Injectable Fillers in Aesthetic Medicine

Mauricio de Maio
Berthold Rzany
Injectable Fillers in
Aesthetic Medicine
Second Edition
123
Injectable Fillers in Aesthetic Medicine
Mauricio de Maio • Berthold Rzany
Injectable Fillers in
Aesthetic Medicine
Second Edition
Mauricio de Maio Berthold Rzany
Clínica Médica Dr Mauricio de Maio RZANY & HUND
São Paulo Privatpraxis für Dermatologie und
São Paulo Ästhetische Medizin
Brazil Kurfüstendamm
Berlin
Germany
ISBN 978-3-642-45124-9 ISBN 978-3-642-45125-6 (eBook)

DOI 10.1007/978-3-642-45125-6
Springer Heidelberg New York Dordrecht London
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Foreword II
During my residency in plastic surgery at The John Hopkins Hospital in the

mid-1970s, I visited the Stanford University plastic surgery program, where I
saw residents, faculty and researchers literally “squeezing” collagen out of
cow hides in an attempt to create an injectable material to fill out soft tissue
depressions. Fascinated by this concept, I joined the original plastic surgical
advisory board of the Collagen Corporation in the early 1980s. The original
commercial collagen product was viewed more as a “wrinkle filler”, and to a
great degree was embraced in the market place more by dermatologists to
treat wrinkles non-operatively, than by scalpel-wielding plastic surgeons.
While the field of aesthetic dermatology evolved in part triggered by this
original collagen product (enhanced of course by lasers, neurolytics, and
other topical advances), plastic surgeons, for the most part, stuck with
surgery.
Mauricio de Maio was the first plastic surgeon to appreciate the full aes-
thetic potential of the use of fillers in total facial rejuvenation, not simply in
the treatment of wrinkles. I first met Mauricio 15 years ago, when he was a
young.
Brazilian plastic surgeon using hyaluronic fillers. I was immediately taken
by his artistic brilliance in the assessment of facial anatomy and proportion
and his revolutionary approach in correcting disproportion, asymmetry and
aging via injectable fillers, rather than surgery. I have watched his career
evolve from a little-known Brazilian artistic pioneer, to an internationally,
experienced master injector and physician. His techniques, his selection of
ever evolving products and his own self-critique and constant striving for
safety and improved outcomes have placed him at the highest level amongst
his world-peers in aesthetic plastic surgery and dermatology.
The importance of this book is the combined input of facial aesthetic med-
ical pioneer and aesthetic dermatology master, Berthold Rzany, along with
that of Mauricio de Maio. For as the world of “fillers” has evolved from the
original bovine collagen product to various hyaluronic acids and beyond, and
the location of their placement and volume goes deeper than the skin. The
combined expertise of aesthetic dermatology and aesthetic surgery now work
hand in hand to evaluate patients, consider various treatment options, pro-
mote patient safety, and improve predictable aesthetic outcomes.
v
vi Foreword II
This book is a “must-read” manual, reference and desk-top text for all
practitioners working with “fillers” in the “aesthetic medical space”.
I congratulate the authors as well as thank them for creating and updating
this much needed body of work.
G. Patrick Maxwell, MD, FACS

Maxwells Aesthetics, Plastic and
Reconstructive Surgery,
South Nashville,
TN, USA
Foreword I
It has been 5 years since the publication of the 1st edition of Drs. De Maio
and Rzany’s book Injectable Fillers in Aesthetic Medicine. During this time a
revolution has occurred in our understanding of facial anatomy and its rela-
tionship to the aging process as well as the development of new and improved
products. We no longer “cookbook” the nasolabial fold or lips in all patients
alike, but have evolved our understanding of the development of folds, creases
and atrophy related to the aging process. It is the incorporation of these new
principles to the practice of aesthetic medicine that makes this new 2nd edi-
tion a hallmark in our understanding of injectable correction and an invalu-
able guide to personalizing the practice in practical terms. Of extreme
importance are the chapters that set the stage for injecting, injectable products
and their applications, patient evaluation and selection of treatment and
development of a treatment plan. Rather than simply separating injection
areas, as has previously been done, this guide gives the clinician a broader
view of facial aging, then interprets the areas together for a more complete
program to reverse facial aging. The attention to “blind spots” for patients
and physicians instruct as how to evaluate patient needs in a fresh new man-
ner. This gives the physician a plan to treat the aging face and satisfy the
patient. The emphasis on “Do’s”, “Don’ts”, ‘Key points” and “FAQ’s” sum-
marize the essentials of each chapter in a readable, yet complete guide to
injectable facial treatment.
This is the first practical compendium for a new era of injectable filler
treatment of the aging face. In this case, the 2nd edition is not just an update,
but a new approach to facial treatment. It is the closest experience to a tutorial
lesson with two masters of aesthetic facial injection treatment.
Gary D. Monheit, MD
Departments of Dermatology and Ophthalmology
Total Skin & Beauty Dermatology Center, P.C.,
University of Alabama at Birmingham
Birmingham, AL, USA
vii
Preface
The book on injectable fillers was our first book and was like our book on
botulinum toxin A very successful. Why did we decide on an update? Of
course the 1st edition still stands its ground in many aspects. However, during
the last years we have seen many changes in the filler market. Fillers have
been withdrawn from the market (some for very good reasons!), and new fill-
ers did appear. Furthermore, we have improved, too. We increased the num-
ber of indications we can offer, and we advanced our injection techniques.
Furthermore, we made a great step forward in how we analyze our patients
and how we set up the most optimal treatment strategy – the treatment plan –
that includes the doctors’ and the patients’ perspectives.
The tasks of this book though remain unchanged: first, to give an overview
on the most common biodegradable and nonbiodegradable fillers and how to
approach them and, second, to lead through the most common indications of
the face and other body areas. This book kept the hands-on approach from the
1st edition. However, we included new features. From our last common book
on Male Aesthetics, we included the “Do’s”, “Don’ts”, and the “Key Points”
to highlight the most important points. Last but not least, we tried to be as
specific as possible. However, in case we missed something or something
appears to be unclear or even wrong, please do not hesitate to contact us by
mail, and we will both try to answer your questions as clearly and quickly as
possible.
Berlin, Germany Berthold Rzany

São Paulo, Brazil Mauricio de Maio
ix
About the Authors
Berthold Rzany
Berthold Rzany is a dermatologist and clinical epidemiologist in private prac-

tice (RZANY & HUND) in Berlin, Germany. Between 2002 and 2011 he
held the position of C3-Professor of Evidence Based Medicine in Dermatology
at the Department of Dermatology and Venereology at the Charité
Universitätsmedizin. He studied medicine in Freiburg, Germany; Vienna,
Austria; and Harvard Medical School, Boston, USA. He received his derma-
tological education at the Department of Dermatology at the University of
Freiburg, Germany, and worked as a consultant in dermatology in Mannheim,
Fakultät für Klinische Medizin, University of Heidelberg. He has a special
interest in aesthetic medicine and tries to incorporate evidence-based medi-
cine in aesthetic medicine. He is the author of several leading publications in
the field of Aesthetic Medicine. He likes teaching and frequently gives hands-
on workshops on botulinum toxin A and injectable fillers. He is also a consul-
tant for various companies for these substances.
Conflict of interest Berthold Rzany is a speaker and/or advisor for the following filler
companies (2013): Merz Pharmaceuticals, Q-Med Galderma, Teoxane Laboratories and
Sinclair Pharmaceuticals.
Mauricio de Maio
Dr. de Maio is a board certified plastic surgeon from the Brazilian Society of
Plastic Surgery and member of the International Society of Aesthetic Plastic
Surgery. Dr. de Maio graduated in Medicine in the Medical School of the
University of Sao Paulo in 1990. He specialized in plastic surgery in Brazil in
1996. He obtained his Master’s Degree in Medicine in 1997 and Doctorate in
Sciences in 2006 at the University of Sao Paulo, Brazil. He was a clinical
assistant professor of the Plastic Surgery Department of the University of Sao
Paulo from 1996 to 2002. Dr. de Maio has authored scientific publications and
articles as well as published several books including the following books he
coauthored with B. Rzany: Fillers in Aesthetic Medicine, 2006; Botulinum
Toxin in Aesthetic Medicine, 2007; and The Male Patient in Aesthetic Medicine,
xi
xii About the Authors
2009, by Springer-Verlag – Germany. He is actively involved in research and

teaching in international training courses in America, Europe, and Asia-Pacific
as well in consulting companies.
Conflict of interest Mauricio de Maio is a speaker and advisor for the following filler
company (2013): Pharm-Allergan.
Acknowledgments
The 2nd edition of this book would not have been possible without the help
of many others. First, we would like to thank our patients and colleagues with
whom during the last years we advanced together discovering new indica-
tions and techniques. We would like to thank those who helped us with their
skills and support during the completion of this book. Furthermore, we would
like to take this opportunity to thank Mrs. Ellen Blasig from Springer
Heidelberg for her guidance and her continuous support, which enabled us to
keep the project going.
From the German team, we are grateful to Julian Wiora and Twyla
Michnevich for proofreading the text. From the Brazilian team, we would
like to thank the staff, who are always prompt in providing support with new
tasks: Mrs. Liliann Amoroso Ribeiro and Lilian de Toledo Lima.
xiii
Abbreviations
BoNT-A Botulinum toxin A

CE Conformité Européenne
CaHa Calcium hydroxylapatite
CIA Cosmetic investment advisor
FDA Food and Drug Administration
HA Hyaluronic acid
HEMA Hydroxyethylmethacrylate
HIV Human immunodeficiency virus
KTP laser Kaliumtitanphosphat (potassium titanyl phosphate) laser
PLLA Poly-l-lactic acid
PMMA Polymethylmethacrylate
SMAS Submuscular aponeurotic system
SOOF Suborbicularis oculi fat
xv
Contents
1 Overview on Injectable Fillers: Efficacy and Safety . . . . . . . . 1

1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Classification of Fillers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2.1 Classification by Biodegradability . . . . . . . . . . . . . . 2
1.2.2 Classification by the Quality of Clinical Data . . . . . 2
1.3 Biodegradable Fillers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.3.1 Collagen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.3.2 Hyaluronic Acid. . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.3.3 Combination of Hyaluronic Acid
with Other Substances . . . . . . . . . . . . . . . . . . . . . . . 7
1.3.4 Alginates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.3.5 Poly-l-lactic Acid . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.3.6 Calcium Hydroxylapatite . . . . . . . . . . . . . . . . . . . . . 10
1.4 Nonbiodegradable Fillers. . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.4.1 Silicone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.4.2 Polyacrylamide . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.4.3 Polyalkylimide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
1.5 Combination of Nonbiodegradable
and Biodegradable Fillers . . . . . . . . . . . . . . . . . . . . . . . . . . 13
1.5.1 Polymethylmethacrylate
and Collagen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
1.5.2 Hydroxyethylmethacrylate and Hyaluronic Acid . . . . 15
1.6 Combining Different Fillers in One Area . . . . . . . . . . . . . . 15
1.7 General Approach to New Fillers . . . . . . . . . . . . . . . . . . . . 15
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2 Selection of Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.2 General Rules. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2.3 The First Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
2.4 The Facial Thirds System . . . . . . . . . . . . . . . . . . . . . . . . . . 25
2.5 The Ideal Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
2.6 The Aging Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
2.7 The Patient with Facial Imperfections . . . . . . . . . . . . . . . . . 26
2.8 The Patient You Do Not Want to Treat . . . . . . . . . . . . . . . . 27
2.9 The Dysmorphic Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
xvii
xviii Contents
3 Requirements and Rules. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

3.1 General Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
3.1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
3.1.2 Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
3.1.3 Charts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
3.1.4 Photographs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
3.1.5 Consent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
3.1.6 Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
3.1.7 Staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
3.2 Technical Requirements. . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
3.2.1 Room . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
3.2.2 Chair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
3.2.3 Mirror . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
3.2.4 Small Things . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
3.2.5 First Aid Kit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
3.2.6 Tips, Tricks and Key Points . . . . . . . . . . . . . . . . . . . 35
3.3 The 13 General Rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
3.3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
3.3.2 Rule 1: Listen to the Patient. . . . . . . . . . . . . . . . . . . 35
3.3.3 Rule 2: Fillers Are Only One Tool. . . . . . . . . . . . . . 35
3.3.4 Rule 3: Talk About Money . . . . . . . . . . . . . . . . . . . 36
3.3.5 Rule 4: Talk About Possible Adverse Events . . . . . 36
3.3.6 Rule 5: Avoid Disturbed Patients . . . . . . . . . . . . . . . 36
3.3.7 Rule 6: Anesthesia (Treat with as Little
Pain as Possible!) . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
3.3.8 Rule 7: Position (Keep the Patient Upright) . . . . . . 37
3.3.9 Rule 8: Use the Mirror/Digital Images . . . . . . . . . . 37
3.3.10 Rule 9: Start with a Biodegradable Filler First . . . . 38
3.3.11 Rule 10: Quantity of Filler
(Do Not Inject Insufficient Amounts) . . . . . . . . . . . 38
(Do Not Inject Too Much) . . . . . . . . . . . . . . . . . . . . 38
3.3.13 Rule 12: Use the Appropriate Depth of Injection . . 38
3.3.14 Rule 13: If Something Goes Wrong . . . . . . . . . . . . 39
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
4 Treatment Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
4.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
4.1.1 Product-Related Barrier . . . . . . . . . . . . . . . . . . . . . . 42
4.1.2 Patient-Related Barrier . . . . . . . . . . . . . . . . . . . . . . 43
4.1.3 Injector-Related Barrier . . . . . . . . . . . . . . . . . . . . . . 45
4.1.4 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
4.1.5 The MdM 8-Point Lift . . . . . . . . . . . . . . . . . . . . . . . 52
4.2 Treatment Plan and Exponential Aging . . . . . . . . . . . . . . . . 56
4.3 Cosmetic Investment Advisor . . . . . . . . . . . . . . . . . . . . . . . 58
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
5 Anesthesia and Analgesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
5.2 Evaluation Prior to Injection . . . . . . . . . . . . . . . . . . . . . . . . 62
Contents xix
5.3 Local Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

5.4 Topical Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
5.5 Infiltrative Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
5.6 Nerve Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
5.6.1 The Supraorbital Nerve . . . . . . . . . . . . . . . . . . . . . . 64
5.6.2 The Supratrochlear Nerve . . . . . . . . . . . . . . . . . . . . 64
5.6.3 The Infraorbital Nerve . . . . . . . . . . . . . . . . . . . . . . . 64
5.6.4 The Mental Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . 65
5.6.5 The Zygomaticofacial Nerve . . . . . . . . . . . . . . . . . . 66
5.7 Adverse Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
5.8 Disadvantages of Local Anesthetics . . . . . . . . . . . . . . . . . . 67
5.9 Tips, Tricks and Key Points . . . . . . . . . . . . . . . . . . . . . . . . . 68
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
6 The Most Common Indications . . . . . . . . . . . . . . . . . . . . . . . . . 69
6.1 Forehead and Glabella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
6.1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
6.1.2 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
6.1.3 Patient Evaluation and Selection . . . . . . . . . . . . . . . 71
6.1.4 Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
6.2 Temples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
6.2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
6.2.2 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
6.2.4 Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
6.2.5 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
6.3 Eyebrow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
6.3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
6.3.2 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
6.3.4 Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
6.3.5 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
6.4 Epicanthal Fold and Sunken Upper Eyelid . . . . . . . . . . . . . 80
6.4.1 Epicanthal Fold . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
6.4.2 Sunken Upper Eyelid . . . . . . . . . . . . . . . . . . . . . . . . 80
6.5 Infraorbital Hollow, Tear Trough, Cheekbones,
and Cheek Reshaping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
6.5.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
6.5.2 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
6.5.4 Tear Trough and Infraorbital Area . . . . . . . . . . . . . . 85
6.5.5 Cheekbones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
6.5.6 Cheek . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
6.5.7 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
xx Contents
6.6 Nose Reshaping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

6.6.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
6.6.2 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
6.6.4 Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
6.6.5 The Nasofrontal Angle . . . . . . . . . . . . . . . . . . . . . . 102
6.6.6 The Nasolabial Angle . . . . . . . . . . . . . . . . . . . . . . . 102
6.6.7 The Tip and the Columella . . . . . . . . . . . . . . . . . . . 102
6.6.8 Dorsum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
6.6.9 Selection of Filler . . . . . . . . . . . . . . . . . . . . . . . . . . 105
6.6.10 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
6.7 Nasolabial Folds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
6.7.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
6.7.2 Anatomy/Structure . . . . . . . . . . . . . . . . . . . . . . . . . . 106
6.7.4 Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
6.7.5 Touch-Up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
6.7.6 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
6.8 The Earlobe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
6.8.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
6.8.2 Anatomy/Structure . . . . . . . . . . . . . . . . . . . . . . . . . . 112
6.8.4 Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
6.9 The Upper and Lower Lips . . . . . . . . . . . . . . . . . . . . . . . . . 114
6.9.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
6.9.2 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
6.9.4 Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
6.9.5 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
6.10 Marionette Lines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
6.10.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
6.10.2 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
6.10.4 Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
6.10.5 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
6.11 Jawline and Chin Reshaping . . . . . . . . . . . . . . . . . . . . . . . . 125
6.11.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
6.11.2 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
6.11.4 Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
6.11.5 Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
Contents xxi
6.12 Other Facial Indications for Volumizers . . . . . . . . . . . . . . . 131

6.12.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
6.12.2 Facial Advancement. . . . . . . . . . . . . . . . . . . . . . . . . 131
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
7 Nonfacial Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
7.1 Inverted Nipple . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
7.1.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
7.1.2 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
7.1.4 Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
7.2 Hand Volume Replacement . . . . . . . . . . . . . . . . . . . . . . . . . 137
7.2.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
7.2.2 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
7.2.4 Material to Be Used . . . . . . . . . . . . . . . . . . . . . . . . . 139
7.2.5 Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
7.2.6 Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
7.2.7 Potential Specific Adverse Events . . . . . . . . . . . . . . 141
7.3 Penile Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
7.3.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
7.3.2 Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
7.3.4 Material to Be Used . . . . . . . . . . . . . . . . . . . . . . . . . 143
7.3.5 Procedure Prior to Injection . . . . . . . . . . . . . . . . . . . 145
7.3.6 Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
8 Safety: Assessment and Treatment of Adverse Reactions . . . . 149
8.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
8.2 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
8.3 Identification of the Responsible Filler . . . . . . . . . . . . . . . . 150
8.4 Potential Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
8.4.1 The Doctor as a Risk Factor . . . . . . . . . . . . . . . . . . 151
8.4.2 The Product as a Risk Factor . . . . . . . . . . . . . . . . . . 151
8.4.3 The Patient as a Risk Factor . . . . . . . . . . . . . . . . . . 151
8.4.4 The Biofilm Theory . . . . . . . . . . . . . . . . . . . . . . . . . 152
8.5 Treatment of Adverse Reactions . . . . . . . . . . . . . . . . . . . . . 152
8.5.1 Bluish Discoloration . . . . . . . . . . . . . . . . . . . . . . . . 152
8.5.2 Hypersensitivity Reaction . . . . . . . . . . . . . . . . . . . . 153
8.5.3 Acute Vascular Reaction . . . . . . . . . . . . . . . . . . . . . 153
8.5.4 Nodule Formation . . . . . . . . . . . . . . . . . . . . . . . . . . 154
8.5.5 Abscess Formation. . . . . . . . . . . . . . . . . . . . . . . . . . 156
8.6 Guiding the Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
xxii Contents
9 Combination Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159

9.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
9.2 Lasers and Fillers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
9.3 Chemical Peels and Fillers. . . . . . . . . . . . . . . . . . . . . . . . . . 161
9.4 Botulinum Toxin and Fillers . . . . . . . . . . . . . . . . . . . . . . . . 162
9.5 Facial Plastic Surgery and Fillers . . . . . . . . . . . . . . . . . . . . 166
9.6 Topical Drugs in Combination with Fillers . . . . . . . . . . . . . 167
9.7 Eye Rejuvenation as an Example
for Combination Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . 167
9.7.1 Step 1: Improvement of Eyelashes . . . . . . . . . . . . . 167
9.7.2 Step 2: Restoration of Volume Loss . . . . . . . . . . . . 167
9.7.3 Step 3: Decreasing Muscular Activity by BoNT-A . . . . 169
9.7.4 Step 4: Develop a Plan for Maintenance Therapy . . 170
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Overview on Injectable Fillers:
Efficacy and Safety 1
Berthold Rzany
Contents 1.1 Introduction

1.1 Introduction ................................................ 1
In contrast to the USA, in most countries in Europe
1.2 Classification of Fillers .............................. 1
1.2.1 Classification by Biodegradability ............... 2
and South America, a great variety of injectable
1.2.2 Classification by the Quality fillers are available. Therefore, not only for nov-
of Clinical Data ............................................ 2 ices but also for experienced users it can some-
1.3 Biodegradable Fillers................................. 2 times be quite difficult to decide which filler to
1.3.1 Collagen ....................................................... 2 use. This chapter will give a brief overview on
1.3.2 Hyaluronic Acid........................................... 5 some of the most commonly used present and past
1.3.3 Combination of Hyaluronic Acid
injectable fillers. The selection of products reflects
with Other Substances ................................. 7
1.3.4 Alginates ...................................................... 8 the interest of the authors and might appear arbi-
1.3.5 Poly-l-lactic Acid ......................................... 8 trary to someone familiar with other fillers.
1.3.6 Calcium Hydroxylapatite ............................. 10
1.4 Nonbiodegradable Fillers .......................... 11
FAQs
1.4.1 Silicone ........................................................ 11
1.4.2 Polyacrylamide ............................................ 12 • Why should one show interest with
1.4.3 Polyalkylimide ............................................. 13 fillers which are not on the market
1.5 Combination of Nonbiodegradable anymore?
and Biodegradable Fillers ......................... 13 Even when fillers are not present on
1.5.1 Polymethylmethacrylate and Collagen ........ 14 the market anymore, they may be impor-
1.5.2 Hydroxyethylmethacrylate
tant for two reasons: (1) they may be
and Hyaluronic Acid .................................... 15
marketed again, and (2) permanent fill-
1.6 Combining Different Fillers ers will be always present as they will
in One Area................................................. 15
stay with the patient until the end.
1.7 General Approach to New Fillers ............. 15
References ................................................................. 16
1.2 Classification of Fillers
Basically there is no uniformly accepted classifi-

cation of fillers. Injectable fillers may be grouped
according to (1) the degree of degradability and
(2) the quality of the clinical data behind them.
M. de Maio, B. Rzany, Injectable Fillers in Aesthetic Medicine, 1

DOI 10.1007/978-3-642-45125-6_1, © Springer-Verlag Berlin Heidelberg 2014
2 1 Overview on Injectable Fillers: Efficacy and Safety
1.2.1 Classification by 1.3 Biodegradable Fillers

Biodegradability
Biodegradable fillers are defined as having a lim-
Fillers can be grouped as biodegradable and non- ited life span usually ranging from a couple to
biodegradable (permanent) products. There are several months, or even to a couple of years.
also fillers where biodegradable as well as non- They consist of purified dermal components
biodegradable materials are combined. from human, animal, or bacterial sources and
can be divided into the following categories:
xenografts (donor and recipient are from differ-
1.2.2 Classification by the Quality ent species), autografts (donor and recipient are
of Clinical Data from the same individual), homografts (donor
and recipient are from the same species), and
As the rules for marketing of fillers are quite synthetic materials (Table 1.1). Please note that
relaxed in Europe, e.g., a clinical trial is not in the last couple of years some of the most well-
required, fillers can be grouped in those with and known biodegradable fillers were removed from
without clinical data. Those with clinical data can the market.
be grouped in those with good and less good clin-
ical data.
What means good clinical data? Basically a 1.3.1 Collagen
randomized controlled clinical trial with a suf-
ficient number of patients included (e.g., for a Collagens from various sources and with specific
two-arm trial you want at least 50 patients). characteristics exist or better used to exist as
Based on such a trial simple but important most of the fillers discussed are not on the market
questions as grade of correction that can be anymore.
achieved, durability of the correction (e.g., effi-
cacy), impact on quality of life, and safety (pro- 1.3.1.1 Collagen of Bovine Origin
portion of patients with swelling, etc.) can be Prior to the introduction of the hyaluronic acids,
answered. collagen was the most widely used filler and was
Table 1.1 Overview on biodegradable fillers

Material Origin Productsa
Temporary injectable fillers
Alginate Nonanimal, algae Novabelb
Collagen Bovine Zydermb, Zyplastb
Porcine Evolenceb
Human (cadaver derived) Cymetrab
Human (self-derived) Isolagenb
Human (cultivated) Cosmodermb, Cosmoplastb
Hyaluronic acid Avian Hylaformb
Nonanimal Beloteroc, Emervelc, Juvédermc, Restylanec, Teosyalc,
Juvéderm Volumac
Hyaluronic acid + dextran Nonanimal Reviderm
Poly-l-lactic acid (PLLA) Nonanimal Sculptra (former New Fill)
Calcium hydroxylapatite Nonanimal Radiesse
a
Please note that this list is not intended to be complete
b
Were removed or will be removed from the market
c
HA product families with at least one product with good clinical trial data (RCTs), e.g. for the Emervel family we have
good RCTs on E. deep and E. classic
1.3 Biodegradable Fillers 3
considered the gold standard with which other

dermal fillers were compared. However, the role Key Points
of bovine collagen is declining. In the USA and • So far, bovine collagens are not avail-
in Europe, they are not available on the markets able anymore in Europe and the USA.
anymore. Nevertheless, bovine collagen still There might be two reasons for that: (1)
might be available in other parts of the world, the need of prior skin testing and (2) the
and therefore we will give a brief overview on decreased durability compared to the
that substance. The classical bovine enzyme- hyaluronic acid preparations.
digested collagen (95 % type I, 5 % type III) was • As bovine collagen was the comparator
available in several preparations, which were in the initial non-collagen filler trials,
distinguished by the collagen content and the the evidence behind this group of prod-
addition of glutaraldehyde for stabilization ucts is good.
(Homicz and Watson 2004).
Depending on the collagen content and the
degree of cross-linking, different products were 1.3.1.2 Collagen of Porcine Origin
designed for different levels of the dermis. For Before Evolence there were only a very few
example, Zyderm 1 and Zyderm 2, which were reports on porcine collagen-based fillers in the
built on noncross-linked collagen, were supposed literature (Saray 2003). Evolence, a novel por-
to be injected into the superficial dermis. Zyplast, cine collagen filler, was introduced into the
a cross-linked form, was supposed to be injected European market in 2004 and withdrawn from
more deeply into the dermis. All of these prod- the markets in 2009. In contrast to other colla-
ucts were easy to inject. In contrast to other prod- gens, this product was cross-linked by glycation
ucts, overcorrection was recommended for using d-ribose as the cross-linking agent. Unlike
Zyderm 1 and Zyderm 2. bovine collagen, no skin testing was necessary.
Zyderm was cleared for marketing in 1981 by This porcine collagen was available in two
the Food and Drug Administration (FDA) after preparations: Evolence and Evolence Breeze.
reviewing clinical data based on a large case Evolence Breeze was indicated for more superfi-
series of 9,427 tested and 5,109 treated patients cial dermal injections and lip augmentation.
(Cooperman et al. 1985; Matti and Nicolle 1990). Being a new filler, efficacy was supported by a
In addition to this case series, which focused couple of good clinical trials (Monstrey et al.
mainly on safety issues, a further clinical trial 2007; Narins et al. 2007, 2008). Furthermore,
showed that it was effective for at least several some smaller case series were reported focusing
months (Cooperman et al. 1985; Matti and on specific areas as nonsurgical rhinoplasty
Nicolle 1990). (Cassuto 2009), tear trough correction (Goldberg
As collagen may elicit quite often hypersensi- 2009), cheek augmentation (Sadick and
tivity reactions, pretesting was mandatory. Palmisano 2009), and lip augmentation (de
Pretesting consisted of an intradermal injection Boulle et al. 2009; Landau 2009).
of Zyderm 1 collagen into the volar aspect of the The risk of hypersensitivity reactions for porcine
forearm. A minimum of one skin test which was collagen was much lower compared to bovine col-
valuated after 28 days was required. The inci- lagen. In an intradermal skin test study, no hyper-
dence of adverse reactions to collagen pretesting sensitivity reactions could be detected in a total of
(here Zyderm I) was approximately 3 %. Of all 519 subjects (Shoshani et al. 2007). Therefore, no
test site reactions, 50 % occurred within the first skin testing was recommended. There are, however,
24 h. An additional 1.3 % of patients experi- a few reports on foreign body reactions inducing an
enced adverse reactions despite a negative pre- abscess-like reaction (Braun and Braun 2008). As
test. The observed reactions ranged from several thousands of patients had been treated
localized swelling to induration, erythema, and before the withdrawal, this risk seemed to be
pruritus (Cooperman et al. 1985). comparable to other biodegradable fillers.
Porcine collagen was not as easy to inject They were made from natural human collagen
compared to bovine collagen. By mixing lido- grown under controlled laboratory conditions. There
caine (0.2 ml) to the syringe, the injectability as was no need for a pretreatment skin test for these
well as the injection comfort (less pain!) could be sterile devices, which were composed of highly
increased. As for Like bovine collagen, the filler purified human-based collagen that is dispersed in
had a yellowish color which could be visible phosphate-buffered physiological saline containing
beneath the mucosal surfaces when the filler was 0.3 % lidocaine. Cosmoderm was a noncross-linked
injected too superficially. For this filler, a guide- formulation that was used in the treatment of super-
line is available (Rzany et al. 2010). ficial lines, whereas Cosmoplast was cross-linked
and was used primarily in the treatment of more pro-
nounced wrinkles. A few clinical trials are available
Key Points using Cosmoderm as a comparator. Based on these
• Evolence was a filler which was sup- trials, the durability seems to be less as for other
ported by good clinical data. products (Man et al. 2008; Smith et al. 2007).
• With the withdrawal of the Evolence
products, no porcine filler is at the 1.3.1.3.3 Collagen of Autologous Nature
moment available in Europe and the The commercial preparation Autologon consists
USA. of dermal extracellular matrix, primarily colla-
• Nevertheless, it cannot be ruled out that gen (types I, III, and VI), that has been harvested
this or a comparable product will be from the patient’s own skin. It requires the exci-
reintroduced to the market again. sion of the patient’s skin and is therefore mostly
suitable for those undergoing surgical proce-
dures. Here again, overcorrection is recom-
1.3.1.3 Collagen of Human Origin mended by the manufacturer. The available data
Collagen of human origin can be of allogenous or on the efficacy and safety of the product are lim-
autologous nature. ited (Sclafani et al. 2000).
Concerning the safety as said before, the num-
1.3.1.3.1 Collagen of Allogenous Nature ber of studies for the above products is limited.
(From Cadaver) Pretesting might reveal adverse self-limited local
In addition to bovine or porcine sources, collagen reactions (Moody and Sengelmann 2000).
can be derived from human cadavers. Data is Adverse reactions after pretesting appeared only
available for two products: Dermalogen and as mild, nontender erythema. Acute or severe
Cymetra. Both products derive from pooled reactions like allergic ulcerations or chronical
human cadaverous tissue from accredited tissue granulomatous reactions were not reported in a
banks. Overcorrection is recommended by the nonsystematic review (Fagien 2000). Case
manufacturer. Here again the available data on the reports describe acute choroidal infarction fol-
efficacy and safety of the product are limited. lowing the subcutaneous injection of allogenous
Cymetra was tested against Zyplast in a small ran- collagen in the forehead region (Apte et al. 2003).
domized controlled trial. A total of 47 patients
were treated: 20 received Cymetra and 27 received
Zyplast. Various photometric outcome measures Key Points
were used in this study, which favored the new • This overview is merely for academic
product over Zyplast (Sclafani et al. 2002a, b). reasons. The products to our knowledge
are either not widely used or not avail-
1.3.1.3.2 Collagen of Allogenous Nature able anymore.
(From Culture) • The quality of clinical data behind these
Later-generation noncadaverous collagen products products varied.
are Cosmoderm and Cosmoplast (Baumann 2004).
1.3.2 Hyaluronic Acid ference between the products could be estab-

lished. After 12 weeks the mean (±standard
After the bovine collagens, the emergence of dif- deviation) wrinkle severity score, which ranged
ferent hyaluronic acid preparations revolution- from 0 to 5, was 3.3 ± 1.11 for Hylaform and
ized the injectable filler market for three main 2.2 ± 1.12 for Zyplast (http://www.fda.gov/).
reasons: (1) no need for skin test, (2) better dura-
bility compared to the other available biodegrad-
able fillers, and (3) the availability of antidote Key Points
(hyaluronidase). • Hylaform is not available anymore.
Hyaluronic acid, which belongs to the family • The product was based on good clinical
of glycosaminoglycans, consists of repeated data.
disaccharide units. The hydrophilic properties of
hyaluronic acid attract water into the extracellu-
lar matrix and therefore increase the skin turgor.
Hyaluronic acid is gradually degraded. In order 1.3.2.2 Hyaluronic Acid of Bacterial
to increase the durability of the various hyal- Origin
uronic acid preparations, stabilization is usually HA preparations of bacterial origin dominate the
obtained by cross-linking mostly with market. They are quite a heterogeneous group
1.4-butanediol diglycidyl ether (BDDE). and sometimes quite confusing to differentiate as
Hyaluronic acids can be derived from avian or each company seems to have its specific wording
bacterial sources; each product has its own, spe- to make it look more different from another one.
cific characteristics. Basically they can be differentiated in prod-
ucts with good and in products with not-so-good
or even nil clinical data.
Key Points
• HA can be derived from different 1.3.2.2.1 Products with Good Clinical Data
sources. Most HAs derive from bacte- The Q-Med Restylane Family
rial origin. The Restylane family is the hyaluronic acid fam-
ily with the best evidence behind it. The reason
for that is as said before that after the bovine col-
lagens it became the gold standard for compara-
1.3.2.1 Hyaluronic Acid of Avian Origin tive trials in the USA.
Cross-linked hyaluronic acid of avian origin The first trial published was a randomized
became the first non-collagen filler to be widely controlled clinical trial conducted to compare the
used. However, it is not available anymore. The efficacy and safety of Restylane and Zyplast. A
Hylaform product family was based on hyal- total of 137 patients were included in the
uronic acid derived from processed rooster intention-to-treat analysis. After 6 months the
combs. The Hylaform product family, with an authors concluded that Restylane was superior to
average content of hyaluronic acid of 5.5 mg/ml, Zyplast (based on the assessment of the Winkle
was easy to inject due to its good rheological Severity Rating Scale). The superiority of
properties and is less palpable than some prod- Restylane (i.e., where the investigator felt that
ucts of bacterial origin (Manna et al. 1999). Restylane was more effective) was observed in
In 2003, data from a clinical trial comparing 56.9 % of their patients, compared to 9.5 %
Hylaform with Zyplast for the treatment of naso- patients in whom the investigator felt that Zyplast
labial folds was presented to the FDA. A total of was superior (p < 0.0001). Those patients in
480 patients were included in this study which, to whom there was no difference between these
our knowledge, was never published. Based on products (33.6 %) were not included in the sim-
the data that are available from the FDA, no dif- ple univariate statistics (Narins et al. 2003).
The Restylane family is sometimes described as The Belotero Family

biphasic HAs. What does biphasic mean? Basically This is a product that was produced by Anteis and
it is a cross-linked HA product that is formed in distributed by Merz, now with Merz having bought
particles which are enclosed by noncross-linked Anteis it is entirely in the hands of Merz. Like the
HA. As noncross-linked HA is degraded easily, the abovementioned products, we have at least one
initial achieved correction might not be as good as good clinical trial here (Narins et al. 2010c).
this has been shown in the Emervel Deep and
Teosyal Deep trials where the products were com- The Teosyal Family
pared to Restylane Perlane (Nast et al. 2011; Rzany Again here we have a product with at least some
et al. 2011). The particle size determines the indi- clinical data behind it (Nast et al. 2011).
cation. The HA products with smaller particles are
intended for more superficial use. 1.3.2.2.2 Products Without Good Clinical
Data
The Q-Med Emervel Family Most available HA products in Europe do not have
The Emervel family is differently designed. All at least one good clinical trial in their background.
products have the same HA content with 20 ng/ They pretend to be as good as the products without
ml. The products, however, are specified for their clinical trials. However, caution is advisable.
designated indications by the degree of cross-
linking and by the grade of calibration. Two good 1.3.2.2.3 Safety of HA Fillers
clinical trials exist comparing the efficacy and Hyaluronic acid is less allergenic than bovine
safety to the Restylane/Restylane Perlane prod- collagen. Skin testing is not recommended.
ucts (Ascher et al. 2011; Rzany et al. 2011). Although hyaluronic acids of human and of ani-
Furthermore, there is a unique case series where mal origins are identical in structure, immuno-
patients could be treated for a variety of indica- logical reactions in the recipient can be caused by
tions with a variety of the Emervel products residual proteins from the donor (avian or bacte-
(Rzany et al. 2012). rial antigens) or from the cross-linking process.
For the products with good clinical trials
The Allergan Juvéderm Family besides the RCTs, several larger case series about
This is a very large family too, offering products safety are available. Lowe et al. (2001) reported
for different wrinkles and volume indications. 709 patients who were observed for a minimum
Like for the Q-Med products, the evidence for of 1 year. Patients were treated with hyaluronic
some of the products from the Juvéderm family is acid of avian or bacterial origin (patient cohort,
excellent (Baumann et al. 2007; Lupo et al. 2008; follow-up study) between September 1996 and
Pinsky et al. 2008). September 2000. The overall incidence of late
inflammatory reactions (indurations, inflamma-
The Allergan Voluma Family (aka Juvéderm tion/erythema, abscess formation an average of 8
Voluma Family) weeks after injection) is given as 0.42 % (3 out of
These are the new products of Allergan. 709 patients). Friedman et al. (2002) retrospec-
Compared to the Juvéderm products, the Voluma/ tively reviewed the data of all unwanted effects
Volbella/Volift fillers are cross-linked with of nonanimal hyaluronic acid from the Restylane
shorter chains. Here we one good randomized family that were reported to the manufacturer
clinical trials and some cases series (Callan et al. between 1999 and 2000, worldwide (Europe,
2013; Jones et al. 2013). The Volbella case series Australia, South America, and Asia). For 1999,
is the case series on lip augmentation with the based on 144,000 treatments, the incidence was
longest duration (e.g., 12 months) (Eccleston and calculated at 0.15 %; for 2000, based on approxi-
Murphy 2012). Please note that as this is a newly mately 262,000 treatments, the incidence of
designed HA filler, no final conclusion on the 0.06 % was given. Since the incidences reported
overall tolerability and safety can be made. by Lowe et al. (2001) and Friedman et al. (2002)
are based on either patients returning to their decided to withdraw Hyacorp H-S 500, H1000,
private practice or voluntary reports, the real inci- and Hyacorp L from the European market (mail-
dence might be higher. ing to doctors using Hyacorp in August 2013).
In 2004, Andre evaluated the incidence of
adverse reactions with nonanimal, stabilized
hyaluronic acid between 1997 and 2001 using a Key Points
questionnaire-based survey. Out of 12,344 • Among the bacterial HAs, there is an
syringes sold and 4,320 treated patients, 16 cases easy way to distinguish between prod-
of immediate hypersensitivity and 18 cases of ucts with good clinical data and those
delayed reactions were recorded. The global risk without.
of sensitivity was calculated at 0.8 %. Since • If you use a product without good clini-
2000, the amount of protein in the raw product cal data, the risk for a not-so-good effi-
was decreased and the incidence of hypersensi- cacy or an increased risk of inflammatory
tivity reactions has been reported to be around reactions is with the patient and the
0.6 %. As 50 % of these reactions were immedi- treating physician.
ate and resolved within less than 3 weeks, the risk
of a strong but transient, delayed reaction is
around 0.3 %. Four cases of sterile abscess were
reported (Andre 2004). Again, although the data 1.3.3 Combination of Hyaluronic
were quite systematically assessed, an underesti- Acid with Other Substances
mation of the real incidence cannot be ruled out.
Further case reports that are available describe 1.3.3.1 Combination with Dextrans
in detail adverse reactions such as erythema, pru- The combination of hyaluronic acid, hydroxpro-
ritus, edema, urticae, and papulocystic nodules ylmethylcelluose and dextrans (dextranomers),
after injection with hyaluronic acid preparations marketed as Matridex, is thought to be more dura-
of various origins. Arterial embolization and exu- ble than other products. However, there is as yet
dative granulomatous reaction after treatment no good clinical data on its efficacy and safety.
with hyaluronic acid of avian origin have also How safe is the addition of dextrans to an HA
been reported (Fernandez-Acenero et al. 2003; preparation? Or how safe are the HAs which are
Lombardi et al. 2004; Lowe 2003; Lupton and combined with dextrans? We do not have good
Alster 2000; Micheels 2001; Raulin et al. 2000; clinical trials to answer these questions. However,
Shafir et al. 2000). In rare cases, a bluish discol- we do have some case reports focusing on adverse
oration might occur. This bluish discoloration reactions to these products (Huh et al. 2010;
may reflect a Tyndall phenomenon. Massone et al. 2009). One patient developed after
Not every product is similar. There appear to 5 weeks a delayed inflammatory reaction to
be products there with an increased risk of Matridex injected in the glabellar fold that lasted
adverse reactions. How are we able to detect more than a year. The patient was treated with oral
these products? Only by communicating adverse doxycycline and intralesional injection of triam-
reactions among colleagues and to the authori- cinolone acetonide; this resulted in almost com-
ties! In the Netherlands the sales of Hyacorp H-S plete resolution of the lesion (Huh et al. 2010).
and H1000 were temporarily stopped after sev- The second patient was a 43-year-old woman who
eral cases occurred with two products of the fam- complained of multiple, painful, reddish, nonul-
ily (Skipr. Tot nu toe 25 klachten over rimpelfiller. cerated, hard nodules on both cheeks and periocu-
Online in the Internet: http://www.skipr.nl/ lar regions 4 weeks after the injection of Matridex.
actueel/id12523-tot-nu-toe-25-klachten-over- Histopathology showed a diffuse suppurative
rimpelfiller.html [2012-10-25]). At the moment granulomatous reaction with the presence of mul-
(August 2013), these cases are still investigated tinucleate giant cells and many neutrophils involv-
by the Dutch authorities. However, the company ing the entire dermis (Massone et al. 2009).
1.3.3.2 Combination with Antioxidants

