Cosmetic Indications

Alternative Therapies

Alternative therapies for the treatment of facial lines and wrinkles include botulinum toxin for dynamic wrinkles, and skin resurfacing procedures such as microdermabrasion, chemical peels, and laser (nonablative and ablative) treatments for static lines. Severe wrinkling with laxity may be better addressed with surgical treatments, such as face-lifts, than with dermal fillers.

Products Currently Available

Dermal filler products can be categorized based on their duration of action as either short acting (less than 4 months), long acting (6 months to 1 year), semipermanent (1 to 2 years), and permanent (2 years or more) (see Table 25-1).^7–9

Injectable hyaluronic acid (HA) products are one of the most versatile dermal fillers currently available. HA is a naturally occurring glycosaminoglycan in the dermal extracellular matrix that provides structural support and nutrients and, through its hydrophilic capacity, adds volume and fullness to the skin. Commercially available HAs vary in formulation, concentration, and degree of cross-linkage, which affects their duration of action as well as postprocedure risks of swelling and bruising.^10,11

Contraindications

Advantages of Dermal Fillers

Disadvantages of Dermal Filler

Anatomy

Facial wrinkles and folds of the lower two-thirds of the face commonly treated with dermal fillers are shown in Figure 25-1. Arterial and venous supply for these areas is shown in Figure 25-2. The lateral nasal artery is a noteworthy vessel for NLF treatments. It is found at the junction of the facial artery and angular artery, and is the main vascular supply for the nasal tip and ala. It is located 2 to 3 mm superior to the nasal alar groove.¹²

FIGURE 25-1 Wrinkles and folds of the face.

FIGURE 25-2 Arterial and venous supply of the face. AA, angular artery; FA, facial artery; FV, facial vein; SOV, supraorbital vein; STV, superficial temporal vein; LA, labial artery; LNA, lateral nasal artery.

Equipment

Anesthesia

Dermal Filler Treatment

Handling and Storage

Hyaluronic acid dermal fillers are supplied in individual prepackaged syringes ranging from 0.4 to 0.8 mL based on the manufacturer. Syringes are typically stored at room temperature (up to 25°C or 77°F) prior to use, and the specific manufacturer package insert guidelines should be followed. Shelf-life ranges from 6 months to 1 year.

Procedure Preparation

Dermal Filler Treatment for Nasolabial Folds: Steps and Principles

The following recommendations are guidelines for treatment using hyaluronic acid dermal fillers.

General Treatment Technique

1. All injections are placed in the mid to deep dermis. Figure 25-3 shows a cross section of skin illustrating appropriate filler placement in the dermis. Placement of DF in the desired level of the skin is one of the challenges with DF treatments and is a skill that takes time and practice to acquire. The depth of injection can be determined by several factors:

• Feel of the needle moving through tissue

• Plunger resistance during injection

• Visibility of the needle tip.

FIGURE 25-3 Dermal filler placement in the skin: (A) before and (B) after filler treatment.

When injecting in the dermis, slight resistance is felt as the needle advances through the tissue, some plunger resistance will be felt during injection, and the needle tip is not visible.

When injecting too deeply in the subcutaneous layer, minimal to no resistance is felt when advancing the needle or against injection, and the needle tip is not visible.

When injecting too superficially in the epidermis or superficial dermis, significant resistance is felt when advancing the needle and during injection, and the gray needle tip is visible in the skin.

TIP: If injecting at the incorrect level, withdraw the needle to the skin insertion and retry.

2. Dermal fillers are injected using firm, constant pressure on the syringe plunger as the needle is withdrawn in a linear thread (called retrograde injection). Pressure on the plunger is released just prior to pulling the needle out of the skin, to avoid tracking product in the epidermis.

CAUTION: Blanching during injection indicates that blood flow to the treatment site has been compromised, either by injecting too much filler into the dermis or injecting intravascularly. Discontinue injecting, massage the area until the tissue appears pink, and institute other measures outlined in the Complications section later in the chapter if indicated.

3. Complete treatment in one area to the satisfaction of the provider and patient before moving on to the next area for treatment.

Methods for Dermal Filler Injection

The two main methods for injecting dermal filler in the dermis are (Figure 25-4):

FIGURE 25-4 Dermal filler injection techniques: (A) fanning; (B) cross-hatching.

• Fanning technique. This technique utilizes a single needle insertion point to inject a series of adjacent linear threads. Upon completion of fanning, product is placed in a triangular area. Fanning is commonly used for treatment of NLFs, particularly in the superior NLFs near the ala of the nose.

