or nasojugal fold gives an odd into lower lid, lateral cheek, and medial cheek,
topography to the face and is one of the most often using different fillers for each region. I am
common novice errors. Additionally, because the hoping that injectors stop referring to the lower
lower eyelid skin has few appendages (and is, lid volume loss as the tear trough deformity.
therefore, relatively see through), HA filler in this When injectors were just starting to use fillers in
area is often visible reflecting light with a blue the lower lids, very small amounts of filler were
hue, commonly referred to as the Tyndall effect. placed deep in the nasojugal groove. In my prac-
Filling the cheek, with a focus on both the medial tice, I am now treating the entire lower lid area of
and lateral deep cheek fat compartments, camou- volume loss over the entire extent of the inferior
flages the zygomatico-cutaneous ligament depres- orbital rim, which may require excessive amounts
sion and recreates a convex cheek with a strong of filler to achieve adequate volume restoration
highlight. Lesser volume is then needed in the and smooth the junction from the lower lid to the
area of the medial and lateral suborbicularis fat. Vol- midface.
ume may need to be added to the zygomatic arch When injecting the lower lid, I have a frank con-
and lateral cheek when there is deficient lateral versation with patients about the difficulty in
bony projection. Supraperiosteal injections done achieving perfect results but how the lower lid hol-
to create lift mimicking deep fat or bone can be lows can certainly be improved. I also counsel pa-
done with more robust HA agents like Voluma, tients who are not candidates for filler to the lower
Restylane Lyft, and Restylane Defyne as well as lids due to excessive fat herniation and would
Radiesse or Scupltra. Evidence from almost a benefit more from a surgical fat removal. Patients
decade ago supports the hypothesis of statistically who present for lower lid filler are told that they
significant bony remodeling in specific areas of the must be patient with the injections because I do
craniofacial skeleton with age, which may affect the not inject more than 1 mL of product along the
230 Kontis et al

inferior orbital rim at each visit. Appointments are whereas using cannulas resulted in the material
separated by 2 weeks to 3 weeks and injections remaining in the targeted layer of intended appli-
performed until I believe the results are the best I cation, leading them to the conclusion that using
can achieve. Occasionally I have patients help cannulas results in higher precision of placement
improve their results by performing warm com- than using needles.4
presses to areas of irregularity. I usually select Bruising may be a little less with cannulas,
Restylane-L or Belotero for injection of the lower although experience, knowledge of anatomy, and
lids, because I find that the hydrophilic nature of speed of injection also play an important role.
Juvederm Ultra and Ultra Plus, as well as their oc- Certainly experienced injectors can treat whole
casional migration, can look like accentuated faces with a needle without causing bruising. I
lower lid bags. sometimes choose needles over cannulas in areas
My treatment of the midface medially is a natural of previous scarring, such as the lateral cheek in a
extension of treating the lower lid volume defi- post-facelift patient, if it is difficult to glide the can-
ciency. With similar HA products, I extend injec- nula. I do use cannulas exclusively in patients who
tions to the anterior midface to improve this area cannot stop their anticoagulants.
if it appears flattened (as is the case with many Regarding safety, ischemia, necrosis, and even,
Asian faces). albeit rarely, blindness, cerebrovascular acci-
My approach to the lateral cheek radically dents, and nonthrombotic pulmonary embolism
changed after I attended a course given by Dr have occurred with cosmetic injection stemming
Mauricio deMaio. His technique is pulling the from vascular occlusion. Blunt cannulas may
cheek back and depositing high lift (high G0 ) prod- reduce, but not eliminate, risk, because they can
ucts, like Voluma or Restylane Lyft, to spot-weld still penetrate vessels with sufficient force. Some
the cheek laterally.3 This technique revolumizes practitioners aspirate prior to injection to reduce
the malar cheek laterally and somewhat risk with both cannulas and needles. Aspirating
improves the nasolabial folds, jowls, and mario- blood is indicative of intravascular needle place-
nette lines. I have noticed that inexperienced injec- ment and warrants removal of the needle and
tors continue to fill just the nasolabial folds, repositioning. Failure to aspirate blood, however,
marionette lines, and lips and ignore the midface is not a guarantee that the needle is not in a vessel,
or, worse, inject too medially in the midface. These because the bevel of the needle may be suctioned
injection techniques build out the central contours against the vessel wall, preventing aspiration.