There are also HA products available where the Key Points
HA is combined with, e.g., antioxidants. No good • The efficacy and safety of alginates
comparative trial data exists for these products. were supported by a large case series.
Therefore, it is not clear if these added substances • At the moment the filler is not available
have any clinically measurable effect at all. any more.
Key Points
1.3.5 Poly-l-lactic Acid
• We do not have good clinical data on
HAs in a fixed combination with dex-
Poly-l-lactid acid (PLLA) is a synthetic biode-
trans or antioxidants.
gradable material. It has an unique collagen stim-
• Caution is therefore advisable as case
ulating quality. When injected into the dermis or
reports of adverse reactions have been
subdermis, it gradually stimulates collagen for-
reported.
mation and by this restructures the facial tissue,
making it a facial volumizer. This is a gradual
process, and the manufacturer recommends three
1.3.4 Alginates initial treatment sessions, each approximately
6–8 weeks apart. After the three initial treat-
At the end of 2009, a new filler, an alginate, ments, the results are supposed to last for up to 2
which derives from brown algae was introduced years and longer.
to the market. Based on the results of the initial This product comes as a powder and needs to
large cases series, the product looked very good. be diluted with sterile water several hours before
Erythema, swelling, and even hematomas seem injection. Although initially the recommended
to be less as for HA products (unpublished data dilution for PLLA was 3 ml, the current recom-
presented at IMCAS Paris 2010). mendation is to dilute it in a volume of 5–9 ml or
In contrast to other filler, the alginate could be more. Most colleagues add an additional 2 ml of
very easily injected. And this is probably what a local anesthetic to decrease injection pain. The
caused even experienced and trained injectors to correct recommendation from the SculpTraining
inject too much in nonclinical investigated areas Expert Group is 7 ml + 2 ml of a local anesthetic,
as the infraorbital hollow. making it a total of 9 ml. Furthermore, it is rec-
As some adverse events as nodule formation ommended to dilute the product at least 24 h
were reported specifically in areas as the infraor- before use. Even when administered using the
bital hollow and no antidote was available at that correct injection technique and the higher dilu-
time, the filler was removed from the market tion, in some cases the needle will block during
(Schuller-Petrović et al. 2013). the injection, at which point the syringe has to be
withdrawn and the plunger retracted until the
PLLA flows again.
Before 2010, studies on the efficacy and
safety of PLLA were based mainly on the treat-
Do’s ment of HIV patients with drug-induced lipoat-
• Watch out for this product. If reintro- rophy (Moyle et al. 2004; Perry 2004; Valantin
duced in the market, it could be (if an et al. 2003). Only case reports and case series
antidote is available) an interesting existed for the use of PLLA for aesthetic indica-
alternative in patients prone to erythema tions (Rzany et al. 2004; Woerle et al. 2004). In
and edema after HA fillers. 2010 a large clinical trial was published
comparing PLLA to human collagen (Narins
et al. 2010a) (n = 233). In this trial, at 3 months

already the superiority of this product was Do’s
shown compared to human collagen. The mean • Always dilute the PLLA with at least
number of treatment sessions required per sub- 5–7 ml at least 24 h before treatment.
ject was 3.2 in the injectable PLLA group com- • Add an additional 2 ml of a local anes-
pared with 2.6 in the collagen group. The mean thetic before injection.
(SD) volume of injectable PLLA used per ses- • Patients with severe elastosis might ben-
sion for both nasolabial folds was as follows: efit from a topical co-treatment with
session 1, 4.1 (1.1) ml; session 2, 3.5 (1.2) ml; 0.05 % tretinoin.
session 3, 3.3 (1.2) ml; and session 4, 3.5 (1.1)
ml. For human collagen, the mean (SD) volume
used per session was as follows: session 1, 3.1 Don’ts
(1.1) ml; session 2, 2.1 (1.1) ml; session 3, 1.9 • Do not inject PLLA too superficially in
(1.1) ml; and session 4, 1.7 (1.0) ml. Importantly elastotic or naturally very thin skin as
the correction with PLLA lasted over 13–25 otherwise you might end up with small
months. This is the reason why most patients superficial bumps.
preferred this product (Brandt et al. 2011). • Do not inject PLLA in hyperdynamic
However, the correction that could be achieved areas as the lips.
was less than you would see in HA trials • Do not inject PLLA in patients with active
(approximately 0.66–0.85 on a six-point scale autoimmune diseases as rheumatoid arthri-
– compared to approximately 1 on a five-point tis (see Chap. 8).
scale in HA trials (see above)) (Narins et al. • Do not inject PLLA in patients which
2010a). might be subject to interferon therapy (if
Nodule formation is the main adverse reaction foreseeable) – they might have an
of this filler. Based on the HIV-lipodystrophy increased risk for nodule formation.
data, granulomatous reactions, described as pal-
pable but invisible subcutaneous micronodules,
were observed in 22 out of 50 (44 %) patients. In
6 of these 22 patients, the nodules disappeared at Key Points
week 96. In that particular study, one vial of • This is a product where we have at least
PLLA was diluted in a volume of 3–4 ml (Valantin a one good clinical trial and several case
et al. 2003). series available.
The prevalence of nodule formation seems to • PLLA needs to be injected several times
be associated with the volume that was used for to obtain a clinically relevant result. At
dilution. We have some indirect evidence that least three treatment sessions should be
nodule formation can be reduced when an planed, each session at least 4–6 weeks
increased volume for dilution is used (Rossner apart from the other.
et al. 2009a; Schierle and Casas 2011). • PLLA has a volumizing effect through its
Nevertheless, nodule formation still occurs and unique collagen stimulation properties
was highest in the hands (12.5 %) and the cheeks and is ideal for the temples, the cheeks,
(7.2 %) (Palm et al. 2010). There are case reports and the restoration of the mandibular line.
of large solitary nodular masses, e.g., in the • PLLA does not provide immediate grati-
temporal region (Avery and Clifford 2010) as fication. Patients might be disappointed
well as abscess formation. However, nodule for- when they do not see an immediate
mation is in most patients temporary and will result. In case patients want PLLA and in
decrease over time (Sperling et al. 2010). addition an immediate result before the
Therefore, these nodules should not be too PLLA sessions, an HA might be injected
aggressively treated. followed by the PLLA injections.
1.3.6 Calcium Hydroxylapatite patients treated with CaHa for facial soft tissue aug-
mentation. In addition to mild bruising and swelling,
Calcium hydroxylapatite (CaHa) is made from no immediate side effects were observed. Sklar and
synthetically formed calcium phosphate pearls, a White (2004) reported five patients with complica-
procedure that is classified as bioceramics and tions after CaHa treatment. Three patients had pal-
involves the ionic bonding of calcium and phos- pable bumps, one had puffiness of the lower eyelid,
phate ions. When injected, they form a founda- and another patient developed a pink/white plaque.
tion within a matrix that allows the local cellular The two latter adverse events occurred when treating
infiltration of fibroblasts. The complex is avail- the tear trough area. The treatment period in that
able as a gel to allow easier application. The sub- study was 6 months. In a 6-month nasolabial fold
stance comes in 1.2-ml syringes and is injected trial of CaHa compared to human collagen, patients
through a 25- to 27-gauge needle. treated with CaHa reported more edema (73.9 %
Early studies focused on drug-induced lipoat- compared to 56.4 %) and had more ecchymosis
rophy in HIV patients (Comite et al. 2004; Silvers (63.2 % compared to 43.6 %) (Smith et al. 2007).
et al. 2006). However, due to the quest for an aes- Despite that, patients preferred CaHa compared to
thetic license in the USA, we do have now three the human collagen. CaHa has been also studied in
randomized controlled clinical trials, one against an open-label 6-month study in patients with skin
collagen (Smith et al. 2007) and two against hyal- types IV to VI (Marmur et al. 2009). No reports of
uronic acid products (Moers-Carpi et al. 2007; keloid formation, hypertrophic scarring, hypo- or
Moers-Carpi and Tufet 2008) focusing on the cor- hyperpigmentation, or other clinically significant
rection of nasolabial folds. Not surprisingly CaHa adverse events were recorded in this study compris-
was shown to be superior to human collagen in a ing 100 patients.
6-month study (Smith et al. 2007). For the com- The area where adverse reactions were quite
parison to the HAs, the picture is not as clear. The frequently reported in the beginning is the lip
larger study of the two 12-month studies did not area. In the study of Tzikas (2004), 7 out of 90
show a difference in the WSRS; the smaller study patients developed persistent visible mucosal lip
favored in the WSRS the CaHA-treated site nodules, 4 of whom required an intervention.
(Moers-Carpi et al. 2007; Moers-Carpi and Tufet The treatment period for this study was also 6
2008). Patient preference and satisfaction with months. Furthermore, there are reports of CaHa
treatment favored CaHA (however, one has to note causing arterial occlusion leading to local necro-
that neither study was double blind; therefore, a sis or even blindness (Kim and Choi 2013; Sung
bias might favor the treatment under study). CaHa et al. 2010).
comes without lidocaine. In another RCT on 50
patients who received CaHa injections in the naso-
labial folds, patients favored the site which was Do’s
treated with a CaHA lidocaine mixture (Marmur • Dilute CaHa with lidocaine before
et al. 2010; Grunebaum et al. 2010). injection. Adding 0.2 ml of lidocaine
In contrast to the other fillers, CaHa is visible hydrochloric acid (HCL) to the 1.2 ml of
on x-rays. According to Feeney et al. (2009), CaHa should be sufficient. This is done
hydroxylapatite is hyperattenuating on CT, hyper- through a Luer Lock connector. On one
metabolic on FDG-PET imaging, of intermediate side is the CaHA syringe and on the
signal intensity on MRI, and by this a potential other side a syringe with 0.2 ml of HCl.
cause of a false-positive findings. Patients should In the next step, the content of both
be informed of this so that they can tell their doc- syringes will be mixed. N.B. in case a
tors should they require an x-ray or another premixed combination of CaHA and a
sophisticated radiological examination. LA might become available the separate
There is not much evidence for common adverse dilution of CaHa with lidocaine will not
reactions to this filler. Sklar and White (2004) and be necessary any more.
Tzikas (2004) reported case series with 64 and 90
1.4 Nonbiodegradable Fillers 11
Table 1.2 Nonbiodegradable fillers

Don’ts Material Origin Productsa
• Do not inject CaHa too superficially. If Silicone – ADATO SIL-ol 5000,
you do this, you will end up with visible Bioplastique, Biopolimero,
lumps and an unhappy patient. Dermagen, SILIKON 1000
Silicex
• Do not use this product for lip augmen-
Polyacrylamide – Amazingel, Aquamid,
tation. Nodules due to the mechanical Argiform, Bioformacryl,
accumulation of the material have been Evolutionb, Outline
reported. Polyalkylimide – Bio-Alcamidb
• In case of severe pain, blanching, or a
Please note that this list is not complete
visual disturbances, do not continue b
Not on the market anymore
with the injection of CaHa. These might
be signs of arterial occlusion. account. First, patients of all ages can be treated
in aesthetic medicine. It may therefore be quite
uncertain how a permanent depot will appear
after three or even four decades, by which time
Key Points age and solar-induced elastosis has reduced the
• CaHa is a biodegradable filler with a dermal and epidermal layers. Second, there is
good scientific background on its effi- always a possibility of adverse reactions to fillers.
cacy and safety. The most common subacute or late reaction to
• It comes with a 25- to 27-gauge needle permanent fillers is the development of a granu-
and needs to be injected deep dermal or loma. Treatment of an adverse reaction to a filler
subdermal. material is much more difficult when the filler is
• Diluting it with lidocaine will increase nonbiodegradable because it will provide a per-
the injectability and decrease injection manent stimulus for the surrounding tissue.
pain. In order to ensure patient satisfaction, they
• For the first couple of weeks, it might should be thoroughly advised about the pros and
feel a bit lumpy. Afterward, it will be cons of the suggested treatment with a nonbiode-
nicely integrated in the surrounding gradable product. We would not generally rec-
tissue. ommend the use of nonbiodegradable fillers at
• Please do not forget that there is no anti- the first visit for patients who have never been
dote in case of overcorrection or arterial treated before with a filler. Patients who are inter-
occlusion. ested in being treated with a nonbiodegradable
• Besides of the rate occurrence of arterial filler should first be preinjected with saline or a
occlusion, the use of this product seems biodegradable filler to ensure that they are satis-
to be quite safe. fied with the correction result.
1.4.1 Silicone
1.4 Nonbiodegradable Fillers
Injectable silicone is one of the oldest injectable
Several nonbiodegradable fillers are or were filler materials used. Medical-grade silicon is a
available (Table 1.2). As well as being expensive, clear, oily, colorless liquid composed of long
frequent injections can be quite tiresome for both chains of polymerized dimethylsiloxane.
the patient and the physician, and so the applica- There are several methods of injection for this
tion of a nonbiodegradable or permanent filler product. One of the recommended techniques is
holds a certain attraction. Conversely, there are the microdroplet technique (Orentreich 2000;
certain disadvantages that should be taken into Webster et al. 1986). Fluid silicone is injected
into the dermis as 0.01 ml microdroplets. Each 1.4.2 Polyacrylamide

mircodroplet is separated by 1 mm.
Undercorrection is recommended as the main Polyacrylamide (trade name, e.g., Aquamid) is
side effect is a foreign body (fibrotic) reaction. composed of 97.5 % water and 2.5 % cross-
Despite being touted by many authors as the linked polyacrylamide. It is recommended for
ideal augmentation material, silicone – especially folds, skin sculpturing, and facial atrophy. It is
of questionable sources – has led to some disas- not effective for fine wrinkles. Aquamid should
trous local and systemic effects. In general, the be injected deeply using the subcutaneous tun-
inflammatory reaction surrounding injected sili- neling technique (Breiting et al. 2004; De Cassia
cone is self-limited; however, the extent of the Novaes and Berg 2003). In contrast to the last
reaction is unpredictable and in some cases can be edition when the evidence was very limited, we
quite severe. Local adverse reactions include can look back now to a couple of clinical trials
chronic inflammation, migration, extrusion, ulcer- on this substance (Narins et al. 2010a). This
ation, and silicone granuloma formation. Once large trial (n = 315) compared a polyacrylamide
these complications are recognized, removal of filler to an HA (NASHA) filler over a period of
the injected silicone is quite difficult, necessitat- 12 months. In this study after 6 months and even
ing wide tissue resections and complicated recon- 12 months, the degree of correction was compa-
structions (Homicz and Watson 2004). rable with approximately 2 points on a six-point
Although the quality of the product in terms of scale.
purity has improved significantly in the last Which adverse reactions can appear? In the
decades, a significant number of adverse events small pilot study by De Cassia Novaes and Berg
as granulomatous reactions, infection, ulceration, (2003), aside from mild to moderate immediate
and migration have been published (Ersek et al. redness, swelling, and pain, which dissipated in
1997; Ficarra et al. 2002; Rapaport et al. 1996; less than 36 h, no long-term side effects were
Requena et al. 2001). The frequency of these observed. In 2004, Breiting reported the results
reactions is not known. In a chart review of 916 of a retrospective case series of 104 patients,
patients treated with 1,000-centistoke silicon oil, from which 49 had undergone breast augmenta-
very few adverse events were documented. tion. Migration of the gel was demonstrated in
However, this was a retrospective chart review three women who had their nasolabial folds
without contacting the treated patients (Hevia treated. No long-term adverse effects were
2009). Therefore, the paper is only of limited observed in this study, which reported an aver-
help for assessing the real risk of this product. age observation time of 3.9 years (Breiting
Nevertheless, silicone oil was and still is used et al. 2004).
inside and outside the USA. In a recent paper by In 2003, Wang published a case series of 15
Fulton and Caperton (2012), even a self-mixed patients with adverse reactions assessed over 2
HA-silicone filler was investigated in a larger years and reported the following: nodules (80 %),
case series. Again, as this was a small study, pain (60 %), secondary deformity (20 %), dis-
every conclusion on risk is limited. comfort (13 %), and long-lasting swelling
(6.6 %). Pathologic examinations showed macro-
phagocyte infiltration (60 %), capsule formation
Key Points (53.3 %), and granulomatous reactions (20 %;
• The risk profile even of highly purified Wang et al. 2003).
silicone is still not clear. At least by Christensen and colleagues these
• Better clinical data is necessary for a reactions are associated with biofilm formation,
final conclusion on this controversial and antibiotic treatments are recommended
product. (Bjarnsholt 2009).
1.5 Combination of Nonbiodegradable and Biodegradable Fillers 13
removable when injected in larger volumes

Do’s (Protopapa et al. 2003).
• Before injections, disinfect the skin In 2003 (Protopapa et al.), in 73 patients
thoroughly. follow-up examinations were carried out for up
• In case of an adverse reaction against to 3 years. No implant dislocation, implant
polyacrylamide and a bacterial infec- migration, granuloma, allergic reaction, or
tion is suspected, there is no harm in intolerance was recorded. However, in a retro-
following the therapeutic recommen- spective Dutch study on 3,194 patients, 154
dations from Bjarnsholt et al. (2009), complications were reported, the most common
e.g., clarithromycin 500 mg and moxi- being inflammation, hardening, as well as
floxacin 400 mg, twice daily for 10 migration (Schelke et al. 2009). The authors
days. conclude that the prevalence of these reactions
is too high and that the use of the product can-
not be recommended. Similar conclusions were
drawn from a British group of surgeons when
Don’ts reviewing 67 patients with HIV-drug-associated
• Do not overcorrect. lipoatrophy who had all been treated with poly-
• Do not inject polyacrylamides to super- alkylimide where 50 % of the treated patients
ficially specifically in patients with elas- experienced at least one complication (migra-
totic skin. The injected material might tion, hardening, irregularity) (George et al.
look lumpy. 2012). These results were supported by a
Canadian group where in 19 % of 267 patients,
infectious complications were noted (Nadarajah
et al. 2012). At the moment, the product is not
Key Points available in Europe anymore.
• These are permanent products. For
example, in case of overcorrection or
adverse reactions, some difficulties Key Point
might arise. For abscess-like reactions, a • This is a product without good clinical
course of antibiotics is recommendable. data. It is not on the market anymore.
• In contrast to other filler, we do have at The product was removed due to an
least some good clinical data here. increase risk of adverse reactions.
1.4.3 Polyalkylimide
1.5 Combination of
Polyalkylimide was available as Bio-Alcamid. Nonbiodegradable and
It consists of alkyl-imide group networks Biodegradable Fillers
(approximately 4 %) and water (approximately
96 %). The product was available at two differ- Some fillers are a combination of nonbiodegrad-
ent viscosities for lip and facial augmentation able (permanent) and biodegradable (temporary)
and is used for folds, skin sculpting (including materials. The purpose of the biodegradable
the lips), and facial atrophy, but not for the treat- material is to act as a carrier and to ensure an
ment of fine lines. The material must be injected immediate effect until the fibrotic foreign body
subdermally and, according to the manufactur- reaction induced by the nonbiodegradable filler
er’s information, is supposed to be easily leads to visible effects (Table 1.3).
Table 1.3 Combinations of permanent and temporary materials

Temporary Permanent Productsa
Collagen (bovine) Polymethylmethacrylate Artecoll/ArteFill
Hyaluronic acid (from cell cultures) Hydroxyethylmethacrylate Dermalive, Dermadeepb
a
Please note that this list is not complete
b
Not on the market anymore
1.5.1 Polymethylmethacrylate 1993 and in 0.5 % of reported cases in 1994. The

and Collagen overall complication rate in 1994 was 3 % (6 out
of 201 patients). In addition, an acute allergic
The combination of polymethylmethacrylate reaction was reported in one woman. Based on
(PMMA) and collagen (ArteFill (former prepara- data from the manufacturer, the rate of granulo-
tion Artecoll)) was introduced at the end of the matous reaction was given as 1 in 1,000 patients.
1980s and is the oldest available combination Nodules did arise 6 months to 2 years after treat-
preparation. PMMA beads are suspended in a ment. Again, as this data relies on spontaneous
solution of 3.5 % bovine collagen (as a carrier) reports, underreporting is likely to have occurred.
and 0.3 % lidocaine (for pain relief). While the This product is under the name of ArteFill, the
collagen resorbs over a period of 2–3 months, the only permanent product available in the USA so
PMMA spheres become encapsulated by fibrotic far. Based on the clinical study that led to the
material. approval of that product and comprised 251
ArteFill should be injected into the lower patients who were followed over 1 year, the risk
third of the dermis with a 26- to 27-gauge nee- for adverse reactions in the observed period is
dle using the tunneling technique. The mate- low (Cohen and Holmes 2004). Even when fol-
rial should not be injected too superficially; the lowed over further 4–5 years, the risk remained
needle should never be visible through the skin. low (Cohen et al. 2006). However, as the product
Careful massage with a fingertip after applica- is permanent, adverse reactions might develop
tion helps to distribute the material more evenly. after years (Zielke et al. 2008). Furthermore, 251
Overcorrection is not advisable; however, a patients are not enough to detect rare events.
second implantation may be necessary after 3 Therefore, the product still needs to be closely
months (Lemperle et al. 2003). Although the monitored.
preparation contains collagen, in Europe, a skin
test is not mandatory.
This is the only permanent filler that has been Do’s
subject to a large clinical trial (Cohen and Holmes • Be careful when you inject this product.
2004). Based on this clinical trial data, the efficacy Disinfect the skin thoroughly and do not
and safety have been proven for a 12-month period. inject too much in one spot.
Granulomatous reactions are well-known
complications for this filler (Alcalay et al. 2003).
The retrospective case series by Lemperle et al.
(1998) is based on 515 questionnaires from 290 Key Points
patients treated between 1993 and 1994. • This is one of the few permanent products
Immediately after PMMA implantation, swell- that have been subject to a clinical trial.
ing, redness, and itching were reported. Late • Be aware that this product as other per-
reactions such as erythema, transparency, uneven- manent products has a risk of increased
ness, and dislocation have also been documented. foreign body reactions. Patients should
Longer-lasting redness after Artecoll implanta- be aware of that.
tion was reported in 6.1 % of reported cases in
1.7 General Approach to New Fillers 15
1.5.2 Hydroxyethylmethacrylate
and Hyaluronic Acid Don’ts
• We would not recommend using this or
Hydroxyethylmethacrylate (HEMA) and ethyl- a similar product in patients.
methacrylate microspheres suspended in hyal-
uronic acid were available in Europe as Dermalive
since the end of the 1990s until 2007. This prod-
uct consisted of 40 % bacterial hyaluronic acid Key Points
and 60 % acrylic hydrogel particles (diameter of • This product had a bad efficacy/safety
45–65 μm). A similar formulation with larger- ratio. Adverse events as nodule forma-
sized particles (about 85–110 μm) and a some- tion were not infrequent and very diffi-
what higher hyaluronic acid content was cult to treat (see Chap. 8).
marketed as DermaDeep and was intended to be • Although the product is not on the mar-
injected deeper. ket anymore, we still do see adverse
Dermalive was supposed to be injected with reactions against it. Therefore, it is still
a 27.5-gauge needle into the deeper layers of important to know the product.
the dermis, at the junction between the dermis
and the hypodermis, with the tunneling tech-
nique, while DermaDeep was supposed to be
injected with a slightly bigger needle (26.5 1.6 Combining Different Fillers
gauge) deeper into the subperiosteal layer or in One Area
the hypodermis. Overcorrection was to be
avoided. At least 3 months should be left Nonbiodegradable and biodegradable products
between two injection sessions (Bergeret- may be combined by the injector in one area, but
Galley et al. 2001). should this be done? This question raises some
This product was probably the product with controversy. For example, with PLLA, where the
the highest risk of adverse reactions to inject- onset of efficacy may be delayed, combination
able fillers (Rossner 2009b). Early after the with another biodegradable filler such as hyal-
introduction to the market, case reports uronic acid might improve the patient’s satisfac-
became known focusing on nodule formation tion. On the other hand, if an adverse event
to HEMA (Requena et al. 2001; Waris 2003). occurs, the culprit filler might be much more dif-
Besides nodule formation, abscesses as well ficult to identify. Nevertheless, the combination
as ulcerations are part of the adverse reactions of different fillers in one area does not necessar-
spectrum of this product (Zielke et al. 2008). ily increase the risk. Only 8.9 % of patients with
In 2001, Bergeret-Galley published an over- adverse reactions to injectable fillers from the
view in which the overall incidence of late Berlin registry reported an individual combina-
side effects and complications (nodules, swell- tion therapy. Nevertheless, since good epidemio-
ing, and erythema, on average 6 months after logical data is lacking, we would recommend
injection) based on data from the manufac- using extreme caution when combining fillers of
turer is given as <1.2 per 1,000 patients different origin for the same indication.
(Bergeret-Galley et al. 2001). As the data from
the manufacturer is based on spontaneous
reports and with this being an early study, e.g., 1.7 General Approach to New
with a limited observation period, the real Fillers
incidence will be higher.
Although this product is not produced any- Especially in Europe, South America, and Asia,
more, we will very likely see further adverse new injectable fillers are popping up like daisies.
reactions to this permanent product. CE certification is the official way to introduce a
new product onto the European market, but data

from clinical trials are not required for a new Key Points
filler if comparable filler substances are already • Ask for good clinical data before you
on the market. As such, no clinical data on effi- use a new filler. As good as Restylane or
cacy and safety exist for most of the new inject- Juvéderm is not enough. You should ask
able fillers. for clinical data depicting efficacy (does
Users should thus be cautious in embracing the filler do the job?), durability (how
new products. Marketing approaches tend to long does it last?), and patient’s percep-
include claims of durability and safety for biode- tion (did the patient like the product?).
gradable and nonbiodegradable products that
may not stand the scrutiny of a clinical trial or
postmarketing safety studies. Good data on effi-
cacy and safety should be requested by every user References
to prevent patients being used as guinea pigs for
companies that are reluctant to invest in clinical Alcalay J et al (2003) Late-onset granulomatous reaction
trials. to Artecoll. Dermatol Surg 29(8):859–862
Fortunately there is a tendency for improve- Andre P (2004) Evaluation of the safety of a non-animal
stabilized hyaluronic acid (NASHA – Q-Medical,
ment, although at the moment most studies are Sweden) in European countries: a retrospective study
being carried out in the USA. In general, it is from 1997 to 2001. J Eur Acad Dermatol Venereol
advisable not to conduct studies in only one 18(4):422–425
country but to place clinical trials in Europe or Apte RS et al (2003) Acute choroidal infarction following
subcutaneous injection of micronized dermal matrix in
South America, for example, to acknowledge the forehead region. Retina 23(4):552–554
cultural differences and provide a broader and Ascher B, Bayerl C, Brun P, Kestemont P, Rzany B,
better base for regulatory decisions. Poncet M, Guennoun M, Podda M (2011) Efficacy and
safety of a new hyaluronic acid dermal filler in the
treatment of severe nasolabial lines – 6-month interim
results of a randomized, evaluator-blinded, intra-indi-
Do’s vidual comparison study. J Cosmet Dermatol
• If a new filler is introduced to you, ask 10:94–98
Avery C, Clifford N (2010) Foreign body granulomatous
for clinical data. A randomized con-
reaction of the temporal region following dermal filler
trolled clinical trial against an estab- administration. Br J Oral Maxillofac Surg 48(6):488,
lished HA would be the best base. Epub 2010 Jul 7
However, a large case series, e.g., 50 Baumann L (2004) CosmoDerm/CosmoPlast (human bio-
engineered collagen) for the aging face. Facial Plast
and more patients, can also give you
Surg 20(2):125–128
some important information on efficacy Baumann LS, Shamban AT, Lupo MP, Monheit GD,
and safety. Thomas JA, Murphy DK, Walker PS, Juvéderm vs.
Zyplast Nasolabial Fold Study Group (2007)
Comparison of smooth-gel hyaluronic acid dermal fill-
ers with cross-linked bovine collagen: a multicenter,
double-masked, randomized, within-subject study.
Don’ts Dermatol Surg 33(Suppl 2):S128–S135
• Do not believe everything the marketing Bergeret-Galley C et al (2001) The value of a new filler
guys from the company will tell you. material in corrective and cosmetic surgery:
Dermalive and Dermadeep. Aesthetic Plast Surg
Ask yourself if being “made in 25(4):249–255
Germany” or “Switzerland” is enough Bjarnsholt T, Tolker-Nielsen T, Givskov M, Janssen M,
to make it a good filler. Christensen LH (2009) Detection of bacteria by fluo-
• Do not start to treat tricky areas with a rescence in situ hybridization in culture-negative soft
tissue filler lesions. Dermatol Surg 35(Suppl 2):1620–
new filler, e.g., the tear trough and lips 1624, Epub 2009 Aug 26
are the second step. Brandt FS, Cazzaniga A, Baumann L, Fagien S, Glazer S,
Kenkel JM, Lowe NJ, Monheit GD, Narins RS,
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Fitzpatrick skin types IV to VI. Dermatol Surg Glogau R, Brandt F, Bruce S, Colen L, Dayan S,
35(Suppl 2):1641–1645 Jackson I, Maas C, Rivkin A, Sclafani A, Spivak JC
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Giovanna Brunasso AM, Cerroni L (2009) Foreign States of the safety and efficacy of a permanent 2.5 %
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Matti BA, Nicolle FV (1990) Clinical use of Zyplast in Narins RS, Coleman W, Donofrio L, Jones DH, Maas C,
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14(3):227–234 dermal filler using a cohesive polydensified matrix
Micheels P (2001) Human anti-hyaluronic acid antibod- technology is superior to bovine collagen in the cor-
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Moers-Carpi M et al (2007) A multicenter, randomized from a 6-month, randomized, blinded, controlled,
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Monstrey SJ, Pitaru S, Hamdi M, Van Landuyt K, niques for soft tissue augmentation. Clin Plast Surg
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Protopapa C et al (2003) Bio-Alcamid in drug-induced eign body reactions to a novel alginate dermal filler:
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Aesthetic Plast Surg 20(3):267–276 (Autologen) as a dermal filler: clinical observations
Raulin C et al (2000) Exudative granulomatous reaction to and histologic findings. Arch Facial Plast Surg
hyaluronic acid (Hylaform). Contact Dermatitis 2(1):48–52
43(3):178–179 Sclafani AP et al (2002a) Rejuvenation of the aging lip
Requena C et al (2001) Adverse reactions to injectable with an injectable acellular dermal graft (Cymetra).
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23(3):197–202 Sclafani AP et al (2002b) Homologous collagen disper-
Rossner F, Roßner M, Hartmann V, Erdmann R, Wiest sion (dermalogen) as a dermal filler: persistence and
LG, Rzany B (2009a) Decrease of reported adverse histology compared with bovine collagen. Ann Plast
events to injectable polylactic acid after recommend- Surg 49(2):181–188
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Dermatol 8(1):14–18 Plast Reconstr Surg 106(5):1215–1216
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(2009b) Increased risk of severe adverse reactions A (2007) Skin test hypersensitivity study of a cross-
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Selection of Patients
2
Mauricio de Maio

2.1 Introduction ................................................... 21
Patients’ perception of their needs and medical
2.2 General Rules ................................................ 22
diagnosis differs much more than we imagine.
2.3 The First Consultation.................................. 24 One important reason is that patients usually look
2.4 The Facial Thirds System ............................. 25 at themselves at the mirror in frontal view while
2.5 The Ideal Patient ........................................... 25
the observers (including the doctor) look at them
mainly in the oblique view. Differences in posi-
2.6 The Aging Patient ......................................... 25 tion and angles result in differences in prioritiza-
2.7 The Patient with Facial Imperfections ........ 26 tion of aesthetic needs for both patients and
2.8 The Patient You Do Not Want to Treat ....... 27 doctors. We also find differences in treatment
planning among doctors which may lead to con-
2.9 The Dysmorphic Patient ............................... 28
fusion to patients if they happen to consult more
References ............................................................... 28 than one injector for the same indication.
Differences in experience, problems in commu-
nication, and to a large extent limitation in injec-
tor’s technical skills represent the main reasons
for discrepancy in treatment planning among dif-
ferent doctors. For example, the reasons that
some injectors will not suggest volume replace-
ment in a patient with severe sunken temples
include (a) the unawareness of the patient of this
indication which therefore remains unrequested
and/or (b) the doctor’s inability to give a proper
diagnosis, technical deficiency, and lack of expe-
rience to predict whether the diagnosis, tech-
nique, and product will lead to a result that will
finally make the patient happy! Cultural aspects,
poor training in medical/patient communication,
and lack of time or patience to educate patients
are further barriers to obtain more efficient results
(see also Chap. 4).
Technical ability is fundamental for good
medical practice, but the correct selection of

22 2 Selection of Patients
patients is mandatory. Physicians who would like has to find a compromise between the expecta-
to successfully practice aesthetic medicine must tions of the patient and what is feasible.
understand that the vast majority of patients are Patients are prone to ask for procedures that
unaware of what they really need (see above). they have heard of or read about in lay maga-
They know (hopefully) what they want; however, zines. For example, it is quite common for
it is the physician who has the knowledge of the patients to request treatment of nasolabial folds
anatomical base and the aging process and who with botulinum toxin A (BoNT-A) only because
this product is widely advertised. In most cases,
however, injection of BoNT-A into the nasolabial
Do’s
fold would result in an unhappy patient because
• Do take time to educate your patient
this would have little effect on the depth of the
about the benefits of the treatments that
fold. Understanding patients’ complaints and
you believe are important to them.
educating them according to their needs will
• Do try to overcome the barriers that
minimize patient dissatisfaction and increase
block you to obtain more efficient treat-
patient retention.
ments. Long-term patient retention will
Patients with multiple needs and requesting
depend on that.
immediate results are legendary. The first consul-
tation is very important, as it gives the physician
the opportunity to establish the kind of patient he
Don’ts
will be treating. Uncompromising patients, for
• Do not automatically deliver what the example, are best avoided. Dissatisfaction with
patients are asking for. They may have a prior aesthetic procedures is one of the most
wrong perception of their needs. important points to be evaluated. It is therefore
mandatory to conduct a thorough examination of
their past history, which should include any prior
cosmetic procedure, and how the result was per-
Key Points ceived by the patient. Depending on the answer,
• All injectors will sooner or later be able the practitioner can evaluate the patient’s percep-
to deliver a satisfactory technical result. tion. Unrealistic expectations are another impor-
Long-term patient retention does not tant factor to be analyzed before starting with any
rely on delivering patients’ request only. treatment. Experience shows that sometimes it is
preferable not to treat a specific patient because,
whatever is done, dissatisfaction will invariably
result.
FAQs
• Why are some doctors reluctant to be
more active in indicating a procedure 2.2 General Rules
that the patient is unaware of?
Cultural aspects, problems in com- As mentioned before, the first consultation is
munication, lack of time or patience to very important for both the patient and the physi-
educate patients, the inability to perform cian. Before the advent of the digital camera, the
proper diagnosis, technical deficiency, physician would make a communicative effort to
and lack of experience to predict whether make the patient understand the limits of treat-
the diagnosis, technique, and product ments and, in particular, the limits of a specific
are the main reasons that prevent injec- treatment for a specific patient. The lack of
tors from being more active and efficient knowledge of the vast majority of patients would
in treating cosmetic patients. often make it difficult for them to truly under-
stand what the physician is telling them. Showing
2.2 General Rules 23
some before and after pictures could be useful in view and basically the signs that come with the
some cases but may be disastrous in others. Only aging process. So, a patient that was born with a
the best cases would be shown, and patients may distracting nose but is used to it since she was
gain an unreasonably positive impression of the born will most likely complain about the nasola-
results, since these results may not be achievable bial fold that became more prominent with aging
in their case. (and in the frontal view!). So, her nose is in the
Without the digital camera, it is particularly “blind spot” of self-perception. This is so true
hard to make patients understand the physi- that when a doctor, a relative, or a friend uncov-
cal limitations of certain procedures. Patients ers it, patients become aware and may decide to
often do not look at themselves in the mirror have that area treated. The “blind spot” also
in the proper way (they perceive themselves in affects the doctors’ ability to assess patients unbi-
a more frontal view). Patients unconsciously ased. These blind spots might be ethnic related.
correct any defects by smiling or changing the For a Caucasian doctor, wide, low, and flat noses
angle when facing the mirror. It is quite difficult may be considered distracting because he under-
for human beings to face differences in beauty stands that noses are expected to be high and nar-
and accept the aging process. If a woman was row as commonly found in Caucasians. That
quite beautiful when she was young, it is even means that low noses should be included in the
harder to accept that she cannot become that treatment plan of a patient. Some noses that are in
beautiful again, even after an invasive cosmetic the “blind spot” for Asian doctors are not for
procedure. Caucasian doctors. The same is found for the lack
After many years working with cosmetic of chin projection, mid-cheek deficiency, or
patients and also teaching injectors worldwide, prominent ears in Asians. In contrast, Caucasians
it became evident that there is a “blind spot” for are happy when they have only three to five wrin-
both patients and injectors when it comes to the kles in the crow’s feet area (where they may have
evaluation of facial features. Basically, cosmetic 15!) compared to a single wrinkle in a young
practitioners aim to beautify, correct, or prevent Asian female patient (that she considers distract-
aging signs. When assessing a patient, we may ing) which may be in the “blind spot” for a
use a simple quantitative scale that almost every- Caucasian doctor when prioritizing the treatment
body in the world is familiar with: 0–10. We for that patient.
may deliberately say that 0 (zero) is the worst
that someone may look at that specific age, eth-
nicity, and gender and 10 (ten) is the top, the Do’s
most desirable, and perfect human being that • Do analyze the structural and aging
exists on the planet. We dare say that no one will signs of your patient before establishing
be a zero or 10! But we can exercise and assess the treatment plan.
a patient and roughly and subjectively give a • Do take a mirror and/or digital photo-
grading in this scale. Even more interesting is to graphs when communicating with the
evaluate what upgrades and downgrades the patient.
overall grading. For instance, a 50-year-old • Take sufficient time for yourself and
woman may have a beautiful nose according to your patients when analyzing the facial
the beauty pattern of that specific community structures.
but may have an unfavorable lip. We may then
say that her nose upgrades her but her lips down-
grades her. Facial shape, proportion, eyebrows,
cheekbones, and so forth should receive the Don’ts
same rule. • Do not disregard yours and your
As discussed previously, patients are mostly patient’s ethnic background.
aware of problems that they see in the frontal
analyzed, and as such the practitioner should be

Key Points very sensitive towards their potential feelings.
• Remember the “blind spot”: patients It is interesting that it is usually the patient
usually complain about aging signs and him- or herself who points out what treatment is
they are blind to structural problems or required rather than the practitioner. It is also at
deficiencies. this point that some patients quickly change their
• Patients see what is in the frontal view, mind about what they want to treat and discrep-
while observers mainly see the oblique ancies that arise with regard to what was noted on
view. the consultation form and what is desired now
• If you want to give a “WOW” look to can be pointed out. This is the best opportunity to
your patients, try to enhance the facial enlist the patient’s trust and when we can begin to
aspects that are seen mainly in the point out what we can do to help the patient
oblique view. Make a test! improve.
• Ask your patients to look at the mirror The first consultation is also an important
or to look at their photos and ask them to moment to get in contact with the patient’s per-
describe what they see. You will be sonality. Anxious and very talkative patients may
impressed by the complete absence of affect our judgment and influence our decision. It
self-perception that most of them have. is also the moment to reflect the patients’ and
On the other hand, you may also find injectors’ blind spots. Initially, the patient’s moti-
some that are extremely accurate and vation has to be verified, followed by a systemati-
help you see details that were in the zation of the diagnosis process and the design of
injector’s blind spot! a consistent treatment plan.
Do’s
2.3 The First Consultation • Do take time to listen and observe your
patient in the first consultation. It is one
When patients come into the office, they usually of the most important moments to build
complete a consultation form in which they are up a long-term relationship with your
asked what they would like to be treated. In the patient.
next step, a complete past history should be • Do have time to think and design your
obtained and pictures taken in several positions treatment plan for your patient before
(frontal, oblique, profile), from both the static you both decide what is the best option
and dynamic points of view. Before the consulta- for them.
tion, the photographs are downloaded onto a
computer, and the physician and the patient go
through the consultation form and finally the
Don’ts
photographs themselves. It is important to tell the
• Do not let yourself be contaminated or
patients before the pictures are shown that
influenced negatively by your patients’
nobody likes this phase of the consultation but
anxiety or misperception of their needs.
that it is the most effective way of getting straight
to the point and that it will be helpful to make
them understand their needs. By following this
procedure, the consultation becomes more objec- Key Points
tive and time is not wasted. • The first consultation is the ideal oppor-
It is impressive how difficult it is for patients tunity to identify both patients’ and
to see themselves exposed in this way, particu- injectors’ “blind spots.”
larly when it is the own body that is being
2.6 The Aging Patient 25
2.4 The Facial Thirds System 2.5 The Ideal Patient
To ensure that patients understand their aesthetic The ideal patient is happy to listen to what the
problems, the face is divided didactically into the physician has to say. This patient is able to
classical three thirds: superior, medial, and infe- point out what is bothering him or her and is
rior. The patient will be informed that in the pro- willing to understand what steps must be taken
cess of the consultation, all of the positive and in order to reach the desired aesthetic improve-
less positive aspects of their face will be dis- ment. The ideal patient is able to balance the
cussed (it is recommendable that physicians positive and negative outcomes and therefore is
avoid the use of any negative word during the able to make the most suitable choice. It is clear
consultation). Any possible negative aspect to him or her that even minimum invasive pro-
should be balanced by some positive aspect in the cedures must be handled by experienced physi-
face. The physician should point out what must cians. The ideal patient discusses the type of
be treated and whether it is a surgical or nonsur- product to be injected and is concerned about
gical procedure that should be performed. In gen- adverse effects. When it comes to the duration
eral, saggy skin is treated with surgery, peels, or of the fillers, the ideal patient can understand
fractionated lasers, dynamic wrinkles with perfectly differences in degrees of permanence
BoNT-A, and wrinkles, folds, and volume loss when informed about the internal and external
with fillers. Patients start to realize what can be factors that may influence filler duration. The
treated with these different types of procedures ideal patient is willing to learn what can be
and what is needed to promote a real improve- done to maintain good results and what should
ment. Some patients cannot be subjected to all be avoided. It is perfectly understandable to
procedures due to either social or economic rea- him or her that the aging process is a continuing
sons. Depending on specific circumstances, the process and that there will be a need to return
intended procedures need to be discussed and for other procedures to maintain the aesthetic
their limitations pointed out. It is very important result.
to tell patients directly about the benefits and
limitations of each procedure that they will be
subject to. 2.6 The Aging Patient
The facial thirds system is very helpful to
structure the consultation so that no important The aging process happens to all people who
aspect on the face is overlooked (see also live long. This does not mean, however, that our
Chap. 4). patients are prepared for that. Women, in gen-
eral, are more likely to feel depressed by age-
related changes to their body. Saggy skin, deep
Do’s folds, wrinkles, and aging spots are some of the
• Do use the facial thirds system to struc- major signs that develop during this phase. It is
ture the consultation and to bring aware- hard to look at the mirror and at previous photo-
ness about the potential of the areas to graphs and realize that time has passed. It is
be treated. important to explain to patients that the aging
process is complex and it results from various
factors. If that is understood, patients may admit
that a single procedure is not enough to solve all
Don’ts of the disturbances that accompany the aging
• Do not forget to observe every detail process. It is easier if it is explained to the
during the facial thirds analysis. It will patients that the aging process derives from
be helpful for the treatment plan. intrinsic and extrinsic reasons. Extrinsic aging
results from environmental influences such as
sun exposure, smoking, and climate. Intrinsic

aging is influenced mainly by genetics. Asking FAQs
the patients what their parents look like makes • Why should we start treating our
them aware of the fact that what is happening to patients early when the problems are
them is natural. The most important information still mild?
that patients must be given is that nothing can Firstly, because at an early stage,
stop the aging process but that something can mild problems are easier to handle from
always be done to smooth the signs of aging. a technical point of view; secondly, the
The better they are, the better they can get. The quantity of product used and the total
sooner they start, the less invasive the procedure number of procedures to achieve satis-
will be. It happens very often with fillers. The factory results are lower when compared
deeper the fold is, the greater the number of to severe cases.
injections must be given. When I am asked • Why do older patients seem to be hap-
about duration, I advise patients that they are pier than younger patients with the
starting a recovery process and that they should results?
not let the wrinkles or folds get that deep again. Younger patients may become very
Patients must be told that when they are starting happy with our results, but some
a new procedure, they will have to come more younger patients in contrast will be
frequently during the first year and that it is pos- more demanding and are much less tol-
sible that the intervals between visits will erant to any not-so-perfect result. This
increase if they are to be properly treated. They might be even a barrier for some injec-
must be told that even with very good fillers, tors who finally may end up avoiding
there is no permanent miracle. The aging pro- treating younger and/or very attractive
cess is dynamic, and so, therefore, must be the patients.
procedures.
Do’s 2.7 The Patient with Facial

• Do remind yourself and your patients Imperfections
that the sooner the treatment is started,
the better the results will be. We are all quite asymmetric, and yet beauty is
defined by balance and symmetry. The vast
majority of patients that search for cosmetic
improvement may be neither symmetric nor bal-
Don’ts anced. Before initiating the consultation, it is
• Do not ignore the external and internal important to define as objectively as possible the
factors that might have influenced the evaluation of the patient’s physical attributes.
aging process. The patient should be examined in the anterior,
posterior, oblique, and profile positions. Static
and dynamic analyses are also important.
Key Points A patient’s imperfections may only be observed
• Aging is a continuous process that starts during dynamic analysis. It is usually quite impo-
from mild to moderate and may end up lite for the practitioner to start pointing out all the
severe or even finally very severe. imperfections that patients present. Here, a digi-
• We do not go to sleep looking young tal camera may play a fundamental role in pro-
and wake up looking old the following tecting the physician against being unkind to the
day. patient. As it is often said, a picture or a short
video in case of dynamic asymmetries says more
2.8 The Patient You Do Not Want to Treat 27
than 1,000 words. It is the patient who, when

looking at the picture, will see and describe what Do’s
he or she sees. This may be very difficult for • Do remember that with accurate assess-
patients, and the physician again should be gentle ment and proper technique, we may
and lead them to understand what can be done to help with injectables many patients with
improve their facial imperfections. It is not facial imperfections that are not eligible
uncommon that patients feel depressed when for surgery or do not desire surgery.
they look at their pictures.
The dialogue starts and the patient’s wishes
and expectations are evaluated. Patients with Don’ts
imperfections may say they want everything • Do not promise anything that you can-
changed; they feel themselves distorted, old, and not or are uncertain to deliver to patients
imperfect. Dividing the face into the aforemen- with facial imperfection. They may
tioned three thirds is useful for the physician to already be a victim of an inexperienced
focus on specific areas and ask the patient ques- or unethical injector.
tions such as: What do you see in your forehead?
Is there anything that bothers you there?
Questions like these help the physician to indi-
cate either surgical or nonsurgical methods. It is 2.8 The Patient You Do
also important to determine whether or not the Not Want to Treat
patient is open to a surgery or a nonsurgical pro-
cedure. Depending on the patient’s answer, the Bad candidates for cosmetic procedures may
physician may explain what result is achievable come from different economic, social, and ethnic
by surgical or nonsurgical methods. A patient’s backgrounds. The physician must be able to see
dissatisfaction arises mainly from promises made the red flags behind some patients at the first con-
by the physician that remain unfulfilled after the sultation. At this time the physician must evalu-
procedure. ate whether it is worthwhile recommending the
Patients should be told that there are imperfec- procedure or not. Patients with unrealistic expec-
tions that arise from the osseous structures and tations will invariably be dissatisfied with the
that it is hard to treat these with noninvasive results of cosmetic procedures. Extreme expecta-
methods. The practitioner should be experienced tions may lead to poor results. For the cosmetic
enough to establish whether the imperfections practitioner, some results may be considered
are from soft or hard tissues or from skin, fat, or excellent, but the patient may consider them
muscle. The combination of BoNT-A and fillers extremely poor. Patients may believe that a cos-
may solve many imperfections in the skin, fat, metic procedure will solve their personal prob-
and muscle. It is advisable to treat the imperfec- lems, such as the expectation of looking 30 years
tions step by step to perceive the gradual improve- younger, getting a new job, and improving their
ment. The physician may, based on experience, love life. Patients who have suffered any acute
start with the procedures that will produce the extreme psychological stress (e.g., the loss of a
most benefit for the patient. The patient’s confi- spouse) should also be avoided until they recover
dence grows and so will continue to allow other from it. Cosmetic procedures should not be con-
procedures. It is important to point out that bal- sidered as a compensation for life’s disappoint-
ancing both the static and dynamic aspects of the ments. Both the physician and the patient must
face involves more than simply filling a wrinkle agree with the expected final result; if not, it is
or fold. It is very rewarding for a physician to advisable to avoid the procedure.
realize that the patients with unusual cosmetic Patients are sometimes reluctant to hear what
imperfections that they have treated feel much they are being told; they are considered poor lis-
better after the procedure. teners. Patients with deficient communication
skills are also undesirable candidates. The under-

standing of possible adverse events and compli-
cations is very important. Poor listeners do not
tend to hear topics like these. They must be
encouraged to repeat what the likely result is and
the risks of any procedure. Care should also be
taken with manipulative, indecisive, impulsive,
and hysterical patients. Other patients to be
avoided are those who are obsessively concerned
with some aspects of their appearance; they may
be dysmorphic.
Fig. 2.1 Dysmorphic patient. The patient perceived her