• Cross-hatching technique. This technique utilizes multiple insertion points with placement of linear threads in a grid pattern. Upon completion of cross-hatching, product is placed in a square area.

Planning and Designing

The goal of NLF treatment with dermal fillers is to soften NLFs without full effacement. The NLF is a natural facial contour and full effacement gives a simian appearance and is not aesthetically pleasing. In addition, undertreatment with small volumes may not yield a visible change to the NLF.

Figure 25-5 shows a grading scale for the severity of NLFs. Patients with mild, moderate, and severe NLFs are candidates for dermal filler treatments. Deep folds with excess laxity may have less satisfactory outcomes with dermal filler treatments and may require surgical interventions for significant improvement.

FIGURE 25-5 Nasolabial fold grading scale of (A) mild, (B) moderate, and (C) severe.

(Copyright Rebecca Small, MD.)

Dermal filler is placed within the Nasolabial Fold Safety Zone, which is bounded laterally by the nasolabial fold superiorly by the edge of the nasal ala and extends to the inferior-most portion of the nasolabial fold (Figure 25-6).

FIGURE 25-6 Nasolabial Fold Safety Zone.

(Copyright Rebecca Small, MD.)

CAUTION: Injection superior-lateral to the NLF Safety Zone can accentuate the folds and can result in dermal filler placement in the angular artery (see Figure 25-2).

CAUTION: Injection inferior to the NLF Safety Zone, or placement of too much DF product in the NLF, can add heaviness to tissues and turn down the corners of the mouth, accentuating oral commissures and marionette lines.

 

An overview of injection points for treatment of NLFs using an HA dermal filler is shown in Figure 25-7. All injections are placed medial to the NLFs. Injections proceed superiorly from number 1 to 3, with the filler product fanned medially at the nasal ala.

FIGURE 25-7 Overview of nasolabial fold injection points and technique.

(Copyright Rebecca Small, MD.)

The estimated HA dermal filler volume necessary for treatment is based on patients’ observed facial anatomy and volume loss in the treatment area (see Figure 25-5):

• Mild NLFs typically require 0.5 syringe (0.4 mL) per side of the face.

• Moderate NLFs typically require one syringe (0.8 mL) per side of the face.

• Severe NLFs typically require 1.5 syringes (1.2 mL) per side of the face.

 

Maximum doses of dermal filler vary by manufacturer and are reported in the product package insert. For example, the maximal dose for Juvederm is 20 mL/year and for Restylane 6.0 mL per patient per treatment.

Anesthesia

Providing adequate anesthesia is an essential part of dermal filler treatments. Minimizing discomfort improves provider injection precision and offers the patient a better experience. The goal for anesthesia with dermal filler treatments is to achieve maximal anesthesia while minimizing tissue distortion of the treatment area to preserve the baseline anatomy.

The four main methods for providing anesthesia to the nasolabial folds are as follows:

1. Local infiltration adjacent to the NLFs. Figure 25-8 shows an overview of injection points and doses for local infiltration of anesthetic for treatment of NLFs. After preparing the skin with alcohol, 0.1 mL of 2% lidocaine with epinephrine 1:100,000 is injected subcutaneously at each injection site, superior to the NLFs. The injection sites are compressed to minimize edema from the anesthetic.

FIGURE 25-8 Nasolabial fold anesthesia.

(Copyright Rebecca Small, MD.)

CAUTION: Placing anesthetic into the nasolabial fold may blunt the fold and make filler treatment volumes more difficult to determine.

TIP: Sensitivity increases with proximity to the nose, and injections are started at the inferior portion of the NLF and advance superiorly toward the nose.

2. Infraorbital nerve block. Nerve blocks are recommended instead of local infiltration when several facial regions are being treated simultaneously. For example, when treating lips and NLFs in the same visit, an infraorbital nerve block can be used to anesthetize both treatment areas. See Chapter 20, Anesthesia for Cosmetic Procedures, for details of performing nerve blocks.

3. Topical anesthetic. In-office application of a topical anesthetic, such as benzocaine : lidocaine : tetracaine (BLT), with a maximum dose of ½ g applied for 15 minutes, may be used prior to treatment of NLFs. See Chapters 3 and 20 for additional information on topical anesthetics.

TIP: Topical anesthetics reduce discomfort associated with needle insertion but do not reduce the burning sensation that frequently accompanies HA fillers during the injection. Less burning sensation is reported by patients with HAs formulated with lidocaine.

4. Ice may be used as an alternative to or adjunctively with the methods listed above. Anesthesia is achieved by applying ice to the skin immediately before the injection until the skin is erythematous but not blanched.