of the face producing a horse-like face or cherubic Recommendation of aspiration as a risk reduction
face, neither of which is aesthetically pleasing. strategy is controversial because many injectors
believe that aspiration may not be reliable (or
Question 3: What is your opinion of cannulas
even possible) with thin needles and thick gels.
versus needles?
Product diluted with saline or lidocaine (0.5 mL
FITZGERALD per 1-mL filler) and/or used with larger gauge nee-
dles may make this possible but has not been
I like and use both for different areas of the face. I studied. I have refluxed blood on aspiration on
use 26-gauge needles with product diluted with many occasions over the years using Sculptra
saline (0.5 mL per 1 mL of filler) for supraperiosteal with a 25-gauge needle.
injections in the midface, usually Voluma or Resty- Unanimously accepted risk reduction practices
lane Lyft, and 26-gauge needles with Juvederm include any and all measures that could prevent
Ultra Plus diluted with saline (2 mL saline per an inadvertent intravascular injection of filler mate-
1 mL of filler) deep to the temporalis muscle in rial, especially large amounts under high or sus-
the temple. I occasionally use 27-gauge or 30- tained pressure. Because the volume and speed
gauge needles in the lips or oral commissures of filler material inadvertently injected in a vessel
but more often use cannulas, and I use cannulas may play a role in the severity and prognosis of
everywhere else with HA filler or Radiesse. I use an occlusive event, it is prudent to use small
a 25-gauge 1.5-in needle with Sculptra. amounts per pass through a constantly moving
The biggest concern with injections, of course, needle or cannula tip to minimize the risk of inject-
is safety. Other important concerns are precision ing significant volumes into a vessel. Smaller sy-
and the degree of swelling and bruising. In my ringe size may facilitate this. It is important to
experience, precision is possible with both nee- avoid placing a bolus of material unless the needle
dles and cannulas. One recent study using fluoro- is in a known avascular area (eg, on bone). Addi-
scopically controlled injection of material found tionally, avoiding high-pressure injections is of
that when using needles the injected material is paramount importance. Unintended high-pressure
more prone to migrate to more superficial layers, injections may occur inadvertently from pushing
 Injectable Fillers 231

against a small blockage in a needle or cannula. placing filler, and success with either depends on
Therefore, if any resistance is felt on injection, technique, the filler used, the area to be filled,
removal of the syringe to clear (or replace) the nee- and the length and gauge of the needle or cannula
dle or cannula prior to reinjecting the patient is pru- used. In general, needles are easier for beginner
dent. In areas of rich vascular anastomoses, such injectors to understand exactly what level they
as the central face, even a very small amount of vol- are in and for anyone when precise placement is
ume under high pressure can be devastating if it needed in small areas or for fine lines. If used care-
reaches the retina. It is important to know the loca- fully, slowly, and under magnification, risks of
tion and depth of facial vessels as well as the com- bruising are minimized. Slow injection and pulling
mon variations of vascular patterns. Scheuer and back on the syringe before injecting minimize risks
colleagues5 presented an excellent review of facial of injecting into a vessel. Proponents of cannulae
danger zones. use suggest that there is less risk of both of these,
Finally, a sharp needle can injure an artery from but poor technique mitigates any advantages. Use
every direction. Perpendicular alignment of the of cannulas has a longer learning curve, and it can
needle is advised to approach an artery. With a be more difficult to gauge the level of placement. It
needle, it is believed that parallel insertion in- is also harder to pass through prior filled areas
creases the chance of residing within the arterial where some scarring has occurred and to be as
segment compared with perpendicular insertion. precise in small areas, such as fine tuning the
Creases form over underlying arterial vasculature nasal tear trough and treating superficial fine lines.