Do’s lips as too small and requested a touch up. Please note the
small excoriations on the patient’s cheek, which are con-
• Do give yourself the right NOT to treat a sistent with the features of acne excoriée, a neurotic skin
patient that you are not comfortable disease
with. There will always be the right
patient for the right injector. Refer them! result they are looking for cannot be obtained
by him.
Don’ts Don’ts
• Do not treat patients that have suffered • Do not try to compensate dysmorphic
from an acute psychological stress until patients with cosmetic procedures. It
they have recovered. will usually not work well.
2.9 The Dysmorphic Patient Key Points

• If your assessment differs considerably
Patients with dysmorphism are those obsessively from the assessment of a patient (e.g.,
preoccupied with real or imaginary defects. They the lip looks normal to you; for the
may even take the mirror to point out a defect patient the lips looks disastrously
that has not been noted by the physician. In gen- wrong), be very careful. It might be a
eral, those defects are minor but are perceived patient who suffers from dysmorphism.
by them to be disfiguring. The inability to deal You will very unlikely be able to make
with unavoidable scars is also a warning that dis- this patient happy.
satisfaction may arise after the cosmetic proce-
dure. Some patients do have a real psychiatric
or emotional disorder. Patients with depression,
borderline personality, obsessive-compulsive, References
and narcissistic disorders should be avoided
(Fig. 2.1). Adamson PA, Kraus WM (1995) Management of patient
dissatisfaction with cosmetic surgery. Facial Plast
The physician should decline any patient that Surg 11(2):99–104
they consider to be a poor candidate, telling them Baker TJ (1978) Patient selection and psychological eval-
objectively, but, in a compassionate way, that the uation. Clin Plast Surg 5(1):3–14
References 29
Katez P (1991) The dissatisfied patient. Plast Surg Nurs and body dysmorphic disorder. Plast Surg Nurs 17(4):
11(1):13–16 193–197, 209
Lewis CM et al (1983) Patient selection and patient satis- Vuyk HD, Zijlker TD (1995) Psychosocial aspects of
faction. Clin Plast Surg 10(2):321–332 patient counseling and selection: a surgeon’s perspec-
Sarwer DB (1997) The “obsessive” cosmetic surgery tive. Facial Plast Surg 11(2):55–60
patient: a consideration of body image dissatisfaction
Requirements and Rules
3
Berthold Rzany and Mauricio de Maio
Contents 3.1 General Requirements

3.1 General Requirements ............................... 31
3.1.1 Introduction.................................................. 31 3.1.1 Introduction
3.1.2 Documentation ............................................. 31
3.1.3 Charts ........................................................... 31
3.1.4 Photographs ................................................. 32 To ensure a safe and efficient procedure, several
3.1.5 Consent ........................................................ 33 requirements must be met. The following list is not
3.1.6 Treatment Plan ............................................. 33 intended to give a complete overview, but to give
3.1.7 Staff .............................................................. 33
some tips on preparations that might be helpful.
3.2 Technical Requirements ............................ 34
3.2.1 Room............................................................ 34
3.2.2 Chair............................................................. 34
3.2.3 Mirror ........................................................... 34 3.1.2 Documentation
3.2.4 Small Things ................................................ 34
3.2.5 First Aid Kit ................................................. 34 A thorough documentation of all treatment-
3.2.6 Tips, Tricks and Key Points ......................... 35
related data is highly recommended. This not
3.3 The 13 General Rules ................................ 35 only is advisable for legal and billing reasons but
3.3.1 Introduction.................................................. 35 will help to improve your own performance and
3.3.2 Rule 1: Listen to the Patient ......................... 35
3.3.3 Rule 2: Fillers Are Only One Tool............... 35 consequently the patient’s satisfaction.
3.3.4 Rule 3: Talk About Money .......................... 36
3.3.5 Rule 4: Talk About Possible
Adverse Events ............................................ 36 3.1.3 Charts
3.3.6 Rule 5: Avoid Disturbed Patients ................. 36
3.3.7 Rule 6: Anesthesia (Treat with as Little
Pain as Possible!) ......................................... 37 The patient’s chart should include all neces-
3.3.8 Rule 7: Position (Keep sary information. It does not matter if the chart
the Patient Upright) ...................................... 37 is paper based or electronic. The only thing that
3.3.9 Rule 8: Use the Mirror/Digital Images ........ 37
3.3.10 Rule 9: Start with a Biodegradable counts is that the information in the chart is com-
Filler First .................................................... 38 plete and accurate.
3.3.11 Rule 10: Quantity of Filler (Do Not As with every chart, the patient’s iden-
Inject Insufficient Amounts) ........................ 38 tification data, gender, and age need to be
3.3.12 Rule 11: Quantity of Filler (Do Not
Inject Too Much).......................................... 38 documented first. In the next step, the reason
3.3.13 Rule 12: Use the Appropriate for the patient’s visit should be documented.
Depth of Injection ........................................ 38 Furthermore, at this step, the history of rel-
3.3.14 Rule 13: If Something Goes Wrong ............ 39 evant concomitant diseases (e.g., autoimmune
References ................................................................. 39 diseases), present relevant drug intake (e.g., the

32 3 Requirements and Rules
0 1 2 3 4
Very Thin Thin Moderately Thick Thick Full
Fig. 3.1 Validated Lip Fullness Grading Scale (Carruthers et al. 2008d; © Merz)
intake of acetylsalicylic acid!), and previous should be photographed frontal and at 90° and/
aesthetic procedures should be documented. or 45°. Standardization requires some effort,
In particular, all previous injections of fillers such as using a fixed setting or following stan-
should be thoroughly assessed. dard procedures. In addition to being useful as
Patients must be thoroughly examined. legal documentation, these photographs will help
Clinical severity can be assessed by using to improve your communication with the patient
clinical wrinkles and volumes scales as the Merz (see Chaps. 2 and 4).
Aesthetics Scales™ (Carruthers et al. 2008a, b, c, If you already have incorporated standard-
d, e (several publications) and 2012; Flynn et al. ized photographs in your practice, you may also
2012) (Fig. 3.1). consider taking the full set of photos in selected
Besides that, the treatment itself needs to be cases. There are five traditional positions as
documented. The product used, the dilution (if described above (frontal view, right and left
any), the injected areas, the depth of injections, oblique, right and left full profile) in variable
and the injected volumes should be logged. A situations such as angry, surprised, kissing, full
graphical sketch might be helpful, too. Special smile, chin down, and chin up depending on the
attention should be given to the “lot” number of type of treatment that is being carried out on the
the filler used because this identifies the produc- patient (Fig. 3.2).
tion batch and, in the event of adverse effects,
might allow the manufacturer to trace an entire
Do’s
batch.
• Do take photographs! You need them any-
Last but not least, the chart should always
way for the first consultation when the first
include the informed consent of the patient. If
steps of the treatment plan are laid out.
you use electronic medical records, the consent
should be scanned. For legal reasons, however, it
might be necessary to keep the original in a spe-
cific binder. Don’ts
• Do not worry if the photographic quality
is not as good as you want it to be. This
3.1.4 Photographs is not a photography contest but a tool
for patient communication and docu-
It is advisable to document the status of the mentation. A photo from your
patient before the treatment. If possible, the smartphone might be sufficient enough.
photographs should be standardized. Patients
3.1 General Requirements 33
Guidelines on before and after photography

At rest Smile Brow raised Frown Kiss Bend,eyes up Chin up, eyes up
Frontal
Right
oblique
Right
profile
Left
oblique
Left
profile
Fig. 3.2 Ideal baseline documentation of a patient’s full face (© de Maio and Allergan)
3.1.5 Consent recommended. A treatment plan allows realistic

planning, taking into account the patient’s and
The consent of each patient should be thor- the doctor’s perspectives (see Chaps. 2 and 4).
oughly documented. Patients should date and
sign a consent form for each new filler substance.
A patient information brochure that includes all 3.1.7 Staff
of the necessary information on the estimated
efficacy and possible adverse events should Staff needs to be trained in marketing, quality
accompany the consent form. control, and assistance. They should be aware of
the aesthetic procedures offered and should be
able to provide some information about the fill-
Don’ts
ers used. They are responsible for monitoring the
• Do not forget to also get the photo- patient’s chart and for ensuring that all necessary
graphic consent if you would like to use documents are available and signed by the patient.
the photos for educational purposes. And finally, the staff may help to apply topical
anesthesia, massage the area after the injection of
the filler, or add cooling before or after the injec-
3.1.6 Treatment Plan tion to reduce pain and swelling. Staff might also
assist with, makeup after the treatment, so that
When using fillers, which ususally require the patient leaves the clinic with no or little vis-
repeated injections, a treatment plan is highly ible signs of the procedure performed.
3.2 Technical Requirements 3.2.4 Small Things
3.2.1 Room A standard setting can prove useful to ensure that

all tools required are available. All required tools,
The procedure room should be brightly lit. Light listed below, should all be within reach.
from above might be helpful to detect even the • Patient information and consent forms
tiniest areas to be corrected. • Documentation material for source data (elec-
tronic or conventional charts)
• Handheld mirror
Do’s
• Camera (conventional or digital) for photo-
• Do provide good light for result evalua-
graphic documentation (an iPad or another
tion. Make sure your patient leaves the
tablet computer might prove to be very helpful
office assured that expectations have
here – or even an iPhone or another
been met.
smartphone)
• Gloves (unsterile gloves are usually
sufficient)
Key Points • Topical local anesthetic or syringe, cannulas,
• It is not uncommon that patients com- and/or needles with appropriate local
plain about results when they evaluate anesthesia
themselves at home under improper • Topical disinfectant (octenidine-containing
light conditions. solutions will be fine)
• Compresses
• The injectable filler, appropriate syringes,
3.2.2 Chair cannulas and/or needles
• Cool packs or precooled saline to soak the
For most procedures, patients should have a compresses
relaxed upright position to ensure that optimal • Cosmetic powder makeup powder to decrease
correction of the facial lines or volume deficits the visible redness after the filler injections
can be achieved. However, a more reclined posi- (this works for men too!)
tion might be helpful when treating more painful • Emergency kit (in case of an anaphylactic
areas such as the upper lip. In case of a vasovagal reaction towards the local anesthetic). Please
syncope – which occasionally might happen – note for some procedures such as high-volume
the chair should be adjustable, allowing an eleva- replacement (e.g., penile enlargement) more
tion of the legs. sterile conditions apply.
3.2.3 Mirror Do’s

• Do not forget to stack make up or cos-
Like the patient’s baseline digital photography, a metic powder. Your patients will be
mirror should be provided to ensure that patient– thankful if they can cover post-injection
doctor communication is optimal from the start. redness before leaving your practice.
The doctor should use the mirror to ensure that
patient and doctor are discussing exactly the
same areas to be treated and the grade of correc- 3.2.5 First Aid Kit
tion that is desired. When using the mirror, ask
the patient to point at the area where he or she Most injectable fillers have zero risk for systemic
wants the correction. This will reduce the risk of reactions. However, local anesthesia might cause
misinterpretations. anaphylactic reactions (fortunately very rarely),
3.3 The 13 General Rules 35
and it is possible for patients to collapse due to that have been treated in a similar way. However,
circulatory imbalance, for example, when treat- try to make it clear that every patient presents dif-
ing the upper lip area with insufficient local ferent responses and the patient must understand
anesthesia (Berkun et al. 2003). The first aid kit that the very same result is not applicable and it
should also include hyaluronidase which needs to is used mainly for patient education.
be used immediately after an inadvertent arterial
occlusion after an HA injection.
Do’s
• Do explain the potential of treatment of
Do’s areas that are not primarily requested by
• Do include hyaluronidase in your first your patient, but are important to aes-
aid kit in case you are treating with thetic balance of the face. Most of the
HAs. time, patients’ dissatisfaction results
from wrong perception or lack of proper
medical advice (see Chap. 4).
3.2.6 Tips, Tricks and Key Points
Most complaints from unsatisfied patients can Key Points

be attributable to insufficient communication • Check the legal aspect in your country
between the doctor and the patient. So please regarding showing other patients’
take your time to listen to the patient and make results. This may be seen as a “promise”
sure that you understand what the patient actually of result and may lead to legal issues
wants and not what you want to understand (see when not obtained.
also Chaps. 2 and 4).
3.3 The 13 General Rules 3.3.3 Rule 2: Fillers Are Only

One Tool
3.3.1 Introduction
Even when you are very enthusiastic about fill-
Working with injectable fillers can be extremely ers, do not forget that fillers are only one tool in
rewarding for both the patient and the treating aesthetic medicine. Do not treat indications with
physician if some simple rules are followed. fillers that might better be treated with another
These rules will be discussed more in depth in method. For example, BoNT-A is the first-line
other chapters of this book. treatment for wrinkles of the glabella; biodegrad-
able injectable fillers should come as a second
step in this area (see also Chap. 9).
3.3.2 Rule 1: Listen to the Patient
Patients and doctors are prone to the same ver- Key Points
bal misunderstandings as everybody else. In aes- • Some patients are reluctant to the use of
thetic medicine, the results may be disastrous if botulinum toxin due to negative media
the doctor misunderstands the patient. It is there- information. Proper patient’s education
fore very important to listen to the patient, to try is mandatory.
to understand what the patient really wants. If • Aging process is multifactorial and a
possible, use a digital photograph of the patient single tool cannot cope with the com-
as the basis for your discussions and also intro- plexity of it.
duce realistic pre- and post-photos of patients
3.3.4 Rule 3: Talk About Money 3.3.5 Rule 4: Talk About Possible
Adverse Events
The patient should have a clear understanding
of what he will have to pay for which treatment. Adverse events can occur with all fillers (see
If you use biodegradable fillers, make it clear Chap. 8). Make sure that patients understand
that for most patients, one treatment will not be what might occur without frightening them.
enough and that subsequent treatments will be
necessary to ensure a good result. It might be
Key Points
helpful to include the subsequent treatments in
• With the advent of longer-lasting bio-
the first cost estimation for the patient. Tell the
degradable fillers, the proportion of
patient, for example, “If you start with this pro-
patients suffering from adverse reac-
cedure (and you like it), you will need to have at
tions to nonbiodegradable fillers will
least two to three treatments over the following
decrease as nonbiodegradable filler will
12 months, which will cost you approximately
be used less and less. However, adverse
this amount of money per month.”
events will be always present.
• Adverse events might be patient related,
product related, and/or injector related.
Do’s
The triad of an inexperienced injector,
• Do explain to your patients what the products not evaluated in good clinical
benefits are of starting the treatments trials, and patients with present risk fac-
when the problems are mild to moderate. tors might multiply the risk of adverse
• Do make realistic estimations. If the or an unwanted reaction.
final bill is somewhat less than the initial • Patients need to be aware of a certain risk
estimate, patients will appreciate that. without being unnecessarily frightened.
3.3.6 Rule 5: Avoid Disturbed

Don’ts Patients
• Do not lure patients with unrealistically
cheap prize calculations. They will be Dysmorphia (see Chap. 2) exaggerates the nega-
disappointed when they discover at some tive implications of certain bodily features for
time point that they will need far more a patient. The patient shown in Fig. 2.1, for
money to achieve satisfying results. example, felt her lips to be particularly small and
requested a touch up to make the lips even bigger.
Patients with a dysmorphic disorder can make a
physician’s life miserable. Therefore, be very
Key Points careful if there is a disproportion between what
• Most of the difficulties when dealing the patient sees and what you can see. If you have
with patients’ budgets derive from the doubts, talk the patient out of the procedure (or
inability of the injector to thoroughly your office).
explain the benefits of the investment.
• The sooner we start, the less amount of Don’ts
product is needed and the lower the cost • Don’t try to apply the very same recipe
will be. to all patients. Patients must be analyzed
• Aesthetic financial planning is as much correctly in order to understand their
an art as it is to inject properly! motivation.
3.3 The 13 General Rules 37
should be seated in the upright position. If not,

Key Points the deficits or folds will be under- or even over
• Most of the time, dysmorphic patients corrected.
are impossible to please because their Some injectors feel more comfortable to
complaints are not realistic. inject the patient lying down than in an upright
position. This is helpful in reducing a vasovagal
syncope. But the evaluation of results is prefer-
3.3.7 Rule 6: Anesthesia (Treat with ably performed with the patient in an upright
as Little Pain as Possible!) position where the effect of gravity can be
verified.
You do not want a patient with tears running
down the cheeks. Using a filler which is pre-
Do’s
mixed with lidocaine (as most of the HA fillers
• Do evaluate your patient in the upright
are now [Monheit et al. 2010]) or mixing lido-
position to check if the treatment with
caine to a filler which otherwise might be painful
fillers or volumizer was effective.
(as hydroxylapatite) will reduce pain consider-
ably (Marmur et al. 2010). Pain can be further
reduced by topical anesthetics or local anesthesia
(see Chap. 5). Key Points
• Do not forget to evaluate the patient not
Do’s only in upright position but also in the
• Use lidocaine-containing fillers or add a leaning forward position (chin down –
local anesthetic to the filler. eyes up). If there is loss of correction in
• Usually a topical local anesthetic will be these positions, patients might not be
sufficient when a lidocaine-containing satisfied for a long time.
filler is used.
• For very pain-sensitive patients, a nerve
block might be considered. 3.3.9 Rule 8: Use the Mirror/Digital
Images
Using mirror and/or digital images will help your

Key Points communication with the patient: to plan the pro-
• Patients may be reluctant to undergo cedure appropriately, to increase the patient’s
cosmetic procedures due to bad experi- understanding of the nature and the possibilities
ences related to pain. of the procedure, and to ensure that the final effect
• Cosmetic experience must be pleasant is what the patient wants. Although most patients
and not a nightmare due to pain. do not want to watch the procedure itself, they
• Be especially cautious with novice are usually very interested in taking a look at the
patients. preliminary results. Showing the patient the half-
treated status will ensure that they acknowledge
the difference. The frequency of sentences like “I
3.3.8 Rule 7: Position (Keep the do not see any difference” may be reduced by this.
Patient Upright)
You might treat the patient in a supine position. Do’s

However, when gravity is likely to influence the • Do encourage the patients to look at the
depth of the wrinkles, for example, in the case mirror/digital images before starting the
of volume deficiencies or deep folds, the patient
understands that if he wants an optimal result, he

treatment and do ask them to clearly must make the according investment.
point out the areas that they consider to
be treated.
• With a small quantitiy of the the product Key Points
left in the syringe hand the patient the • One of the trickiest topics with inject-
mirror again and ask them what in their able fillers is the proper evaluation of
eyes still needs correction. It is a disaster the amount of product that patients may
if the patient has the final look in the mir- need to obtain optimal results. Duration
ror and sees something that, with an addi- is also affected by the quantity of fillers
tional 0.1 ml, could have been corrected. injected. The patient’s satisfaction is
directly influenced by immediate per-
formance and duration of results.
Key Points
• Women and mirrors are interesting to
watch! They are likely to start fixing the
(Do Not Inject Too Much)
hair and pursuing before they can really
focus and point out the distracting areas.
Too much filler is not a good idea either. You do
Another habit is to put down the mirror
not want a patient with large lumps of injectable
and avoid looking at it. Be aware of this
filler that can be seen or felt for weeks or even
and guide them gently back on track.
months.
3.3.10 Rule 9: Start with a

Biodegradable Filler First Key Points
• Over-injected patients are unpleasant to
If you have a patient who comes for a nonbio- look at especially on animation.
degradable filler, start with a biodegradable filler • Cheekbones and lips are two areas of
first. Injecting a nonbiodegradable filler at the frequent overtreatment.
first visit can lead to very unhappy patients, e.g.,
if the results are not what the patient expected.
3.3.13 Rule 12: Use the Appropriate
Key Points Depth of Injection
• The use of nonbiodegradable fillers was
frequent in the past due to the short dura- Not all fillers are intended for superficial injec-
tion of biodegradable fillers. Nowadays, tions. You can end up with very unhappy patients
high performance and long duration of if you inject a material that is designed for deep
biodegradable fillers have made “per- injections such as hydroxylapatite too superfi-
manent” fillers much less opted both by cially. This will result in papules and nodules that
injectors and patients. will take a very long time to go away.
Key Points
3.3.11 Rule 10: Quantity of Filler • In the past, we basically had “dermal
(Do Not Inject Insufficient fillers.” Nowadays, a greater variety of
Amounts) products are available on the market and
injectors must know beforehand what
Injection of insufficient filler will leave you with the correct level to inject is.
an unhappy patient. Make sure that the patient
References 39
3.3.14 Rule 13: If Something Carruthers A, Carruthers J, Hardas B et al (2008b) A

validated grading scale for marionette lines. Dermatol
Goes Wrong Surg 34(2):S167–S172
Carruthers A, Carruthers J, Hardas B et al (2008c) A
If something goes wrong, for example, the patient validated lip fullness grading scale. Dermatol Surg
is overcorrected or the patient has an adverse 34(2):S161–S166
Carruthers A, Carruthers J, Hardas B et al (2008d) A vali-
reaction to the injectable filler, be accessible and
dated grading scale for forehead lines. Dermatol Surg
understanding. Most lawsuits arise when the doc- 34(2):S155–S160
tor/patient relationship is dysfunctional. Carruthers A, Carruthers J, Hardas B et al (2008e) A vali-
dated brow positioning grading scale. Dermatol Surg
34(2):S150–S154
Key Points Carruthers J, Flynn TC, Geister TL et al (2012) Validated
assessment scales for the mid face. Dermatol Surg
• When something goes wrong, we must 38(2):320–332
not add distance and lack of care to Flynn TC, Carruthers A, Carruthers J et al (2012) Validated
patients. They have already the compli- assessment scales for the upper face. Dermatol Surg
cation to carry on their shoulders. 38(2):309–319
Marmur E, Green L, Busso M (2010) Controlled, ran-
domized study of pain levels in subjects treated with
calcium hydroxylapatite premixed with lidocaine
for correction of nasolabial folds. Dermatol Surg
36(3):309–315
References Monheit GD, Campbell RM, Neugent H et al (2010)
Reduced pain with Use of proprietary hyaluronic acid
Berkun Y, Ben-Zvi A, Levy Y et al (2003) Evaluation of with lidocaine for correction of nasolabial folds: a
adverse reactions to local anesthetics: experience with 236 patient-blinded, prospective, randomized controlled
patients. Ann Allergy Asthma Immunol 91(4):342–345 trial. Dermatol Surg 36(1):94–101
Carruthers A, Carruthers J, Hardas B et al (2008a) A
validated grading scale for crow’s feet. Dermatol Surg
34(2):S173–S178
Treatment Planning
4
Mauricio de Maio
We do not go to sleep looking young and wake up in the following morning

looking old. Aging is a continuous process that starts from mild aging signs
to moderate that become severe and lead to very severe aesthetic problems.
The sooner we start to correct them, the better!
Maurício de Maio

4.1 Introduction ................................................ 41
4.1.1 Product-Related Barrier ............................... 42 Treatment planning for medical cosmetic proce-
4.1.2 Patient-Related Barrier................................. 43 dures is a challenge. When we compare it with
4.1.3 Injector-Related Barrier ............................... 45 the medical interventions, one becomes aware of
4.1.4 Assessment................................................... 46
4.1.5 The MdM 8-Point Lift ................................. 52 the difference. One reason is that minimal inva-
sive cosmetic procedures are relatively new when
4.2 Treatment Plan and Exponential
Aging ........................................................... 56
compared with cardiology where commonly used
interventions such as cardiovascular stent appli-
4.3 Cosmetic Investment Advisor ................... 58
cations have a much longer history of use.
References ............................................................... 59 Another difference is the different input of the
patient. When a patient sees a cardiologist for
high blood pressure, for example, the treatment
planning is usually done by the doctor and not by
the patient. There may be slight different
approaches among cardiologists, but when fol-
lowing existing guidelines, we might assume
quite consistent and reproducible treatment sug-
gestions. But when it comes to aesthetics and
cosmetic procedures, the rules are different.
Patients are more likely to take responsibility for
the treatment planning. They might even try to be
the decision makers of what should be treated
and – what is even worse – with what kind of
product should be injected! For some mostly less
experienced injectors, this might be even wel-
come because they find themselves relieved from
designing an accurate treatment plan for their
patients. For the experienced injector, however,
this might pose a challenge.
Although the use of fillers in aesthetics is not
new and if we think about collagen, silicone, or
even paraffin, which goes back several decades,
so far we have not succeeded in establishing a

42 4 Treatment Planning
consented strategy for a treatment plan. In this Table 4.1 De Maio/Rzany rough classification for the
clinical use of HA fillers and volumizers
chapter we will try to help our readers with the
treatment planning of their patients, but before Degree 0 Very-low-density HA: to be used preferably
intradermally or high subdermally
that we will briefly describe the barriers that may
Degree 1 Medium- or high-density HA: to be used in
interfere with accomplishing this task. any layer except intradermally
Degree 2 Very-high-density HA: to be used ONLY in
deep planes close to the bone
4.1.1 Product-Related Barrier
Since our first edition of the book Injectable volumization as well as a volumizer (i.e., high-
Fillers in Aesthetic Medicine, we have pointed density HA) to be used in the fine lines of the
out in the first chapter by “At the moment new lower eyelid – which might end up in an aesthetic
injectable fillers are popping up like daisies” that challenge (e.g., a very visible HA roll).
we have an abundance of fillers. Specifically for Sometimes a specific product is designed and
Europe and Latin America, the situation is not clinically investigated by good trials for a specific
much different by now. Fortunately for some indication in a specific way, and we discover in our
products we do know now at least something practice that there is another way to inject it (e.g.,
about their clinical behavior. Nevertheless, there with a cannula instead of a needle) or that a differ-
are still unanswered questions even for those spe- ent indication can be treated (e.g., a volumizer that
cifically when it comes to the understanding of was designed to be injected down deep to the bone
the long-term behavior. and found useful in treating folds in a more super-
We started with silicone, PMMA, methyl meth- ficial, e.g., subcutaneous mode) (Table 4.1). If we
acrylates, polyacrylamides, collagens (bovine and are working with a versatile HA product, we may
later porcine), poly-l-lactic acid, hydroxylapatite, obtain an accurate response of this product regard-
and HAs. Lately we seem to be focusing mostly less of the area we are injecting it as long as we
on HA-based fillers and HA-based volumizers. respect its limits. If we are working with a less
However, within the HAs themselves it is easy to versatile product, there might be still some vari-
get confused as industry gives us different names ability. We may use a volumizer (degree 1) to treat
(all the brands), types (mono- and biphasic), as a prominent nasolabial fold as long as they are
well as cross-linkers that initially made us curi- injected subdermally. By using such a filler, less
ous but finally ends up making us more and more volume compared to a standard filler might be
confused. We have now products for fine lines, needed. On the other side a very-low-viscosity
folds, lips, cheekbones, jawline, etc., with and product (degree 0) may also be injected into a deep
without lidocaine. These products have helped fold but with the certain disadvantage of using
us to achieve many incredible results in an indi- more volume and a shorter durability.
vidual patient but also make it sometimes difficult The performance of a product also depends on
for us to position a specific product. For exam- the experience that we develop by injecting it
ple, can we or can we not use a product that was over the years. The same product may perform
designed to be used in lips and nasolabial folds? differently in different patients and among differ-
The answers are not so simple. ent injectors. So, it is basically quite important to
There are indeed products that perform well in keep a clear and critical mind to be aware of the
different areas and are very much versatile when product as well as the injection technique for the
it comes to different indications. There are other benefit of the patients and us.
products that are obviously only suitable for a We will be constantly invited to try different
specific area such as a fine line product (i.e., low- products and requested by patients to inject new
density HA) which does not make a lot of sense areas. We have to remember that respecting the
to be injected into the chin area for projection and science behind the products and our learning
4.1 Introduction 43
Table 4.2 A practical reminder to deal with new chal-

lenges of areas and/or products FAQs
New area Known area • Why should an injector be interested in
New product High risk Intermediate clinical data?
risk If good clinical data (e.g., random-
Known product Intermediate Low risk ized controlled trials or at least large
risk
case series) are available, you have a
Colleagues should be aware that the risk may differ
pretty good idea about the efficacy and
depending on the combination of factors
common adverse events for the investi-
gated areas.
curve is of utmost importance to protect our • Why should an injector link a product to
patient and also us against avoidable reactions a technique?
from both products and techniques. We have to For example, use in a new area only a
try to be as good as possible when it comes to product you are familiar with. Just to
new challenges, and we have to be very careful give you a picture: imagine you were a
with new products specifically when treating new horse jumper; in a competition a suc-
areas (Table 4.2). cessful horse jumper will not jump
obstacles with a horse that he had never
tried before. We should do the same
Do’s with our patients.
• Do try to understand what product you
are using and check the performance in
different areas and in different patients.
4.1.2 Patient-Related Barrier
Don’ts
Another barrier to overcome when putting a
• Do not try a new product in area which treatment plan together may be the patient-
is new for you (e.g., an area where you injector relationship. As discussed before, when
have little or no experience). The result it comes to aesthetic procedures, patients have a
can be frustrating if not a disaster. stronger influence on treatment decision when
compared to other medical fields. Sometimes
one may wonder if medical aesthetics is not
closely associated to buying/selling a car than to
Key Points health care.
• If possible stay with products where There are patients that are very much aware
there is at least one good clinical trial of their needs and open to listen to advice. These
available (this will give you at least a are considered the ideal patients. But unfortu-
good idea on the expected common nately it is not the rule. There are many patients
adverse events). that will not listen to the physicians’ opinions
• If you are interested in injecting a com- and only see the injector as a “deliverer” of their
pletely new area, use a product that you wishes. That would be acceptable if the patients’
are familiar with. perceptions were always accurate – which is of
• If you are interested in trying a new prod- course not always the case. Patients usually tend
uct, inject into an area that you are famil- to look at themselves in the mirror in the frontal
iar with and observe for consistent results view and their complaints are usually focused on
compared to the product you are used to. the glabella, tired eyes, and nasolabial folds.
They only see what can be seen in the frontal
view and this is not necessarily what makes them Table 4.3 Barriers between patients and injectors
look more exhausted or older (Rzany et al. Barrier 1 Patients with misperceptions and which are
2012). In society, however, we do not look at not open for advice
each other frontal to frontal – which is consid- Barrier 2 Patients with coherent different requests for
which the injector is unable to technically
ered confronting – but instead we look at each deliver the treatment
other more in the oblique view which is softer Barrier 3 Patients that do not know what they want
and nicer. Only by this can we see a discrepancy and seek for advice and in whom the
of analysis and perception between patient and injector is unable to promote a treatment
physician. plan
The “blind spot” definition presented in the
chapter “Patient Selection” is another important and in whom the injector is unable to promote a
aspect to be considered. We defined “blind spot” treatment plan (Table 4.3).
as the area/areas that untreated worsen the Female patients might be highly influenced
patients’ appearance. Usually the patients are by the media and celebrities. It is not uncom-
unaware of these areas – that are mainly deter- mon to have a patient asking an injector for
mined by the patients’ genetics, for example, Angelina Jolie’s lips. But what she is unaware
very small chin, sunken eyes, and asymmetries. of is that those lips will only be suitable on her
Patients usually complain and request treatment face if she has similar facial structure as
of the areas that worsen with aging. So patients Angelina. As a result of this misconception,
may be biased toward aging signs and will disre- many distracting lips are seen in real life as well
gard their “blind spots” completely. In fact this as on TV. Some other patients feel that
would be adequate if these patients only want to they become a more accentuated look when they
look younger but not more attractive. Bringing have their lips injected. The problem is that they
awareness to the “blind spots” must be handled request further injections to make their lips even
with care as it may lead up to the patient’s frus- more pronounced and by this (in their view)
tration especially when we cannot or can only more attractive. The result is that (in case
with great difficulties or expenses improve or they find an injector and of course they will)
solve the underlying defects. A careful way to they will do get more attention but not
help patients discover their “blind spots” is to because they look more attractive but because
show their pictures in different positions (frontal, they look weird. Patient education about propor-
oblique, profile, leaning forward) in different tion and beauty is very important to avoid dis-
situations (at rest, full smile, angry, kissing, etc.) tracting results. A very important rule must be
and ask them what they like and dislike when observed here: “the posttreatment photo must be
they see their pictures. At this moment we may more pleasant to look at than the before-treat-
find people that will get frightened by their look ment photo.” Obvious as it can be, we might
and even patients that are really becoming dis- surprise ourselves with the opposite.
tressed. For those patients that feel severely
impaired and depressed with their looks, we
advise to stop the photo analysis and proceed to Do’s
treatment options, and for those patients that are • Do deliver patients’ request if you agree
completely blind and cannot establish an ade- with their perception. You will make the
quate analysis, we should try to help them see patient happy.
their aesthetic problems and monitor and control
their reaction.
The interaction between patients and injectors Don’ts
may also be a challenge and may differ depend- • Do not inject a patient with mispercep-
ing on cultural aspects. We may separate those tion of his/her needs. It is quite likely
patients that are aware of what they want and that you will be creating a future prob-
seek for advice and those patients that are lem for yourself.
unaware of what they want and seek for advice
4.1 Introduction 45
The easiest way to learn is to start by writing

Key Points down the areas and types of patients that we have
• If you only treat the aging signs of your difficulty treating and secondly to check if some-
patients, they may look better, someone is obtaining good results for this indication.
times younger but not necessarily more Be aware that sometimes, what is difficult for you
attractive. We also need to pay attention is difficult for everybody!
to structural or genetic flaws and Accurate patient assessment and the judgment
improve them (the so-called blind spots). if that product or technique will work are much
more difficult than overcoming technical deficien-
Table 4.4 The three important questions to answer to cies – as incredible as it may seem. Injectors that
understand our status quo as an injector are not familiar with exercising the assessment pro-
Question 1 Am I aware of and have I solved my
cess and usually are only used to delivering
technical deficiencies? Or do I still have patients’ requests (usually glabella with BoNT-A
technical deficiencies? and nasolabial fold with dermal fillers) should be
Question 2 Can I properly assess the patient by aware that patients’ needs are not restricted to these
identifying the main needs? two areas and they may end up suffering from low
Question 3 Am I able to build up a coherent
patient retention. Assessing patients does take time
treatment plan for that patient?
and the speed that we can reach a final conclusion
will vary according to our experience and the type
4.1.3 Injector-Related Barrier of patient we are dealing with. It is also a longtime
learning curve and requires exercise.
This is the most difficult area because injectors After solving the two first barriers (technique
also have their “blind spots.” Many aspects may and assessment), we can really assume that we are
hinder the injector to deliver an accurate treat- now prepared to tackle the last barrier: to build up
ment plan for their patients. The Greek proverb the treatment plan. The treatment plan is to be pro-
“In the kingdom of the blind, the one-eyed man is grammed according to patients’ social and eco-
king” teaches us that this is more an opportunity nomic situation, and that is a tremendous
than a barrier. The more we are aware of our abil- opportunity for us to become a long-term trusted
ities and limits, the faster we may try to solve cosmetic investment advisor (CIA) for the patient.
them (Table 4.4). A CIA is someone that is able to build up consis-
Technical deficiency is the barrier number one tent treatment plans for their patients along the
that we have to overcome to evolve as an injector years and is able to work efficiently with the
especially if we are interested in delivering a patients’ budget. One of the biggest challenges of
global approach with injectables. The first step it the cosmetic business is patients’ retention. They
is to be aware of our deficiencies. As otherwise are looking for someone that is able to help them
we might continue overtreating an area that we look better, increase their self-esteem, or rejuve-
are confident to treat (e.g., the nasolabial folds) nate. Regardless of their initial request, they will
instead of treating the area that poses a challenge be happy to find an aesthetic physician that they
for us. We may be able to make the proper diag- can trust and guide them. That is the gap in the
nosis, i.e., sunken temples, but avoid discussing it market. Hence, there is the opportunity!
or indicating it as a treatment option for the
patient because of our technical deficiency. In
some cases, patients themselves might request Do’s
such a treatment and we may find us saying that • Do try to be aware of our skills, try to
“treating your temples is not important.” up-skill yourself, and overcome your
If we are not prepared to successfully inject technical deficiencies. Both your patient
into an specific area, we should either search for and you will benefit from that.
adequate training or refer the patient to a more • Do try to assess your patients without
experienced injector. Sooner or later, all injectors knowing what motivated them to visit
will be able to inject the commonest facial areas.
your office then contrast their opinion

with yours. You will have a surprising
experience! 1 2 3 4 5 6
Fig. 4.1 Facial shape according to Terino and Flowers

(2000)
Don’ts
• Do not deny the benefit of the treatment as, e.g., facial shape, proportion, symmetry,
to your patient of an area that you are and facial units.
not trained yet. You may refer this The first aspect that should be analyzed is the
patient to a colleague who is more expe- facial shape (Figs. 4.1 and 4.2, Table 4.4) because
rienced with this indication. it will give us important information regarding
• Do not forget to benchmark your techni- how close or far we are to the oval shape which is
cal abilities and assessment skills – it is considered the most attractive for females
for the good of your patients and (Terino and Flowers 2000).
yourself. Facial proportion is an important aspect for
facial balance and harmony. The proportions of
the three facial thirds need to be analyzed to get
an idea if volumization of any of the thirds is
Key Points
required. The evaluation should include always
• There are difficult areas to treat only
the profile where we need to establish if it is
with injectables because results will be
straight, convex, or concave. Usually, patients
limited. If you are not sure, check with
with a straight profile are easier to treat. Severe
experts if that is the case. Differentiating
concavities or convexities may limit the results
what is easy from what is technically
with injectables.
difficult is a huge step in the learning
Another important aspect is symmetry.
curve.
Symmetry is beauty but we are all asymmetrical
• It is not only the technical skill that
and correction of asymmetries should follow a
makes a top injector.
reasonable rule. Slight natural asymmetries are
acceptable and sometimes do bring even charm
to the patient’s appearance. Injectors, however,
FAQs are not expected to produce asymmetry and defi-
• What is a cosmetic investment advisor nitely prohibited to enhance it. If the asymmetry
(CIA)? is mild, acceptable, or even charming, no specific
A CIA is someone that has surpassed treatment planning is needed. Please observe the
technical and diagnosis deficiencies and following example: imagine a patient whose right
is able to build up a coherent treatment side contains a total of 100 ml of volume and
plan, working efficiently with patients’ whose left side is somewhat bigger and contains
budget over a long time period. 110 ml. The percent difference is 10 %. Now let
us suppose that we decide to add the same amount
of volume in both sides and add 100 ml for each.
4.1.4 Assessment The right side has 100 ml + 100 ml, which will
end up with 200 ml of total volume, and the left
A systematic approach is recommended when side has 110 ml + 100 ml, which will result in
assessing the aesthetic patients. This approach 210 ml. The percent difference is now 5 %. This
might be quite individual and might differ simple mathematical explanation shows that only
from injector to injector. Some important by adding the same volume, a reduction in asym-
aspects, however, should always be considered metry is obtained (Table 4.6).
4.1 Introduction 47
Convex Straight Concave
Fig. 4.2 Facial profile according to Terino and Flowers (2000)
Table 4.5 Facial shape according to Terino and Flowers Qualitying the problem
(2000)
1 Oval Facial shape
2 Heart-shaped
3 Round
4 Square
5 Round head and square jaw
Proportion
6 Round head and oval jaw
Table 4.6 The effect of volumization on the improve-

ment of asymmetry
Symmetry
Right Left side Percent
side (ml) (ml) difference (%)
Baseline 100 110 10
differences
Volume 100 100
Facial units
replacement
Final difference 200 210 5
Just by adding the same volume, the asymmetry will
improve Fig. 4.3 Qualifying the problem by analyzing facial
shape, proportion, symmetry, and facial units
4.1.4.1 Step 1: Qualify the Problem! there are static and/or dynamic forehead lines
After assessing facial shape, proportion, and (Fig. 4.3). Treatment planning might be facili-
asymmetry, the injector should analyze the facial tated by a chart (Table 4.7).
units. It is important to analyze the face at rest, on The treatment plan chart is a guide to help injec-
animation, and in a forward position to qualify tors to include all important areas during the patient
the important points. For example, when assess- assessment. After filling up the chart, the top part is
ing the upper third, we may start by the forehead completed with the areas to be treated, the products
and verify if the shape is adequate, if there is a to be used, and the prioritization. Below there is an
volume loss at frontal view and profile, and if example of qualifying the problems (Fig. 4.4).
Table 4.7 Chart for treatment planning

4.1 Introduction 49
Fig. 4.4 First rule: qualify

the problems!
First rule
Qualify the problem
• Low eyebrow
• Flat midcheek
• Prominent NLF
• Droop nose tip
• Prominent marionnette line

• Lack of chin projection
• Saggy skin
4.1.4.2 Step 2: Quantify the Problem! same happens with injectables. Patient and injec-
After a detailed qualification of the problems, the tor may only decide to treat when the problems
next step is quantifying them. There are many become severe and sometimes when the solution
validated 4- or 5-point scales that can be used and is better handled by surgery or another interven-
simple work with classifications of none, mild, tion and not by injectables.
moderate, severe, and very severe/extreme The correct approach for minimal invasive
(Carruthers et al. 2008a, b, c, d, e; Rzany et al. procedures such as the use of injectables should
2012). These scales come quite handy. Another be “the sooner, the better,” not only from a finan-
very simple way to document the present status cial point of view but also from a technical point
of the patient is to work with crosses (+) of view. Despite the injector’s philosophy, mild
(Table 4.8). For example, a prominent nasolabial problems are easier to improve than severe prob-
fold may be mild (+) or mild to moderate (+/++). lems, and that is unquestionable.
Culturally, patients and cosmetic surgeons The sequence of deficits that may be found
tend to decide for treatment when the problems during the aging process is easily diagnosed
are severe. Facelifts are performed when saggy when we analyze patients’ photos or if we hap-
skin has become intolerable! Unfortunately, the pen to know someone for a long time but only see
this person from time to time. As mentioned
Table 4.8 Quantifying the problem with a simple scale before, we do not age in a single night. It takes
using crosses to evaluate the degree of severity years to move from mild to very severe deficien-
Number of crosses Degree of severity cies. The problem is that patients’ and injectors’
+ Mild perception seems to be more sensitive when the
++ Moderate exponential aging has started. Below there are
+++ Severe examples of different patients in different degrees
++++ Very severe of severity for the same area (Fig. 4.5). After
Quantifying the problem : linps and

jowl and neck
Mild Moderate Severe Very sever
Fig. 4.5 Quantify the problem! We do not go to sleep with mild problems and wake up in the following morning with
very severe deficiencies. How can someone develop a severe problem if we never let it become moderate?
Fig. 4.6 Quantifying

the problems for this patient
demonstrated that they are
still mild, and that means
high probability of success-
ful outcomes Second rule
Quantity the problem
• Flat midcheek: mild