(such as the nasolabial crease over the angular ar- Currently, I like to use cannulas for filling the
tery), and can be used as a topographic landmark lower face and jaw line and for the lateral and tem-
to guide needle placement. In contrast, when us- poral fat pockets. I often use smaller cannulas for
ing a cannula, a recent cadaveric study by Tansatit filling the periorbital area but may touch up the
and colleagues6 found that insertion of a cannula true tear trough area (nasal) with a 30-gauge nee-
parallel to the artery could not create arterial injury, dle for more precision. Longer cannulas can be
leading these investigators to conclude that paral- harder to manipulate but work well for filling the
lel insertion is, therefore, safer when using a blunt lower face and up into cheek hollows. Thicker
cannula. This may be negated if the artery has a products require larger gauge cannulas, which
tortuous path, the cannula hits a bifurcation in can also add to tissue trauma if not handled with
the artery, or if the artery is fixed to the tissue by expertise.
a fibrous septum from previous scarring (trauma, When I do use needles, especially for the lips, I
surgery, or injections). Again, be aware that during like to use longer needles than are often included
a blinded insertion of a cannula to reach the target with the syringe in the box of filler. I regularly use
area, the injector cannot discriminate the sensa- a 30-gauge 1-in needle or a 28-gauge 3/4-in needle
tion at the cannula tip between the resistance of for the lips, depending on the thickness of the filler
a fibrous septum and the resistance of an artery used. Fewer needle pokes means less swelling,
that is held in place by a fibrous band. This pre- less eosinophilic response, less bruising, easier
sents a high chance of arterial injury. When resis- gauging of filler results, and potentially faster re-
tance is encountered, reinsertion to pass around covery. For the marionettes and jawline, I usually
the resistance is a better choice than a forceful use a 1.25-in needle near the jawline, allowing for
insertion to pass through the resistance. Never a wide access from 1 focal point.
force the cannula through a resistance—change
direction or reinsert. KONTIS
Prompt recognition of an embolic event, of
course, enables prompt management, and prompt I believe that injecting with a cannula is like using a
management can hasten resolution and minimize fire hose to deposit filler. It may be fine for large de-
undesired sequelae. Immediate blanching or a positions of product, but I like to inject product at
dusky color consistent with ischemia should be varying depths and do not believe I have the fine
treated as such as soon as possible with hyaluron- control of a needle when I am using a cannula.
idase to the entire dusky area (because the The proponents of cannula use believe they
embolus may be distal to the original site of improve the safety of injections and diminish
injection). bruising, but there is no literature supporting that
cannula use is really safer and that belief can pro-
BUNIN vide a false sense of security when injecting.7 I
would argue that a large deposition of product
To someone with a hammer, everything looks like can externally collapse a vessel even if it does
a nail. Both cannulas and needles are useful when not embolize it. I have also had patients bruise
232 Kontis et al

after cannula use because I have to use a needle to of the most common patient complaints because
initiate the tract into the skin. In addition, it does they believe they are signing up for a no downtime
require some pushing and shoving to get the can- procedure and do not want to field questions
nula to tract in the skin, whereas the needle usually about it from family, friends, and coworkers.
glides freely. I have on occasion caused bruising Bruising may be minimized with the use of blunt
with a cannula due to the shoving I needed to tip cannulas as well as with slow injections with
perform to move it subcutaneously. I think those smaller aliquots of the product. Some practitioners
who say that cannulas do not cause bruising are believe that bruising may be reduced by using
mistaken. A 1-entry point with a needle and fan- arnica, aloe vera, or vitamin K creams. Use of an
ning out the product can also be used in similar AccuVein AV300 (AccuVein, Cold Spring Harbor,
way that a needle is used. Needles are more pre- New York) near-infrared device to image veins
cise in my hands. I also believe that I end up otherwise not readily visible from the skin surface
wasting more product with a cannula because I has helped me reduce the incidence of bruising
deposit more out of the syringe, I believe I use in my practice. Additionally, pulsed dye laser at
less product in each area with a needle. That 24 hours to 48 hours may hasten the resolution
said, this is not an all-or-nothing answer. In certain of bruising.
cases, I do prefer a cannula, such as for injection Severe filler complications are fortunately rare.
of the upper lid A-frame deformity and along the These include occlusive vascular events, as
jawline. The skilled injector should be facile with discussed previously, as well as late and delayed
either technique. inflammatory events, which may represent infec-
In my opinion, if an injector injects slowly and tious (biofilm) or immune-mediated events.
carefully and knows the anatomy, then the injector In cases of vascular occlusion, as discussed
is a safe injector, regardless of using a needle or previosuly, prompt recognition enables prompt
cannula. I think possibly the safety in cannula management, and prompt management can has-
use is that it results in slower injections, a process ten resolution and minimize undesired sequelae.
that increases safety. I believe that with needles, I Immediate blanching or a dusky color consistent
can achieve safe and minimally traumatic injec- with ischemia should be treated as such as soon
tions with slow, meticulous injections, even in pa- as possible with a high dose of hyaluronidase
tients who are anticoagulated. (300–600 units) to the entire dusky area (because
What is interesting to me about those who advo- the embolus may be distal to the original site of in-
cate 100% cannula use for safety is that they all jection) at intervals of 30 minutes to 60 minutes un-
agree that there are areas where cannulas cannot til cleared. Adjuvant therapy includes aspirin and
be used well, like the lips, lower lids, fine lines, and antivirals and antibiotics. Hyperbaric oxygen can
so forth. also be used (particularly if the occlusion is a
non-HA product and cannot be dissolved).
Question 4: What complications with fillers
In cases of delayed inflammatory reactions, a
have you seen and how do you avoid them?
definitive, conclusive explanation of the mecha-
FITZGERALD nism of action of these events—including whether
they are infectious or immune mediated or both—
My practice has been almost 100% injectables for remains elusive, making prevention and treatment
many years now (other doctors in the office use la- challenging. Cultures (for bacteria and atypical
sers and devices) so I have seen my fair share of mycobacterium) can be obtained but are often
complications of my own as well as many referred negative. Biopsy may confirm the presence of a
in by other physicians.8 Fortunately, a vast major- granulomatous reaction. If the product is HA, hyal-
ity of adverse events are not severe, although they uronidase can be used to dissolve the product. If a
are fairly commonplace. They are mostly second- lot of inflammation is present, the lesions must be
ary to the injection itself or to the injector and incised and drained but often recur intermittently
include transient swelling, erythema, and bruising over time with each flare a little less than the pre-
as well as various technical errors leading to sub- vious one; 5-fluorouracil is an antimicrobial and
optimal outcomes. These include errors in the antimetabolite and has been used successfully to
amount of volume used, depth of placement, loca- resolve these reactions. It may be prudent to avoid
tion of placement, and/or product choice for a treatment in patients with active autoimmune
specific location. Obviously, with any preventable disease or poor dental hygiene. Additionally,
complication, avoidance is preferable to manage- thorough facial cleansing and preparation (avoid-
ment and becomes possible with a thorough ing the use of tap water, which can be contami-
knowledge of anatomy, adequate practical nated with atypical mycobacterium) are strongly
training, and shared experience. Bruising is one recommended.