• Prominent NLF: mild
• Droop nose tip: mild
• Prominent marionnette lines: mild
• Chin projection: mild
• Saggy skin: mild
qualifying the problem, it is time to quantify Don’ts

them according to the degree of severity as fol- • Do not forget to qualify then quantify
lows (Fig. 4.6). the problems to build up an efficient
treatment plan.
Do’s
• Do start to correct problems when they
are still mild. Key Points
• Do educate your patients about the ben- • Mild problems are easier to improve
efits of starting the treatment at an early than severe problems.
stage. • The sooner we start to correct, the better.
4.1 Introduction 51
finishing the treatment plan, one step further is to

FAQs contrast the technical evaluation with the patients’
• How can someone develop a severe request. At this time, we may discuss different
problem if we never let it become possibilities finding in the extremes either total
moderate? agreement or complete disagreement. In the latter
They will not and that is the impor- situation good communication skills are manda-
tance of creating an efficient treatment tory. A treatment plan is only efficient when there
plan. We can and we should slow down is synchronicity between the injector’s and the
aging process as soon as possible. patient’s beliefs. Here communication is every-
thing! Please find below some possibilities that
may arise when patients’ and injectors’ opinions
4.1.4.3 Step 3: Create a Treatment Plan! are contrasted and suggestions (Table 4.9).
After qualifying and quantifying the problems, When patients present mild problems, we
the next step is to build up the treatment plan. should try to correct them so that they maintain
Depending on the patient, multiple diagnoses always the status of mild degree. The patient will
might be made and the next step is to prioritize continue aging but in a slower speed (Fig. 4.7).
and include them in the treatment timeline. After
Table 4.9 Different Possibilities Comparison Suggestion to injectors

assessment situations for
1 Patient’s request is in Proceed with the treatment
patients and injectors and
agreement with injector
possible solutions
2 Patient’s request is in Discussion on prioritization tends to
agreement with injector but come easily into agreement between
prioritization is different both parts
3 Patient’s request is different Deliver patient’s request and learn
and better than injector’s with patients
opinion
4 Patient’s request is different Take time to educate your patient. It
and does not make sense will be good for you, for the patient,
according to injector’s and for the next injector if you are
opinion able to convert the patient
Treatment plan
• Glabella: 20 U Botox
• Cheekbones: 1 ml Juvéderm Voluma per side
• NLF: 0,4 ml Juvéderm ultra plus per side

• Nose: 0,2 ml Juvéderm Voluma
• Lips and comissure: 0,55 ml JU ultra plus
Fig. 4.7 Both structural • Chin and pre-Jowl: 1 ml Juvéderm Voluma per side
and aging problems were
improved in this patient. Her
aging process will be slower
now
deficiencies are expected to be solved and

Do’s longer-lasting results are expected. However,
• Be open. Contrast your opinion with the there are some patients that already present
patients’ opinion. Sometimes we learn a severe and very severe problems and may not be
lot from them. open for surgery or present a medical condition
• Do invest time for creating a treatment that contraindicates the surgical option (Fig. 4.8).
plan for your patients. The challenge to treat patients that present for-
mal surgical indication is higher than treating
mild to moderate deficiencies with injectables.
Don’ts Before volumizers such as Juvedérm Voluma got
• Do not let patients confuse or contami- to the market, treatments with injectable fillers
nate your therapeutic concept and try to for this kind of patients were often not really sat-
develop your communication skills to isfying. Besides, the product in complex cases
guide them. requires a technical strategy as important ques-
tions should be asked before the treatment starts
(Table 4.10).
Key Points If an injector injects this patient in the tradi-
• It is also the injectors’ responsibility to tional way, a large amount of product may be
educate and guide patients when they required and the lifting effect may not be
have misperception of their needs. To achieved. We decided to describe the MdM
invest time in communication is an (Mauricio de Maio) 8-point lift to cope with this
important aspect to increase treatment
success and patient retention. Table 4.10 For complex cases, a more refined strategy
needs to include also the injection sequence
Questions Important aspects to consider
4.1.5 The MdM 8-Point Lift 1 Where to inject?
2 What to inject?
Patients with mild or moderate problems may 3 How to inject?
present some technical challenges, but those 4 What sequence to inject?
a b c
Fig. 4.8 (a–c) This is a typical surgical patient that presents severe to very severe problems on the face including exten-
sive saggy skin
4.1 Introduction 53
Table 4.11 Qualifying and quantifying steps for the

patient with severe (+++) and very severe (++++)
problems
Mid-third Qualify the problem! Quantify the
problem!
Infraorbital hollow +++
Volume loss in +++
mid-cheekbone
Volume loss in lateral +++
cheekbone
Prominent nasolabial fold +++
Lower third Qualify the problem! Quantify the
problem!
Fig. 4.9 To build a house there is a sequence of events that
Marionette lines ++++
should be respected. We all understand pretty well that to
reach the ceiling (point 8), we must have started by point Pre-jowl sulcus +++
Jowls ++++
Jawline loss of definition ++++
kind of patients. For better understanding, please Parotid area volume loss ++++
follow the illustration below where respecting the These steps are important before creating the treatment
sequence is mandatory (Fig. 4.9). plan
It should not be forgotten that faces are com-
posed as a mechanical structure with hard and
soft tissues that need support to cope with grav-
ity. As described in Chap. 6, the treatment of the
cheekbone area with volumizers may improve
the appearance of the nasolabial fold and the lid-
cheek junction. That clearly means that there is
an improvement of an area that was not injected
only by injecting in the neighborhood. Let us
apply the 1st (qualify the problem!) and the 2nd
(quantify the problem!) rules for the following
patient that will be submitted to the MdM 8-point
lift (Table 4.11).
As it could be noticed above, the lower third
presents more and more severe challenges than
the mid-third. Starting the treatment in the lower
third is not the best technical approach even if the
patient is requesting only the treatment of mari-
onette lines. Results are limited if only a direct
approach to this area is undertaken (Fig. 4.10). Fig. 4.10 The MdM 8-point lift: note that 8 areas are to
The MdM 8-point lift follows a multiple region be injected with small bolus technique and massage. By
respecting this sequence, the volume requirement along
strategy (Table 4.12).
the jawline will be lower. Area number 9 represents chin
Patients with very severe saggy skin should be projection when improvement of area 6 (pre-jowl sulcus)
injected with caution. Any product injected into is still needed
the NO GO! area may lead to worsening of the
fold or sagginess. Represented in the illustration not much quantities used, the results with the
are the GO! areas (in blue) and the NO GO! areas MdM 8-point lift may be amazing (Figs. 4.12,
(in red), which must be avoided (Fig. 4.11). With 4.13, and 4.14).
Table 4.12 The MdM 8-point lift: the areas, regions, and comments
Point Region Comments
1 Zygomatic region Lifting point of lateral cheekbone
2 Intermediate infraorbital region Projection of cheek bones and improvement of
elongated lid-cheek junction
3 Medial infraorbital region Improvement of tear trough
4 Canine fossa and upper part of nasolabial Less volume requirement is needed after areas 1, 2,
fold and 3 were treated
Lower third Region Comments
5 Marionette lines Start from top to bottom by strengthening the oral
commissure
6 Pre-jowl sulcus Small bolus or retrograde techniques are suitable here.
Do not inject the jowls!
7 Jawline Linear and retrograde technique is preferable at this
level
8 Parotid region When volume loss is replaced here, lifting effect is
obtained
a b
Fig. 4.11 (a, b) It is very important to demarcate the GO! (blue) and NO GO! (red) areas before starting. Note that the
NO GO! areas must also be evaluated with the patient with “eyes up and chin down”
It must be reinforced that the amount per point Younger patients with moderate saggy skin usu-
will vary from patient to patient depending on the ally require 1 ml of Juvedérm Voluma or a com-
volume loss, bone structure, and degree of laxity. parable product per side.
4.1 Introduction 55
a b
Fig. 4.12 (a, b) Before and after frontal view photos from the patient that was treated with “the MdM 8-point lift.”
Note that it seems that the patient was submitted to eye surgery and a light surgical lift
a b
Fig. 4.13 (a, b) Profile view of the pre- and post-photos jowls, and jawline definition. The overall saggy skin was
after the MdM 8-point lift. Note the shortening of the lid- also improved. A total of 2.7 ml of Juvedérm Voluma was
cheek junction, projection and lifting of the cheekbones, injected per side and 20 U of Vistabel in the glabella
and improvement of the marionette lines, pre-jowl area,
The aging process
Drastic
Rate of ageing
hormonal
decline
0 10 20 30 40 50 60 70
Age (years) Menopause
Fig. 4.15 The aging curve in females: aging is linear and

becomes exponential with hormonal decline especially
for women but also for men
change nearby, which then will cause another

similar change, and so on in linear sequence.
The term is best known as a mechanical effect,
and is used as an analogy to a falling row of
dominoes. It typically refers to a linked sequence
of events where the time between successive
events is relatively small. It can be used literally
(an observed series of actual collisions) or
metaphorically.”
Fig. 4.14 Quantity of Juvedérm Voluma and Juvedérm
smile (points 4 and 5, Marionette lines and nasolabial folds) An injector that only delivers what the patients
injected per point in ml. Note that point 9 was also injected request will not help the patient to prevent or
to increase chin projection and enhance the pre-jowl sulcus combat aging and properly risk patients’ long-
term retention. It is important to understand that
it is not the injection technique that makes the
Key Points
difference but the understanding of the aging pro-
• As a conclusion, the MdM 8-point lift cess and at what point of that curve the patient
may be considered an important ally and stands. Aging occurs in early stages in a linear
an alternative in facial rejuvenation for ascendant curve, and at a certain point (e.g.,
patient’s signs of severe aging that are menopause/andropause), the deflection of the
not eligible for the surgical option for curve changes and the speed of aging becomes
variable reasons. exponential. The conclusion is simple: the worse
we are, the worse we get; the older we are, the
older we get (Fig. 4.15)!
4.2 Treatment Plan So if we understand that there is a moment
and Exponential Aging where the speed of aging becomes exponential,
then we should ask ourselves two questions
As stated in the beginning of this chapter, aging is (Table 4.13).
a continuous process that goes from mild to very The next curve shows a possibility of slowing
severe deficiencies. Aging obeys the linear rule down the aging process by medical intervention,
of the domino effect, but at a certain point, it and that is the importance of creating an effective
becomes exponential. Please find bellow the treatment plan for the patients. By controlling the
definition: worsening of aging signs, which means avoiding
“The domino effect is a chain reaction that problems to go from mild to moderate then to
occurs when a small change causes a similar severe, there will be a reduction in the speed of
4.2 Treatment Plan and Exponential Aging 57
Table 4.13 Important questions that injectors should be

Medical intervention
aware of
Injectables
Questions Answer
Question 1 Can we slow down the Yes
aging process?
Question 2 Are patients technically No
prepared to decide how to
slow down aging? Lasers/chemical Hormone Topical
peels replacement creams/agents
Changing curve deflexion

Rate of ageing
Medical
intervention
Surgery
Fig. 4.17 Treatment options to combat and slow down

aging process
0 10 20 30 40 50 60 70
Age (years) Menopause
Table 4.14 Three aspects that should be taken into con-
Fig. 4.16 Medical intervention is of utmost importance sideration for cosmetic practice
to postpone the exponential aging and keep the aging Comments
linear
Step 1 Qualify the Each year the number
problems! of aging signs tends
aging and the exponential aging will be post- to increase
Step 2 Quantify the Each year the degree
poned more as possible (Fig. 4.16).
problems! of severity of the aging
Many treatment options exist to slow down signs will increase
aging at different stages. Injectables such as fill- Step 3 Create a Each year lost will lead
ers and BoNT-A are powerful tools to prevent treatment plan! to more complexity in
and correct aging signs. The performance of treatment planning
many different types of treatments is influenced
by adequate hormonal condition especially lon- Depending on the age that our patients come to
gevity of results. Premenopausal phase does visit us, there is more or less time to be effective
present better results than long postmenopausal in slowing down aging process. A patient under
treatments do. It is important to understand that 40s may have their requests satisfied although we
several interventions need to be employed to get do believe that we should have started earlier to
the best results (Fig. 4.17). correct aging signs or intrinsic cosmetic deficien-
To effectively achieve the desirable outcomes cies – even before 40s. However, a patient in her/
with our patients, a treatment plan timeline his 40s, who still has 10 years before exponen-
should be incorporated into the injectors’ daily tial aging, is the best candidate to “prepare for
practice. We will not be young forever and we the impact!” of menopause/andropause. Female
become each year more and more complex to patients are usually asked about their first period
treat due to three aspects that may be seen below and the age their mother entered menopause to
(Table 4.14). estimate the average number of years we have to
It is becoming clearer and clearer that injec- work with them. This knowledge will also influ-
tors need to reflect if they want to be technical ence the prioritization as well as the effort that
deliverers of patients’ requests or if they want to will be given to educate them during this crucial
combat the aging process more effectively by cre- phase for prevention. Menopause changes will be
ating a long-term treatment plan for their patients. affected by the presence or absence or hormonal
Treatment plan for aging timelines
Prioritize
needs 1. Assessment and
prioritisation
Prepare for the
IMPACT!
May deliver promote

request support
Patient satisfaction
=
0 15 ~40 ~50
reputation
Age (years)
Fig. 4.18 Treatment plan for aging timelines 3. Communication

2. Technical skill and treatment
planning
replacement therapy and is not the scope of this
book. But if there is no formal contraindica-
tion to it, patients should be motivated to have Fig. 4.19 The power of three: the important pillars that
a second opinion of a hormone specialist on this lead to patient satisfaction and reputation
topic because the performance of surgical and
nonsurgical cosmetic treatments may be influ- treatment plan which will reflect best practice in
enced positively by hormone replacement ther- aesthetic medicine (Fig. 4.19).
apy (oral as well as topical). Regardless of that, As a final conclusion, we would like to present
menopause is a moment to prioritize needs and an illustration with the standards of 8 that include
choose which treatment should start first, and the important topics that an injector should observe
follow-up plan is mandatory to maintain results. and develop to become an expert in this field
Postmenopausal patients that were never treated (Fig. 4.20).
before are a challenge for injectables. The further
they are from the 50s, the more formal indica-
tions are found. Promoting support with volumiz-
ers become mandatory because more superficial Do’s
fillers may have very little effect if deep tissue • Do verify at which stage your patient is
support is not provided (Fig. 4.18). in the aging curve and try to identify the
time point when the exponential aging
will start.
4.3 Cosmetic Investment • Do postpone the exponential aging with
Advisor appropriate interventions to avoid the
domino effect.
To become a cosmetic investment advisor (CIA),
it is important to develop skills that are beyond
technique. The first pillar is the ability to do
proper assessment and prioritization. The second Don’ts
pillar is the appropriate injection technique. An • Do not wait too long to put your patients
appropriate injection technique is the base for an in the best aesthetic condition before the
efficient treatment, and deficiencies at this level exponential aging occurs.
will pose as a barrier for the injectors – that when • Do not forget that fillers are only one
one is aware of those should be solved as soon as intervention. Other interventions as bot-
possible. The third pillar is the communications ulinum toxin, topical (e.g., retinoids),
skills which are necessary to teach and convert hormone replacement therapy, peels, and
patients if they present misperception of their laser need to be taken into account, too.
needs. These three pillars will finally lead to a
References 59
1 - Science and 3 - Communication 5 - Treatment 6 - Technique

products process plan strategy
2 - Anatomy 4 - Assessment 8 - Financial 7 - Complication

beauty and and planning and management
ageing diagnosis follow up
Fig. 4.20 The standards of eight: injectors should recognize their strengths and weak points that need improvement
based on the eight important aspects that are found in real-world clinical practice
Carruthers A, Carruthers J, Hardas B, Kaur M,

Key Points Goertelmeyer R, Jones D, Rzany B, Cohen J, Kerscher
M, Flynn TC, Maas C, Sattler G, Gebauer A, Pooth R,
• The older we are, the older we get. McClure K, Simone-Korbel U, Buchner L (2008b) A
• It is important to correct all unfavorable validated grading scale for crow’s feet. Dermatol Surg
signs (including genetic and aging) 34(Suppl 2):S173–S178
before the exponential aging occurs. Carruthers A, Carruthers J, Hardas B, Kaur M,
Goertelmeyer R, Jones D, Rzany B, Cohen J, Kerscher
McClure K, Simone-Korbel U, Buchner L (2008c) A
validated grading scale for marionette lines. Dermatol
FAQs Surg 34(Suppl 2):S167–S172
• What is the advantage of becoming an Carruthers A, Carruthers J, Hardas B, Kaur M,
efficient cosmetic investment advisor? Goertelmeyer R, Jones D, Rzany B, Cohen J, Kerscher
M, Flynn TC, Maas C, Sattler G, Gebauer A, Pooth
It is based on increased patient satis-
R, McClure K, Simone-Korbel U, Buchner L (2008d)
faction which will along the years ulti- A validated lip fullness grading scale. Dermatol Surg
mately lead to increased patient 34(Suppl 2):S161–S166
retention and an increased reputation Carruthers A, Carruthers J, Hardas B, Kaur M,
Goertelmeyer R, Jones D, Rzany B, Cohen J, Kerscher
among your patients.
McClure K, Simone-Korbel U, Buchner L (2008e) A
validated grading scale for forehead lines. Dermatol
Surg 34(Suppl 2):S155–S160
Rzany B, Carruthers A, Carruthers J, Flynn TC, Geister
References TL, Görtelmeyer R, Hardas B, Himmrich S, Jones
D, de Maio M, Mohrmann C, Narins RS, Pooth R,
Carruthers A, Carruthers J, Hardas B, Kaur M, Sattler G, Buchner L, Merito M, Fey C, Kerscher
Goertelmeyer R, Jones D, Rzany B, Cohen J, Kerscher M (2012) Validated composite assessment scales
M, Flynn TC, Maas C, Sattler G, Gebauer A, Pooth for the global face. Dermatol Surg 38(2 Spec
R, McClure K, Simone-Korbel U, Buchner L (2008a) No):294–308
A validated hand grading scale. Dermatol Surg 34 Terino EO, Flowers RS (eds) (2000) The art of alloplastic
(Suppl 2):S179–S183 facial contouring. Mosby, St. Louis
Anesthesia and Analgesia
5
Mauricio de Maio

5.1 Introduction ................................................ 61
Do we really need a chapter on local anesthesia?
5.2 Evaluation Prior to Injection .................... 62
We have good topical anesthetics and by now a
5.3 Local Anesthesia ........................................ 62 large amount of new preparations of HA-based
5.4 Topical Anesthesia ..................................... 62 fillers and volumizers containing lidocaine
5.5 Infiltrative Anesthesia................................ 63
(0.3 %). Both measures have helped to decrease
injection pain considerably. Furthermore, prepa-
5.6 Nerve Block................................................. 63 rations with lidocaine have an additional advan-
5.6.1 The Supraorbital Nerve ................................ 64
5.6.2 The Supratrochlear Nerve ............................ 64 tage as we can go back to the treated area as many
5.6.3 The Infraorbital Nerve ................................. 64 times as needed to enhance the results. The lon-
5.6.4 The Mental Nerve ........................................ 65 ger it takes to retouch the area, the more efficient
5.6.5 The Zygomaticofacial Nerve ....................... 66 the numbness will be – e.g., our results will be
5.7 Adverse Events ........................................... 67 better as we no longer have to be afraid of inflict-
5.8 Disadvantages of Local Anesthetics ......... 67 ing more pain to the patient.
Although the products with lidocaine are here
5.9 Tips, Tricks and Key Points ...................... 68
to stay, topical anesthetics or ice bags continue to
References ................................................................. 68 play a part in reducing pain during the penetra-
tion of the needle through the skin, especially for
sensitive patients.
Cannulas are becoming ever more popular.
The gauge may vary from 30 to 18. Even when
cannulas are to be used with products with lido-
caine, some injectors still perform nerve blocks
to minimize patients’ discomfort during the
injection. This chapter should help those col-
leagues less familiar with these procedures to
understand and perform local anesthesia prop-
erly, as the main goal should be to make the pro-
cedure as comfortable as possible.

62 5 Anesthesia and Analgesia
5.3 Local Anesthesia

Do’s
• Do try to avoid pain for your patients. Local anesthetics decrease or completely block
For example, they may like the results sensory, autonomic, and motor functions. They
but never undergo a lip treatment again act by blocking sodium channels at the cell mem-
if the overall experience (nice lips, too brane and interrupting the excitation-conduction
much pain) was unpleasant. process (Carvalho and Mathias 1997). The sys-
temic absorption of local anesthetics depends
upon the vascular flow at the injection site, the
chemical and physical characteristics of the
5.2 Evaluation Prior to Injection agents, and the adjunctive use of vasoconstrictors
such as epinephrine. Vasoconstrictors will
The evaluation prior to injection helps to deter- decrease the absorption and enhance the avail-
mine the type of anesthetic procedure to be used ability of the local anesthetic to the nerve cells,
as well as the need for any analgesic after the thus prolonging the duration of action and
treatment. Simple procedures rarely require the decreasing possible systemic effects. Care should
use of adjunctive agents, except for very anx- be taken not to inject local anesthetics with epi-
ious patients. Be aware that a medical history nephrine into areas of terminal circulation, due to
must be taken and a physical examination per- an increased risk of necrosis.
formed prior to the use of any medication (Snow
1982). Preexisting medical conditions such as
hypertension and heart diseases may influence 5.4 Topical Anesthesia
the use of anesthetics in combination with epi-
nephrine. A history of alcohol consumption, use In most cases, the level of anesthesia achieved
of sedatives, and problems with anesthetics dur- with a topical anesthetic will be sufficient to alle-
ing dental procedures may indicate that extra viate discomfort during the injection of dermal
care should be taken with these patients. It is fillers. There are basically two groups of topical
important to ask the patients if they have had agents: the ester group (cocaine, tetracaine, and
any undesirable experience with topical, infil- benzocaine) and the amide group (lidocaine and
trative, or blocking procedures. Patients should prilocaine).
also be asked about the use of any illegal drugs The stratum corneum is a strong barrier to the
before the administration of any anesthetic absorption of drugs through the skin. The skin
medication. should be cleaned with antiseptics before apply-
ing the topical anesthetic cream, as this will allow
better permeation of the topical agents. The effect
may also be enhanced by rubbing dry gauze onto
Do’s the surface to remove dead cells and grease. The
• Do make it clear to patients that they vasodilatation that results from this rubbing of
must report any use of recreational the skin may also increase the permeation of the
drugs before anesthetic procedures. drug.
One of the most common topical anesthetics is
a eutectic mixture of 2.5 % lidocaine and 2.5 %
prilocaine, which is marketed as EMLA cream. It
Key Points is a nontoxic mixture which use results in very
• Be aware that the usage of recreational low plasma levels. The usual dose is 1 g for each
drugs such as cocaine might interfere 10 cm2 of intact epidermis. The cream should be
with the anesthesia. in contact with the skin for approximately 45 min
to 1 h with occlusive dressing (Hallen and
5.6 Nerve Block 63
Uppfeldt 1982). There is a new lidocaine and tet-

racaine mixture on the market which is marketed Key Points
in Europe as Pliaglis. So far (Summer 2013) the • Infiltrative anesthesia is not commonly
experience with this product, which is quite dif- used before injectable fillers because it
ferent from EMLA (more a paste than a cream), can distort the analysis of the treatment
is limited (Cohen 2013). area.
Cryoanesthesia is another method of inducing
topical anesthesia. The simple application of ice
bags may enhance the anesthetic effect. In fact,
for some patients, the use of ice bags alone will 5.6 Nerve Block
provide enough anesthesia. Other topical freez-
ing agents include ethyl chloride or dichlorotetra- Nerve block anesthesia is performed by an injec-
fluoroethane sprays, but these are unlikely to be tion of a small amount of local anesthetic around a
used when the treatment involves dermal fillers. nerve, resulting in anesthesia within the area sup-
plied by that nerve. The volume of anesthetic used
in these procedures is small. Therefore, the risk of
Key Points systemic toxicity is low. In contrast to the infiltra-
• Skin permeation of topical anesthetic tive method, there is almost no imbalance with
may be enhanced by rubbing dry gauze nerve blocks, and they are associated with less dis-
on the skin. comfort. However, this method requires good tech-
• When you use topical anesthetics, make nical and anatomical knowledge to obtain optimal
sure that the topicals are applied a suffi- results with few injections and to avoid adverse
cient time before the injection. events. There is the possibility of inadvertent lac-
eration of the nerve and blood vessel injuries.
Long-lasting dysesthesia and hematoma or ecchy-
mosis may occur in a few patients, which may be
5.5 Infiltrative Anesthesia quite distressing (Laskin 1984). The sensitivity and
motion of the face depend on the fifth pair of cra-
Direct inhibition of nerve ending excitation may nial nerves (Fig. 5.1). The main trigeminal branches
be achieved by infiltrative anesthesia. The drug of have independent exits from the skull. The ophthal-
choice is generally 1 % lidocaine, which is mic branch is more superior and passes inside the
injected intradermally or subcutaneously. orbit, forming the frontal branch, which bifurcates
Intradermal injection results in a rapid onset and into the supraorbital and supratrochlear nerves. The
longer duration of anesthesia, but it has the disad- other two branches are the maxillary nerve, which
vantage of being painful and causing tissue distor- produces the infraorbital nerve, and the mandibular
tion. Subcutaneous injection is less painful but nerve, which is the largest, the only one to contain
has a shorter-lasting effect (Arndt et al. 1983). motor fibers, and which produces the mental nerve.
During infiltrative anesthesia, patients usually Nerve block is usually achieved with 1 or 2 % lido-
feel a prick when the needle pierces the skin and a caine. A combination of epinephrine and lidocaine
burning sensation with infusion of the anesthetic is preferable when a quicker and longer-lasting
itself. Pain results from rapid tissue distention. anesthetic response is required. Care should be
Therefore the use of smaller volumes is advised to taken not to inadvertently inject this into the blood
avoid discomfort. The combination of freshly pre- vessels. Epinephrine should also be avoided in
pared solutions with epinephrine or bicarbonate patients with hypertension or cardiovascular dis-
can greatly reduce the pain during infiltration eases. Pain results from tissue expansion during the
(McKay et al. 1987). For very anxious patients, it injection, and irritation from the anesthetic itself.
may be useful to apply topical anesthetics before Gentle injections are preferable and provide a quite
administering the infiltrative anesthesia. tolerable nerve block.
Fig. 5.1 Areas supplied by

the main facial nerves
(de Maio 2011)
Ophtalmic nerve
Maxillary nerve
Mandibular nerve
5.6.2 The Supratrochlear Nerve

Do’s
• Do verify the type of preparation that 5.6.2.1 Anatomy and Territory
will be used, 1 or 2 % with or without The supratrochlear nerve exits the skull along the
epinephrine before the injection. medial corner of the orbit. It supplies the medial
portion of the forehead.
5.6.2.2 Technique
Key Points Inject 0.1–0.3 ml lidocaine at the junction of the
• The need of nerve blocks has tremen- root of the nose and the upper rim of the orbit,
dously decreased after the advent of fill- just below the medial portion of the eyebrow
ers containing lidocaine. (Fig. 5.4).
5.6.3 The Infraorbital Nerve

5.6.1 The Supraorbital Nerve
5.6.3.1 Anatomy and Territory
5.6.1.1 Anatomy and Territory The infraorbital nerve exits the infraorbital fora-
The supraorbital nerve exits the skull through the men in the midpupillary line about 1 cm inferior
supraorbital foramen, which lies along the supra- to the infraorbital ridge. It supplies the lower eye-
orbital ridge in the midpupillary line. It supplies lid, nasolabial fold, upper lip, and parts of the
the forehead. medial cheek and nose.
5.6.1.2 Technique 5.6.3.2 Technique

Inject 0.1–0.3 ml lidocaine right into the depres- The infraorbital foramen can usually be palpated.
sion in the internal third of the eyebrows (supra- There are two ways of blocking it: by a cutaneous
orbital notch) with the needle pointed toward the and a mucosal approach. For cutaneous injec-
forehead (Figs. 5.2 and 5.3). tions, the needle should be placed 1 cm below the
5.6 Nerve Block 65
Fig. 5.2 Anatomy and

blocking of the supraorbital
nerve. (1) External branch of
the frontal nerve and (2) and
(3) internal branch of the
frontal nerve (de Maio 2011)
1 2 3
Fig. 5.4 Blocking of the supratrochlear nerve
using a retrograde technique. Control of the

needle is undertaken externally with palpation
(Figs. 5.5 and 5.6).
Fig. 5.3 Blocking of the supraorbital nerve
5.6.4 The Mental Nerve

inferior orbital rim in the midpupillary line and
0.1–0.3 ml lidocaine injected around but not into 5.6.4.1 Anatomy and Territory
the canal. The needle should be advanced through The mental nerve exits the mental foramen
the mucosa and then through the superior labial approximately 2.5 cm away from the midline of
sulcus, aiming at the iris at the canine level. the face in the midpupillary line. It supplies the
A total of 0.5–1 ml lidocaine should be injected lower lip and chin.
5.6.4.2 Technique the second and third inferior premolars aiming at

Inject 0.1–0.3 ml of lidocaine through the infe- the foramen mentalis (Fig. 5.7).
rior labial sulcus, inserting the needle between
5.6.5 The Zygomaticofacial Nerve
5.6.5.1 Anatomy and Territory

The zygomatic nerve (temporomalar nerve,
orbital nerve) is a branch of the maxillary nerve
(a trigeminal nerve branch) that enters the orbit
and helps to supply the skin over the zygomatic
and temporal bones. The zygomatic nerve is not
to be confused with the zygomatic branches of
the facial nerve. The zygomatic nerve arises
in the pterygopalatine fossa. It enters the orbit by
the inferior orbital fissure and divides into two
branches at the back of the cavity into two
branches, the zygomaticotemporal nerve and
zygomaticofacial nerve.
5.6.5.2 Technique
Inject 0.1–0.3 ml of lidocaine 1 cm below the lat-
Fig. 5.5 Blocking of the infraorbital nerve (1) (de Maio eral canthus and at level of the zygomaticofacial
2011) foramen in the zygomatic bone.
Fig. 5.6 The mucosal

approach for infraorbital nerve
blocking
5.8 Disadvantages of Local Anesthetics 67
a b
Fig. 5.7 (a) The mental nerve may be blocked either transcutaneously or through the mucosa (b)
5.7 Adverse Events Allergic reactions to anesthetics are rare but

have been known to occur with ester preparations
Adverse events can result from the anesthetic (Brown et al. 1981).
itself but are usually more common when epi-
nephrine is used concomitantly. Short-term sys-
temic reactions to epinephrine include tremor, Key Points
tachycardia, restlessness, palpitations, headache, • Short-term systemic reactions to
increased blood pressure, and chest pain (Grekin local anesthetics containing epineph-
and Auletta 1988). Systemic reactions to local rine include tremor, tachycardia,
anesthetics can occur when toxic levels are restlessness, palpitations, headache,
reached. The use of larger volumes than recom- increased blood pressure, and chest
mended and inadvertent intravascular injection pain.
are the most common causes of toxicity. • Real allergic reactions are very rare with
Systemic toxicity of local anesthetics is char- local anesthetics.
acterized by central nervous and cardiovascular
impairment. Signs and symptoms of toxicity
depend on the velocity of injection and plasma
concentration of the drug. The diagnosis of
severe toxicity is mandatory: lip and tongue par- 5.8 Disadvantages of Local
esthesia, blurred vision, motor fasciculations, tin- Anesthetics
nitus, seizures, unconsciousness, coma, and
respiratory and cardiovascular depression The eutectic mixture of 2.5 % lidocaine and
(Mather and Cousins 1979). Local anesthetics 2.5 % prilocaine may decrease the visibility of
block sodium channels, causing myocardial fine wrinkles, thus making it impractical for
depolarization and a reduction in nerve conduc- treatments involving very fine fillers such as
tion velocity. Aesthetic treatment involving local some hyaluronic acid products. Nerve blocking
anesthetics should therefore be carried out in might considerably change the shape of, for
conjunction with support measurements such as example, the nasolabial fold and the upper lip
ventilation, oxygenation, and cardiovascular and may therefore encourage under- or
optimization. overcorrection.
5.9 Tips, Tricks and Key Points

Key Points
Never let the patients feel pain during aesthetic • Products containing lidocaine have tre-
procedures. Any negative experience may mean mendously improved patients’ comfort
that patients refuse to continue with facial during the treatment, especially the
improvement. Anesthesia should be seen as one most sensitive areas such as lips, peri-
of the most important steps during aesthetic treat- oral, and nose.
ment with fillers and volumizers.
References
Arndt KA et al (1983) Minimizing the pain of local anes-
Do’s thesia. Plast Reconstr Surg 72(5):676–679
• Do use products with lidocaine, or if the Brown DT et al (1981) Allergic reaction to an amide local
products (e.g., PLLA) do not contain a anaesthetic. Br J Anaesth 53(4):435–437
Carvalho JCA, Mathias RS (1997) Chapter 22.
local anesthetic, add a local anesthetic Farmacologia Do’s anestésicos locais. In: Manica JT
to the solution/the filler. They reduce the et al (eds) Anestesiologia: Princípios e Técnicas, 2nd
patient’s discomfort during the edn. Artes Médicas, Porto Alegre, pp 332–340
injection. Cohen JL (2013) Pain management with a topical lido-
caine and tetracaine 7 %/7 % cream with laser derma-
• Do perform nerve blocks if you are tologic procedures. J Drugs Dermatol 12(9):986–989
working with 21–18 gauge cannulas. It De Maio M (ed) (2011) Tratado De Medicina Estetica,
brings more comfort to the patient. 2nd edn. M. Ed. Roca, Sao Paulo
Grekin RC, Auletta MJ (1988) Local anesthesia in derma-
tologic surgery. J Am Acad Dermatol 19(4):599–614
Hallen B, Uppfeldt A (1982) Does lidocaine-prilocaine
cream permit pain-free insertion of IV catheters in
children? Anesthesiology 57(4):340–342
Laskin DM (1984) Diagnosis and treatment of complica-
Don’ts tions associated with local anaesthesia. Int Dent J
• Do not forget to slow down the speed of 34(4):232–237
Mather LE, Cousins MJ (1979) Local anaesthetics and
injection if you are working with prod- their current clinical use. Drugs 18(3):185–205
ucts that contain lidocaine. It takes McKay W et al (1987) Sodium bicarbonate attenuates
around 3–5 s to take effect. pain on skin infiltration with lidocaine, with or without
• Do not get too hectic. If you are relaxed, epinephrine. Anesth Analg 66(6):572–574
Snow J (1982) Manual of anesthesia. Little, Brown,
the patient will be relaxed and therefore Boston
will experience less discomfort.
The Most Common Indications
6
Mauricio de Maio and Berthold Rzany
Contents 6.6.2 Anatomy....................................................... 98

6.6.3 Patient Evaluation and Selection ................. 100
6.1 Forehead and Glabella .............................. 70 6.6.4 Technique ..................................................... 101
6.1.1 Introduction.................................................. 70 6.6.5 The Nasofrontal Angle ................................. 102
6.1.2 Anatomy....................................................... 70 6.6.6 The Nasolabial Angle................................... 102
6.1.3 Patient Evaluation and Selection ................. 71 6.6.7 The Tip and the Columella........................... 102
6.1.4 Techniques ................................................... 71 6.6.8 Dorsum......................................................... 103
6.1.5 Tips, Tricks and Key Points ......................... 74 6.6.9 Selection of Filler......................................... 105
6.2 Temples ....................................................... 74 6.6.10 Complications .............................................. 105
6.2.1 Introduction.................................................. 74 6.6.11 Tips, Tricks and Key Points ......................... 106
6.2.2 Anatomy....................................................... 74
6.2.3 Patient Evaluation and Selection ................. 74 6.7 Nasolabial Folds ......................................... 106
6.2.4 Technique ..................................................... 75 6.7.1 Introduction.................................................. 106
6.2.5 Complications .............................................. 75 6.7.2 Anatomy/Structure ....................................... 106
6.2.6 Tips, Tricks and Key Points ......................... 75 6.7.3 Patient Evaluation and Selection ................. 108
6.7.4 Technique ..................................................... 108
6.3 Eyebrow ...................................................... 76 6.7.5 Touch-Up ..................................................... 109
6.3.1 Introduction.................................................. 76 6.7.6 Complications .............................................. 110
6.3.2 Anatomy....................................................... 76 6.7.7 Tips, Tricks and Key Points ......................... 111
6.3.4 Technique ..................................................... 78 6.8 The Earlobe ................................................ 112
6.3.5 Complications .............................................. 79 6.8.1 Introduction.................................................. 112
6.3.6 Tips, Tricks and Key Points ......................... 79 6.8.2 Anatomy/Structure ....................................... 112
6.4 Epicanthal Fold and Sunken
6.8.4 Technique ..................................................... 113
Upper Eyelid ............................................... 80
6.4.1 Epicanthal Fold ............................................ 80
6.4.2 Sunken Upper Eyelid ................................... 80
6.9 The Upper and Lower Lips ....................... 114
6.9.1 Introduction.................................................. 114
6.5 Infraorbital Hollow, Tear Trough, 6.9.2 Anatomy....................................................... 114
Cheekbones, and Cheek Reshaping ......... 83 6.9.3 Patient Evaluation and Selection ................. 116
6.5.1 Introduction.................................................. 83 6.9.4 Technique ..................................................... 117
6.5.2 Anatomy....................................................... 84 6.9.5 Complications .............................................. 120
6.5.3 Patient Evaluation and Selection ................. 85 6.9.6 Tips, Tricks and Key Points ......................... 120
6.5.4 Tear Trough and Infraorbital Area ............... 85
6.5.5 Cheekbones .................................................. 89 6.10 Marionette Lines ........................................ 123
6.5.6 Cheek ........................................................... 92 6.10.1 Introduction.................................................. 123
6.5.7 Complications .............................................. 96 6.10.2 Anatomy....................................................... 123
6.5.8 Tips, Tricks and Key Points ......................... 96 6.10.3 Patient Evaluation and Selection ................. 123
6.10.4 Technique ..................................................... 123
6.6 Nose Reshaping .......................................... 97 6.10.5 Complications .............................................. 123
6.6.1 Introduction.................................................. 97 6.10.6 Tips, Tricks and Key Points ......................... 124

70 6 The Most Common Indications
6.11 Jawline and Chin Reshaping .................... 125 and procerus. Horizontal forehead lines appear
6.11.1 Introduction.................................................. 125
when the occipitofrontal muscle is activated. The
6.11.2 Anatomy....................................................... 125
6.11.3 Patient Evaluation and Selection ................. 126 vertical glabellar folds result from the continuous
6.11.4 Technique ..................................................... 127 contraction of both corrugator muscles. The hori-
6.11.5 Complications .............................................. 128 zontal lines in the glabellar area arise from pro-
nounced procerus muscle activity. With time,
6.12 Other Facial Indications these lines become embedded into the skin and
for Volumizers ............................................ 131 will not disappear after BoNT-A treatment.
6.12.1 Introduction.................................................. 131
6.12.2 Facial Advancement ..................................... 131 Therefore, the best possible overall effect may be
6.12.3 Tips, Tricks and Key Points ......................... 132 gained using fillers (Fig. 6.1).
References ................................................................. 132
6.1.2 Anatomy
In the following chapter, the indications will be
discussed separately. However, one must be aware The aesthetic forehead unit comprises the upper
that treating one indication might influence the one-third of the classical “facial thirds.” It extends
other indication, e.g., treating the temporal region vertically from the supraorbital rim to the ante-
may influence the position of the eyebrow and rior hairline. The skin on the forehead is gener-
treating the cheek will influence the appearance of ally thicker than on the lower face, and five layers
the tear trough and infraorbital hollow. are encountered at this level: the skin, the subcu-
taneous tissue, the galea aponeurotica, a part of
the submuscular aponeurotic system (SMAS),
6.1 Forehead and Glabella the loose subaponeurotic areolar layer, and the
periosteum.
6.1.1 Introduction The fascia superficialis is known as the tempo-
roparietal fascia in the temporal area and as the
The forehead and glabellar areas are character- galea in the forehead. There is a fat pad called the
ized by extensive mimic movements of three galea fat pad in the glabella and above the eye-
main muscles: Mm. occipitofrontal, corrugator, brows. The superficial fat is sparse in the forehead,
a b
Fig. 6.1 (a) Analysis of the patient at rest: observe that maintain a long-lasting result. (b) The patient was submit-
due to overcontraction of the corrugators over time, the ted to deep injection with HA with a 21G blunt cannula in
patient became hypertonic and is unable to relax these both scar-like medial and lateral vertical wrinkles. No
muscles anymore with the result of deep static wrinkles. BoNT-A was injected and there is persistence of corruga-
BoNT-A alone would not be able to correct those lines or tors contraction
6.1 Forehead and Glabella 71
glabella, temporal, and orbital areas. It is dense therapy in these areas often turns out to be unnec-
due to fibrotic septa in the forehead region. Deep essary after pretreatment with BoNT-A. Persistent
fat is dense in the temporal and periocular areas. wrinkles after BoNT-A treatment as the residual
At this level, the temporal extension of the deep wrinkles above the lateral eyebrows may benefit
fat pad of Bichat may be found. In the upper face, from the treatment with an injectable filler.
the SMAS denominated the galea aponeurotica, Patients presenting deep forehead and glabellar
which envelops the frontalis, the occipitalis, and folds will require a filler that can be injected
the procerus. The frontalis forms the frontal belly more deeply (subcutaneous or intramuscular
of the occipitofrontal muscle and is inserted into planes) to increase volume (Fig. 6.2). Patients
the galea aponeurotica. The galea connects the presenting superficial forehead and glabellar
frontalis and the occipital muscles. In the central folds or lines may benefit from a fine or very fine
forehead, the frontalis muscle is paired and united filler that must be injected more superficially
by the superficial fascia. It raises the eyebrows (Fig. 6.3). Furthermore, for patients with
and produces the forehead hyperkinetic lines. The advanced elastosis, repeated treatments with
frontalis antagonists are the corrugators, procerus, injectable fillers may rejuvenate the whole area.
and orbicularis oculi. For deep and superficial forehead and glabellar
The supraorbital artery is a terminal branch of folds, the appropriate fillers should be combined
the ophthalmic artery from the internal carotid and the proper use of needles or cannulas should
artery. The superficial temporal artery is the ter- be considered.
minal branch of the external carotid artery and
divides into two major branches. The carotid
veins accompany these arteries. The frontal 6.1.4 Techniques
branch of the facial nerve may be found within
the temporoparietal fascia, from the midportion Anesthesia is not usually necessary. Most injec-
of the zygomatic arch up to its entrance to the tors use the retrograde tunnel technique (i.e., the
frontalis muscle. It provides motor innervation to filler is injected while withdrawing the needle),
the frontalis, corrugator, and procerus muscles. It as it allows a faster application. However, the
also innervates the cephalic portion of the orbicu- multiple injection site technique can also be used.
laris oculi (Pitanguy and Ramos 1966). The This technique will help to blend the filler better
supratrochlear nerve exits the orbit between the into the surrounding area. Deep and superficial
periosteum and the orbital septum at the medial forehead and/or glabellar lines may require mul-
supraorbital rim. It runs along the caudal aspect tilevel injections. The injection should not be too
and within the corrugator muscle and then supe- deep. An injection below the fascia may encour-
riorly on the inner surface of the frontalis fascia age migration of the filler (e.g., from the glabella
to supply sensation to the medial and central to the perinasal area). To avoid an occlusion of
forehead. The supraorbital nerve exits between the arteries, which have been reported for the gla-
the medial and central thirds of the superior bella and forehead area, all injections should be
orbital rim and runs superiorly and laterally on done very carefully, if possible through a 30G or
the inner surface of the frontalis fascia and galea. even blunt cannulas when deep planes are treated.
It is responsible for sensation in the anterior lat- Higher volumes should be avoided in this area.
eral forehead and scalp. Usually 0.2–0.3 ml of an HA filler may be suffi-
cient for the glabellar area (Bachmann et al.
2009). During treatment, avoid injecting into the
6.1.3 Patient Evaluation and direction of the upper eyelid if volume replace-
Selection ment at this level is not necessary.
Usually, volume requirement for the whole
Patients should be critically appraised for possi- forehead is high especially when there is severe
ble pretreatment with BoNT-A; additional filler volume loss and depressions (Figs. 6.4 and 6.5).
a b
c d
e f
Fig. 6.2 (a, b) Before and 3 weeks after treatment with (e, f) Immediately after injection of hyaluronic acid
BoNT-A. Status: relaxed. (c, d) Before and 3 weeks after relaxed and maximum frown. Please note: the erythema is
the treatment with BoNT-A. Status: at maximum frown. not always necessarily present
Medium- to high-viscosity HA products are used patients with severe dermal and subcutaneous
with cannulas for forehead and glabella reshape atrophy, lower-viscosity HA products are
to improve contour and volume loss. In elderly preferred.
6.1 Forehead and Glabella 73
a b
Fig. 6.3 (a) Superficial static lines over the glabella. (b) The patient was submitted to the injection of HA fine lines
with a 30G cannula into the superficial dermis to avoid vascular occlusion. BoNT-A was not injected
a b
Fig. 6.4 (a) In Asians, due to structural aspect, concavity Voluma with a single entry point in each eyebrow between
in the upper forehead and convexity at the glabella level the supratrochlear and supraorbital foramina. A 21G non-
may be found and is considered undesirable. (b) The flexible blunt cannula was used. The after photo was taken
patient was submitted to an injection of 4 ml Juvéderm after 8 months
a b c d
Fig. 6.5 (a–d) Before, immediately after, as well as 1 and 8 months after the forehead reshaping. Note: the consistency
of the results over an 8-month period
6.1.5 Tips, Tricks and Key Points face, this area should not be forgotten as it may
impact the overall expression of the patient, e.g.,
the combination of full cheeks and hollow tem-
Do’s ples may not be aesthetically wanted. Furthermore,
• Before injecting a filler treating forehead treatment of the temporal area may improve eye-
and glabellar folds, it is recommendable brow positioning (see below) and thereby add fur-
to pretreat this area with BoNT-A. The ther improvement to the upper face.
combination of BoNT-A and an inject-
able filler usually leads to a better overall
result. BoNT-A should be injected 6.2.2 Anatomy
approximately 2 weeks before the filler,
although both procedures can be Lateral to the forehead region lies the temporal
performed at the same time in this area. area. It is located above the zygomatic arch, lim-
• Any remaining superficial lines above the ited by the temporal crest or linea temporalis (the
eyebrow after treatment of the upper third junction of the frontal, temporal, and parietal
with BoNT-A can easily be corrected with bones) and laterally by the hairline. Below the
a biodegradable filler of low viscosity. skin and subcutaneous tissue, there are three fas-
Correction with small dosages of BoNT-A cial layers within the temporal region, compris-
is also possible. However, this might carry ing the superficial temporal fascia (or
a small risk of brow ptosis if a significant temporoparietal fascia), which is strongly
part of the M. frontalis is affected. attached to the subcutaneous tissue, and the
superficial and deep layers of the deep temporal
fascia attached to the bony floor. The trigeminal
nerve supplies the sensory innervation of the
Don’ts temporal region. The temporal branch of the
• Do not inject too much volume into the facial nerve passes posterior to the middle aspect
glabella and forehead area. In rare cases of the zygomatic arch, where it lies quite superfi-
focal necrosis is reported after the treat- cially beneath the subcutaneous fat. The superfi-
ment of the glabella and/or the forehead. cial temporal artery and vein are also found in the
subcutaneous layer in the temporal area.
Key Points 6.2.3 Patient Evaluation and