 Injectable Fillers 233

BUNIN using large doses of hyaluronidase and totally

removing the filler and starting again with a
Careful technique and thorough knowledge of different filler with deep placement, I find most pa-
facial anatomy are imperative for good outcomes tients are happier if I reduce the overfill and leave
and for avoiding most complications. Understand- some filler in place. I use very small aliquots and
ing the characteristics and ideal placement of each see the patient back in 2 weeks, at which time I
filler are also critical, as is managing patient ex- may use more hyaluronidase to further reduce
pectations. It is important to separate mild side ef- the filler or may touch up the area with properly
fects of any injection, such as bruising and placed filler if a patient wishes.
swelling, which are transient (although aestheti- Nodules that are palpable but not visible are
cally displeasing) from true complications, which usually due to clumping of material in muscle fi-
can be sight threatening and disfiguring. bers or having had some calcification of a bruise.
Swelling can be due to the hydrophilicity of the Reassuring patients that these nodules are not
filler, from Juvéderm, which is the most water- dangerous and will gradually resolve with mas-
loving (it routinely swells), to the newer Restylane sage or on their own is usually treatment enough.
Defyne and Restylane Refyne, which hardly swell I have had a few patients develop nodules with
at all. Using ice before and after injection and using Sculptra, which were treated with intralesional in-
longer needles with fewer sticks (less immuno- jection of Kenalog. I have only had to excise 2 nod-
globulin E–mediated reaction) and/or using a can- ules, which occurred in the suprabrow area in a
nula can all help to minimize swelling. Bruising can very thin patient, and they healed beautifully.
be minimized by having the patient stop all blood These all occurred early in my career, and I now
thinners, including aspirins, nonsteroidal anti- dilute the Sculptra with 9 mL to 10 mL of sterile wa-
inflammatory drugs, vitamins, fish oil, flaxseed ter and inject deeply, especially in the temples,
oil, gingko balboa, and green tea 10 days to and avoid the suprabrow area.
2 weeks before treatment, and by using loupes Fortunately, I have not had patients develop any
or a vein locator to avoid vessels. Pulling back red, painful nodules, but if I did I would immediately
on the needle prior to injecting and slow injection consider infection or a biofilm as the cause and
are helpful, and, if bleeding occurs when the nee- would use oral and topical antibiotics. It is impera-
dle or cannula is withdrawn, simply applying pres- tive that thorough cleansing of any area be done
sure and ice for several minutes can go a long way prior to breaking the skin surface with a needle.
toward minimizing a bruise. I also like to use Finally, there is the remote possibility of more
sublingual arnica pills preinjection for sensitive severe complications of injecting into a vessel
patients and when injecting Sculptra, and I use with tissue necrosis and even blindness. Slow
K-Derm Cream on the area postinjection. I use careful injections with aspiration on the needle
this on all of my eyelid surgery patients and find should minimize this risk but does not completely
it resolves the bruise in half the time. eliminate it. If any blanching is seen, or a patient
Other common complications that are mild complains of pain out of proportion to the injection,
include lumpiness and small noninflamed nodules, stop injecting immediately and assess for compli-
poor placement, inadequate volumization, poor cations. In addition to using warm compresses
aesthetic result, and asymmetry. Most of these and massage if vascular compromise is sus-
can be avoided or minimized with careful prepro- pected, every injector should be prepared with a
cedure assessment, careful injection technique, crash cart of aspirin, nitropaste and hyaluronidase.
and proper depth of placement of each filler. I al-
ways photograph the patient pretreatment, point
out any natural asymmetries of the area before KONTIS
filling, and give the patient a hand mirror to assess Fortunately, I have had few serious injectable com-
the results before I finish the injections so they can plications and none with permanent sequelae;
point out any asymmetries or areas of concern, however, these patients tend to be remembered
which I can address right then. in vivid detail.