• The glabella is a combination therapy Selection
area. BoNT-A therapy should go first.
• Do not inject too much volume into the Ideally, the temporal area should be slightly con-
glabella and forehead area. A little less vex. With aging, it becomes straight, then con-
may be preferable to decrease the risk of cave. The concavity progresses from mild to
an unwanted arterial occlusion or extra- moderate, then severe and very severe with a
vascular compression. skeletonized appearance of zygomatic arch. The
higher the volume loss, the higher volume
replacement is required. A total amount of 0.5 ml
of HA-based volumizer is enough for mild/mod-
6.2 Temples erate cases (Fig. 6.6) and an average of 1–2 ml
per side in severe cases, and in very severe vol-
6.2.1 Introduction ume loss, a total of 4 ml of an HA-based volu-
mizer may be required. A treatment of the
Thus far the temples are not frequently requested temporal area may also have a beneficial effect
for treatment. However, when treating the whole on the lateral eyebrows. Some patients will
6.2 Temples 75
a b
Fig. 6.6 (a) Volume loss and concave aspect at the temporal area down to the projection of the zygomatic arch before
treatment. (b) After injection of 0.5 ml of Juvéderm Voluma per side, a convex aspect was obtained
present lateral eyebrow lifting only with injection irregularities of skin surface after subcutaneous
into the temporal area. filling with either needles or blunt cannulas.
6.2.4 Technique 6.2.5 Complications
Volume replacement at the temporal area may be With anatomical landmarks marked before, the
carried out with needles or cannulas. Products injection itself is a very safe procedure performing
may be placed deep down to the bone and/or sub- deep temple volume replacement by needle. With
cutaneously. After marking the area of volume the subcutaneous approach, bruising and surface
loss and identifying the superficial temporal irregularities may be found more commonly. As for
artery (may be visible or may identifiable by its the glabella and the nasolabial area also come cases
pulse) and the veins, the filler can be injected of arterial occlusion have been reported for this area.
very safely by needle. The needle should be
inserted perpendicular to the skin penetrating the
epidermis, dermis, subcutaneous, superficial 6.2.6 Tips, Tricks and Key Points
temporal fascia, temporal muscle, and deep tem-
poral fascia up to the bone. The periosteum Most patients are not aware of volume loss at the
should not be scratched to avoid pain. After aspi- temporal area. Therefore, the treating physician
ration to rule out vascular injection, the filler/ may suggest this area when designing the treat-
volumizer may be delivered safely. Advise the ment plan.
patient that (specifically with deep injections) a
slight pressure at the temple level may be felt
especially during mastication in the first post- Do’s
treatment day. The disadvantage of this approach • Remember that temporal volume
is more volume usage compared to the subcuta- replacement may be accompanied by
neous approach. The subcutaneous approach is lateral eyebrow elevation.
the second possibility. As needles may lead to • The use of blunt microcannulas is
bruising and/or intravascular injections, cannulas encouraged using the subcutaneous
are encouraged. However, specifically patients approach for temporal elevation.
with severe subcutaneous atrophy may present
of the face. Eyebrow position will change with

Don’ts age, as gravity and loss of soft-tissue support
• Do not forget to assess and point out the result in ptosis, thereby creating a tired and sad
volume loss in the temporal area in your look. Eyebrow ptosis leads to lateral hooding of
patients. The sooner it is corrected, the eyelids. The resulting skin excess influences the
lower the volume requirement will be. crow’s feet lines. Hyperactivity of the frontalis
muscle is an attempt to correct malposition of the
eyebrow and results in transverse lines in the
forehead.
Key Points Rejuvenation of the upper face may be accom-
• Temple volume replacement has become plished using surgical and nonsurgical tech-
more effective since the introduction of niques. Nonsurgical techniques include ablative
HA-based volumizers. We are able not methods, BoNT-A, and fillers. The surgical
only to correct the sunken aspect but approach includes the temporal lift, the endo-
also to lift the lateral aspect of the eye- scopic brow lift, and the coronal lift. Some of the
brow. It is an important ally to BoNT-A surgical techniques targeting upper-third rejuve-
treatments for the upper third. nation present certain limitations. Depending on
the chosen technique, there may be no effect on
glabellar and forehead lines or those in the mid-
dle and medium part of the eyebrow. Therefore,
6.3 Eyebrow other methods, such as fillers and BoNT-A, are
mandatory for a complete improvement.
6.3.1 Introduction
One of the most important aspects of beauty con- 6.3.2 Anatomy

cerns the position of the eyebrows. It has been
established that “well-demarcated eyebrows The forehead and eyebrow positions are depen-
should arch slightly at the junction of the medial dent on the frontal bone, the supraorbital rims,
two-thirds and lateral one-third of the face.” and the zygoma. The action of the frontalis, cor-
Variations of color and texture of the hair contrib- rugator, and procerus muscles also influence their
ute significantly to the overall perception of the position. The underlying bone structure, rather
image. However, it is the volume and mass at this than the soft tissues, can be responsible for aes-
level that determine the uniqueness of beauty. thetic challenges. The contour of the orbital bone
Eyebrow dimensions vary widely on an individ- and its prominence, which can be targeted by fill-
ual and ethnic basis. Eyebrow hair in the medial ers, is very important for the eyebrow position.
one-third is full and tends to sweep upward and The eyebrow is an important demarcation line
laterally. In the middle one-third, hair direction is dividing the upper and the mid-third of the face.
more horizontal and lateral; in the lateral one- Understanding the eyebrow shape and its
third it points downward. It should be noted that position with respect to the supraorbital rim is
normal eyebrow position differs from men to essential for promoting good results. The eye-
women, and this has to be taken into account brows should be 5–6 cm below the hairline. The
when proper correction of undesired aspects of medial portion of the eyebrow should lie on a
the eyebrows is considered. perpendicular line that crosses the lateral portion
The eyebrows not only frame the upward arc of the ala nasi and rest around 1 cm above the
of the orbit but express emotions such as anger, inner canthus of the eye. The lateral eyebrow
frustration, and uncertainty. Any negative aspect ends at an oblique line drawn from the alar base
concerning the eyebrow symmetry, position, and through the lateral canthus. The medial and lat-
fullness influences the overall aesthetic balance eral end of the eyebrow lies at the same horizontal
6.3 Eyebrow 77
Fig. 6.7 Examples of different eyebrow shapes
a b
Fig. 6.8 (a, b) Patient before and after injection of 0.8 ml product per side both with a 21G blunt cannula. Note the
of Juvéderm Ultra Plus along the eyebrow per side and projection of the upper lateral aspect of the orbit
upper eyelid volume replacement with 0.8 ml of the same
level. In women, the eyebrow should lie above Patients should understand that it is not a surgical
the supraorbital rim and in an arch shape with its procedure. What fillers may promote is basically
highest point at the level of the lateral limbus of a mild volumetric augmentation of the lateral
the eye at approximately the junction of the orbital roof and an elevation of the eyebrows in
medial two-thirds and the lateral third of the eye- the range of millimeters (Fig. 6.8). Other aspects
brow. In men, the arch must be smaller and must of the upper third such as hyperkinetic forehead
lie slightly lower at the supraorbital rim than in and glabellar lines and the desire to have a major
women. It also tends to be heavier in men than in lifting of the eyebrows should be treated with
women (Fig. 6.7). BoNT-A or with selective endoscopic muscle
transection. The patient should be evaluated for
eyebrow position and mobility, eyelid function,
6.3.3 Patient Evaluation and and the presence of skin excess and eye bags.
Selection Pretreatment planning should include photo-
graphic documentation and a clear explanation of
The initial consultation should include a physical the final result.
evaluation and provision of education about the Some clinical situations make treatment with
benefits that fillers may bring to brow reshaping. fillers difficult or are contraindicated. Severe or
Fig. 6.9 In lateral eyebrow

lifting, a small quantity of the
product may be enough for
the lateral upper part of the
orbital roof
moderate ptosis of the eyebrows cannot be After examining the patient, the requirement
improved with fillers because of the inherent lim- for medial, central, or lateral elevation must be
itations of the procedure. The best results are evaluated. Before starting the injection, it is
those with symmetric mild ptosis of the eyebrows advisable to stretch up the eyebrow with the fin-
and thin skin. In these cases, the skin tends to ger to verify the mobility of the medial, central,
have more mobility for both expansion and eleva- and lateral part of the eyebrow. When major
tion. Mild upper eyelid skin excess can be expansion is desired, the entire eyebrow should
improved in selected cases. be injected. In this case, the use of blunt cannula
Eyebrow position is one of the common areas (21, 25, or 27 gauge) may minimize bruising.
for asymmetry. It is quite difficult to find someone If only lateral elevation is desired, a small
with eyebrows that are same shaped and posi- quantity of the product (0.2 ml) is needed for the
tioned. Therefore, any asymmetry, which is quite lateral part of the eyebrow and is usually per-
common in middle-aged women, must be thor- formed with needles (Fig. 6.9). Mild differences
oughly documented before injection. Please note in positions may be achieved by varying the
that most patients will present lateral eyebrow lift- quantity of the product injected.
ing only with injection at the temporal level. Although the vast majority of fillers are
designed for dermal injections, biodegradable
products can be injected into all layers beneath
6.3.4 Technique the eyebrow for a better impression of the filler.
The filler should be injected onto the periosteum,
Eyebrow elevation usually does not require local into the muscle, and subdermally, especially
infiltration or nerve blocking prior to injection of when volumizers are used to improve eyebrow
the filler. Only topical or no anesthetic at all is contour and projection. The injection must be
usually required for this procedure. With the soft, and touching the periosteum (which would
proper technique, this procedure may be consid- cause pain) should be avoided. While injecting, it
ered quite painless. is advisable to stretch the eyebrow and place the
6.3 Eyebrow 79
Fig. 6.10 Pinching the

eyebrow with the fingers is
helpful both to avoid
migration of the product
down to the upper eyelid.
Furthermore, it might
decrease pain
thumb on the upper eyelid to avoid migration of control bleeding. Immediate compression is
the product down this area (Fig. 6.10). advisable in these cases. Local pain and discom-
After injecting the entire eyebrow or into a fort during injection is probably the result of
specific area, it is advisable to compress the eye- touching the periosteum with the needle.
brow for a few seconds to avoid bleeding and Edema after injection is quite common and
keep the product at the proper site. Bleeding is should be explained to the patient beforehand.
generally light and only minor edema usually Surface irregularities result from irregular
occurs. Ice bags are put in place immediately placement of the fillers. Asymmetry can be cor-
after the procedure. Micro-tapes may be placed rected with complementary injections of
onto the site for 2 days to help maintain the eye- fillers.
brow shape and to reduce edema and migration The most feared complication is migration of
of the product down to the upper eyelid if we are the filler down to the upper eyelid. Using the
treating restless patients. However, for the vast proper technique and injecting only small quanti-
majority of patients, no tape is needed. ties of the required product can avoid this. Other
Posttreatment pain is usually minimal and the complications, such as those in association with
use of any medication is rare. Patient’s satisfac- surgical procedures (e.g., numbness, paresis,
tion is usually good if the limitations of the scars, alopecia, and nerve damage), do not occur
results have been understood. When fillers/volu- in treatment with fillers.
mizers are combined with BoNT-A treatment,
the results tend to be longer lasting and more
gratifying. 6.3.6 Tips, Tricks and Key Points
Fillers injected into the eyebrow may be easily

6.3.5 Complications combined with BoNT-A in the upper part of the
face. This will improve the eyebrow position,
Bleeding at the injection site is rare and may especially in its upper lateral part. Care should be
cause local and upper eyelid ecchymosis. Proper taken to avoid migration down to the skin of the
delicate injection avoiding blood vessels may upper eyelid.
eye. One of the primary facial features often

Do’s closely associated with epicanthal folds is the
• Do remember that temporal volume nasal bridge. Indeed a lower-based nose bridge is
replacement may lift the tail of the eye- more likely to cause epicanthal folds, and a
brow in selected cases. higher-based nose bridge is less likely to do so.
There are various factors influencing whether
someone has epicanthal folds, including geo-
graphical ancestry, age, and certain medical con-
Key Points ditions. Epicanthal folds are sometimes found as
• Eyebrow lifting is crucial for facial reju- a congenital abnormality, e.g., in patients with
venation. When low positioning of eye- Down’s syndrome, the nasal bridge does not
brows are associated with volume loss mature. Epicanthoplasty is the eye surgery to
in the temporal area, the latter should be remove the epicanthal folds. It can be a challeng-
treated first to provide support for the ing procedure because the epicanthal folds over-
lateral aspect of the eyebrow. lay the lacrimal canaliculi (tear drainage canals).
Epicanthoplasty may leave visible postsurgical
scar lines. A common corrective technique
involves using a Z-plasty. The use of HA-based
6.4 Epicanthal Fold and Sunken injectables with cannulas may be helpful to
Upper Eyelid address epicanthal folds. This can be achieved by
advancing the supraorbital ridge, the medial
The following two indications are advanced indi- aspect of the orbit, and the nose. With this inter-
cations. The indication of the epicanthal fold vention the features can be improved without sur-
applies almost exclusively to Asian patients. The gery. An office-based procedure with no time off
sunken upper eyelid is an indication that applies may meet patients’ expectations that are not
for all ethnic groups. inclined for surgical corrections (Figs. 6.11, 6.12,
6.13, 6.14, 6.15, and 6.16).
6.4.1 Epicanthal Fold

6.4.2 Sunken Upper Eyelid
Epicanthal fold, epicanthus, or simply eye fold
are names for a skin fold of the upper eyelid When we are young the upper eyelid is full and
covering the inner corner (medial canthus) of the there are only a few millimeters of the upper lid
a b
Fig. 6.11 (a) Epicanthal fold at rest. (b) Epicanthal fold on animation
6.4 Epicanthal Fold and Sunken Upper Eyelid 81
showing. There is no shadow of the upper lid ing where fullness was, and the shadow of the
sulcus (see also Sect. 6.1). During aging the upper lid sulcus appears. The fold of the upper
upper lid deflates, there is skin excess and fold- lid skin often droops and may reach the lash
line and hide completely the upper lid. This
status is an indication for aesthetic rejuve-
nation.
The treatment of the sunken upper eyelid with
HA fillers should only be performed by experi-
enced injectors that have already succeeded with
the treatment of complex tear troughs. Persistent
edema and mechanical impairment of the upper
eyelid excursion may be found if inappropriate
technique is performed. Serious risk of vascular
injuries may happen if sharp needles are used.
The use of blunt cannulas, gentle technique, and
low volume is advisable to avoid complications.
If proper technique is used, the result may be
amazing and much better than fat grafting
(Figs. 6.17 and 6.18).

Fig. 6.12 Description of the areas and the quantity of
Juvéderm Voluma injected with a 21G blunt cannula: gla-
bella (0.3 ml), supramedial orbit (0.25 ml), nose (1.0 ml), These are tricky indications. Both of them should
anterior nasal spine (0.7 ml), and cheekbone (1.0 ml) be restricted to advanced users.
a b
Fig. 6.13 (a) Sunken frontonasal angle and epicanthal fold. (b) After the augmentation of the glabella and nasal bridge,
an improvement of the epicanthal fold can be seen
a b
Fig. 6.14 (a, b) Profile view of the same patient: before and after augmentation
a b c
Fig. 6.15 (a–c) Frontal view of the same patient, before, 1 month, and 8 months after treatment
a b c
Fig. 6.16 (a–c) Observe the projection of the nose, the medial aspect of the upper part of the orbit, and the evolution
of the epicanthal fold
6.5 Infraorbital Hollow, Tear Trough, Cheekbones, and Cheek Reshaping 83
a b
Fig. 6.17 (a) Frontal view: presence of sunken upper amount of 0.45 ml of Juvéderm Ultra Plus was injected
eyelid with excessive palpebral show. (b) The patient was into the right side and 0.35 ml into the left side without
submitted to an injection with a 21G cannula. A total any complications
a b
Fig. 6.18 (a) Oblique view: distracting appearance of the upper eyelid. That was patient’s main complaint. (b) After
the treatment, a more attractive look was achieved
beauty and youthful appearance. Therefore, it is

Key Points important to remember which signs mark a
• We would recommend approaching these youthful appearance. In youth, the lower eyelid
indications only after a specific training. starts at the tarsal insertion and flows in a smooth
• For the sunken upper eyelid, only HA convexity all the way down to the nasolabial fold
fillers are recommended as in case of and buccal region. The lid-cheek junction is
overcorrection or edema hyaluronidase smooth and short, and observing a youthful mid-
might be easily used for correction. face, there is no distinction between the lower
eyelid and the cheek.
Volume loss in these areas is a very important
landmark and so is the increase of shadows
6.5 Infraorbital Hollow, Tear (Pessa 2000). In the lower eyelid, the loss of
Trough, Cheekbones, and orbital volume may cause the infraorbital hollow
Cheek Reshaping and create a sharp distinction line or shadow that
separates the lower eyelid from the cheek. The
6.5.1 Introduction same loss of orbital volume may reveal the under-
lying orbital fat provoking eye bags (Lambros
The midface specifically malar projection and 2002). At the cheek level, the anterior view deter-
full cheeks are important hallmarks of facial mines the volume loss creating the midface
depression. Cheek ptosis with a depression paral- portion and the jowl portion. The deep fat is
lel to the nasolabial fold and the face and the dense in the anterior and the middle cheek. The
presence of the malar mound are important aging deep components of the malar fat pad may be
signs that are placed in the midface. encountered between the facial muscles. The
HA volumizers have dramatically changed the buccal fat pad of Bichat is anterior to the masse-
approach to the mid-third of the face. In the upper ter and lies deeper to the deep fascia at the buccal
mid-cheek and upper lateral cheek area (cheek- level.
bone level), volume deficiencies are mostly cor- The suborbicularis oculi fat (SOOF) is situ-
rected by the injection of volumizers at this level. ated over the lower portion of the zygomatic
Whenever a patient presents infraorbital hollow, body and beneath the muscles. It is separated
tear trough, mid-cheek deficiency, and prominent from the periorbital fat by the thin orbital and the
nasolabial fold, always start by restoring volume malar septum. The presence of malar bags may
at the cheekbone level which will usually lead to result from the ptosis of the SOOF.
an improvement of the infraorbital hollow and In the cheek area, the buccinator muscle arises
the nasolabial fold. posteriorly from the pterygomandibular raphe.
The buccinator muscle is localized deep to the
buccal fat pad and extends anteriorly to attach the
6.5.2 Anatomy orbicularis oris. The masseter has a superficial
and a deep part. The superficial part arises from
The middle third of the face encompasses the the lower border of the anterior two-thirds of the
area between the eyebrows and the base of the zygomatic arch, and the deep part originates from
nose. The inferior third reaches from the nasal the inner surface of the posterior third. It inserts
base to the menton. The ideal location of the the entire lateral ramus of the mandible. Its func-
cheekbone prominence is 10 mm lateral and tion is to elevate the mandible.
15 mm inferior to the lateral canthus. Deficits The malar prominence area has large muscu-
at this level are the result of maxillary elonga- locutaneous perforators. Just lateral to the nasola-
tion and are usually accompanied by a lack of bial groove, there is a concentration of fatty
midface projection. The cheek is framed supe- tissue, the so-called malar fat pad. The facial
riorly by the malar complex and inferiorly by nerve branches and the parotid duct are deep to
the mandible. The size and the shape of the the SMAS and superficial to the masseter and
cheeks are determined by the parotid gland, buccal fat pad. The zygomatical and buccal
the musculature (mostly the m. masseter), and branches of the facial nerve become more super-
the buccal fat. ficial in the medial cheek (Hamra 1992). The
Any midface analysis must include the infra- infraorbital nerve is located deeply, along the
orbital, the tear-trough area, and the submalar bony midface. It is responsible for the sensitivity
triangle (Tobias and Binder 1994). Tear-trough of the cheek and the lip.
deformities become visible in cases of infraor- As the aging process progresses, ptosis and
bital rim depression. The submalar triangle is an pseudoherniation of the SOOF and the orbital fat
inverted triangular area of midfacial depression pads occur. Malar bags result from the ptosis of
and is limited superiorly by the prominence of the SOOF and occur below the level of the orbital
the zygomatic, medially by the nasolabial fold, rim. Loss of the midfacial cheek support causes
and laterally by the body of the masseter accumulation of anterior and inferior cheek fat
muscle. and loss of the lateral and superior cheek fat. This
The SMAS comprises the superficial fascia change of anatomy results in deep nasolabial
and envelopes the majority of the midfacial mus- folds, multiple folds in the cheek (while smiling),
culature. The superficial fat to the SMAS is dense and a hollowness of the submalar area. The
in the cheek, the nasolabial fold, and jowls. The descendent vector will also produce a skeleton-
superficial malar fat pad is divided into the cheek ized appearance of the cheekbones.
6.5.3 Patient Evaluation and Depending on ethnicity, a trough may be seen in

Selection youth in many individuals, and it is its depth or
true indentation that leads to a distracting appear-
The use of fillers for reshaping the midface area ance. The tear-trough deformity may be defined
must obey specific rules: the best results are as the concavity at the junction of the thin eyelid
obtained in patients with good midfacial fullness skin above and the thicker and different nasal and
but insufficient malar projection and with minor cheek skin below, with attenuated subcutaneous
malar and submalar deficiencies. It is also a good tissue overlying the maxillary bone. The skin in
option for young patients with a good malar bone the area of the concavity is indeed of different
structure who complain of early onset of flatness quality, texture, and color. Hyperpigmentation or
in the midface. full transparency may be found in the skin over
Patients with extreme malar deformities and a the tear trough. Volume loss can be present later-
severe submalar recess are not good candidates ally in more advanced aging, at or just below the
for fillers. Conventional malar implants must be orbital rim. At this level, the retaining ligaments
considered. Patients with a deficient midface are thicker and less distensible. In some individu-
present a narrow nose with a shallow dorsum and als, the concavity in the groove is often associ-
a sunken and thin upper lip. The treatment of ated with orbital fat herniation superiorly in the
choice is usually maxillary advancement, and lower lid fat compartments, accentuating its
there is generally a 0.5:1 ratio of soft tissue to appearance (Fig. 6.19). The orbicularis oculi
bony movement. Fillers and specifically the muscle has a direct attachment to the inferior
volumizers may also be helpful for complement- orbital rim from the anterior lacrimal crest to the
ing soft-tissue advancement. medial limbus or approximately one-third of the
Balancing the midface in selected cases may orbital rim length. Laterally, bone attachment to
promote nice and natural results without the need the bone is given by the orbicularis retaining
of surgical procedures with their accompanying ligaments which may vary in length, then
postoperative period with ecchymosis and edema. decreases laterally until these ligaments merge
The skin of the cheeks may show considerable with the lateral orbital thickening in the lateral
elastosis. Patients with thin skin are in general also canthal region. The levator labii superioris
suitable for this procedure. Elastotic skin, how-
ever, may be difficult to treat. For the forehead
area, for example, multiple sessions with a low-
viscosity hyaluronic acid may be useful to increase
its consistency. Alternatively (see Chap. 9) other
interventions as fractionated lasers, peels might be
used to improve the texture of the skin.
6.5.4 Tear Trough and

Infraorbital Area
The term nasojugal groove was used to describe

the concavity at the border of the eyelid and the
cheek medially and was named as tear trough
later (Flowers 1993; Loeb 1993). It refers to the
medial one-third of the infraorbital hollow and
Fig. 6.19 Presence of prominent nasojugal fold, tear
may be the first early concavity at the lid-cheek
trough, and palpebro-malar sulcus. Observe the malar
junction in early aging. It is found at the inferior mound and the projection of the orbicularis oculi retaining
orbital rim down to the hemi-pupillary line. ligament
a b
Fig. 6.20 (a) Presence of tired look with elongated lid- lower eyelid and cheeks was softened. A direct injection
cheek junction. (b) After the injection of 0.5 ml of into the tear trough was not performed
Juvéderm Voluma per side, the transition between the
a b
Fig. 6.21 (a) On the profile view, it is evident that the ment, there is no evidence of a noticeable transition line
volume loss in the mid-cheek was the cause of the elon- between both structures
gated lid-cheek junction and tired look. (b) After the treat-
originates just below the orbicularis oculi muscle Mild tear-trough deformities (e.g., infraor-
attachment to the medial orbital rim (Muzaffar bital rim depression) are a good indication for
et al. 2002). fillers. The presence of fillers along the infraor-
As there is scant subcutaneous tissue between bital rim may improve the suborbital groove.
the skin and the orbicularis muscle in this area, This is considered an advanced area for injec-
the tear-trough skin is attached direct to the tors, and complications are not rare, especially in
orbital rim. The cause of the tear-trough defor- the hands of inexperienced users who tend to use
mity may include volume loss, orbital fat hernia- too much volume or inappropriate fillers.
tion, and skin laxity in different degrees of Minimizing adverse events is of utmost impor-
severity among patients. tance here.
used. Infraorbital and zygomatic facial nerves

block might be needed if working with larger
cannulas and with HA products without
lidocaine.
Volume replacement in the infraorbital and
cheekbone areas can be performed with either
needles or blunt cannulas. Deep injections
touching the bone at the infraorbital foramen
level must be avoided to high risks of complica-
tions. Both bolus and retrograde techniques can
be performed at the cheekbone level. The accu-
rate choice will depend on the degree of volume
loss and bone projection. Flat bone and univer-
Fig. 6.22 Skin demarcation is very useful for treating the sal volume loss at this level is better treated
tear-trough deformity. After demarcation follows the with retrograde or small bolus injection to
injection. Care should be taken not to produce excessive avoid irregularities. High volume concentrated
ecchymosis in a single point could lead to difficulty in
molding the product and higher risk for
unwanted effects.
It is important to highlight that much of tear- In general, volume replacement in the infraor-
trough deformities can be effectively treated only bital and cheekbone areas may solve totally or
by mid-cheek volume replacement. Aging pro- partially problems at the lid-cheek junction espe-
cess provokes elongation of the lid-cheek junc- cially when it is not a real tear-trough deformity.
tion, and shortening of the lower lid height can be If direct injection into the tear trough is needed,
also obtained only by volumizing the cheekbones the volume requirement will be lower and so will
(Figs. 6.20 and 6.21). the risk of adverse events such as Tyndall effect
If a hydrophilic product such as HA is to be or prolonged edema after HA injection. It is
used at this level, undercorrection is advisable to important to avoid injecting a large continuous
avoid prolonged edema. Ideally, low-viscosity column of filler along the tear trough because a
products are to be injected at the tear-trough level “sausage” appearance can result. Multiple entry
due to the thin aspect of the skin. However, other points with either micro bolus (0.01–0.02 ml per
products as low-viscosity HA preparations may point) or retrograde product delivery along or
be injected in this area too – provided they are preferably below the inferior orbital rim may be
injected deeply. considered for needles or cannulas. Low volume
Treatment in the infraorbital area starts with is desirable for both injection types. Gentle mas-
the marking (Fig. 6.22). The patient should be sage with finger or cotton buds is advisable
in upward position and should bend the head (Figs. 6.23, 6.24, 6.25, 6.26, and 6.27).
forward with “chin down, eyes up.” This posi- The advantages of cannulas at this level
tion enables more accurate distinction of the include fewer entry sites and more safety if cor-
elongated lid-cheek junction and accentuates rection above the orbital rim of sunken and/or
the tear-trough deformity and volume loss skeletonized eyes either genetic or post-
along the infraorbital and cheekbones areas. blepharoplasty is needed.
The inferior orbital rim is usually higher, so The duration of results has been longer than
any intraorbit injection is avoided if the upper expected in the infraorbital and tear-trough areas.
limit of this marked line is respected. Usually For most patients, results can be expected for 1 or
only topical anesthetics and/or ice packs are even 2 years in younger patients.
Fig. 6.23 Careful injection

into the tear trough may
expand the skin and decrease
the deformity
a b
Fig. 6.24 (a) This patient presented eye bags in the 25G microcannula. The product was delivered along the
lower eyelid. She was searching a nonsurgical solu- periosteum of the inferior orbital rim and under the m.
tion. (b) She was submitted to the injection of 1 ml of orbicularis oris. Note that the eye bags have completely
Juvéderm Volbella per side in a single entry point with a disappeared. No late edema was found
Key Points Do’s

• It is important to differentiate the real • When correcting the infraorbital area,
tear-trough deformity from elongated lid- undercorrection is advisable. The use of
cheek junction, eye bags, and skin excess. cannulas in this area might reduce the
Inaccurate diagnosis might lead to risk of postinjection hematoma.
unwanted effects or even complications.
a b
Fig. 6.25 (a, b) The same patient before and after treatment smiling. Please note the reduction in the number of subor-
bicular wrinkles
a b
Fig. 6.26 (a, b) Profile analysis of the same patient before and after treatment. Observe shortening of the lid-cheek
junction and improvement of dark circles through tissue expansion with the HA
6.5.5 Cheekbones
Don’ts
• Do not use high-viscosity HAs for this There has been a huge change in cosmetic prac-
indication. tice since the introduction of volumizers in the
market. Before that when assessing the midface,
a b
Fig. 6.27 (a, b) Profile analysis of the same patient leaning forward with “chin down and eyes up.” In this position the
protrusion of the eye bags makes it easier to understand the importance of lower eyelid by the injected HA
Fig. 6.28 Split photograph: patient is leaning forward.

Note before treatment the elongation of the lid-cheek
junction, ptosis of cheek, and the prominent nasolabial
fold (right side). After volume replacement with 2 ml of
the Juvéderm Voluma (left sided), there is improvement of
the mid-third of the face (right and left is based on the Fig. 6.29 A small triangle is demarcated at this level.
patients perspective) Both the frame and the internal area should be filled
both injectors and patients would focus on the Either no anesthetic or only topical anesthesia
nasolabial fold and sometimes in the tear-trough is usually required for this procedure especially
area, but cheekbones were in the “blind spot.” when the product contains lidocaine. Nerve
The introduction of volumizers did show us how blocks may be necessary if cannulas are to be
important the replacement of volume loss in the used especially 18 and 21 G. Outlining the entire
cheekbones is. Not only have we noticed the area with, e.g., an eyeliner before injection may
WOW effect in our patients but an additional promote accurate filling and easy removal of the
improvement in the nasolabial fold and tear marking (Figs. 6.29 and 6.30).
trough. Depending on the HA volumizer preparation,
There are different approaches to volume injections should be deep down to the bone.
replacement in the cheekbones. It is important to However, for some volumizers as Juvéderm
mark the lid-cheek junction and the volume loss Voluma injections may be performed in the
in the mid and lateral aspects of the cheekbones. superficial and deep fat malar compartment. This
I usually perform the marking with the patients enables a better lifting effect with less quantity of
with “eyes up and chin down.” This position product. The multilayer approach is recom-
enables a more accurate definition of the areas to mended when the deficiency also results from
be treated as well as a very efficient way to verify lack of good bone projection. There are different
the immediate response (Fig. 6.28). approaches that may lead to the same result.
Fig. 6.30 When major projection is desired, the zygo- Fig. 6.31 Injection is performed after an injection plan of
matic arch level is also filled the area to be treated has been drawn. At this level, the
malar prominence is enhanced
Bolus or small bolus, retrograde/anterograde require 0.5 ml, moderate deficiencies may be
techniques are possible at this level. Massage is improved with 1.0 ml per side (Fig. 6.34), severe
very important to smooth out any irregularity. deficiencies may need a minimum of 2.0 ml per
Both cannulas and needles can be used for side, and very severe may require up to 4.0 ml
cheekbone volume replacement, and care should be when submalar deficiency is also present. Volume
taken to avoid deep direct injection into the infraor- restoration in the mid-cheek may also be helpful to
bital foramen. It is also noticeable that more volume promote facial advancement (Figs. 6.35 and 6.36).
is used when the treatment is delivered with cannu- A frequent challenge that can be seen is the
las. Maybe it is due to the fact that more superficial over-injection at the cheekbone level, what is con-
product placement is obtained with needles. sidered not aesthetically appealing. Patients and
During the injection, the fan technique is under- injectors need to be aware about balance and pro-
taken from each edge of the drawing in order to portion in this area. A simple rule to be followed
promote a crossing of micro-tunnels. M multilayer includes the following: treatment should stop if at
injections are conducted. The deep reticular dermis rest we still believe that a little more product is
will be filled by starting more superficially with the required, and then the patient will be good on ani-
needle almost parallel to the skin. Opening the mation. If full cheekbones are slightly big at rest,
angle of the needle to 30–45° will allow it to reach the result may be catastrophic on animation!
the subcutaneous and the muscular layers
(Fig. 6.31). After filling all layers, a soft massage is
conducted and a final analysis of the obtained pro- Key Points
jection is undertaken. Finally, if needed, the needle • The injection of volumizers in the cheek-
must be inserted at a 90° angle almost touching the bone area has changed the understanding
periosteum on the most prominent parts of the of treatment sequence. Patients present-
malar bone for major projections. Drapes are may ing elongated lid-cheek junction, volume
be applied to reduce edema but are usually not nec- loss in the cheekbones, and prominent
essary and for correct maintenance of the position nasolabial fold sometimes might only
of the filler. After the edema has subsided, the final need treatment at the cheekbone area,
result may be evaluated (Fig. 6.32). The filling of and improvement of the tear trough and
the cheekbones should be subtle and increase nasolabial fold will not be necessary.
slightly the midface width (Fig. 6.33). • Overtreatment of the cheekbone area is
The amount of product will vary according to not recommended.
the degree of volume loss: mild deficiencies may
a b
Fig. 6.32 (a, b) Before and after injection of the cheekbone area. After treatment, with the improvement of the mid-
third of the face, a more youthful appearance is evident
a b
Fig. 6.33 (a, b) The filling of the cheekbones must be subtle and increase slightly the midface width
Do’s 6.5.6 Cheek

• Do not forget to get a three-dimensional
view of your patient. What looks good Cheek augmentation follows the same initial
from the front might not look good from steps as that of the cheekbones. Topical anesthe-
the sides. sia is usually sufficient for this area if the treat-
ment is with needles and the product containing
lidocaine. Visual analysis is important to estab-
lish the markings, which should be done with
Don’ts the patient in an upright position and leaning
• Do not create bean-shaped cushion-like forward (eyes up and chin down). When the
depots in the cheekbone area. It rarely patient is leaning forward, we may mark the NO
looks good. GO areas (Fig. 6.37). These are the areas that if
injected may worsen by causing bulging areas
a b
Fig. 6.34 (a, b) A male patient with elongated lid-cheek junction, volume loss in the mid-cheek, and prominent naso-
labial fold before and after 2 ml of Juvéderm Voluma into the cheekbones and nasolabial fold
a b
Fig. 6.35 (a, b) Asian patient with volume loss in the canine fossa and 1 ml Juvéderm Ultra Plus injected into
mid-cheek and retruded upper maxilla before and after the lips. The injections in the midface were done with a
2 ml of Juvéderm Voluma per side for the mid-cheek and 21 G blunt cannula
a b
Fig. 6.36 (a, b) Same Asian patient as before in negative negative photo analysis is an alternative way of reviewing
photo analysis. Observe that after advancement of the improvements in volume restoration. Shadow vs light
mid-third of the face with injectable fillers, less concavity analysis after volumizing cheekbones
is obtained and consequently less shadow is noticed. The
Fig. 6.37 Skin demarcation for injection: it is helpful to

delimitate the area that be injected
both at rest and on animation. Pinching the skin

at this level may also indicate the area where the
Fig. 6.38 When the patient is leaning forward, the NO
skin and underlying tissues are atrophic. A tri-
GO areas should be marked to avoid any inadvertent
angle is usually drawn to limit the area to be injection into areas of laxity such as the malar mound and
treated (Fig. 6.38). Retrograde injections are jowls
a b
Fig. 6.39 (a, b) Cheek lines before and after injection of buccinator was provided and resolution of the lines
1 ml of Juvéderm Voluma per side. The injections were obtained. Please note that direct injection with needles
done with a 21G cannula. By this a deep support at the M. usually does not lead to prolonged correction
a b
Fig. 6.40 (a, b) Both the left cheek and the upper lip were filled. Symmetry and balance were obtained after the filling
procedure
undertaken beneath the lines. Placing the thumb ute to fight gravity (Fig. 6.41) Besides HAs
against the cheek intraorally may be helpful PLLA is the product for cheek rejuvenation. As
during the injection, especially when the inter- here the results are based on gradual collagen
nal part is treated. Immediately after the fan stimulation, the desired effect will show only
technique, a smooth massage with both the after several sessions over several months.
thumb and the index finger will make the sur- PLLA should be diluted with 9 ml (see Sect.
face more uniform and make any small untreated 1.3.4) to avoid unnecessary adverse effects. For
areas evident. Both cannulas and needles may cheek augmentation, PLLA should be injected
be used in this area. The treatment of accordion deeply approximately 0.3 ml per 1 cm2 follow-
lines is better handled with blunt cannulas ing the cheekbone. In the lower cheek area, sub-
(Fig. 6.39). In some cases only one specific area cutaneous injections of approximately 0.1 ml/
needs to be filled to promote facial balance and cm2 are recommended (European Expert
correct asymmetries (Fig. 6.40). In other situa- Recommendations for Sculptra, unpublished
tions, cheek volume replacement may contrib- data).
a b
Fig. 6.41 (a, b) Before and after treatment of the volume loss and sagginess of the cheeks with 2 ml of Juvéderm
Voluma per side by a 21G cannula. Besides correcting the volume loss, observe the improvement of sagginess

Key Points
• For severe volume loss at the cheek level, The most important advice for this area is a care-
it is better to inject HAs with blunt can- ful approach that follows the patient’s anatomy.
nulas as several tissue layers should be As for the lips, a three-dimensional view is rec-
injected. Inadvertent vascular and nerve ommended. For example, results should always
injury is reduced. Extensive bruising is be seen not only from the front but also from both
not uncommon when needles are used. sides.
• In severe volume loss treatment might
also be done in steps. When volume Do’s
replacement is distributed in several steps, • Do start the treatment of tear-trough
the outcome might be more natural. deformity by volumizing the mid-cheek.
• Besides HAs this is an area for PLLA We may not need direct injection there.
treatment. • Do ask your patient to be with “eyes up
and chin down” before marking the tear-
trough and cheekbone volume loss. Use
6.5.7 Complications also this position to evaluate immediate
results.
The most common adverse events for cheekbones
and cheeks include edema, bruising, visible nod-
ules, and overcorrection. The infraorbital hollow/
tear-trough area is more prone to adverse events Don’ts
compared to the cheekbone area and cheeks. • Do not over-treat the tear-trough area
Some of the complications that are found in with HAs. It is likely to produce Tyndall
the tear trough result from the presence of effect and prolonged edema.
highly hydrophilic products such as some prep- • Do not use PLLA for tear-trough rejuve-
arations of HA when the injector inadvertently nation. PLLA is a good product for
injects too superficially or promotes full correc- cheekbone and cheek augmentation.
tion of the deformity to please the patient. As a • Do not over-inject cheekbones. If they
suggestion in this case, undercorrection is advis- are already slightly big at rest, they will
able for it may reduce Tyndall effect and be catastrophic on animation.
prolonged edema.
6.6 Nose Reshaping 97
6.6 Nose Reshaping

• Do not aim for round faces when recon-
structing cheeks (specifically in male 6.6.1 Introduction
patients). Most patients will naturally
present some concavity here. The surgical approach to the nose may be seen
as a quite invasive procedure, especially when
surgery is based on fracturing the nasal bone.
Key Points Reshaping the nose with injectable fillers,
• Whenever a patient presents infraorbital however, is a minimally invasive technique
hollow, mid-cheek deficiency, and prom- with a quick recovery time that has revolution-
inent nasolabial fold, start always by ized cosmetic practice. Reshaping the dorsum
restoring volume at the cheekbone level, and lifting the tip of the nose can be effectively
and improvement in both the infraorbital achieved with injectables, what was only pos-
hollow and nasolabial fold is obtained. sible with surgery before. It is known that dis-
tracting noses are usually corrected during
adolescence for those who are bothered with
their nose appearance. However, the vast
• The best results for cheekbone reshape majority of people get into adulthood with dis-
are obtained in patients with good mid- tracting noses that tend to worsen during aging
face fullness but insufficient malar pro- process. It is very much unlike that senior and
jection and with minor malar and adult patients go to operating room to have
submalar deficiencies. their nose fixed with surgery even when they
are unhappy with it. That is the reason why
injectables have become a powerful tool for
FAQs nose reshape and will be a more frequent solu-
• For cheekbone volume replacement, tion than surgery to improve the distracting or
which one should we choose: needles or aging nose.
cannulas? The knowledge of anatomy and gold
Both tools can be used in this area. A standards of the nose are important tools for
simple rule is asking yourself: Is it pos- those who are willing to start working in this
sible to solve this problem with a needle? facial region. Not only because it is an impor-
If yes, needles might be very helpful. The tant area but also due to serious complications
reasons include less pain, lower quantity as tip necrosis that may happen in the hand of
of product, and more lifting effect due to inexperienced injectors. Due to the risk that this
more superficial product delivery. area presents, it is highly advisable that appro-
However, if the patient presents very priate training is performed.
severe lipoatrophy, which means the skin Reshaping the nose with injectables is a
is adhered to the bone and multiple layer- method from which there is quick recovery
ing and more products are required, there time with no need for general anesthesia or
is an option for cannulas. sedation and does not result in ecchymosis. It
• When should be HAs used and when definitely may produce similar final results as
PLLA? surgery, but they are not as long lasting if bio-
If an immediate effect is desired, HAs degradable fillers are used. Lately, the use of
are the first choice. When gradual rejuve- newer volumizing HA products has filled the
nation is desired, the choice can be PLLA, duration gap, and longer results for more than
however, never in the tear-trough area. 2 years can be expected for this indication
(Fig. 6.42).
a b
Fig. 6.42 (a) At rest, there is an evident nose hump and Injections into the frontonasal angle, supratip, and tip
caudal rotation of the nose tip. This patient considered his areas were carried out. A total amount of 1 ml of
nose to be distracting but he was not open for surgery. (b) HA-containing lidocaine was injected
He accepted the nonsurgical approach with HA fillers.
6.6.2 Anatomy and the external nasal arteries are branches of the
ophthalmic artery. The lateral nasal vessels are
The nose consists of a framework of skin, carti- 2–3 mm above the alar groove and together with
lage, and bone that is supported by connective the columellar artery arise deep at the nasal base
tissue and ligaments that hold them all together. and end at the tip in the subdermal plexus
The skin is thicker and adherent in the lower third (Rohrich et al. 1995; Fig. 6.43).
of the nose and is thinner and more mobile in the The skeletal component of the nose consists of
upper two-thirds. The blood supply to the exter- bone and cartilage. The nasal bones are paired
nal nose is based on the facial artery. The supe- and the frontal process of the maxilla is found
rior labial and the angular artery are the main laterally. The dorsum of the nose is where the
branches that respectively form the columellar lateral surfaces of the upper two-thirds join the
branches and the lateral nasal branch. Both of midline. The upper lateral cartilages are conti-
them supply the tip of the nose. The dorsal nasal nuous with the nasal bones. The lower lateral
cartilaginous vault is comprised of the medial,

middle, and lateral crura. The anatomic dome is
the junction of the medial and lateral crura.
Depending upon the intrinsic relationship of
these structures, the tip of the nose can be nor-
mal, bulbous, or boxy. Tip support is basically a
combination of skin, ligaments, and cartilage.
The depressor septi nasi is the most important
muscle that acts on the tip and lip complex. It
shortens the upper lip and drops the tip when
smiling. Surgical resection or blocking with
BoNT-A may be necessary to enhance the result
of fillers. However, this is not the rule (Figs. 6.44
and 6.45).
When reshaping the nose with fillers, the
angles with the lips and the forehead are quite
Fig. 6.43 The nose blood supply: a superficial temporal important. The former is the nasolabial angle and
artery, b occipital a., c transverse facial a., d posterior
auricular a., e maxillary a., f inferior alveolar a., g external should be between 90° and 100° in men and
carotid a., h ascending pharyngeal a., i internal carotid a., between 100° and 110° in women. The latter is
j common carotid a., k superior thyroid a., l lingual a., m the nasofrontal angle, which is between the fore-
facial a., n submental a., o mental a., p inferior labial a., q head and the nasal dorsum (Fig. 6.46).
superior labial a., r angular a., and s infraorbital a
a b
Fig. 6.44 (a) During animation, a downward rotation of Juvéderm Voluma into the nasal dorsum and into the naso-
the nose tip can be noticed. Note the presence of an evi- labial angle, straightening of nasal dorsum is observed
dent nose hump. (b) After the injection of 1 ml of
a b
Fig. 6.45 (a, b) Nose reshape with 1 ml of Juvéderm Voluma. Note the straightening of the nose dorsum
thin skin. Thicker skins do not expand as easily