Moderate and more troubling complications My first complication occurred while I was per-
include Tyndall effect, painful nodules (biofilm), forming a nasal dorsum augmentation on a patient
and true granulomas. Tyndall effect is most com- who had undergone 2 previous rhinoplasties and I
mon around the eyes and is more common with was trying to improve some mild supratip depres-
Juvéderm, so I never use that product in this sion. My injection with HA was too superficial and
area. I have many patients sent to me because of his nose immediately blanched (as did I); then
this, and careful use of hyaluronidase can dissolve the skin became mottled and purple. With the im-
the HA filler. Although some injectors advocate mediate use of massage, warm compresses,
234 Kontis et al

hyaluronidase, and nitropaste, he went on to but my experience is limited, and I have no expe-
completely recover. I am now extremely careful rience with fillers for buttocks augmentation.
injecting operated noses. I reflux before every
nasal injection and make sure I am injecting into KONTIS
the avascular preperiosteal or preperichondrial
plane. As patients become more savvy about injectables,
The 2 other serious complications I have seen they are starting to ask about off-face injections. I
(1 was my patient and 1 was referred to me) find that treatment of the dorsum of the hands in
were due to vascular injury to the superior labial women and men is becoming more popular.
artery. The key to injecting these patients is rapid In hand dorsum injections, I prefer Radiesse
diagnosis and treatment. I think the photos of pa- because the 1.5-mL syringe is usually enough to
tients with necrosis of facial tissues needing hy- treat both hands. The filler is placed in depot
perbaric oxygen treatments are those who went fashion between the muscle tendons and
home after their injection with an undiagnosed massaged to fill in the furrows. It is important to
vascular injury. explain to patients that the veins in their hand
Every injector should have a protocol to follow may look less prominent but still be visible.
for suspected vascular injury.9 My protocol is to I have experimented using Volbella as a skin
stop injections if a blanching is noted and to booster in the anterior neck to improve crepey
massage and apply warm compresses. Gener- skin; however, there seems to be some persistent
ally, this improves the majority of cases. For pa- lumpiness for several weeks postinjection.
tients who do not respond to these measures, I I do not find patients request fillers much to treat
proceed with oral aspirin (for the patient), hyal- the neck and décolletage. I have had some suc-
uronidase injection to the site of suspected cess with treating the necklace lines and décollet-
vascular occlusion, and topical nitropaste (kept age with neurotoxins but have not used fillers in
in the office.) these areas.
I have seen a few nodules with products, which
generally resolve with massage or injection with FITZGERALD
hyaluronidase or Kenalog. I did have 1 patient
develop severe nodules over her entire face 2 years I use a fair amount of Sculptra in the décolletage. I
after Sculptra injection. These were firm, lumpy am not treating buttocks or knees, but many prac-
nodules that gave the face almost a cottage titioners have obtained nice results with this prod-
cheese appearance. She was taking an antime- uct in those areas.
tabolite (mercaptopurine) for inflammatory bowel I also use a fair amount of Radiesse in the dorsal
disease, which may have been associated with hands.
this complication. The nodules all appeared at Question 6: How have your techniques
the same time and responded to intramodular in- changed over the past 5 years?
jection of 5-fluorouracil with Kenalog.
Question 5: What role do fillers play in BUNIN
off-face treatment in your practice?
My techniques now involve more volumizing,
BUNIN layering, combining treatments, using cannulas
as well as replacing areas of facial volume loss
Aging tends to show in the face, neck and décol- to restore a more youthful appearance. Doctors
letage, and most patients seek rejuvenation in have stopped looking at wrinkles and sagging
these areas, but aging hands give away a patient’s skin in isolation and are considering how volume
true age. Hand volumizing and rejuvenation have loss in 1 area affects others, how muscle pulling
been a big part of my practice for more than plays a role, and how bone loss affects the sup-
10 years. I love using Radiesse to volumize the porting framework. Filling the temples makes a
hands, and find results can last 2 years or more. large impact on the brows and upper eyelids;
I use intense pulsed light (IPL), fractionated lasers, assessing the masseter, jawline, preauricular
and medical-grade skin care to reduce pigmenta- area, and chin and combining well-placed filler
tion and change the skin texture. Recently I with neuromodulators can give subtle but defi-
have used Restylane Defyne to volumize hands nite changes in proportion that appear more
because there is minimal swelling with this prod- beautiful. I am using more neuromodulators in
uct but have no data on longevity yet. the lower face and neck than ever before. Treat-
Sculptra has been used at high dilutions for off- ing the platysmal bands, performing a Nefertiti
face rejuvenation for the hands and décolletage neck lift, treating overactive masseter muscles,
 Injectable Fillers 235

and relaxing muscles to enhance the effect of fillers, neuromodulators, and good health all play
filler have become routine. I am using a lot a role in maintaining a rested youthful appearance,
more Sculptra to support the underlying founda- and the time to start is now.