Nasion or nasofrontal angle as the thinner ones and usually require more
product or larger molecules.
Rhinion Another aspect to be analyzed should be the
presence of deviations. Deviations can be evidenced
Supratip with an imaginary line from the midglabellar area to
Tip-defining piont the middle of the chin, crossing the nasal tip and the
Cupid’s bow. The width of the alar base should be
Facet
the same as the intercanthal distance. The columella
Ala
should be only slightly visible on the frontal view. If
the columella is too small, filling may produce a
Columella
nicer aspect of the nose. The ratio between the colu-
Fig. 6.46 Anatomy of the nose mella and the nasal lobule should be 2:1. If the nos-
trils are flat, increasing the height of the columella
may be desirable. On the basal view, the nose should
6.6.3 Patient Evaluation be like an equilateral triangle (Farkas et al. 1986).
and Selection When analyzing the profile, some important
aspects must be evaluated: the nasofrontal angle,
Patient selection is of utmost importance for nose the nasolabial angle, and confirmation of the
reshaping with fillers. Both thin and thick skin is presence of a supratip break. The nasofrontal
suitable for fillers. Patients with thinner skin usu- angle should be gentle and a concave curve. It is
ally require less product. In these patients in par- the connection between the brow and the nasal
ticular, however, any mistake (too much material dorsum. Lack of tip projection is found in short
either absolutely or relatively) can be evidenced noses. An imaginary vertical line adjacent to the
during and after treatment. Biodegradable sub- projection of the upper lip should divide the dis-
stances, although temporary, are thus the best to tance between the nasal base and the apex of the
start with. The vast range of products available nasal tip. If less than 50 % of the tip is anterior to
nowadays enables the right choice for each case. this line, augmentation should be conducted.
Small molecules can provide a subtle result and The nasal dorsum should be evaluated after
are the first choice for beginners in patients with treating the tip projection. Ideally, the dorsum
a b
Fig. 6.47 (a) This female patient presents a low nasal was done with 1 ml Juvéderm Voluma using a 25G blunt
dorsum and an excessive concave frontonasal angle giv- cannula through correction of the saddle appearance of
ing the impression of a frontal fossa. This pattern may be the nose and the retruded columella
found in infants and Afro-descendants. (b) Nose reshape
should lay 2 mm posterior to a parallel line from used. Lately, HA preparations containing lido-
the nasofrontal angle to the nasal tip in women caine have brought enough comfort for patients
and a little less in men. The best cases to be during the injection, and the use of nerve blocks
treated with fillers are those too far posterior to is unnecessary when working with needles.
this line; in these cases the whole dorsum should Tissue expansion is easier on the bone dorsum
be augmented. If the dorsum is on the line or and more difficult in the lower third. Care should
projects over it, filling the tip and the nasofrontal be taken with the vessels that pass within the sub-
angle should be the choice. cutaneous tissue above the muscles. The injec-
Nose reshaping with injectables can enhance tion of any substance into patients with oily skin
dorsum projection, correct nose hump, lift the and large pores may be followed by extrusion
nose tip, and improve the retruded columella and loss of the product, so injections should
(Fig. 6.47). always be below the subdermis and the bevel
down. When contrasting thin with thick nasal
skin, the latter will require larger polymers and
6.6.4 Technique quantities of products. Any mistake will become
quite evident in patients with thinner skin. For
As the nose is quite a sensitive area, topical anes- safety reasons beginners are advised to start with
thesia might not be sufficient. Therefore, a block biodegradable products. As mentioned previ-
of the fibers of the ophthalmic and maxillary ously, HA preparations are lasting longer and the
nerve branches is recommended. Usually block- use of permanent fillers tend to decrease.
ing the supratrochlear and infraorbital branches The use of cannulas for nose reshape is the
will suffice especially when cannulas are to be best alternative to treat very low and flat noses
Fig. 6.48 Treatment of the nasofrontal angle must be Fig. 6.49 The nasolabial angle filling enables the lifting
undertaken closely to the periosteum, injecting into the of the tip of the nose. For women, this angle must be 100°
muscular and subdermal layers. This filling will make the or 110°. It produces a delicate appearance of the nose
bone dorsum more even and straighter
spine will expand the inferior part of the membra-

such as those found in Asian patients. One of the nous septum. If necessary, the columella base can
challenges to enhance nose projection in those also be injected, especially if widening of the
patients is to maintain the height of dorsum pro- medial crura is desired. More volume is needed
jection. By creating a single connective tissue here especially if the columella is retruded or
tunnel with a cannula, lateral displacement is underdeveloped such as in Asian patients. A total
avoided and projection is maintained. of 0.5 ml may be required. Elongation of the upper
lip may occur and should be avoided. Longer
upper lip is distracting in the vast majority of
6.6.5 The Nasofrontal Angle patients. However, patients with excessive short
upper lip and gummy smile may benefit from it.
The best patients to fill are those whose nasofron-
tal angle is too deep. When the dorsum is exces-
sive, filling the nasofrontal angle and reducing its 6.6.7 The Tip and the Columella
concavity may straighten the dorsum and the
nose may look smaller (Fig. 6.48). If too much 6.6.7.1 Columella Height
product is injected into this area, the nasofrontal The medial crura should be expanded if the nos-
angle may become too shallow, producing an trils are flat. It should be teardrop shaped. A
undesirable effect. This area is not painful and retracted columella can also be filled. Depending
patients do tolerate the injection without any on the degree of retraction, soft-tissue expansion
anesthetic at all. Nose deviation may occur espe- should be handled in more than one session.
cially if the injection is performed by the side of Expansion is undertaken with an injection into the
the patient instead of the cranial approach. membranous septum. Injecting into the footplates
Usually 0.1–0.2 ml is needed at this level. of the medial crura may increase tip projection
(Fig. 6.50). Before injecting, it is advisable to
pinch the columella to check how expandable it is.
6.6.6 The Nasolabial Angle
6.6.7.2 Supratip Deformation
The opening of the nasolabial angle is obtained Care should be taken not to erase the supratip
with the filling of the anterior nasal spine break. Filling into this point may cause supratip
(Fig. 6.49). Injecting deeper adjacent to the nasal deformation and consequent dropping of the nasal
Fig. 6.50 When injecting into the columella basis, care

Fig. 6.52 The tip filling: a direct injection into the tip of
should be taken not to wide this area too much. So, the
the nose promotes both lifting and projection increase.
thumb and index finger must be in a position to avoid it
Too much of the injected product may provoke a boxy
deformation
crura. When only the domes need augmentation,

injections must only be made into the upper por-
tion of the tip. If the whole tip must be treated,
upper and lower injections must be undertaken.
This is a nice solution for patients with thin skin
who present surface irregularities on the tip.
Care must be taken not to inject too much
product as this may produce widening of the mid-
dle crura and a boxy tip aspect, which is undesir-
able. During the injection, pinching the tip may
be helpful to avoid excessive filling. A delicate
Fig. 6.51 Injecting into the cartilaginous dorsum must be caudal injection into the tip may produce an
carefully performed to avoid a supratip deformation and a
increase in tip projection and a nice upward tip
falling of the tip
rotation. When a major increase in tip projection
is necessary, filling into the soft tissue of the pre-
tip (Fig. 6.51). To enhance the supratip break, maxilla is advisable.
there must be a difference in height between the Injection into the tip should be carried out
domes and the septal angle; a tiny injection into with caution. The use of biodegradable products
the tip of the dome may produce this effect. is recommended.
6.6.7.3 Tip Projection

To evaluate whether the filling of the tip was cor- 6.6.8 Dorsum
rectly performed, the final tip projection must
equal the width of the alar base. An increase in When the tip of the nose is adequate but the naso-
tip rotation is conducted in patients with a frontal angle and dorsum are low, fillers are very
reduced nasolabial angle. Increasing the nasal tip suitable for nose reshaping (Fig. 6.53). The tip
projection may be undertaken by direct injection height helps to give an idea of the quantity of prod-
into the domes (Fig. 6.52). When treating the tip, uct to be injected. Injections should start with the
it must be established whether the patient needs nasofrontal angle to reduce its concavity up to the
augmentation of the domes and/or the middle point where it equals the tip height. The dorsal
a b
Fig. 6.53 (a, b) Saddle deformity after rhinoplasty before and after treatment with a filler. Fillers may be an important
ally to prepare patients for surgery or may even be the only treatment
a b
Fig. 6.54 (a, b) This typical surgical nose was only treated with fillers. After a 5-min procedure, the patient could leave
the office with no postoperative period, no ecchymosis, and no bandages
augmentation should almost reach the imaginary native is to use injectables (Fig. 6.54). After
line between these two points. Injections should be treating the tip, injections must be made into the
carried out with a retrograde technique. Any irreg- nasofrontal angle, onto the bone and cartilagi-
ularity should be treated with a slight massage. nous dorsum, and into the nasolabial angle. Care
In the past, the dorsal hump was treated should be taken not to produce a supratip
mainly by surgery. However, a very good alter- deformation.
6.6.9 Selection of Filler each time less as longer-lasting HA preparations

are coming into the market
If it is the first time that the nose has been
injected, it is preferable to get experience with
biodegradable products. Only experienced phy- 6.6.10 Complications
sicians should handle nonbiodegradable prod-
ucts. Even some experienced physicians only The most frightening complication associated
use biodegradable products to avoid complica- with nasal reshaping is necrosis and blindness. It
tions. Hyaluronic acid enables a good start; is rare and occurs mainly with nonbiodegradable
although the results did not last long in the past, products. Blood vessel impairment with biode-
new HA preparations such as Juvéderm Voluma gradable materials is much less common, and if
or comparable HA products have increased an HA filler is inadvertently injected into a blood
dramatically the performance and duration of vessel, a massage should be promptly undertaken
nose reshape. Due to its hydrophilic properties to break up the polymers and hyaluronidase
and pseudoplasticity, it can be easily molded should be immediately used.
(Fig. 6.55). Excessive filling of the cartilaginous dorsum
Nonbiodegradable products are a good choice may lead to supratip deformation and irregulari-
for longer-lasting results, but care should be ties. The nasofrontal angle and the nasolabial
taken with blood vessels. Accidental injection angle rarely produce deformities if properly
into the nasal blood vessels, especially into the injected, but nose deviation may result though.
columella base, may result in tip necrosis, which Care should be taken not to produce a widening
may lead to a catastrophic result. PMMA prepa- of the nose at these areas. If too much product is
rations are examples of products that usually pro- injected into the tip of the nose, a boxy deforma-
duce longer-lasting results but tend to be used tion may occur.
a b
Fig. 6.55 (a, b) Presence of nasal hump and a droop of nasal tip. The treatment was carried out with 1.0 ml of Juvéderm
Voluma. A straightening of the nasal dorsum and correction of the tip were obtained

• Needles or cannulas for nose reshape?
Nasal filling should be undertaken with care and It depends on the case. Needles are
knowledge of the anatomy. Some of the results useful to correct dorsal humps and lift
are comparable to those achieved with surgery. the tip of the nose by injecting into the
This is a good option for patients who are not nasolabial angle but may be limited in
willing or are unable to submit to surgical very flat and low noses where cannulas
procedures. are the best option.
Do’s
• Do educate your patients with nasal def- 6.7 Nasolabial Folds
icits about the benefits of nose reshape
with injectables. 6.7.1 Introduction
• Please remember that nasal injections
will not change the physiology of the Nasolabial folds are still the major indication for
nose. In case of a distorted nasal sep- injectable fillers. Furthermore, they are the best
tum, surgery is the option. investigated filler indications as the FDA requests
this indication for fillers entering the US market.
Based on these studies we have for the investigated
products good data to answer simple questions as
Don’ts the following: (1) How much filler do I need to
• Do not inject noses if you are not prop- inject on average? (2) How long will the filler last?
erly trained. After one injection? After repeated injections?
And what is the safety of this procedure?
There is no such thing as the nasolabial fold.
There are deep nasolabial folds and more superfi-
Key Points cial ones; there are nasolabial folds that are
• Nose reshaping with injectables have induced by strong facial mimics (Fig. 6.56) and
filled a gap to the treatment of the dis- those induced by ptosis of the SMAS (Fig. 6.57).
tracting or the aging nose when we had Each of these folds requires special attention
only surgical solutions in the past. with regard to the injection technique, the mate-
• To have good results and avoid adverse rial to be used, and the amount of filler necessary.
events, extreme care in technique and Last but not least, a word of caution: this is like
proper antisepsis is of utmost the glabella, an area where an inadvertent injec-
importance. tion in an artery (a. nasalis) might lead to the
occlusion of the vessel with subsequent necrosis,
e.g., of the ala nasi (see Sect. 8.5.3).
FAQs
• What are the benefits and limits of nose 6.7.2 Anatomy/Structure
reshape with injectables?
Nose reshape with injectables may Nasolabial folds – the small triangle between the
have limited results in the correction of ala, the nose, and the cheek – can be deepened by
a bulbous tip, but it definitely can contracting the levator labii superioris alaeque nasi
enhance dorsum projection, correct nose and the levator labii superioris muscles. Both mus-
humps, lift the nose tip, and improve the cles are activated when patients wrinkle their nose.
retruded columella. Strong muscular tonus might lead to very deep
wrinkles at quite an early age (Fig. 6.58). The depth
6.7 Nasolabial Folds 107
a b
Fig. 6.56 (a, b) Nasolabial fold on animation before and after correction with Juvéderm Volift (0.4 ml in the NLF and
0.1 ml in the marionette line per side)
a b
Fig. 6.57 (a) Before treatment, patient is leaning for- labial folds and marionette lines, mechanical support was
ward to show and analyze the degree of skin laxity at the provided and less sagginess resulted
nasolabial fold and cheek. (b) After treatment of the naso-
a b
Fig. 6.58 The same patient in her twenties (a) and her forties (b). Please note the deepening of the nasolabial folds
a b
Fig. 6.59 (a, b) Before and after treatment or the nasolabial fold with 1 ml of Juvéderm Voluma per side. The lips were
treated with 0.6 ml of Juvéderm Ultra Plus
a b
Fig. 6.60 (a, b) Before and after treatment of the nasolabial fold of a male patient. A total of 1 ml of Juvéderm Volift
was injected by side. Note the softening and natural aspects of the folds
of the nasolabial folds at rest in contrast correlates older patients with very deep folds, for example,
well with the degree of cutaneous elastosis and the it might be necessary to inject up to 2 ml per site.
tonus of the SMAS. Therefore, nasolabial folds are The best results are obtained in patients with
one of the signature folds to be affected by aging. either no or mild saggy skin over the nasolabial
fold (Figs. 6.59 and 6.60). With the introduction
of HA volumizers in the market, nasolabial folds
6.7.3 Patient Evaluation and are often treated in a second step, e.g., after vol-
Selection ume replacement in the cheekbones (Fig. 6.61).
The nasolabial folds must be analyzed prior to

filler injection. If there is an active contraction of 6.7.4 Technique
the levator labii superioris alaeque nasi and the
levator labii superioris muscles, fillers may be Stretching the skin between two fingers prior to
accompanied by a pretreatment with BoNT-A of injection helps to visualize the fold and to ensure
these muscles. In addition, the amount of filler that the material is injected where it should be
required should be realistically estimated. In (Figs. 6.62 and 6.63). To avoid an increase in the
a b
Fig. 6.61 (a) This male patient is leaning forward. A fold is not fully corrected under this position of stress,
worsening of the nasolabial fold is seen. (b) To be sure the short-lasting result may be expected. A total of 4 ml of
correction of the nasolabial fold will be long lasting, Juvéderm Voluma was injected into the cheekbones and
observe if the correction is still maintained with the NLF. With this a duration of the result should last over
patient leaning forward, after treatment. If the nasolabial 18 months
Fig 6.62 Native nasolabial fold Fig. 6.63 Stretching of the skin of the nasolabial fold
prior to injection
visibility of the fold, especially in patients with

SMAS-related deep folds, the injections should multilevel approach, e.g., applying the filler or
be performed slightly more medially (Fig. 6.64). different fillers on different levels of the skin.
Nasolabial folds are quite easy and fast to treat
with the retrograde injection technique. Cannulas
and sharp needles might be used. The multiple 6.7.5 Touch-Up
injection site technique can be applied, too. This
technique will help to blend the filler better in the When using a biodegradable filler for deep naso-
surrounding area. Deep nasolabial folds and folds labial folds, a touch-up will prolong the durability
in patients with elastotic skin might require a of the effect. The touch-up can be early
approximately 3–4 weeks after the initial

treatment (when the result after the initial treat-
ment is not sufficient) or late 4.5–9 months after
the treatment (when a prolonged durability is
intended) (Narins et al. 2008; Figs. 6.65 and 6.66).
6.7.6 Complications
There are some general pitfalls that are attribut-

able to an inappropriate injection technique that
should be avoided:
1. The sausage: the sausage constitutes the
Fig. 6.64 Medial injection with an HA in a patient to remains of a filler that was too superficially
avoid an unwanted increase of the cheek ptosis
a b
Fig. 6.65 (a–c) Deep nasolabial folds treated with PLLA prior to and immediately after treatment and 5 months later
a b
Fig. 6.66 (a, b) Superficial nasolabial lines in a patient successfully pretreated with PLLA for deep nasolabial folds
before and 3 months after the superficial injection of a total of 1.4 ml of a low viscosity hyaluronic acid
injected (n.b. the sausage can be found in

other areas as the infraorbital area, too). Don’ts
2. The lump: injecting large amounts of a filler • Do not inject too laterally in patients
will result in filler depots that might be pal- with saggy skin. If you inject too later-
pable for several weeks. ally, the fold might be become more
3. The increased fold: in a patient with SMAS- visible.
related ptosis of the cheek, an injection made • Do not inject if not enough. If you inject
too laterally will lead to an increase in the just one syringe in a patient who in fact
depth of the fold. needs two or three syringes per side, the
4. A necrosis of the ala nasi: thankfully this is a patient will not be happy because the
rare complication. If severe pain during injec- visible changes are not as the patient
tion is reported and a whitish discoloration would have liked them.
develops, the injection has to be immediately • If the patient has strong marionette lines
stopped, and if an hyaluronic acid is injected, too, please do not forget to treat them in
hyaluronidase should be injected immediately the same session. Otherwise the patient
(see also Chap. 8). might look quite weird.
6.7.7 Tips, Tricks and Key Points Key Points

• Despite all the talk on the overall volu-
mization of the face, the correction of
Do’s the nasolabial fold is still a major indi-
• Have the patient comfortably sit up either vidual indication. One reason for that is
during the whole procedure or at the end that patient might more easily afford one
to make sure that you evaluate the naso- or two syringes instead of three or more.
labial folds at maximum gravity. • If you start to work with injectable fillers,
• In patients with moderate to extreme start with this indication. The treatment is
nasolabial folds, consider a planned straightforward and the results predictable.
touch-up after 4.5–9 months to increase • Always inject enough but do not
the durability of the injections. overcorrect.
6.8 The Earlobe earlobes. About 30 % of people have attached

earlobes, which represents a recessive gene
6.8.1 Introduction (Figs. 6.68 and 6.69).
Earlobes have been ornamented with jewelry for

thousands of years, traditionally by piercing of 6.8.3 Patient Evaluation
the earlobe. In some cultures, ornaments are and Selection
placed to stretch and enlarge the earlobes. Tearing
of the earlobe from the weight of heavy earrings, As we age, the unattached portions of the earlobes
or from traumatic pull of an earring (e.g., by increase in size. The earlobes also “deflate” by
snagging on a sweater), is fairly common. losing some of the fat under the skin. This results
Patients with loose or atrophic earlobes can an increase in wrinkles and creases. Just like else-
benefit from injectables (Fig. 6.67). where on the face, the earlobe skin is susceptible
to sun damage. Sun exposure also contributes to
wrinkling of the earlobe as well as discoloration.
6.8.2 Anatomy/Structure Atrophic earlobes that present wrinkles and
creases can effectively be improved with inject-
The earlobes are composed of 2 portions – an ables that will plump them back up, resulting in
attached upper part and an unattached lower part. more youthful appearance. Torn or stretched ear
There is significant variability in the shape and piercing holes are to be repaired by surgery.
contour of the earlobes. Ideally, the earlobe However, orifice narrowing may also be improved
should comprise about 20 % of the length of the with injectables. Patients who received a face lift
ear. The average length of the lobe itself is about and present deformities in the earlobe may also
18 mm. Most people are born with unattached benefit from injectables.
a b
Fig. 6.67 (a, b) Before treatment, there is a deflation of the earlobe and presence of a vertical wrinkle. After injection
of 0.5 ml of Juvéderm Ultra Plus per side, volume restoration is achieved
6.8 The Earlobe 113
Fig. 6.68 A typical attached earlobe
Fig. 6.69 The unattached earlobe
a b
Fig. 6.70 (a, b) Before treatment, it seems that it is a improvement. Right after the injection of 0.5 ml of
ripped earlobe with an enlarged orifice. Usually, this Juvéderm Ultra Plus per side, the torn aspect is resolved
patient would be submitted to surgical correction for
6.8.4 Technique filler should be sufficient. If narrowing of the ori-

fice is needed, HA may be injected around to
The skin is stretched and then the filler is injected constrict it (Fig. 6.70). Usually no anesthesia is
in the subdermal tissue. Usually 0.2–0.5 ml of the required.
6.8.5 Tips, Tricks and Key Points undesirable results that even for lay persons are
detectable. Together with the eyes, the perioral
area is under direct attention and any inadvertent
Do’s injection will lead to distraction.
• Stretch the skin while injecting.
6.9.2 Anatomy
Don’ts The lips cover more than the area of the red part
• Do not overdue it – the patient does not of the mouth. They also include the skin adjacent
want a big lump as an earlobe. to the red part of the mouth. It must be considered
as an anatomic unit with extensions superior to
the nose and inferior to the chin. Perfect lip struc-
ture includes a visible white or transition line
Key Points between the mucosa and skin, a “V”-shaped
• This is usually an indication of which Cupid’s bow, fulfilled medial tubercle and ver-
the patient is not aware. You might point million, and ascendant line in the oral commis-
this out in case you have a patient with sures. The ratio between the upper and lower lips,
loose earlobes while treating another at golden proportions, is 1:1.618.
indication. A very important topographic landmark is the
philtrum. The midpoint of the upper cutaneous
lip is highlighted by the two vertically oriented
ridges of the philtrum. The Cupid’s bow is the
6.9 The Upper and Lower Lips concavity at the base of the philtrum (Fig. 6.71).
It is also very important to take into account the
6.9.1 Introduction surroundings of the lips, which are the labiomen-
tal and nasolabial lines. If too deep, these lines
The lips are very important for social interac- may give an older appearance which will prevail
tion. A wide spectrum of emotions is repre- even after a sufficient augmentation by a filler.
sented by the lips, from happiness to sadness The skin of the upper lip is very thin and lacks
and sorrow. It also plays an important role in the subcutaneous fat. The lack of additional support
expression of sensuality and sexuality. When at this level and excess of muscular movement
the sphincter mechanism is intact, normal lip may lead to the breakdown of the perioral area,
function promotes a competent oral seal for liq- producing wrinkling (Fig. 6.72).
uids and solids, especially the lower lip. The The major muscle of the lips is the orbicularis
free movable nature of the vermillion and cuta- oris muscle. It has circumferential fibers that are
neous skin makes this area quite suitable for dis- responsible for the sphincter function of the
tortion. The use of BoNT-A, although sometimes mouth. There are circumoral muscles, which are
quite helpful, may lead to asymmetries and tem- intimately associated with the orbicularis oris.
porary loss of function (see Sect. 9.4). Fillers, These muscles elevate, depress, and retract the
on the other hand, are highly suitable for both lips, producing complex movements during nor-
lip augmentation and improvement of perioral mal function. The levators lie from medial to lat-
wrinkles. eral: the labii superioris alaeque nasi levator, the
Nevertheless, one has to be aware that the labii superioris levator, the zygomatic minor and
variety of lip shape, occlusion, and muscle activ- major, the levator anguli oris, and the risorius
ity at this area make the treatment of the lips a muscles. The depressors include the depressor
challenge. Lack of understanding of the lip anat- anguli oris, the depressor labii inferioris, the
omy and muscular activity patterns may lead to mentalis muscles, and the platysma.
6.9 The Upper and Lower Lips 115
a b
Philtrum dimple
Philtrum column
White line
Tubercle
Philtrum dimple
Philtrum column
Cupids bow
Tubercle
White line
Fig. 6.71 (a, b) Frontal and lateral view on landmarks of the upper lip
a b
Fig. 6.72 (a, b) At the age of 28 this patient already pres- static as well. After the injection of 1 ml of Juvéderm
ents excessive perioral wrinkling on animation. If left Volbella into the vermillion, less wrinkling is observed
untreated, these dynamic rhytides are likely to become and a younger condition is provided
The upper and lower lips are supplied respec- innervated by the mental nerve. The motor inner-
tively by the superior and inferior labial arteries vation of the orbicularis oris is provided by the
within the submucosa. Both of these are branches buccal branches of the facial nerve. The muscles
of the facial artery. that act around the mouth are either innervated by
Sensory innervation of the upper lip is pro- the buccal or the marginal mandibular branches
vided by the infraorbital nerve. The lower lip is of the facial nerve.
6.9.3 Patient Evaluation The physical examination is of utmost

and Selection importance in lip reshaping. Both the upper and
lower dental arcades promote an important role
The best results and most natural results are in lip augmentation. Sometimes, advancement
found in young patients who desire lip augmenta- of upper maxilla is necessary to promote bal-
tion and present with preserved lip landmarks ance of the perioral area (Figs. 6.77 and 6.78).
(Fig. 6.73). Sometimes even in younger female If the teeth (central and lateral incisors) are
patients, the mouth may present with perioral inclined backward, lip projection is extremely
radial grooves and a decrease in the volume of difficult and mucosal approach should be used
the lips that tend to worsen with aging process to compensate it (Fig. 6.79). Muscular activity
(Fig. 6.74). Lip reshaping will require not only in patients with very thin lips should also be
augmentation but also improvement of the radial evaluated. During the smile, there may be
grooves (Figs. 6.75 and 6.76). The patient’s excessive inversion of the vermillion, espe-
expectations should be established to avoid unre- cially in patients with gummy smile. Fillers
alistic results. may not produce the desired effect in this case.
a b
Fig. 6.73 (a, b) Analysis of the young lip before and boluses and massages. Note the absence of edema, bruis-
right after treatment with 1 ml of Juvéderm Volbella ing, or unnatural appearance of the lips
injected into the upper and lower vermillion through small
a b
Fig. 6.74 (a, b) The same patient 20 days after treatment. vermillion, better structure and less wrinkling were
Despite her young age (32 years old), she presents peri- observed. The presence of the product avoids excessive
oral wrinkling on animation. After the treatment of the puckering of the lips
a b
Fig. 6.75 (a, b) Profile analysis of photos before and million through small boluses and massage. Note the
right after the patient has been treated with 1 ml of adequate and pleasant projection of both the upper and
Juvéderm Volbella injected into the upper and lower ver- lower lips
a b
Fig. 6.76 (a, b) Profile analysis of photos before and after treatment. Note the natural aspect on animation without
excessive lip projection and improvement of perioral wrinkles
Injection of BoNT-A into the levator labii supe- 6.9.4 Technique

rioris alaeque nasi muscle may be instead help-
ful in these patients. Patients must be evaluated Filling the lips used to be quite painful for
in both static and dynamic situations. There patients before HA products containing lido-
are at least four different types of smile, and caine came on the market. To avoid imperfect
dynamic asymmetries are very common results or the necessity for frequent retouches,
and should be demonstrated to the patient filling the lips should be achieved with as little
beforehand. pain as possible. HA products with lidocaine are
a b
Fig. 6.77 (a, b) Patient with a retruded upper maxilla. Lip into the upper lip, and 1 ml of Juvéderm Volift has been
treatment in male patients requires a conservative approach. injected into the NLF per side. Note the natural result that
A total of 0.5 ml of Juvéderm Volbella has been injected was obtained with both procedures
a b
Fig. 6.78 (a, b) Oblique view before and after the treatment. Note the upper maxilla advancement with a slight and
natural eversion of the upper lip and a more youthful appearance
a b
Fig. 6.79 (a, b) Note the retruded upper lip in comparison projection of the upper lip and more balance between the
with the lower lip due to underbite occlusion, before treat- lips. Observe the nice curvature in the philtrum area. The
ment. Injection along the lip border and volume replace- total volume of 0.8 ml Juvéderm Ultra Plus has been
ment into the medial tubercle through the mucosa lead to injected into the upper lip and oral commissure
a b
Fig. 6.80 Transition lines of both the upper (a) and the lower lips (b) are treated with an HA filler
the first choice. Prior topical anesthetics or lower lips. Attention must be paid to the dental
nerve blocking might further reduce pain. For arcade at this time. If more projection is desired,
the upper lip, the infraorbital nerve may be the medial tubercle may be filled either from the
injected followed by infiltration of lidocaine in mucosa or intraorally through the submucosa
the submucosa laterally and medially to the (Figs. 6.81 and 6.82). Mild perioral wrinkling
frenulum linguae. For the lower lip, the mentalis may be improved only by this method. If not,
nerve may be blocked and infiltration into the direct injection into each small rhytide should be
submucosa is also beneficial. Both the intraoral performed (Fig. 6.83). This is done best when the
and transcutaneous approach may be chosen. lip is stretched and the needle is placed directly
The intraoral approach is generally preferable as under the rhytide.
it is usually less painful (see Chap. 5). In senile lips, a nicer look will be achieved if
Nevertheless, in some patients topical anesthe- the entire lip structure is treated (Fig. 6.84). All
sia alone or even ice bags may be acceptable perioral area should be treated in order to provide
when associated with HA and lidocaine balance and natural result is mandatory
preparations. (Fig. 6.85). If the lips are surrounded by elastotic
Biodegradable products, although tempo- skin, combinations of injectable fillers are recom-
rary, promote the most natural results. The lip mended with ablative methods, such as chemical
border may be reshaped with HA to enhance lip peels or laser resurfacing. The best results are
definition (Fig. 6.80). For the vermillion, hyal- obtained in those patients whose anatomic land-
uronic acid gives the volume and the mobility marks are preserved and who have soft, distensi-
that only this highly hydrophilic substance may ble skin.
provide (Fig. 6.76). Nonbiodegradable prod- In some cases, direct injection in the lip border
ucts are less and less used for lip augmentation may increase inversion of the lips and causing
as the durability of HA preparations has excessive protrusion if too much product is inject
increased. in trying to correct this deficiency. Preferably
Injections may be started from Cupid’s bow or some senile lips and mostly young inverted lips
from the oral commissure. It is most important to with poor dental arcade support should be
perform it as a retrograde injection. Serial tech- approached differently. Instead of using needles
niques increase bleeding and may lead to irregu- as described before, the use of a delicate cannula
lar filling. The frame of the lips (the white line) with submucosal injection will avoid inversion
should be injected first; this will help to limit the and promote lip eversion with adequate projec-
expansion of the vermillion in both the upper and tion (Figs. 6.86 and 6.87).
a b
Fig. 6.81 (a, b) Augmentation of the vermillion with an HA filler
a b
Fig. 6.82 (a, b) Filling the medial tubercle may improve the lips on profile examination
6.9.5 Complications formation may provoke unnatural and quite obvi-

ous results.
Lump formation and lip asymmetries are some of
the complications that can result from this proce-
dure. Swelling, ecchymosis, and redness are very 6.9.6 Tips, Tricks and Key Points
common and are dependent on the type of prod-
uct, quantity of material injected, and the tech- Be careful, lips tend to look bigger when the
nique used. In cases of severe swelling, a short patient is filmed or photographed. Sometimes
course of oral steroids might be helpful. patients ask for more material and we should
Nonbiodegradable products are those more often show them how they would look in a photo before
found to be associated with complications. Due going any further. Avoid excessive treatment at
to the intrinsic mobility of the lips, any capsule the medial tubercle level; this may result in
patients presenting a duck-like appearance in the

oblique and profile analyses. Don’ts
• Do not forget to check the dental status
of the patient. A new set of teeth or a
Do’s better prosthesis might improve the lip
• When augmenting the lip do not only presentation considerably.
look at the patient from the front but • Do not only treat the upper lip. The
also from both sides. lower lip needs to be in harmony with
• Do educate your patient about “less is upper lip.
more” for lip augmentation. • Do not try to correct inverted lips with
• Do advice the patient that even with the the traditional needle technique.
newer HA products, some temporary Injecting the submucosa with cannulas
swelling might occur. might be a better option.
Key Points
• Lip reshape with HA products contain-
ing lidocaine has dramatically changed
the cosmetic practice. Patient discom-
fort during injection was one of the
main barriers for the use of injectables
in the lips.
• Evaluate the lip not only statically but
also during animation.
• Overtreatment should be strictly
avoided.
Fig. 6.83 Direct injection of a porcine collagen (Evolence

Breeze) filler into the small rhytides
a b
Fig. 6.84 (a, b) Filling the lips should target the restructuring of the anatomical landmarks. The philtrum has been
injected as well
a b
Fig. 6.85 (a, b) This 64-year-old patient presents promi- the NLF and 0.1 ml into the marionette lines per side. She
nent nasolabial fold (NLF) and downturn of the oral com- was also submitted to lip contour with 1 ml of Juvéderm
missure with moderate degree of severity. She asked for a Volbella. She was very pleased with the natural result that
natural result and was in restricted budget. Result imme- enabled her to return to her social activities soon after
diately after the injection of 0.4 ml of Juvéderm Volift into treatment
a b
Fig. 6.86 (a, b) Inverted thin lips with flat philtrum and eversion of the lips, lip contour and philtrum reshape were
immediate result after the injection of both the upper and undertaken with 0.55 ml of Juvéderm Ultra Smile using a
lower lips with 1.0 ml of Juvéderm Ultra Smile by a 25G 30G needle
blunt microcannula. After promoting deep support and
a b
Fig. 6.87 (a, b) Oblique view: inverted thin lips with a flat philtrum before and after treatment
6.10 Marionette Lines 123
6.10 Marionette Lines 6.10.4 Technique
6.10.1 Introduction Pretreatment of the depressor anguli oris and the

platysma muscles with BoNT-A is encouraged as it
Marionette lines are no friendly lines. They make decreases the downward movements of the corner
the face appear to be sad or harder. Usually they of the mouth (Fig. 6.90). Topical anesthesia is rec-
are associated with deep nasolabial folds. In ommended. Biodegradable fillers usually give the
cases when just the nasolabial fold is corrected most natural expression. The most appropriate filler
and the marionette lines disregarded (like in clin- must be chosen according to the depth of the lines,
ical trials on nasolabial folds), the overall picture wrinkles, or folds. The caudal triangle at the corners
of the treated patient might look weird. of the mouth, which is formed by the margin of the
lower lip and the marionette line and continues to
the nasolabial fold, is injected first. Here, a triangu-
6.10.2 Anatomy lar feathering might elevate the whole area. For
deep and medium-sized lines, the retrograde tunnel
Marionette lines might become pronounced due technique (i.e., the filler is injected while withdraw-
to muscular hyperactivity and/or elastosis. On the ing the needle) or the multiple injection site tech-
muscle base a hyperactivity of the depressor nique can be used. These techniques will help to
anguli oris and the platysma muscles might not blend the filler better in the surrounding area and
only pull the corners of the mouth down but also avoid the appearance of an unnatural elevation at
contribute to these lines. However, in most of the the area of the former fold. Deep folds usually
cases, it is the increased laxity of the SMAS and require multilevel injections (Fig. 6.91). As for
the overlying elastotic skin that will provoke nasolabial folds, it is advisable to inject the filler
these lines. medial to the fold; a more lateral injection technique
would increase the visibility of the fold in patients
with increased laxity of the SMAS.
6.10.3 Patient Evaluation
and Selection
6.10.5 Complications
Patients with shallow or very deep lines are
suitable for treatment (Carruthers et al. 2008, A lateral injection will increase the visibility of
Figs. 6.88 and 6.89). the fold. In older patients with increased elastosis,
a b
Fig. 6.88 (a, b) Before treatment, presence of prominent Juvéderm Ultra (Plus), all the units of the perioral area
nasolabial fold, marionette lines, and prejowl sulcus. were improved. Note the improvement in the jawline as
After injection of 1 ml of Juvéderm Voluma and 0.8 ml well
a b
Fig. 6.89 (a, b) A difficult marionette line to treat due to Voluma into the nasolabial fold and chin and 0.8 ml of
the inversion of the lateral aspect of the vermillion and Juvéderm Ultra Plus, eversion of the oral commissure and
oral commissure. After injection of 1 ml of Juvéderm correction of the marionette lines were obtained
a b
Fig. 6.90 (a, b) Marionette lines before and 1 week after treatment with BoNT-A while the patient is grimacing
a very deep injection may have little effect other

than creating an unpleasant deep lump of filler.
Do’s
• Do not forget to check the dental status
of the patient. With no teeth laterally or
an otherwise insufficient dental correc-
tion, a treatment with an injectable filler
will not be enough.
Fig. 6.91 With BoNT-A pretreated marionette lines • As for nasolabial folds have the patient
immediately after the injection of an HA filler while the comfortably sit up either during the
patient is grimacing
6.11 Jawline and Chin Reshaping 125
may impair the sense of beauty. Women must

whole procedure or at the end to make have a more delicate chin, with less fullness con-
sure that you evaluate the marionette centrated at the central part. Men, on the other
lines at maximum gravity. hand, may have heavier features and should have
• In patients with deep folds due to a stronger chin. In all cases, a youthful and clean
increased elastosis, the multilayer tech- jawline is desired. Reshaping the mandible area
nique is recommended (i.e., after inject- promotes chin and jawline contours.
ing these patients carefully with a deep Despite the scientific studies concerning the
filler, a filler comprising medium-sized safety of the use of silicone prostheses for chin
particles should be injected more super- augmentation, some patients simply refuse to be
ficially to extend the dermis and thus submitted to it. The use of fillers may be helpful
decrease the depth of wrinkles). in such cases. Patients prefer minor and mini-
mally invasive procedures, although some doc-
tors would indicate more complex procedures
such as chin advancement. However, most
Don’ts
patients may accept time limited results with fill-
• Do not inject too laterally in patients ers more rather than submitting to cranial sur-
with saggy skin. If you inject too later- gery. The introduction of HA volumizer in the
ally, the fold might become more market has changed the treatment of chin and
visible. jawline reshape. High-performance, longer-
• Do not inject too much too deep. You lasting, and natural results are expected now.
might end up with a big lump that will
stay for a long time and will remind the
patient of your injection. 6.11.2 Anatomy
The chin may be defined as the area between the

mental foramina and the central part of the man-
Key Points
dible. The midlateral zone can be defined as the
• The marionette lines are an important region extending from the mental foramen pos-
and frequently treated indication. teriorly to the oblique line of the horizontal body
Overcorrection should be avoided. of the mandible. The posterior lateral zone is
Repeated injections over a couple of defined as the posterior half of the horizontal
months might yield better results. body including the angle of the mandible and the
• As for the nasolabial folds, do not first 2–4 cm of the ascending ramus. The sub-
undertreat this indication. Severe mari- mental area is located under the chin between the
onette lines might require 1 ml of a filler platysmal band and above the cervicomental
per side. angle.
The most suitable skin for chin and mandible
reshaping is that which is soft and has mild atro-
phy. The fat tissue superficial to the SMAS in the
6.11 Jawline and Chin Reshaping mental area is densely attached to the dermis by
strong fibrous septa. It makes the deep soft tis-
6.11.1 Introduction sues very adherent to the skin at this level. It
becomes progressively looser and more mobile
The chin is a symbol of masculinity for men and lateral to the cheek and caudal to the neck.
sensuality for women. Any negative marks such The contraction of the mentalis muscle pro-
as wrinkles, folds, or a deep oral commissure duces protrusion of the lower lip. This muscle
arises from the mandible below the central and the increase of the jowl pad and soft-tissue
lateral incisors and inserts into the skin of the atrophy, marionette lines and a sad mouth
chin. Wrinkles can form in a cobblestone pattern develop. The migration of fat down to the man-
where it inserts into the skin in some patients. dible creates the jowls that may extend below the
The chin is supplied by the mental and sub- lower mandible border. The superficial subcuta-
mental arteries: the former a branch of the infe- neous tissues tend to sag more than the deeper
rior alveolar artery and the latter a branch of the subcutaneous tissues.
facial artery. The venous drainage corresponds to
the arterial supply. The mandible is supplied by
the facial and inferior alveolar artery. The man- 6.11.3 Patient Evaluation
dibular branch of the facial nerve passes just and Selection
anterior to the middle portion of the mandible
into the midlateral zone. The marginal branch of The ideal relationship in a patient’s face is one-
the facial nerve has a variable course, but its loca- third upper lip and two-thirds lower lip and chin.
tion is normally at the angle of the mandible. The Patients with mandibular hypoplasia appear to
greater auricular nerve is in the cervical fascia, have a round face due to a short lower facial
posterior to the angle of the mandible. The men- height. The ratio between the upper lip and lower
tal nerve exits from the mental foramen, below lip and chin becomes 1:1. On the profile exami-
the second mandibular premolar. nation, the face presents a convex appearance,
The aging process may be accompanied by a jowls, and obtuse mentocervical angle with
reduction in the size of the mandible with redundant skin (Fig. 6.92).
absorption of the alveolar processes. In older When considering a patient for chin augmenta-
patients, there may also be soft-tissue atrophy lat- tion with fillers, evaluations of the occlusion, skel-
eral to the anterior chin, producing a deep trian- etal, and dental relationships must be performed.
gle almost directly underneath the oral Patients with a normal occlusion are the best
commissure. It is known as prejowl sulcus. With candidates for fillers. Patients with class II or III
a b
Fig. 6.92 (a, b) A male patient presenting retrusion of Juvéderm Volift for NLF, and 1 ml of Juvéderm Volbella
the upper maxilla, protrusion of the lower lip, and retruded for the upper lip. Note the improvement of the neck con-
chin. The patient was submitted to structural correction tour and the balance between the upper and the lower lip
with 4 ml of Juvéderm Voluma for the chin, 1 ml of
a b
Fig. 6.93 (a, b) A female patient presenting volume loss the chin with 2 ml of Juvéderm Voluma has improved the
in the mid-cheek and consequently elongated lid-cheek convexity appearance of the face. Nose and lip reshape
junction. The tip of the nose rotates downward, and an with 0.8 ml of Juvéderm Ultra Plus has also helped to
unbalance between the upper and the lower lip and the improve the balance of the patient’s profile
chin is seen. Volume replacement in the mid-cheek and
malocclusion were considered surgical candidates also suitable as a pretreatment before surgery to
in the past. In some cases, avoiding extensive give an idea of the amount of projection either
orthognathic surgery means giving fillers a try, required or desired by the patient.
while understanding their limitations and the num-
ber of sessions involved to obtain a nice result.
The classic mandibular retrognathia patient 6.11.4 Technique
presents with a retruded mandible and convex
soft-tissue profiles. Treatment involves orthodon- Fillers may be placed in the central segment
tic correction: surgical mandible advancement alone, between the mental foramina and along
with osteotomy with rigid fixation. the mandible body. When the central mentum
Patients may present good chin projection and and the midlateral zone are augmented, there is a
no lateral fullness. These patients are ideal candi- resulting widening of the anterior jawline con-
dates for fillers in these areas (Fig. 6.93). Fillers tour. Fillers in the mandibular angle will either
will improve chin projection and promote a jaw- widen or elongate the posterior mandibular angle,
line reshape and also improve the aspect of sub- promoting a strong posterior jawline contour.
mental fat deposit (Fig. 6.94). Some patients may Before starting the injection, topical anesthe-
need forward and downward projection; filling sia is applied and drawings are performed to limit
into the upper and lower part of the menton may the area to be treated (Fig. 6.95). The filling of
increase the distance between the mandible tip the mandible area associated with the nasolabial
and the lip, thus balancing the face. Fillers are fold may promote an interesting result, especially
a b
Fig. 6.94 (a, b) Due to the small size of the chin and its elongation of the chin and the hidden underchin fat in
upward rotation, the submental fat deposit is evident. frontal view
After the injection of 2 ml of Juvéderm Voluma, note the
corrective procedures. In older patients, this tri-

angle of soft tissue is generally atrophic, and this
area may be filled because of its mobility.
Injection at the chin or jawline level may be
carried out with needles or cannulas. If needles are
to be used especially along the jawline, pinching
the skin and keeping the needle between the fin-
gers will protect the patient of adverse events. The
facial artery is found anteriorly to the anterior mar-
gin of the masseter muscle and is deeply located.
The marginal mandibular nerve is more superficial
and is located at the subcutaneous level.
Retrograde injection is started by filling along
Fig. 6.95 The purpose of filling the mandibular angle is
to enhance the definition of the mandibular angle. Marking the frame, followed by a soft massage to smooth
the area with an eyeliner enables the physician to limit the the surface. Placement of the filler should be in
area to be injected. The masseter and the posterior bony all layers from the deep reticular dermis next to
border of the ascending ramus are important hallmarks for the periosteum. The multilayer technique pro-
mandibular angle reshaping
motes augmentation of all soft tissues within the
delineated area. The use of cannula is appropriate
among patients who do not desire a surgical pro- if enhancement of vertical dimension is required.
cedure or do not have enough time to be submit- Less bruising is expected.
ted to it (Figs. 6.96 and 6.97). A face-lift effect One of the greatest advantages of fillers is the
may be obtained (Fig. 6.98). possibility of using complementary volumes if
Depending on the physical examination, needed. Although edema usually appears during
patients are only treated in the chin area for minor the injection, a predictable view of the augmenta-
chin advancement and balance (Fig. 6.99). If the tion can be foreseen (Fig. 6.100).
patient is older, the presence of jowls of mild
degree can be improved with the injection of the
triangle reaching from the mental foramen to the 6.11.5 Complications
midlateral zone of the mandible. This area may
not be easily expanded, and the mobility of the In contrast to surgical procedures with implants,
skin at this site must be evaluated prior to starting there is no bone resorption, no fistula, no nerve
a b
Fig. 6.96 (a, b) A female patient presenting perioral reshape, and chin advancement with HA-based fillers.
wrinkling and skin excess in the neck. This patient was Note the improvement of the skin laxity under the chin
submitted to lip treatment, prejowl sulcus and mandible
a b
Fig. 6.97 (a, b) Profile view: before and after treatment prejowl area and along the jawline and chin, reduction of
of the lip, prejowl sulcus, and chin advancement with HA. the skin in the neck area can be obtained
Note that by expanding the skin with volumizers in the
damage, and rarely any extrusion or nodule for- 6.11.6 Tips, Tricks and Key Points
mation. Chin prostheses may cause an abnormal
projection, even in patients with adequate soft tis-
sue. Mandibular and chin reshaping with fillers Do’s
may only produce mild ecchymosis and edema • Do encourage chin and jawline reshape
and entails a quick recovery. Proper technique in female patients. The loss of jawline
and a good choice of products may decrease contour leads to an older appearance.
these adverse events.
a b
Fig. 6.98 (a, b) Mandible filling may improve the definition of the mandible and even treat mild saggy skin
a b
Fig. 6.99 (a, b) Either one or the other demarcation may hand side is suitable when both mid and lateral
be chosen depending on the projection desired. The right- augmentations are needed. After proper demarcation, the
hand side demarcation is for mild projection and the left- injection technique is started
a b
Fig. 6.100 (a, b) Chin advancement may be obtained with fillers. It is useful both as a single treatment and for surgical
planning
6.12 Other Facial Indications for Volumizers 131
6.12 Other Facial Indications