tion of the face in a global fashion, then layering
fillers over that in specific areas. Rejuvenating FITZGERALD
the skin with medical-grade skin care, facials,
peels, microdermabrasion, IPL, and/or lasers is Over the last five years, I have become better at
important, but I now have far more laser and light recognizing how to approach some problems
options available. and in recognizing which patients I can or cannot
The biggest challenge is deciding how much to help. This recognition and targeted correction of
do and in what order. This depends on patients’ currently recognized specific anatomic defi-
desires, budget, timeline, and anatomy and ciencies are constantly improving because of the
whether they are also having eyelid or brow sur- wealth of studies available. These gains in knowl-
gery. If a patient flies in from out of town, or has edge sometimes enable site-specific correction
a big event in a month, I do as much as I can in of areas primarily responsible for the development
1 sitting. Otherwise, I prefer to rejuvenate the pa- of downstream markers of aging to give predict-
tient in stages. able targets for predictable and natural appearing
In general, I like to start almost everyone on results. There is still so much to learn and under-
medical-grade skin care because healthy skin re- stand; however, advances and innovations in
sponds better to any treatment, even when doing technology have given faster and more efficient
neurotoxin or a little bit of filler. ways to both gather and share information and
I routinely perform neurotoxin and filler on the are accelerating understanding of this complex
same day if they are done to different areas and process. This has led to a paradigm shift in the
sometimes in the same areas. I am more cautious way the changes seen in the aging face are both
using neurotoxin to elevate the lateral brow if I perceived and approached. The answer to the
have used a large volume of filler around the brows question of whether the face sinks or sags has
and temples because I have seen fluid influx into become a “yes” to both, as aging is beginning to
this area carry the neurotoxin inferiorly and cause be seen as a complex and interdependent inter-
a mild ptosis. play between all structural layers culminating in
If IPL, skin-tightening lasers, or other noninva- the collapse of 3-D construct. Newer understand-
sive procedures to the face are being done, I ing of volume loss as a critical component of facial
perform those first and then do filler and/or neuro- aging and the integration of volume replacement
toxin. I not do invasive procedures and fillers or into the surgical and nonsurgical therapeutic algo-
neurotoxin on the same area on the same day rithm will greatly enhance the ability to address the
but may do them in a distant area (eg, fill lips and loss with site-specific corrections to achieve
also laser resurface around the eyes). I routinely optimal and natural-looking results in a predictable
combine laser resurfacing with eyelid surgery manner.
and suggest neurotoxin to the crow’s feet and At the same time, the products used to achieve
lateral eyebrow, either 2 weeks or more before these corrections are constantly improving. I feel
the surgery or a few weeks after the lasered areas lucky to practice in a time of renaissance in this
have healed. This enhances the surgical results field of cosmetic injectables.
and allows better skin remodeling by reducing
muscle traction on the area. KONTIS
I try to convey to my patients how investing in
themselves earlier gives long-term results. Taking I am certainly using more syringes of fillers in a
care of their skin, putting collagen “in the bank” treatment than I used 5 years ago. In the past, in-
through tissue stimulation with Sculptra and skin- jectors were taught to focus on the nasolabial
tightening modalities like the Titan laser, softening folds, marionette lines and lips. Now not only is
muscle contraction lines with neuromodulators, there a better understanding of facial volume loss
and reinflating early with fillers can stave off the but also the injectable products themselves are
need for surgery and can actually slow the aging being created to give more options for “total
process: 60 is the new 40, and 80 is the new 60. correction.”