Don’ts for Volumizers
• Encourage the patient to have the men-
talis muscle blocked with BoNT-A 6.12.1 Introduction
before chin augmentation with volumiz-
ers. Better projection and longer-lasting Some patients may present with osseous malfor-
results are expected. mations that usually would require surgery. Here
volumizers might be an alternative.
FAQs 6.12.2 Facial Advancement

• Should cannulas or needles be preferred
for chin and jawline injections? Some patients may present a concave face with,
Both may be used although needles e.g., class III occlusion where the LeFort I sur-
are easier to handle at these levels as long gery would be the formal indication. Here the
as anatomical structures are respected. injection of volumizers will open new possibili-
Cannulas are preferable for severe cases. ties to patients reluctant to surgery (Figs. 6.101
and 6.102).
a b
Fig. 6.101 (a) Patient with class III occlusion, underbite, with 4 ml of Juvéderm Voluma injected into cheekbone,
and retruded upper maxilla. The traditional surgical indi- canine fossa, and nose and 1.2 ml of Juvéderm Ultra Plus
cation would be LeFort I. (b) After midface treatment into the lips, nonsurgical facial advancement was obtained
a 6.12.3 Tips, Tricks and Key Points
Key Points
• Volumizers might be an alternative in
patients reluctant toward surgery.
References
Bachmann F, Erdmann R, Hartmann V et al (2009) The
spectrum of adverse reactions after treatment with
injectable fillers in the glabellar region: results from
the Injectable Filler Safety Study. Dermatol Surg
35(2):1629–1634
Carruthers A, Carruthers J, Hardas B et al (2008) A vali-
dated grading scale for marionette lines. Dermatol
Surg 34(2):S167–S172
Farkas LG, Kolar JC, Munro IR (1986) Geography of the
nose: a morphometric study. Aesthetic Plast Surg
b 10(4):191–223
Flowers RF (1993) Tear trough implants for correction of
tear trough deformity. Clin Plast Surg 20:403–415
Hamra ST (1992) Composite rhytidectomy. Plast Reconstr
Surg 90(1):1–13
Lambros VS (2002) The dynamics of facial aging. Paper
presented at the 35th annual meeting of the American
Society for Aesthetic Plastic Surgery, Las Vegas
Loeb R (1993) Naso-jugal groove leveling with fat tissue.
Clin Plast Surg 20:393–401
Muzaffar AR, Mendelson BC, Adams WP Jr (2002)
Surgical anatomy of the ligamentous attachments of
the lower lid and lateral canthus. Plast Reconstr Surg
110(873–884):897–911
Narins RS, Dayan SH, Brandt FS et al (2008) Persistence
and improvement of nasolabial fold correction with
nonanimal-stabilized hyaluronic acid 100,000 gel par-
ticles/mL filler on two retreatment schedules: results
up to 18 months on two retreatment schedules.
Dermatol Surg 34(1):S2–S8
Pessa JE (2000) An algorithm of facial aging: verification
of Lambros’s theory by three-dimensional stereo-
lithography, with reference to the pathogenesis of mid-
facial aging, scleral show, and the lateral suborbital
trough deformity. Plast Reconstr Surg 106:479–490
Fig. 6.102 (a) Concave profile before treatment. Observe Pitanguy I, Ramos AS (1966) The frontal branch of the
the position of the nose and the upper lip. (b) After nonfacial nerve: the importance of its variations in face
surgical advancement, a straight profile was obtained lifting. Plast Reconstr Surg 38(4):352–356
References 133
Rohrich RJ, Gunter JP, Friedman RM (1995) Nasal tip Tobias GW, Binder WJ (1994) The submalar triangle: its
blood supply: an anatomic study validating the safety anatomy and clinical significance. Facial Plast Surg
of the transcolumellar incision in rhinoplasty. Plast Clin North Am 2:255
Reconstr Surg 95(5):795–801
Nonfacial Indications
7
Mauricio de Maio and Berthold Rzany
Contents 7.1 Inverted Nipple

7.1 Inverted Nipple ........................................... 135
7.1.1 Introduction .................................................. 135 7.1.1 Introduction
7.1.2 Anatomy....................................................... 135
7.1.3 Patient Evaluation and Selection.................. 135 Patients with inverted nipples are usually
7.1.4 Techniques ................................................... 136
7.1.5 Tips, Tricks and Key Points ......................... 136 ashamed of their condition and may seek surgical
correction, often with variable final results.
7.2 Hand Volume Replacement ....................... 137
7.2.1 Introduction .................................................. 137
Patients weary of a surgical approach might ben-
7.2.2 Anatomy....................................................... 138 efit from filler injections as described in this
7.2.3 Patient Evaluation and Selection.................. 139 chapter.
7.2.4 Material to Be Used ..................................... 139
7.2.5 Anesthesia .................................................... 139
7.2.6 Techniques ................................................... 139
7.2.7 Potential Specific Adverse Events ............... 141 7.1.2 Anatomy
7.3 Penile Augmentation .................................. 143 The nipple area complex consists mostly of con-
7.3.1 Introduction .................................................. 143 nective tissue and glands. Specifically, the
7.3.2 Anatomy....................................................... 143 Montgomery glands: large intermediate-stage
7.3.3 Patient Evaluation and Selection.................. 143
sebaceous glands which are embryologically
7.3.4 Material to Be Used ..................................... 143
7.3.5 Procedure Prior to Injection ......................... 145 transitional between sweat glands and mammary
7.3.6 Techniques ................................................... 145 glands. The Montgomery glands lead to the
7.3.7 Tips, Tricks and Key Points ......................... 147 Morgagni tubercles, which are small (1–2-mm-
References ............................................................... 147 diameter) raised papules on the areola. The
nipple-areolar complex also contains many sen-
sory nerve endings, smooth muscle, and an abun-
dant lymphatic system called the subareolar or
Sappey plexus (Nicholson et al. 2009).
7.1.3 Patient Evaluation

and Selection
Patients that may benefit from the use of inject-

able fillers in the nipple area include those whose
nipples are easily protruded by cold or local

136 7 Nonfacial Indications
a b
Fig. 7.1 (a, b) Inverted nipple on profile view. A total of 1.0 ml of Juvéderm Voluma was injected with a 21G blunt
cannula. Full correction of the deficiency was obtained
stimulation. Patients with local retractions or pre- 7.1.5 Tips, Tricks and Key Points
vious surgery will have limited to no results.
Before indicating the use of injectables for the
nipple area, it is important to guarantee that
Do’s
patients are properly assessed and have no medi-
• Inject a local anesthetic first to (1) eval-
cal conditions in their breasts. Further, only HA
uate the degree of correction that is pos-
products should be used.
sible and (2) provide anesthesia.
• Use medium- or high-density HAs.
7.1.4 Techniques
Besides providing anesthesia, the local infiltra- Don’ts

tion with lidocaine of the nipple area will show • Do not use low-density HA products
the degree of correction which can be achieved. for this indication, because they are
Usually a total amount of 1.0 ml is sufficient for not as long-lasting and patients will be
the nipple and areola complex. It is important to disappointed.
inject into the nipple by bolus technique and into
the areola complex by fan technique to give sup-
port at the bottom of the nipple. The use of a 21G Key Points
blunt cannula is preferable since the use of nee- • In patients with unilaterally inverted nip-
dles may cause inadvertent intraductal product ples, a malignancy should be ruled out
placement which is not desirable and may lead to beforehand. Bilaterally inverted nipples
cysts and injection. No antibiotics are needed. are usually benign. However again, a thor-
With the correct patient selection, results are ough past history and inspection should be
expected to last up to 2 years or more (Figs. 7.1, performed before the aesthetic procedure.
7.2, and 7.3).
7.2 Hand Volume Replacement 137
a b
Fig. 7.2 (a, b) Frontal analysis of the correction of the inverted nipple
a b
Fig. 7.3 (a, b) Bottom view: Not only the inverted nipples were corrected, but a nice projection of them was
obtained
introduction of HA volumizers and also CaHa

7.2 Hand Volume Replacement has revolutionized this area.
Second only to the face, the dorsum of the hand is

the area most visibly affected by aging. Volume 7.2.1 Introduction
loss is often accompanied here by the thinning of
epidermis and dermis as well as irregular pig- Volume loss of the dorsum of the hand is related
mentation. Therefore, injectable fillers are only to lipoatrophy. The volume loss can be graded
one part of hand rejuvenation. To decrease pig- from 0 to 4 using a recently developed clinical
mentation or other signs of photoaging, other scale (Table 7.1) (Carruthers et al. 2008).
tools such as lasers or chemical peels must be Lipoaugmentation (Butterwick 2002) and
used to achieve overall best results. several fillers have been used for this indica-
In the past, volume replacement in hands was tion (Abrams and Lauber 1990; Fournier 2000;
mainly undertaken by lipofilling. Lately, the Coleman 1999; Butterwick 2005; Redaelli 2006;
Table 7.1 Hand Grading Scale (Carruthers et al. 2008) that the visible veins cannot be perceived as
0 No loss of fatty tissue guiding structures to protect cutaneous nerves.
1 Mild loss of fatty tissue and mild visibility Subcutaneously, the veins coming from the
of veins and tendons digiti (usually two joined by anastomoses) are
2 Moderate loss of fatty tissue and mild continued in the dorsal metacarpal veins of which
visibility of veins and tendons
three are usually particularly well developed.
3 Severe loss of fatty tissue and moderate
visibility of veins and tendons The largest are the dorsal metacarpal veins at the
4 Very severe loss of fatty tissue and marked root of the fourth digit which, after merging,
visibility of veins and tendons become the accessory cephalic vein leading to
the forearm. The dorsal metacarpal vein of the
fifth digit represents the beginning of the basilica
Busso and Applebaum 2007; Becker-Wegerich vein. A large number of anastomoses intercon-
2008; Man et al. 2008). The evidence, however, nect all the veins to form the venous network of
is quite limited. There is a small clinical trial the dorsal hand, which may become quite dis-
(n = 10) investigating hyaluronic acid (Restylane) tracting with the volume loss due to aging
versus collagen (CosmoPlast). In this small study process.
(Man et al. 2008), the HA did better than the col- On the ulnar side, covered by veins, runs the
lagen. Besides that, there is a larger case series dorsal branch of the ulnar nerve, while radially
on poly-l-lactic acid (Redaellie 2006) in which the terminal parts of the superficial branch of the
2–4 ml of a highly diluted poly-l-lactic acid radial nerve may be found. After removal of the
mixture was injected in 3–6 sessions as well as fascia (subfascial layer), the extensor tendons
two case reports on hydroxylapatite (Busso and and the branches of the radial artery become vis-
Applebaum 2007) and another on hyaluronic ible. In the region of the radial fovea, the radial
acid (Becker-Wegerich 2008). artery produces the dorsal carpal branch and runs
between the heads of the first dorsal interosseous
into the palm of the hand. The dorsal carpal
7.2.2 Anatomy branch merges into the dorsal metacarpal arter-
ies, which again divide into the dorsal digital
The carpus is formed out of two rows – a prox- arteries.
imal and a distal – of four carpal bones each.
The metacarpus is composed of five short hol-
low bones. The back of the hand is covered by 7.2.3 Patient Evaluation
thin connective tissue so that the bones can be and Selection
easily felt. The visible and palpable bones
serve as leading structures for nerves and Which patient is right for volume replacement of
blood vessels from the forearm to the dorsal the hands? Of course, a patient that presents
hand. The skin is easily movable over the lipoatrophy of the dorsum of the hand. Some
superficial fascia and can be lifted in folds. patients may complain of mild to moderate
Due to the loose and flexible structure of the prominence of the vein or tendon, while others
subcutaneous connective tissue, large amounts are only bothered by a severe skeletonized
of fluids can accumulate causing edema. The appearance of the hands. Depending on the grade
tissue flexibility offers ideal conditions for of lipoatrophy, the choice of filler may vary.
the injection and distribution of fillers. As the Please find below the different stages of volume
veins are minimally fixed by subcutaneous fat, loss with patients of various ages (Fig. 7.4).
they are to a certain extent movable, reducing There are other hand positions that are use-
the risk for puncture. Cutaneous nerves lie ful for evaluating volume loss and prominence
deeper than veins and do not follow their path. of the tendons (Fig. 7.5) and veins (Fig. 7.6) as
They have variable patterns of branching so follows:
Mild Moderate Severe
Fig. 7.4 Different stages of volume loss of the dorsum of the hands. These are best candidates for volume
replacement
Fig. 7.5 Forming a fist to show the tendons
7.2.4 Material to Be Used on the indication. For patients with severe elasto-
sis, at first, a superficial filler should be used to
Several fillers have been used for hand augmenta- strengthen the dermis. In the second step, the vol-
tion. Which one should be chosen? This depends ume loss can be addressed with fillers intended
Fig. 7.6 Increased venous congestions with hands down
using hydroxylapatite, mixing with a local anes-

thetic (lidocaine) is recommended. Edelson
(2009) mixes 1.3 ml of CaHA combined with
0.5 ml lidocaine. When working with blunt can-
nulas, local infiltration of 0.1 ml of lidocaine into
the entry point of the cannula usually suffices.
Although delivery of the products with the can-
nula is tolerable, the use of HA-containing lido-
caine has further lessened the discomfort during
the anterograde/retrograde movement with
cannulas.
Fig. 7.7 Encapsulated bluish lumps of HA (Macrolane
VRF20) which is still visible after 3 months in a patient
with very thin skin. The patient did not complain. 7.2.6 Techniques
Otherwise, an injection of hyaluronidase would have
removed the HA lump There are two techniques: (1) the tunneling tech-
nique and the (2) tenting technique (Fig. 7.8).
for deeper injections, e.g., Juvéderm Voluma or The tunneling technique can be divided into
Macrolane (although with Macrolane encapsula- superficial tunneling (intradermal injections) and
tion has been seen (Fig. 7.7)) or CaHA. subdermal injections.
7.2.6.1 Superficial Tunneling

7.2.5 Anesthesia Technique
This technique is best used when the dorsum of
The dorsum of the hand is not a very painful area. the hand is stretched. For this purpose, the
Usually a topical anesthetic should suffice. When patient must form a fist and then, for example, a
Fig. 7.8 Injection of HA in

tenting technique
hyaluronic acid preparation can be injected with 7.2.7 Potential Specific Adverse
a 30 gauge needle (Man et al. 2008; Redaelli Events
2006).
Besides the typical adverse events as hematoma
7.2.6.2 Deep Tunneling and swelling, some specific adverse events or
Technique unwanted results may occur which will be dis-
For this technique, a blunt cannula is used. cussed briefly.
Different cannula gauges can be used at this level
including 18, 21, or 25. As the blunt cannula does 7.2.7.1 The Pin Cushion Hand
not allow the penetration of the dermis, a small If a high volume is used and the epidermis/der-
incision with needles must be made at the dor- mis is very thin, the whole dorsum of the hand
sum of the hand. The cannula is inserted into this may take on the appearance of a pin cushion.
incision, and then the material (usually hyal- This is not the usual desirable effect.
uronic acid) is distributed subcutaneously by In this case, it is recommended to strengthen
anterograde and retrograde technique. For expe- the dermis by a superficial HA injection before
rienced hands, this is a very fast technique applying a large volume subcutaneously. Here, a
(Hartmann et al. 2010). Regardless of the injec- low-density HA filler is recommended.
tion’s volume, slight massaging should be per-
formed to produce an aesthetic and uniform 7.2.7.2 Visible Depots
result. Please find below the result of the hand In patients with extensive elastosis, depots of the
volume replacement both with hands shut filler may be visible as lumps. To avoid this, the first
(Fig. 7.9), hands up (Fig. 7.10), and hands down step is to use a suitable filler as an HA indicated for
(Fig. 7.11). superficial injections to strengthen the dermis. In
the second step, the deep filler should be used.
7.2.6.3 Tenting Technique
The tenting technique is straightforward. 7.2.7.3 Paraesthesias
0.2 ml or more is injected forming a small nod- In some patients, paraesthesias have been
ule. This nodule will then be massaged into the reported after deep injections with large cannu-
dorsum of the hand (Becker-Wegerich 2008; las. These paraesthesias usually disappear after a
Busso and Applebaum 2007; Hartmann et al. couple of weeks and are hardly bothersome to
2010). most patients.
Fig. 7.9 Before and after augmentation by a 21G cannula and a total of 1.6 ml of Juvéderm 4

hands. The substance could be visible
and/or the whole hand could look like a
Do’s pin cushion, especially while using large
• In a moderate up to very severe lipoatro- volumes.
phy status, use a sufficient amount of
material. In severe lipoatrophy, 5 ml of a
hyaluronic acid preparation per hand is Key Points
recommended. • Several materials have been used for
hand augmentation. As for other indica-
tions, each filler must be injected
according to its specifities.
Don’ts • Superficial injections must be done in
• Do not apply great bulks of material tunnel technique.
(between 5 and 10 ml) to patients with • Deeper injections can be done by either
very thin skin of the dorsum of the tenting technique or tunneling technique.
7.3 Penile Augmentation 143
Fig. 7.10 Before and after augmentation with an 18G cannula and with 1 ml of Juvéderm Voluma
7.3 Penile Augmentation atmosphere between patient and physician before

clinical examination. As with every other indica-
7.3.1 Introduction tion in aesthetic medicine, it is a must to rule out
dysmorphobia. Psychologically stable men with
Penile size – flaccid and/or erected – varies con- realistic expectations are the best type of patients.
siderably. Size – with the exception of the micro- The inspection should include a thorough
penis – does not reflect functionality. However, examination of the penis. How long is the penis
size matters, at least in the eye of the beholder. at inspection? How long can it be extended if the
glans penis is taken and stretched? Is the patient
circumcised or not?
7.3.2 Anatomy
The penis basically consists of the two corpora cav- 7.3.4 Material to Be Used
ernosa and the corpus spongiosum which contains
the urethra. The two corpora cavernosa, which are Most evidence for shaft augmentation can be
essential for the erection, are bound together by the found for lipofilling (Abecassis et al. 2010;
tunica albuginea. Several layers of tunicas enclose Panfilov 2006). Literature for fillers is scarce.
the penis. The superficial penile veins lead between There is a quite enthusiastic paper about the use
these layers. Above the tunicas is the skin which of silicon (polydimethylsiloxane oil) for shaft
ends up in the prepuce of the penis. The prepuce augmentation (Yacobi et al. 2007). This paper
can be divided into the outer and the inner layer. reports on the results for over 300 men. The mean
measured penile circumference is 9.5 cm (7.5–
11.5 cm) pretreatment and increases up to
7.3.3 Patient Evaluation 12.1 cm (10.3–15.3 cm) posttreatment (mean
and Selection increase of 27 % in circumference and 0.84 cm in
diameter). The silicon was injected in a tenting
Most patients are quite shy about this indication. technique using an 18 gauge needle. The mean
Therefore, it is advisable to establish a trustful follow-up was after 20 months with a range of
Fig. 7.11 Same hand positioned down. The degree of venous congestions is significantly decreased
1–36 months. No complications were reported. had significantly increased in maximum com-
Sexual intercourse could be resumed after 8 h. pared to basal circumference of 9.13 ± 0.64 cm
However, two things must be considered: (1) sili- in Group I (p = 0.01) and 9.49 ± 1.05 cm in
con has been associated with partly horrendous Group II (p = 0.01). Net increase of glandular
adverse effects (García Díez et al. 2005; Vardia circumference in maximum after glans aug-
et al. 2008), and (2) the study size and the follow- mentation was 14.93 ± 0.80 mm in Group I
up period do not allow to detect rare and/or and 14.78 ± 0.89 mm in Group II. No abnormal
delayed adverse events. reaction in area feeling, texture, or color was
For the augmentation of the glans penis, described. In most cases, initial discoloration
evidence can also be found. Kim et al. (2003) by glandular swelling recovered to a normal
report in a large case series: 100 patients state within 2 weeks.
with a subjective small penis (Group I) and Concerning the limited evidence, which one
87 patients with a small glans after dermofat should be chosen? In the interest of the patient’s
graft (Group II) were treated with HA. In all well-being and the doctor’s safe sleep, it is rec-
patients, 2 ml of the HA was injected subcu- ommendable to use HAs for this indication as
taneously into the glans penis. One year after unwanted results or adverse reactions might be
the injection, the glandular circumference more easily corrected.
7.3 Penile Augmentation 145
7.3.5 Procedure Prior to Injection with a mere filling of the shaft, a slight elongation
of the penis will be achievable as the weight of the
Prior to injection, a local anesthesia is inevitable. injected HA will lengthen the penis somewhat.
A penile block anesthesia with a standard local
anesthetic (no epinephrine!) is sufficient. Kim 7.3.6.2 The Augmentation
et al. (2003) report glandular enhancement after of the Penis Shaft
EMLA application only. A concomitant antibiotic The augmentation of the penis shaft leads to a
therapy, e.g., with clindamycin or ciprofloxacin, visibly bigger penis. According to Abecassis
is recommendable. (2010), the increase using lipofilling is about
2.6 cm in circumference. To achieve this dimen-
sion, the injectable filler must be placed between
7.3.6 Techniques the tunicas. Usually a bilateral injection
technique between the tunicas is used. The injec-
Several techniques are known for elongation and tion can be done either top down by placing the
augmentation. Elongation is discussed only injections at the beginning of the penis shaft or
briefly as it is a surgical procedure. bottom up (pre-coronally). In that case, the mate-
rial is injected from the prepuce area upward
7.3.6.1 The Elongation of the Penis (Abecassis 2010).
A real elongation of the penis requires a surgical Using blunt cannulas associated with proper
intervention, for example, the dissection of the antisepsis, technique and HA products will guar-
suspensory ligament (Abecassis 2010; Vardia et al. antee a safe treatment. The nerve block anesthe-
2008). This procedure combined with fat augmen- sia at the dorsal penile base is required. Please
tation might increase the penis length by about find below before and after photos for penile
2.5 cm (Abecassis et al. 2010). However, even treatment (Figs. 7.12, 7.13, and 7.14).
a b
Fig. 7.12 (a, b) Increase of the length and diameter of the penis after the injection of 10 ml of Macrolane VRF20. A
blunt 21G cannula was inserted at the foreskin as the entry point
a b
Fig. 7.13 (a, b) Profile view after penile elongation with 10 ml of Macrolane VRF20
a b
Fig. 7.14 (a, b) Before and 14 days after erasing a large Please not another lump of the material on the right side
HA nodule after Macrolane VRF20 injection in the left of the shaft
foreskin area with hyaluronidase (Hylase Dessau, 1:150).
References 147
7.3.6.3 The Augmentation

of the Glans Penis Key Points
The augmentation of the glans penis is done • Penile augmentation may lead to a lon-
either after or without shaft augmentation. The ger penis in flaccid state. It will not
HA is injected in the glans. Kim et al. (2003) change the length of the penis in erected
describe the injection based on a fanning tech- state.
nique using Restylane Perlane. • Do not try to treat a patient based on the
instructions in this book. Find a col-
league who can teach you this proce-
7.3.7 Tips, Tricks and Key Points dure. Basically, it is an easy treatment.
However, some avoidable errors might
occur.
• If you overcorrect with an HA, hyal-
Do’s
uronidase can be used to obtain a better
• Take the time for a thorough anamnesis
result. Dosing is mandatory (e.g., the
of the patient. This is an area of the body
volume of hyaluronidase should match
where dysmorphia is a known chal-
the amount of HA that needs to be dis-
lenge. Patients with diagnosed dysmor-
solved (Fig. 7.13)).
phia should not be treated.
• Always take photographs beforehand.
Besides the frontal view, a lateral view
should be done. If possible, the penis
should be photographed in flaccid as References
well as in erected state. Patient can do
this easily enough themselves or under Inverted Nipple
standardized conditions in the doctor’s
office using an automatic release. McCarthy CM, VanLaeken N, Lennox P et al (2010) The
efficacy of Artecoll injections for the augmentation of
• Inject enough material. 20 ml of an HA nipple projection in breast reconstruction. Eplasty
is usually not sufficient. 10:e7
• After creating a larger shaft with HAs, Nicholson BT, Harvey JA, Cohen MA (2009) Nipple-
having a closer look at the glans penis is areolar complex: normal anatomy and benign and
malignant processes. Radiographics 29(2):509–523
recommended. If the glans penis is
small compared to the shaft, an addi-
tional augmentation of the glans penis
should be considered as well.
Hand Volume Replacement
Abrams HL, Lauber JS (1990) Hand rejuvenation. The

state of the art. Dermatol Clin 8(3):553–561
Becker-Wegerich P (2008) New indications for hyal-
uronic acid of the NASHA-gel-generation–highlights
Don’ts from aesthetical dermatology in clinical daily routine.
J Dtsch Dermatol Ges 6(3):S3–S20
• Do not inject too superficially. If you Busso M, Applebaum D (2007) Hand augmentation with
inject superficially in uncircumcised Radiesse® (Calcium hydroxylapatite). Dermatol Ther
penises from top down, the material 20:385–387
may end up in the prepuce making it Butterwick KJ (2002) Lipoaugmentation for aging hands:
a comparison of the longevity and aesthetic results of
look like a big tear. centrifuged versus noncentrifuged fat. Dermatol Surg
28:987–991
Butterwick KJ (2005) Rejuvenation of the aging hand. and tolerability of Restylane versus Zyplast for the
Dermatol Clin 23:515–527 correction of nasolabial folds. Dermatol Surg 29(6):
Carruthers A, Carey W, De Lorenzi C et al (2005) 588–595
Randomized, doubleblind comparison of the efficacy Redaelli A (2006) Cosmetic use of polylactic acid for
of two hyaluronic acid derivatives, restylane perlane hand rejuvenation: report on 27 patients. J Cosmet
and hylaform, in the treatment of nasolabial folds. Dermatol 5:233–238
Dermatol Surg 31:1591–1598
Carruthers A, Carruthers J, Hardas B et al (2008) A
validated hand grading scale. Dermatol Surg 34(2):
S179–S183 Penile Augmentation
Coleman WP III (1999) Fat transplantation. Dermatol
Clin 17(4):891–898 Abecassis M, Berreby S, Boccara D (2010) Penile
Edelson KL (2009) Hand recontouring with calcium enhancement surgery: widening and lengthening lipo-
hydroxylapatite (Radiesse). J Cosmet Dermatol 8(1): penisculpture. Ann Chir Plast Esthet 55(2):135–142
44–51 García Díez F, Izquierdo García FM, Benéitez Alvarez
Fournier P (2000) Fat grafting: my technique. Dermatol ME et al (2005) Penile silicone granuloma. Arch Esp
Surg 26:1117–1128 Urol 58(5):457–460
Hartmann V, Bachmann F, Plaschke M et al (2010) Kim JJ, Kwak TI, Jeon BG et al (2003) Human glans
Hand augmentation with stabilized hyaluronic acid penis augmentation using injectable hyaluronic acid
(Macrolane VRF20 and Restylane Vital, Restylane gel. Int J Impot Res 15:439–443
Vital Light). J Dtsch Dermatol Ges 8(1):41–44 Panfilov DE (2006) Augmentative phalloplasty. Aesthetic
Lindqvist C, Tveten S, Bondevik BE et al (2005) A ran- Plast Surg 30:183–197
domized, evaluator-blind, multicenter comparison of Vardia Y, Harshaib Y, Gilb T, Gruenwald A (2008) Critical
the efficacy and tolerability of Perlane versus Zyplast analysis of penile enhancement procedures for patients
in the correction of nasolabial folds. Plast Reconstr with normal penile size: surgical techniques, success,
Surg 115(1):282–289 and complications. Eur Urol 54(5):1042–1050
Man J, Rao J, Goldman M (2008) A double-blind, com- Yacobi Y, Tsivian A, Grinberg R et al (2007) Short-term
parative study of nonanimalstabilized hyaluronic acid results of incremental penile girth enhancement using
versus human collagen for tissue augmentation of the liquid injectable silicone: words of praise for a change.
dorsal hands. Dermatol Surg 34:1026–1031 Asian J Androl 9:408–413
Narins RS, Brandt F, Leyden J et al (2003) A randomized,
double-blind, multicenter comparison of the efficacy
Safety: Assessment and Treatment
of Adverse Reactions 8
Berthold Rzany

8.1 Introduction .................................................. 149
A multitude of adverse reactions can occur after
8.2 Epidemiology ................................................ 150
the injection of fillers. It is important to
8.3 Identification of the Responsible understand that there is NO risk-free filler. Even
Filler .............................................................. 150
when using biodegradable fillers with a good sci-
8.4 Potential Risk Factors .................................. 150 entific background, adverse reactions may occur.
8.4.1 The Doctor as a Risk Factor ........................... 151 Fortunately, severe adverse reactions as nodule
8.4.2 The Product as a Risk Factor.......................... 151
8.4.3 The Patient as a Risk Factor ........................... 151 formation or even ulcerations are rare for most
8.4.4 The Biofilm Theory ........................................ 152 fillers.
In general, adverse reactions can be grouped
8.5 Treatment of Adverse Reactions ................. 152
8.5.1 Bluish Discoloration....................................... 152 depending on time after onset into acute, sub-
8.5.2 Hypersensitivity Reaction .............................. 153 acute, and delayed reactions (Table 8.1).
8.5.3 Acute Vascular Reaction ................................ 153 “Subacute” is somewhat vaguely defined; it basi-
8.5.4 Nodule Formation .......................................... 154
cally means something that happens in the weeks
8.5.5 Abscess Formation ......................................... 156
after injection.
8.6 Guiding the Patient ...................................... 157
References ................................................................. 157
Table 8.1 Possible adverse reactions to fillers
Immediate reactions Transient erythema
(within 72 h after Transient edema
injection) (more Transient induration
common)
Transient pruritus
Transient ecchymosis
Subacute reactions Abscess formation
(rare) Discoloration (i.e., bluish)
Persistent local symptoms
(hypersensitivity reactions):
erythema, edema, induration,
pruritus, hyperpigmentation
Local necrosis
Reactivation of herpes
Delayed reactions Nodule formation
(rare) Abscess formation
Ulcerations

150 8 Safety: Assessment and Treatment of Adverse Reactions
8.3 Identification of the

Key Points Responsible Filler
• Every injectable filler can elicit an
adverse reaction. In an ideal world, the patients know with which
• Adverse reactions can be grouped filler they were injected. In reality, this is often
according to their occurrence after the not the case. Patients rarely remember the name
initial injection. or might confuse the filler with a popular brand
• Basically we can distinguish between name, e.g., sometimes Restylane is used synony-
acute, subacute, and delayed reactions. mously with filler.
How can this issue be solved? A thorough past
history analysis, which might include going back
8.2 Epidemiology to the treating physician, might be the first step. If
this is not helpful, the next step is a biopsy. The
Adverse reactions may be also grouped into fre- biopsy may allow identification of the group of
quent and rare ones. The frequent reactions are fillers, e.g., biodegradable versus permanent as
easy to detect, especially if they are acute, e.g., if well as specific fillers as PLLA. However, not
you see an immediate swelling during lip aug- every pathologist is familiar with this task.
mentation. If the event is rare and delayed, it is A diagnosis of “foreign body reaction” is only
much more difficult to detect. partially helpful. If the pathologist seems to be
Having good safety data from a clinical trial insecure, the paper from Dadzie et al. (2008)
does not necessarily mean that you have a safe filler might be helpful.
in your hands. Clinical trials usually cover a time
period ranging 6–12 months. Anything beyond that
would require separate reporting (Strom 1994). Key Points
So how do we get information about these • Identification of the causal filler is very
reactions? There are three basic sources: (1) the important.
companies, (2) the agencies (e.g., the BfArM, the • In case of uncertainty (e.g., nodules are
FDA), and (3) specialized adverse reaction regis- suspicious of an adverse reaction to
tries as the Berlin registry (Zielke et al. 2008). Dermalive but only biodegradable filler
However, one must be aware that these sources injections have been reported), a biopsy
only collect the data. We, the treating physicians, is recommended.
must actually report the data. • Be aware the biopsy might distinguish
between groups of fillers but not
between fillers of one group (e.g., the
Do’s
different HA fillers).
• Communicate and/or report adverse
reactions and their therapy.
8.4 Potential Risk Factors

Key Points
• Frequent and acute adverse reactions What are the risk factors for these reactions? We
are easy to detect. would be pleased to know them because no
• Rare and delayed reactions require decent physician would like to have one of his
much more effort. patients develop one of these reactions. However,
• Only if we report the adverse reactions most of the risk factors have remained unknown
we do see these reactions will become thus far. The main reason is that they are difficult
known. to study, as most of the reactions are rare and
delayed. Therefore, investigating them would
8.4 Potential Risk Factors 151
require the efforts of multicenter case-control might have an increased risk of adverse reac-
studies with a duration of at least a couple of tions. Be specifically suspicious of HAs where
years. no good clinical trial data exists (e.g., this is true
In summary, present knowledge is based on for the majority CE-marked HA products in
case reports and case series and therefore needs Europe).
to be viewed cautiously.
Roughly three groups of risk factors can be
distinguished: 8.4.3 The Patient as a Risk Factor
1. The doctor
2. The product When is the patient a risk factor? As said before,
3. The patient we do not know a lot about the origin of these
adverse reactions. However, there is some evi-
dence that active autoimmune diseases, such as
8.4.1 The Doctor as a Risk Factor rheumatoid arthritis, or a treatment with inter-
feron might increase the risk of adverse reactions
When do we as doctors become a risk factor? specifically when using a tissue stimulation filler
(1) When we use products of questionable ori- such as PLLA.
gin, (2) when we inject the wrong product for
the wrong area or when we inject too aggres-
sively (there is some evidence that arterial Do’s
embolization might be caused by high-pressure • Take a thorough past history in your aes-
injections), (3) when we insufficiently dilute the thetic patients.
product (see PLLA), and (4) when we do not do • If a patient reappears in your office for a
the local disinfection properly prior to the injec- reinjection, take a few minutes and ask
tion – especially when we are using cannulas. him/her if a new medical condition did
Furthermore, this has been reported before – arise.
when we share syringes between different
patients. This might sound economical, but
might be associated with an increased risk of Don’ts
infections. • Do not do routine laboratory screening
tests in your patients. There is no evi-
dence that they are helpful.
8.4.2 The Product as a Risk Factor • Do not do skin testing (except for bovine
collagen) as skin testing would only
Substances with a rough irregular surface seem make sense in patients with a delayed-
to have a higher risk for adverse reactions. There type allergy.
are basically three examples for that: (1) PLLA,
which has a strong tissue-stimulating ability
especially when not correctly diluted upon injec-
tion (Rossner et al. 2009b); (2) hydroxyethyl- Key Points
methacrylate in a fixed combination with • There is no sense of an undirected labo-
hyaluronic acid (Dermalive) (Rossner et al. ratory screening for autoimmune dis-
2009a), which to our best knowledge is currently eases prior to an injection.
for the sake of everybody no longer being pro- • However, it is highly advisable to ask
duced; and (3) polymethylmethacrylate and col- prior to the injection the patient if he/she
lagen, when modifying the surface structure of is aware of any current medical
the rate of adverse reactions could be reduced. conditions.
There are also some suggestions that some HAs
8.4.4 The Biofilm Theory

against thorough disinfection before
The biofilm theory is momentarily quite en vogue. injection. However, steroids have proven
The theory comes from a group of Danish physi- to be very helpful, especially in patients
cians working on adverse reactions to polyacryl- with nodule formation, and should not
amide and who discovered bacterial proteins next be disregarded.
to polyacrylamide depots. It basically states that
bacteria, either from the injection or from an infec-
tion close to the area of the injection, and the filler
form matrix-enclosed aggregates, termed biofilm. 8.5 Treatment of Adverse
The biofilm will then trigger a foreign body reac- Reactions
tion that is difficult to treat. The administration of
steroids is considered contraindicated as it might As said before, adverse reactions to fillers are
lead to abscesses (Bjarnsholt et al. 2009). The not common and so our knowledge of how to
Bjarnsholt et al. (2009) publication is a small pub- treat them is limited to expert opinions and the
lication covering eight patients with complications reporting of case series. Therefore, even these
to polyacrylamide. The theory is based on the recommendations have to be critically reviewed.
detection of bacterial material close to the injected
filler. This was done/discovered by FISH (fluores-
cence in situ hybridization) technique. The 8.5.1 Bluish Discoloration
patients, however, were not only treated with anti-
biotics but also with immunosuppressive therapy Bluish discolorations that arise after injections of
including steroids and surgery. In contrast to hyaluronic acid may be treated with hyaluroni-
Bjarnsholt et al. who focused on polyacrylamide dase (Fig. 8.1). The volume of the injected hyal-
(Aquamid), L. Wiest et al. (2009) were not able to uronidase should reflect the volume of the
detect any bacterial residues when examining nod- injected HA that causes the bluish discoloration.
ules after hydroxyethylmethacrylate and hyal-
uronic acid (Dermalive) injections.
Currently, the theory seems to be too lightly Key Points
appraised by physicians and applied to any • Use hyaluronidase to dissolve the HA
adverse reaction against any filler - even an HA which causes the bluish discoloration.
filler (Marusza et al. 2012). Inject tiny little papules along the line.
Don’ts
• Do not believe in any therapeutic rec-
ommendation before there is some clini-
cal proof that a therapy suggestion based
on a theoretical concept really works.
Key Points
• The biofilm theory is quite popular at
the moment although only limited evi-
dence backs it up. Recommendations
based on this theory must be carefully
reviewed. For instance, nothing speaks Fig. 8.1 Bluish discoloration after injection of an HA
(Restylane)
8.5 Treatment of Adverse Reactions 153
8.5.2 Hypersensitivity Reaction depot following the flow of the artery to make
sure that all the HA that was injected dissolves
Bovine collagen was the only preparation with a (Rzany et al. 2009). The additional use of topi-
significant risk of hypersensitivity reactions cals that enhance the blood flow in this area might
(Fig. 8.2). Treatment of contact dermatitis after be helpful. Both measures, however, only make
collagen injection is usually straightforward and sense in the immediate hours after the injection.
involves topical and oral glucocorticosteroids From animal studies, we know that an occlusion
(oral pulse; see below). was reversible in a 4-h period (Kim et al. 2011).
After 24 h, when there are already erythematous
and pustular changes (Fig. 8.3), the damage is too
Key Points far progressed and the injection of hyaluronidase
• The treatment of hypersensitivity reac- will not be helpful anymore.
tions after bovine collagen was straight-
forward and involved topical and oral
glucocorticosteroids. Do’s
• In case of a likely vascular occlusion,
immediately stop the injection.
8.5.3 Acute Vascular Reaction • In case of an (extremely rare) event of
visual disturbances, have the patient imme-
If the injected filler occludes an artery, patients diately transferred to an ophthalmologist.
will report immediate pain and the injector might • In case hyaluronic acid was used, hyal-
even see a whitish vascular reaction. Usually uronidase should be injected in the area
these reactions can be seen when injecting the where the filler was injected and in the
glabella/forehead area or the nasolabial folds. It area of the supposed arterial distribution
is assumed that high-pressure injections increase as soon as possible (see below).
the risk of embolization. Besides cutaneous reac-
tions (e.g., necrosis of the glabella/forehead area
or the alae nasi), there are recent reports of blind-
Don’ts
ness after filler injections (Lazzeri et al. 2012 and
• Do not inject the hyaluronidase too late.
2013; Kim and Choi 2013; Park et al. 2012).
From animal studies (rabbit ears), we do
In case an HA was injected, hyaluronidase
know that hyaluronidase should be
should immediately be used. 1 to 3 ml of hyal-
injected at least 4 h after the occlusion.
uronidase should be injected around the HA
a b
Fig. 8.2 (a, b) Acute inflammation of injection and testing sites 2 weeks after injection of bovine collagen and 4 weeks
after the second skin test (Zyderm I and II)
Key Points
• Act immediately if there is the possibil-
ity of a vascular occlusion.
• Stop the injection.
• If an HA was used, inject hyaluronidase.
• Do not forget that hyaluronidase of ani-
mal origin (this is the hyaluronidase
available in Europe) might elicit allergic
reactions.
Fig. 8.4 Nodule formation approximately 5 months after

8.5.4 Nodule Formation injection of a combination of hydroxyethylmethacrylate
and hyaluronic acid (Dermalive)
Nodule formation is usually the clinical sign of

a foreign body reaction around the injected filler
Table 8.2 Therapy for nodules (foreign body reactions)
(Fig. 8.4). There is no filler that cannot elicit
Step 1 If the nodule formation is traceable to an HA
filler, hyaluronidase should be injected first
Step 2a Steroid injections therapy
Injection of triamcinolonacetonide 10 or
40 mg if possible directly into or beneath the
granuloma. Injections at weekly intervals
until an improvement can be seen. Then the
intervals can be extended.
5-Fluorouracil can be also added to
triamcinolonacetonide 10 or 40 mg. The
procedure is basically the same
Step 2b Oral pulse steroid therapy with, e.g.,
methylprednisolone tablets of 40 mg.
Day 1 and 2: 1 ½ tablets (e.g., 60 mg)
Day 3 and 4: 1 tablet (40 mg)
Day 5 and 6: ½ tablet (20 mg)
Then no tablets will be given for
approximately 1 week. Afterward the
therapy is resumed. Now after treatment, the
period without treatment will be extended to
2 weeks, then to 3 weeks, etc. (see text)
Step 3 If there is no improvement, a laser (Cassuto
et al. 2009) or a surgical intervention may be
considered.
Please note that laser or surgery might also
be a first step, e.g., on solitary lip nodule
such a reaction. There are several possibilities to

treat these reactions (Table 8.2). The evidence
Fig. 8.3 Forehead showing a patchy macular erythema for the treatment of these reactions, however, is
and pustule formation a couple of days after an injection
based on case reports and case series - if any;
of an HA filler in the glabellar region. This represents a
typical clinical finding for an arterial occlusion after a hence, the level of evidence is not as high as it
filler injection should be.
8.5 Treatment of Adverse Reactions 155
8.5.4.1 Intralesional Injections 5-FU

Steroids Besides steroids 5-fluorouracil (5-FU) might be
Injecting steroids into the nodules will decrease injected (50 mg/ml). As with all therapeutic
the foreign body reactions and subsequently approaches, evidence is very limited. Following
lead to a decrease of the nodules. Patients are the treatment recommendations for keloids, a
treated with triamcinolonacetonide, either dose of 50 mg/ml might be used (Fitzpatrick
10 mg in 1 ml or 40 mg in 1 ml. A local anes- 1999; Nast et al. 2012). Wiest et al. (2009) report
thetic may be added in a 1:1 ratio. Please note a mixture of triamcinolonacetonide 10 mg/ml,
that triamcinolonacetonide 40 mg may induce 1 ml lidocaine, and 5-fluorouracil (250 mg/ml).
severe atrophy in areas with underlying fatty As with steroids, the injections should not exceed
tissue. The steroid should be injected directly an injected volume of 0.05–0.1 ml per injection
into or beneath the granuloma. If this is not pos- point.
sible (granulomas due to HEMA are particu- When injecting steroids, atrophy of the fatty
larly difficult to penetrate), the steroid should tissue might occur, as in the forehead region
be injected around the granulomatous tissue. (Fig. 8.5) or the lip region. This can be corrected
Per granuloma the injected volume should not with a biodegradable filler (e.g., hyaluronic acid,
exceed 0.05–0.1 ml per injection point. Initially if the source of the initial reaction is not hyal-
the injections should be performed weekly. If uronic acid but another filler).
the granulomatous tissue reduces, subsequent
injections can be carried out every 2 weeks. 8.5.4.2 Oral Pulse Steroid Therapy
The duration of therapy varies among patients. When treating patients with foreign body reac-
The aim of the treatment should be to make the tions with an oral pulse steroid therapy, we are
granulomatous reaction less visible. basically treating these patients like patients with
a b
Fig. 8.5 (a, b) Nodular reaction 2 years after injection of a combination of hydroxyethylmethacrylate and hyaluronic
acid (Dermalive). Five months before and after repeated injections of triamcinolonacetonide 40 mg (11 treatments)
a b
Fig. 8.6 (a) Focal lipoatrophy after steroid injections in the upper lip to decrease nodule formation after PLLA. (b) The
same patient after correction of the focal lipoatrophy with an HA
autoimmune reactions. In contrast to autoimmune immunomodulatory potential. In some cases of

diseases, the recommended dosages are lower. inflammed nodules the use of low dose doxycyclin
When prescribing methylprednisolone tablets of for at least 4-6 weeks might be another approach to
40 mg, the patient will take 1 ½ tablets (e.g., try. Again, there is not enough evidence to recom-
60 mg) in the first 2 days followed by 2 days of 1 mend either of these treatment approaches.
tablet (40 mg) followed by an additional 2 days of
½ tablet (20 mg). Then, no tablets will be given 8.5.4.4 Laser Therapy
for approximately 1 week. Then the therapy is Daniel Cassuto et al. (2009) report 21 patients
resumed. The period without treatment will be where they drilled small holes with a lithium tri-
extended to 2 weeks and then to 3 weeks. The borate laser at 532 nm into the nodules and then
intervals may be further extended or decreased squeezed out the granulomatous material and the
depending on the treatment response. Usually the filler material.
treatment is continued for 6–12 months (Fig. 8.6).
The pulse therapy can be resumed when the nod- 8.5.4.5 Surgery for Granulomatous
ules became visible or painful again. Reactions
Usually no serious adverse events occur in these Plastic surgery might be helpful for those patients
patients. Patients with steroid-sensitive diseases as where granulomatous reactions are limited to
diabetes mellitus should be monitored carefully. As defined areas. Patients should be aware that all sur-
some patients might have the tendency to switch to gical interventions lead to some kind of scarring.
a continuous oral steroid intake, the tablets should
only be prescribed in small quantities.
8.5.5 Abscess Formation
8.5.4.3 Other Medical Options
A further case report suggests that oral 200–600 Abscess formation is another common adverse
mg allopurinol per day given over 16 weeks is reaction pattern (Fig. 8.7) must be drained.
helpful. However, this particular patient was also Smaller abscesses may simply be drained with a
treated with topical steroids and the results have large needle (e.g., 19 gauge). Larger abscesses
never been confirmed by another paper (Reisberger will require an incision by a scalpel.
et al. 2003). In a couple of patients, oral fumaric If the abscess is of possible bacterial origin, an
acid (used for the treatment of psoriasis) has also adequate antibiotic response is required. An anti-
been tried. Last not least: antibiotics that have some biotic that focuses on infections of the skin is
References 157
a b
Fig. 8.7 (a) Abscess formation several months after injection of a porcine collagen (EVOLENCE BREEZE). (b) The
histopathology shows a huge amount of neutrophil granulocytes around the injected collagen
recommended. Prior to the treatment a bacterial • If an adverse reaction occurs, the first
culture to identify the pathogen is encouraged. goal is to find out about the filler or the
fillers that have been injected.
• In unclear cases a biopsy is highly
Key Points encouraged.
• Drain the abscesses in the first step. • The treatment should be based on the
• In case of an assumed bacterial infec- clinic of the adverse reaction.
tion, an appropriate antibiotic treatment • Every step should be openly communi-
must be initiated. cated with the patient.
8.6 Guiding the Patient References
Patients with adverse reactions usually feel very Bjarnsholt T, Tolker-Nielsen T, Givskov M et al (2009)
Detection of bacteria by fluorescence in situ hybrid-
insecure. Patients need to be guided. The goal
ization in culture-negative soft tissue filler lesions.
should always be to reduce the visible impact of Dermatol Surg 35(2):1620–1624
the adverse reaction, not to remove all injected Cassuto D, Marangoni O, De Santis G et al (2009)
filler material, which, in some cases of nonbiode- Advanced laser techniques for filler-induced compli-
cations. Dermatol Surg 35(2):1689–1695
gradable injectables, is not possible. The patient
Dadzie OE, Mahalingam M, Parada M et al (2008)
should understand this aim and not focus on Adverse cutaneous reactions to soft tissue fillers–a
something that might not be achievable. review of the histological features. J Cutan Pathol
35:536–548
Fitzpatrick RE (1999) Treatment of inflamed hypertrophic
scars using intralesional 5-FU. Dermatol Surg
Key Points 25(3):224–232
• There is no filler with nil risk. Kim YJ, Choi KS (2013) Bilateral blindness after filler
• Therefore all patients need to be injection. Plast Reconstr Surg 131(2):298e–299e
Kim DW, Yoon ES, Ji YH et al (2011) Vascular complica-
informed about the potential of an – tions of hyaluronic acid fillers and the role of hyal-
even delayed – adverse reaction. uronidase in management. J Plast Reconstr Aesthet
Surg 64(12):1590–1595
Lazzeri D, Agostini T, Figus M et al (2012) Blindness fol- a fix composed of hydroxyethylmethacrylate and eth-
lowing cosmetic injections of the face. Plast Reconstr ylmethacrylate with hyaluronic acid. Dermatol Surg
Surg 129(4):995–1012 35(1):367–374
Lazzeri S, Figus M, Nardi M et al (2013) Iatrogenic reti- Rossner F, Rossner M, Hartmann V et al (2009b) Decrease
nal artery occlusion caused by cosmetic facial filler of reported adverse events to injectable polylactic acid
injections. Am J Ophthalmol 155(2):407–408 after recommending an increased dilution: 8-year
Marusza W, Mlynarczyk G, Olszanski R et al (2012) Probable results from the Injectable Filler Safety-Study.
biofilm formation in the cheek as a complication of soft J Cosmet Dermatol 8(1):14–18
tissue filler resulting from improper endodontic treatment Rzany B, Becker-Wegerich P, Bachmann F et al (2009)
of tooth 16. Int J Nanomedicine 7:1441–1447 Hyaluronidase in the correction of hyaluronic acid-
Nast A, Eming S, Fluhr J et al (2012) German S2k guide- based fillers: a review and a recommendation for use.
lines for the therapy of pathological scars (hypertro- J Cosmet Dermatol 8(4):317–323
phic scars and keloids). J Dtsch Dermatol Ges Strom BL (1994) What is pharmacoepidemiology? In:
10(10):747–760 Strom BL (ed) Pharmacoepidemiology, 2nd edn.
Park SW, Woo SJ, Park KH et al (2012) Iatrogenic retinal Wiley, New York
artery occlusion caused by cosmetic facial filler injec- Wiest LG, Stolz W, Schroeder JA (2009) Electron micro-
tions. Am J Ophthalmol 154(4):653–662 scopic documentation of late changes in permanent
Reisberger EM, Landthaler M, Wiest L (2003) Foreign fillers and clinical management of granulomas in
body granulomas caused by polymethylmethacrylate affected patients. Dermatol Surg 35(2):1681–1688
microspheres: successful treatment with allopurinol. Zielke H, Wölber L, Wiest L et al (2008) Risk profiles of
Arch Dermatol 139(1):17–20 different injectable fillers: results from the Injectable
Rossner M, Rossner F, Bachmann F et al (2009a) Risk of Filler Safety Study (IFS Study). Dermatol Surg
severe adverse reactions to an injectable filler based on 34(3):326–335
Combination Therapy
9

9.1 Introduction ................................................ 159
Aging is a complex process. Single therapies, for
9.2 Lasers and Fillers ....................................... 159
example, botulinum toxin and injectable fillers,
9.3 Chemical Peels and Fillers ........................ 161 might be insufficient in dealing with all the signs
9.4 Botulinum Toxin and Fillers ..................... 162 that appear with time. Instead of using one method
9.5 Facial Plastic Surgery and Fillers ............. 166
exclusively, the tendency in aesthetic medicine
nowadays is toward combined therapies. When
9.6 Topical Drugs in Combination analyzing the aging face, it becomes clear that
with Fillers .................................................. 167
aging signs such as saggy skin, static and dynamic
9.7 Eye Rejuvenation as an Example wrinkles, deep folds, and hyperpigmented spots
for Combination Therapy ......................... 167
9.7.1 Step 1: Improvement of Eyelashes .............. 167
may result from various etiologies. Therefore, it is
9.7.2 Step 2: Restoration of Volume Loss............. 167 comprehensible for physicians that multiple ther-
9.7.3 Step 3: Decreasing Muscular Activity apies should be suggested to the patients, though
by BoNT-A................................................... 169 for patients such an approach might not appear as
9.7.4 Step 4: Develop a Plan for
Maintenance Therapy .................................. 170
obvious at the first time. Patients should be edu-
cated that the most natural appearance can be
References ................................................................. 171
attained in using multiple treatments.
The introduction of HAs with higher viscosity
(volumizers) has changed the way HA injectable
fillers were combined with lasers. Specifically
when using the fractional lasers in contrast to tra-
ditional Er:YAG and CO2 ablative lasers, both
procedures can be combined in one session.
9.2 Lasers and Fillers
Both interventions can be used effectively for the

treatment of static wrinkles. The depth of the wrin-
kles, skin type, and recovery time after the proce-
dure may influence the choice of either method.
Usually, patients with a fair complexion benefit
from laser resurfacing. Patients with a dark

160 9 Combination Therapy
a b
Fig. 9.1 (a) Patient before treatment to improve the lips and balance the asymmetries. (b) Same patient. Submitted to
laser resurfacing. Fillers were injected 6 months later
complexion specifically in the hands of a less Fillers must be seen as the primary therapy for
experienced physician may present hyper- and/or volume loss of the deep dermis or subcutaneous
hypopigmentation after laser resurfacing. In fat. In contrast, laser resurfacing is the first
patients with fair and sun-damaged skin showing a method to be used for superficial rhytides and
full-face fine wrinkling, laser skin resurfacing may elastotic and pigmented skin due to sun damage.
be the treatment of choice to decrease the number For complex scars, both methods should be used.
of rhytides by increasing the dermal strength. If any resurfacing method reaches the deep der-
Awaiting the inflammatory phase to subside, in a mis or in case of bacterial or viral infections, scar
next step, biodegradable fillers may be injected tissue may result. This complication has also
into deeper wrinkles. The degree of collagen been dramatically reduced by the use of frac-
remodeling that occurs following laser treatment tional lasers. Fillers injected too superficially into
varies, depending on laser aggressiveness and lev- rhytides may result in nodule or “sausage” for-
els of enzymes, such as collagenases, which must mations and cause irregularities in the skin – spe-
have stabilized before any biodegradable products cifically when not appropriate fillers are used.
are injected. The appropriate time for beginning When full-face resurfacing is performed, laser
filler treatment is at the subsiding erythema. resurfacing as well as a deep peel may in some
Some patients cannot schedule the required cases decrease the depth of the nasolabial fold,
recovery time for a laser resurfacing. Those may especially a superficial crease, as it tightens the
prefer fillers to improve the appearance of wrinkles skin from both of the cheeks and upper lips. An
and scars until the time is appropriate for laser resur- aggressive therapy, however, may result in scar
facing. The advent of fractional lasers which are tissue formations. Patients with deep nasolabial
characterized by a much faster recovery time allows folds may benefit from a combined therapy with
to use both tools in one session. Therefore, combin- fillers and laser. As a rule, the injection of fillers
ing both of the methods may be more feasible. into the dermis should not be carried out until
Patients with darker skin are not suitable for laser-induced collagen remodeling has ceased. If
aggressive laser resurfacing. For these patients, the injection of nonbiodegradable fillers or fat trans-
combination of a mild exfoliative method or even fer is to be carried out in the subdermal layers (fat
a fractional laser device and fillers is appropriate. or muscle), it may be possible to combine them in
Skin resurfacing should improve skin quality, and the same session. Fillers should be injected
fillers should be used to treat deeper defects. Mid- immediately before laser resurfacing has begun.
exfoliative methods as well as fractional lasers can Vertical lines of the upper and lower lip benefit
be combined with fillers in the same session. from laser resurfacing. Results can be quite
9.3 Chemical Peels and Fillers 161
impressive. If partial improvement is obtained, depending on the skin type and the time required
fillers can be used to achieve better results after from recovery, superficial or medium-depth
laser resurfacing (Fig. 9.1). peels are better suited for some patients – and of
Other lasers may be helpful as well. Vascular course more economical. The rules are the same
lasers such as the KTP laser will reduce telangi- as for laser resurfacing: there are advantages
ectasias and facial erythema. Pigment lasers such and disadvantages with lasers, chemical peels,
as the Rubin laser will decrease lentigines – not and dermabrasion (with the latter being mostly
only in the face but also in all sun-exposed areas used for acne scar treatment). Combining any of
such as the décolleté and the hands. these resurfacing methods may amplify the
advantages of each and reduce the
disadvantages.
Key Points Superficial peels must be used over a course of
• A combination of fillers and lasers is several sessions to produce a visible result. Since
possible in the same session depending they only exert effects in the epidermis, the
on the layer in which the tools are used. recovery time is quite quick, and skin condition-
ing can be obtained. There is no problem with
performing superficial chemical peels and dermal
or subdermal fillers in the same session. Fillers
FAQs must be injected first and the superficial peel
• Which one is better: dermal fillers or applied soon after. Patients must be warned that
laser resurfacing? skin redness may be more prominent at the points
For extensive superficial facial wrin- of injection. It may be the perfect method for a
kling, laser resurfacing, even fraction- “lunch-time” visit. Patients can return to their
ated laser resurfacing, is still superior to social or professional activities immediately
dermal fillers. after.
• When should fractional lasers and On the contrary, medium-depth peels, such as
injectable fillers be combined? trichloroacetic acid peels, require at least 1 week
For patients with fair skin, multiple away from work and social activities. When the
superficial wrinkles, folds, and creases, effect of the chemical peel extends down to the
both methods produce synergistic dermis, dermal fillers should not be injected in
results. the same session. Injections should only be made
• What is the right order of procedures? when the collagen remodeling has ceased and
If a full-face resurfacing is planned, skin redness fades. In general, dermal filler injec-
the resurfacing should lead, and the tion can take place sooner after chemical peels
filler should follow after the inflamma- than after deep laser resurfacing.
tion has subsided. If a fractionated mode
is used, the order is not as important.
The same applies for vascular and pig-
mented lesion lasers. Key Points
• Superficial chemical peels are beneficial
for skin conditioning, and the associa-
tion with fillers is very favorable because
it tends to enhance overall skin
9.3 Chemical Peels and Fillers appearance.
• Deep peels should not be combined with
Chemical peels are also important tools for the fillers in the same session. Here, the peel
removal of superficial wrinkles. Although should precede the filler.
patients may find the word laser more appealing,
9.4 Botulinum Toxin and Fillers area in order to avoid over- or undercorrection.
Experienced practitioners, however, may inject
The use of BoNT-A has changed the way cos- both BoNT-A and fillers in one session.
metic procedures are handled. Nonsurgical treat- Glabellar lines result from the action of the cor-
ment of wrinkles used to consist of filling (with rugator and procerus muscles. Surgical section of
collagen) or peels, both of which were focused both muscles often produces imperfect results and
on static rhytides. At the time, dynamic wrinkles may cause a distorted frown line. BoNT-A is the
could only be treated by a surgical approach and optimal solution to treat this area, and fillers may
only in a few areas, such as the forehead and gla- be used as complementary treatment (see Fig. 6.2).
bella. Muscle action may affect the duration of This is the case when the wrinkle is very deep;
biodegradable fillers. Therefore, the inhibition of some wrinkles are so deep that they seem to be like
muscular activity with BoNT-A might have a scars and are therefore uncorrectable even by the
beneficial effect on the durability of a filler, espe- combination of BoNT-A with fillers. In these cases,
cially in the upper third of the face. Furthermore, subcision or direct excision may be considered.
as the study of the Carruthers et al. (2010) clearly Horizontal lines on the forehead are caused by
shows the combination of BoNT-A and filler in excessive movement of the frontalis muscle.
the same area has a clear advantage over the only BoNT-A is usually the single method needed in this
BoNT-A therapy of the lower third of the face as area. However, specifically in patients with severe
with the combination, adverse effects of BoNT-A elastosis, BoNT-A is often associated with
become less recognizable. unwanted brow ptosis. Depending on the skin’s
The aging process triggers a change in muscular thickness and wrinkle depth, fillers may be very
behavior. Continuous contraction of specific mus- helpful as the only or adjunctive treatment here.
cles may lead to static rhytides. For such wrinkles, After the effects of BoNT-A are at their maximum,
BoNT-A alone might even be the only method fillers can be injected into the remaining wrinkles.
required. In severe cases, however, the dermis is so The use of combination treatment with BoNT-A
affected by both muscular hyperactivity and sun and fillers is also interesting in the oral commissure
damage that fillers and even other interventions (Carruthers and Carruthers 2004, de Maio 2003).
need to be used. Although the onset of the BoNT-A BoNT-A inhibits the hyperactivity of the depressor
effect starts after 24–72 h, a period of 15 days is anguli oris muscle, and fillers promote structural
advisable before treatment with fillers in the same support (Fig. 9.2; see Figs. 6.90 and 6.91).
a b
Fig. 9.2 (a) Patient before treatment to improve perioral injected to block both the overcontraction of the orbicu-
wrinkles. (b) Dermal fillers were injected into the perioral laris oris in the upper and lower lip and into the depressor
wrinkles and into the oral commissure. BoNT-A was anguli oris
9.4 Botulinum Toxin and Fillers 163
a b
Fig. 9.3 (a) On animation, excessive action of the DAO action is clearly visible. Juvéderm Ultra 3 was injected
and platysma bands is observed. (b) After the combined into the lips and oral commissure. Juvéderm Voluma was
treatment, the reduction of DAO, platysma, and mentalis injected into the chin
a b
Fig. 9.4 (a) Patient before treatment to reshape the nose. septum. There is a change in the laugh line and an eleva-
(b) This patient submitted to nasal reshaping with fillers tion of the tip of the nose
and botulinum toxin to block the depressor muscle of the
Platysmal bands reduce or disappear with septum and thus lift the tip of the nose (Figs. 9.4
BoNT-A. However, some of the horizontal lines and 9.5).
on the neck require complementary treatment Treating the nasolabial fold is feasible with
with fillers. Fillers may be injected in one session BoNT-A, but it must be conducted only in very
or after the BoNT-A effect has appeared few cases where muscular action plays an
(Fig. 9.3). important role. In this situation, the opposite
Other areas in which both methods can be happens: fillers should be injected first into the
combined are in the nose and nasolabial folds. As nasolabial fold, and BoNT-A may be injected
mentioned earlier (Chap. 6), nose reshaping may subsequently to decrease the muscular puffi-
be conducted with fillers. Here, fillers can be ness next to the nasal flare. Symmetry can also
effectively combined with BoNT-A, which will be achieved in selected cases (Fig. 9.6). Care
block the action of the depressor muscle of the should be taken because asymmetry is not an
Fig. 9.5 (a) On animation, a b

there is excessive downturn of
the tip of the nose. It is a
typical case where combina-
tion therapy of fillers and
BoNT-A works. (b) After the
treatment, observe the change
of nasal tip position and laugh
line resulting in a softer look
a b
Fig. 9.6 (a) On animation, observe overactivity of the M. combined treatment of BoNT-A into the muscles previ-
zygomaticus major on the right and the DAO on the left. ously mentioned and Juvéderm 3 into the nasolabial fold,
Observe also the widening of the nasal flare due to action balanced symmetry was achieved
of M. alaeque nasi labii superioris levator. (b) After the
a b
Fig 9.7 (a) Young patient

before full-face beauty
makeover. (b) BoNT-A was
injected into the glabella,
crow’s feet, chin, and
masseter. Observe the
slimming of the face and
better aspect of the chin.
Juvéderm Voluma was
injected into the cheekbones
in order to reduce infraorbital
volume loss and into the nose
and chin to improve projec-
tion. Juvéderm Ultra Plus was
injected into lip and oral
commissure
9.4 Botulinum Toxin and Fillers 165
Fig. 9.8 (a, b) Same patient

in oblique view. Observe a b
softer and more attractive
appearance. After the
treatment, she has a happier
look and balanced proportion
(and could not quit smiling for
the photo)
uncommon occurrence. BoNT-A should be

injected to flatten this area. The “gummy smile” FAQs
may also be treated with fillers and BoNT-A. • Where do both procedures deliver their
The former is used to make the lips thicker and best outcome?
the latter to inhibit hyperactivity of the alaeque BoNT-A is the best tool for the upper
nasi labii superioris levator and the labii superi- third of the face, while injectable fillers
oris muscles. are unbeatable for the mid- and lower
One of the most striking uses of combination thirds. Neck treatments have been
of fillers with BoNT-A is the possibility of beau- showing stimulating results with
tifying a young patient, leading to a higher stan- BoNT-A.
dard in beauty perception – full-face makeover • Which treatment should be performed
(Figs. 9.7 and 9.8). first if the same area is treated?
Usually the treatment with BoNT-A
should precede, and then after the
BoNT-A effect is present, the filler
Key Points should be administered in a second step.
• The combination therapy of botulinum However, experienced user profession-
toxin and fillers has changed cosmetic als might inject BoNT-A and filler at the
practice. With only these two tools, the same time.
number of surgical procedures has • What is the advantage of combining
decreased over the years. BoNT-A and fillers in the lower face?
• The global approach of the face with With the combination therapy, adverse
injectable fillers and BoNT-A has given events of BoNT-A in this tricky area
outstanding results, sometimes superior become less recognizable (Carruthers
to surgery. et al. 2010).
9.5 Facial Plastic Surgery or inadvisable. Malar and chin augmentation

and Fillers with fillers is also very helpful during facial sur-
gery, promoting a more harmonious result. If the
Such as BoNT-A has changed the approach to mandible angle becomes too flat after skin trac-
remodeling of the upper face, fillers have revolution, fillers may also be used to diminish this
tionized the surgical approach to the face. Minimal effect with volumetric augmentation.
facial surgery with a quicker recovery time com- In conclusion, the combination of fillers with
bined with fillers is the treatment of choice for other methods in aesthetic medicine is quite
cosmetic facial improvement. In addition to treat- rewarding when they are viewed as more than
ing wrinkles, fillers may be used to promote the just dermal fillers but also as tools to enhance the
volumetric augmentation that was unachievable volume of fat and muscle.
in facial surgery (de Maio 2004) (Fig. 9.9).
As facial subcutaneous tissue decreases with
age, the flattened appearance of the face after Key Points
facial surgery may no longer be considered an • The need of an extensive full-face lift
issue. Fillers may be helpful in eye surgery for has decreased over the years. BoNT-A
both reshaping the eyebrow and treating tear- can effectively tackle the aging process
trough deformities and even to improve the in the upper third of the face. Volumizers
appearance of sunken eyes after excessive and dermal fillers have reduced the
eye-bag removal. When saddle deformity results aging signs from the mid- and lower
from rhinoplasty, fillers are perfect allies, because thirds. Important: skin laxity still needs
they can promptly correct the deformity without a surgical approach. However, the
the need for a second surgical review (see Fig. necessity of extensive undermining and
6.47). Fillers can be used to lift the tip of the nose skin resection has decreased drastically.
in situations where surgery is either unsuccessful
a b
Fig. 9.9 (a) Patient before treatment. (b) Same patient. Submitted to minimum invasive surgery and full-face filling for
volumetric improvement
9.7 Eye Rejuvenation as an Example for Combination Therapy 167
9.6 Topical Drugs in area, especially when they are resistant to alternatives
Combination with Fillers such as injectables or surgery. The effect of bima-
toprost 0.03 %, prostaglandin eye drops, on eye-
Besides topical vitamin A preparations as treti- lashes was first seen in a clinical trial on glaucoma,
noin and topical estrogens, the evidence for the where some patients were forced to trim their eye-
clinical efficacy of topical drugs is very limited. lashes periodically to prevent them from hitting
Topical drugs can be combined with filler treat- their eyeglasses. This leads to further studies and
ments. In case of multiple punctures after a filler in 2008 to the FDA approval of Latisse (Allergan)
treatment, it might be wise to wait 24 h before for eyelash hypotrichosis. Here the bimatoprost
restarting the topical treatment. solution was not used as an eye drop but as a topi-
cal product which was applied to the upper eye-
lashes using an applicator. The bimatoprost
Key Points ophthalmic solution 0.03 % must be applied daily
• Topical drug therapy can be combined to the skin of the upper eyelid margin at the base
with filler treatment. of the eyelashes using the accompanying applica-
• Specifically in patients with severe elas- tors. Excessive application around the eye must
tosis, the combination of a PLLA ther- be avoided since resulting from the drop-skin con-
apy with external tretinoin application tact, pigmentary changes were reported.
has been recommended (Schierle and The ritualistic daily application on the upper
Casas 2011). eyelid margin helps patients focus on the eye area.
The improvement seen in the eyelashes includes
length, thickness, and darkness (Fig. 9.10). This
product produces effective results on a home care
9.7 Eye Rejuvenation as an basis with minimal adverse events giving the
Example for Combination patient a very positive experience. It may also help
Therapy strengthen the patient/physician relationship.
The natural youthful and attractive frame of the

eye is represented by fullness, lack of prominent 9.7.2 Step 2: Restoration of
transitions, and wrinkles with beautiful contours Volume Loss
of the eyelids. In contrast, the aging eye is typi-
cally hollowed out and dominated by the shad- In the lower eyelid, the loss of orbital volume
ows of the lid sulcus, skin excess, eyebrow droop, may cause the infraorbital hollow and create a
skeletonized orbital rim, and deflated cheek. sharp distinction line or shadow separating the
Furthermore, eyelashes are often shorter and rari- lower eyelid from the cheek. This same loss of
fied. In addition to botulinum toxin and injectable orbital volume may reveal the underlying orbital
fillers, nonsurgical “eye rejuvenation” might also fat provoking the eye bags. At the cheek level, the
include a topical drug, bimatoprost 0.03 % anterior view determines the volume loss creat-
(Latisse), which is known to increase length, ing the midface depression. Cheek ptosis with a
thickness, and darkness of eyelashes (please note depression parallel to the nasolabial fold and the
that Latisse is not available in all countries). presence of the malar mound are important aging
signs that are seen midface (Fig. 9.11).
Step 2 focuses on the volume loss. The resto-
9.7.1 Step 1: Improvement of ration of volume loss in the cheekbones and mid-
Eyelashes cheek will lead to shortening of the lid-cheek
junction. Correcting the infraorbital hollow and
In eye rejuvenation, this is step 1 (hook) in mak- the malar depression will decrease the sharp tran-
ing the patient aware of the importance of this sition between these two segments (Fig. 9.12).
Fig. 9.10 (a, b) Step 1 –

a
patient before and after 4
months of daily use of
bimatoprost 0.03 %. The
improvement of the eyelashes
is easily identified by the
patient and may bring
awareness to the eye area. The
communication with the
patient about further
treatments may be facilitated b
after seeing the improvement
in the eyelashes
a b
Fig. 9.11 (a, b) Same patient before treatment with eyes elongated lid-cheek junction, skin excess in the lower eye-
opened and closed: the presence of volume loss in the lid, eye bags, malar mound, and static periorbital
periorbital area is evident. Further aging signs include wrinkles
Treatment in the infraorbital area starts with when it is not a real tear-trough deformity. If
the marking. The patient should be in an upward direct injection into the tear trough is needed,
position and lean its head forward, chin facing the volume requirement will be lower and so
down and eyes looking up. This position will the risk of adverse events. Care should be
enables more accurate distinction of the elon- taken when the malar mound is present.
gated lid-cheek junction and accentuates the Aggressive attempts to overfill a malar mound
volume loss along the infraorbital and cheek- can increase the deformity provoking prolonged
bones and mid-cheek areas. In general, volume and greater swelling. It is most recommendable
replacement in the infraorbital and cheekbone to volumize the surroundings and leave the
areas should come first and may completely or malar mound untouched (Fig. 9.13) (see also
partially solve problems at the lid-cheek junction Sect. 6.5).
9.7 Eye Rejuvenation as an Example for Combination Therapy 169
a b
Fig. 9.12 (a, b) Step 2 – observe the shortening of the Voluma per side. The infraorbital volume loss was treated
lid-cheek junction and the improvement of the tired look with Juvéderm Refine (0.3 ml per side). The upper part of
and skin excess in the lower eyelid after the treatment of the nasolabial fold also improved without direct injection
the cheekbones and mid-cheek with 1 ml Juvéderm
a b
Fig. 9.13 (a, b) The malar mound must be handled with level. Lifting the upper and lower cheek will smooth this
caution. Direct injection into the zygomatic retaining liga- area. The posttreatment picture shows correction of the
ment without providing support to the malar fat pad may volume loss in the cheekbones and infraorbital hollow and
lead to prolonged edema and should be avoided at this improvement of the malar mound
9.7.3 Step 3: Decreasing Muscular frontalis muscle to act unopposed, resulting in brow
Activity by BoNT-A elevation. Step 3 may comprise the treatment of the
glabella area. The dynamic component of wrinkles
BoNT-A has revolutionized the treatment for eye for the eye rejuvenation may be carried out 15 days
rejuvenation. With precise injection sites in the cor- before the filling process. Other alternatives are also
rugators and procerus muscles, elevation of the eye- possible including both treatments in one session or
brows and reduction of glabella lines are obtained. even after the filler component is completed as seen
A weakening of the brow depressors allows the below (Figs. 9.14 and 9.15).
a b
Fig. 9.14 (a, b) Again same patient before and after the the patient is frowning in the picture before treatment. The
treatment with HA-based products only as described picture after treatment shows the improvement of the
above. Note the visible glabella lines and crow’s feet when dynamic periorbital wrinkles after the injection of HA
a b
Fig 9.15 (a, b) The patient has been treated with a total lifting of the eyebrows. The beauty of the curved and lon-
of 20 U of BOTOX® injected into the corrugator and pro- ger eyelashes can be more appreciated now
cerus. Note the improvement of the glabella area and the
9.7.4 Step 4: Develop a Plan for and lead to very severe aesthetic problems. With
Maintenance Therapy that understanding in mind, we need to commu-
nicate with our patients and make them aware
Step 4 is of utmost importance as we are working that the aging process can be effectively slowed
with temporary products. It is important to down. If we do not have a follow-up plan, we will
remember: “We do not go to sleep looking young always be starting from nothing. Book 2 or 3 vis-
and wake up the following morning looking old.” its per year for your patients for touch-ups and/or
Aging is a continuous process that starts with reevaluation. Patients need and appreciate your
mild aging signs, to moderate, that become severe attention.
References 171
Table 9.1 The 4-step approach to periocular

rejuvenation Key Points
Step Action • Combination therapy might be specifi-
1 Build up confidence and trust with patients with cally rewarding in eye rejuvenation. The
bimatoprosta step 4 plan might help colleagues to
2 Treat the first priority, the most important achieve the uttermost benefit.
component in aging sign that may lead to the
most dramatic impact for the patient such as
• Other step 4 ± x plans for other indica-
volume loss in the mid-cheek, glabella line, tions might follow a similar approach.
eyebrow lift, or skin resurfacing
3 Treat all other components to promote the global
approach for eye rejuvenation
4 Create a follow-up plan that will maintain the
References
results and effectively slow down the aging
process Carruthers J, Carruthers A (2004) Aesthetic botulinum A
a
toxin in the mid and lower face and neck. Dermatol
Please note that this product is not available in all Surg 29(5):468–476
countries Carruthers A, Carruthers J, Monheit GD, Davis PG,
Tardie G (2010) Multicenter, randomized,
parallel-group study of the safety and effectiveness of
onabotulinumtoxinA and hyaluronic acid dermal fill-
As a conclusion, with the introduction of new
ers (24-mg/ml smooth, cohesive gel) alone and in
techniques and HA products of longer durabil- combination for lower facial rejuvenation. Dermatol
ity, we can now say that it is possible to deliver Surg 36(Suppl 4):2121–2134
effective results with injectables previously only de Maio M (2003) Botulinum toxin in association with
other rejuvenation methods. J Cosmet Laser Ther
obtainable by surgical procedures. Some patients
5(3–4):210–212
may be reluctant to any minimal invasive pro- de Maio M (2004) The minimal approach: an innovation
cedures and be skeptical toward the benefits of in facial cosmetic procedures. Aesthetic Plast Surg
injectables for eye rejuvenation. The 4-step plan 28(5):295–300
Schierle CF, Casas LA (2011) Nonsurgical rejuvenation
may be helpful in those cases but will also prove
of the aging face with injectable poly-L-lactic acid for
helpful for any other patients presented with peri- restoration of soft tissue volume. Aesthet Surg J
ocular aging (Table 9.1). 31(1):95–109
Index
A F
Abscess, 3, 6, 7, 9, 13, 15, 149, 152, 156–157 Facial plastic surgery, 166
Acute vascular reaction, 153–154 Facial thirds system, 25
Adverse reactions, 3, 4, 7–15, 36, 144, 149–157 First consultation, 22, 24, 27, 32
Alginates, 2, 8 Forehead and glabella, 70–74, 77, 153, 162
Anesthesia, 34, 37, 61–68, 71, 97, 113, 136, 140, 145
Asian patients, 23, 73, 80–83, 93, 94, 102
Asians, 23 H
Hand volume replacement, 137–143
Hyaluronic acid, 2, 3, 5–7, 10, 14, 15, 67, 72, 85, 105,
B 111, 119, 138, 141, 142, 151–155
Biodegradable fillers, 1–11, 13–16 Hyaluronidase, 5, 35, 83, 105, 111, 140, 146, 147,
Biofilm, 12, 152 152–154
“Blind spot” of self-perception, 23 Hydroxyethylmethacrylate (HEMA), 14, 15, 151, 152,
Bluish discoloration, 7, 149, 152 154, 155
Botulinum toxin A (BoNT-A), 22, 25, 27, 35, 45, 57,
70–74, 76, 77, 79, 99, 108, 114, 117, 123, 124,
131, 162–166, 169–170 I
Ideal patient, 25, 43
Intralesional injections steroids, 155
C Inverted nipple, 135–137
Calcium hydroxylapatite (CaHa), 2, 5, 10–11
Cheek, 3, 7, 9, 28, 37, 49, 50, 53–55, 64, 70, 74, 95–97,
106, 107, 110, 111, 125, 127, 160, 167–169,
171 L
Cheekbones, 23, 38, 42, 51, 53–55, 81, 90, 95–97, 108, Lips, 3, 6, 9, 10, 13, 16, 23, 28, 32, 34–36, 38, 42, 44,
109, 131, 164, 167–169 62, 64, 65, 67, 68, 84, 85, 93, 95, 96, 99, 100,
Chemical peels, 119, 137, 161 102, 108, 114–123, 125–127, 129, 131, 132,
CIA. See Cosmetic investment advisor (CIA) 150, 154–156, 160, 162–165
Combination of nonbiodegradable and biodegradable
fillers, 13–15
Combination therapy, 15, 74, 159–171 M
Cosmetic investment advisor (CIA), 45, 46, 58–59 Marionette lines, 53–55, 107, 111, 122–126
MdM 8-point lift, 52–56
Merz aesthetics scales, 32
D
Dextranes, 2, 7, 8
Documentation, 12, 14, 31–34, 49, 77, 78 N
Dysmorphia, 36, 147 Nasolabial folds, 5, 9, 10, 12, 22, 23, 42, 43, 45, 49, 53,
The dysmorphic patient, 28, 37 54, 64, 67, 83, 84, 90, 91, 93, 97, 106–111,
118, 122–125, 127, 153, 160, 163, 164, 167,
169
E Nerve block, 37, 61, 63–68, 78, 90, 101, 119, 145
Earlobe, 112–114 New products, 4, 6, 16, 43
Epicanthal fold, 80–82 Nodule, 7–10, 12, 14, 15, 38, 96, 129, 141, 146, 149,
Eyebrow, 23, 49, 64, 70, 71, 73–80, 84, 166, 167, 169–171 150, 152, 154–157, 160

DOI 10.1007/978-3-642-45125-6, © Springer-Verlag Berlin Heidelberg 2014
174 Index
NO GO area, 53, 54, 92, 94 Poly-l-lactic acid (PLLA), 2, 8, 9, 15, 42, 68, 95–97, 110,
Nonbiodegradable fillers, 11–13, 36, 38, 160 111, 138, 150, 151, 156, 167
Nose, 23, 49–51, 64, 68, 80–82, 84, 85, 97–106, 114, Polymethylmethacrylate (PMMA) and collagen, 14, 151
127, 131, 163, 164, 166
S
Scales, 5, 9, 12, 23, 32, 49, 137, 138
O
Silicone, 11–12, 41, 42, 125
Oral pulse steroid therapy, 154–156
Sunken upper eyelid, 80–83
P T
Penile augmentation, 143–147 Tear trough and infraorbital area, 70, 85–89
Photographs, 23–25, 32–35, 77, 90, 120, 147 Temples, 9, 21, 45, 74–76
PLLA. See Poly-l-lactic acid (PLLA) Topical anesthesia, 33, 37, 62–63, 87, 90, 92, 101, 119,
Polyacrylamide, 11–13, 42, 152 123, 127
Polyalkylimide, 11, 13 Treatment plan(ing), 21, 23–25, 32, 33, 41–58, 75, 77

Injectable Fillers in Aesthetic Medicine

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Injectable Fillers in Aesthetic Medicine

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Mauricio de Maio

ISBN 978-3-642-45124-9 ISBN 978-3-642-45125-6 (eBook)

Library of Congress Control Number: 2014933679

© Springer-Verlag Berlin Heidelberg 2014

Printed on acid-free paper

Springer is part of Springer Science+Business Media (www.springer.com)

During my residency in plastic surgery at The John Hopkins Hospital in the

G. Patrick Maxwell, MD, FACS

Berlin, Germany Berthold Rzany

Berthold Rzany is a dermatologist and clinical epidemiologist in private prac-

2009, by Springer-Verlag – Germany. He is actively involved in research and

BoNT-A Botulinum toxin A

1 Overview on Injectable Fillers: Efficacy and Safety . . . . . . . . 1

3 Requirements and Rules. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

5.3 Local Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

6.6 Nose Reshaping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

6.12 Other Facial Indications for Volumizers . . . . . . . . . . . . . . . 131

9 Combination Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159

Contents 1.1 Introduction

1.2 Classification of Fillers

Basically there is no uniformly accepted classifi-

M. de Maio, B. Rzany, Injectable Fillers in Aesthetic Medicine, 1

1.2.1 Classification by 1.3 Biodegradable Fillers

Table 1.1 Overview on biodegradable fillers

considered the gold standard with which other

1.3.2 Hyaluronic Acid ference between the products could be estab-

The Restylane family is sometimes described as The Belotero Family

1.3.3.2 Combination with Antioxidants

et al. 2010a) (n = 233). In this trial, at 3 months

Table 1.2 Nonbiodegradable fillers

into the dermis as 0.01 ml microdroplets. Each 1.4.2 Polyacrylamide

removable when injected in larger volumes

Table 1.3 Combinations of permanent and temporary materials

1.5.1 Polymethylmethacrylate 1993 and in 0.5 % of reported cases in 1994. The

new product onto the European market, but data

Contents 2.1 Introduction

M. de Maio, B. Rzany, Injectable Fillers in Aesthetic Medicine, 21

analyzed, and as such the practitioner should be

2.4 The Facial Thirds System 2.5 The Ideal Patient

sun exposure, smoking, and climate. Intrinsic

Do’s 2.7 The Patient with Facial

than 1,000 words. It is the patient who, when

skills are also undesirable candidates. The under-

Fig. 2.1 Dysmorphic patient. The patient perceived her

2.9 The Dysmorphic Patient Key Points

Contents 3.1 General Requirements

M. de Maio, B. Rzany, Injectable Fillers in Aesthetic Medicine, 31

Guidelines on before and after photography

3.1.5 Consent recommended. A treatment plan allows realistic

3.2 Technical Requirements 3.2.4 Small Things

3.2.1 Room A standard setting can prove useful to ensure that

3.2.3 Mirror Do’s

Most complaints from unsatisfied patients can Key Points

3.3 The 13 General Rules 3.3.3 Rule 2: Fillers Are Only

3.3.6 Rule 5: Avoid Disturbed

should be seated in the upright position. If not,

Using mirror and/or digital images will help your

You might treat the patient in a supine position. Do’s

understands that if he wants an optimal result, he

3.3.10 Rule 9: Start with a