Even though I am a surgeon, surgery is not the When I assess a patient for injectables, I now
only answer. I tell them I am like a seamstress—I evaluate the entire face. Do the temples look hol-
can sew a beautiful garment, but I cannot make low? If so, I may consider Sculptra, Restylane
leather into silk, and how the garment drapes de- Lyft, or Voluma to those regions. If the hollow-
pends on the underlying tissue. So, skin care, ness extends into the preauricular regions, I
236 Kontis et al

may prefer Sculptra because lumpiness of the HA questions and hopes readers improve their inject-
fillers is difficult to avoid in that area. I address able knowledge from this discourse.
midface volume next and find I am injecting the
actual nasolabial folds either not at all or with
REFERENCES
much less product once the cheeks have been
volumized. Then I work inferiorly to the circumo- 1. Glasgold MJ, Glasgold RA, Lam SM. Volume restora-
ral region, where I now like to use Restylane tion and facial aesthetics. Facial Plast Surg Clin North
Refyne. I find this filler takes almost no skill to Am 2008;16(4):435–42.
use and produces fantastic, smooth results.
2. Karunanayake M, To F, Efanov JI, et al. Analysis of
I am also more aggressive with lower lid injec-
craniofacial remodeling in the aging midface using re-
tions. I treat the entire lower lid crescent to
constructed three-dimensional models in paired indi-
maximal correction using not more than 1 syringe
viduals. Plast Reconstr Surg 2017;140(3):448e–54e.
of filler at a time. Where in the past 1 area tended
to be focused on, I think now injectors are looking 3. de Maio M, Rzany B. Injectable fillers in aesthetic
at reshaping the face and trying to restore the medicine. 2nd edition. Berlin: Springer-Verlag; 2014.
heart-shaped, volumized youthful look. p. 89–92.
I often inject 1 side of the face and stop to show 4. Pavicic T, Frank K, Erlbacher K, et al. Precision in
patients the difference between the treated and dermal filling: a comparison between needle and
untreated sides. I point out to them where I cannula when using soft tissue fillers. J Drugs Derma-
injected the filler to create the volumization and tol 2017;16(9):866–72.
lift. I would say that 99% of patients are “wowed” 5. Scheuer J, Sieber D, Pezeshk R, et al. Anatomy of the
by the results they see in the mirror. facial danger zones: maximizing safety during soft-
As new products are developed with increasing tissue filler injections. Plast Reconstr Surg 2017;139:50e.
longevity, I believe patients are more willing to pur- 6. Tansatit T, Apinuntrum P, Phetudom T. A dark side of the
chase multiple syringes at a setting, especially cannula injections: how arterial wall perforations and
once they see how total facial rejuvenation im- emboli occur. Aesthetic Plast Surg 2017;41(1):221–7.
proves their appearance. Combined with neuro- 7. Yeh LC, Fabi SG, Welsh K. Arterial penetration with
toxins, many call this a “liquid facelift,” although blunt-tipped cannulas using injectables: a false sense
it is neither liquid nor a facelift. I may start telling of safety? Dermatol Surg 2017;43(3):464–7.
my patients this is “panfacial rejuvenation with
8. Fitzgerald R, Bertucci V, Sykes J, et al. Adverse reac-
injectables.”
tions to injectable fillers. Facial Plast Surg 2016;32:
532–55.
ACKNOWLEDGMENTS
9. Dayan SH, Arkins JP, Mathison CC. Management of
T.C. Kontis thanks L. Bunin and R. Fitzgerald for impending necrosis associated with soft tissue filler
their thoughtful and thorough responses to these injections. J Drugs Dermatol 2011;10(9):1007–12.