Performing the Dermal Filler Injection

1. Position the patient comfortably in a semireclined position for the procedure, at about 65 degrees.

2. Prepare the skin with alcohol.

3. Anesthetize the treatment area using the minimal necessary anesthetic volume to reduce tissue distortion (see earlier Anesthesia section).

4. A soft white eyeliner pencil or surgical marker may be used to draw on top of the NLFs prior to administering anesthesia to better define the area for treatment.

5. Attach a 30-gauge, 0.5-inch needle to the prefilled dermal filler syringe.

6. Prime the needle by depressing the syringe plunger until a small amount of dermal filler extrudes from the needle tip. Ensure that the needle is tightly affixed to the dermal filler syringe to prevent the needle popping off when plunger pressure is applied.

7. The first injection is medial to the NLFs at the inferior portion of the fold (Figure 25-9). Insert the needle at a 30-degree angle to the skin and advance to the needle hub. Apply firm and constant pressure on the syringe plunger while gradually withdrawing the needle to inject a linear thread of filler in the mid to deep dermis.

8. The second injection point is approximately 1 cm superior to the first injection point (Figure 25-10).

9. The third injection point is 1 cm superior to the second injection point closer to the nose (Figures 25-11A and B). Use the fanning technique: Advance the needle to the hub and inject filler in a linear thread; without fully withdrawing the needle from the skin, redirect the needle counterclockwise and advance the needle to the hub again, and repeat.

10. Repeat injections 1 to 3 for the contralateral side of the face.

11. Compress the treatment area with thumb and first finger to smooth any visible or palpable bumps of filler product by placing the thumb on the skin and the first finger intraorally. If bumps do not easily compress, the area may be moistened with water and stretched between the provider’s fingers. The more the filler product is compressed and manipulated, the more swelling and bruising may occur.

FIGURE 25-9 First injection point for nasolabial fold dermal filler treatment.

(Copyright Rebecca Small, MD.)

FIGURE 25-10 Second injection point for nasolabial fold dermal filler treatment.

(Copyright Rebecca Small, MD.)

FIGURE 25-11 Third injection point for nasolabial fold dermal filler treatment with fanning from (A) superior to (B) inferior.

(Copyright Rebecca Small, MD.)

CAUTION: Avoid placing filler product in the superficial dermis because this may result in an undesirable visible ridge of filler that does not readily compress.

CAUTION: Avoid overfilling the treatment area because this may eliminate the nasolabial folds altogether resulting in an unnatural appearance.

Results

Immediate correction of lines and contour defects are seen with dermal filler injections. Figure 25-12 shows a 38-year-old patient with moderate nasolabial folds (A) before and (B) 1 week after treatment with an HA dermal filler, Juvederm Ultra Plus^®, using 0.8 mL (one syringe) in each nasolabial fold for a total volume of 1.6 mL.

FIGURE 25-12 (A) Before and (B) after hyaluronic acid dermal filler treatment of the nasolabial folds.

(Copyright Rebecca Small, MD.)

Figure 25-13 shows a 46-year-old patient with severe nasolabial folds (A) before and (B) 4 weeks after layering treatment with 1.5 mL of a calcium hydroxylapatite filler, Radiesse^®, and 0.8 mL of a hyaluronic acid filler, Juvederm Ultra Plus^®, in the nasolabial folds.

FIGURE 25-13 (A) Before and (B) after calcium hydroxylapatite and hyaluronic acid dermal filler treatment of the nasolabial folds.

(Copyright Rebecca Small, MD.)

Aftercare

Ice is applied to treatment area for 10 to 15 minutes every 1 to 2 hours and continued for 1 to 3 days, or until swelling and bruising resolve. Patients are instructed to avoid activities that can cause facial flushing, such as application of heat, alcohol consumption, exercising, and tanning, until swelling resolves. Patient self-massage of the filler in the treatment areas is not recommended. Acetaminophen may be used if needed for discomfort.

Follow-Up

The longevity of visible tissue filling with dermal fillers depends on several factors including: the type of product and volume used, the patient’s metabolism, degree of motion in the treatment area, and facial expressivity. Hyaluronic acid dermal filler effects typically last 6 months to 1 year. To maintain the desired results, subsequent treatment is recommended at about 6 to 9 months, when the volume of dermal filler product visibly diminishes but is still palpable. Maintenance treatments usually require less product volume, particularly if some volume from the initial treatment is still present.

Complications

Some degree of transient postinjection bruising, swelling, erythema and tenderness is common and expected with any dermal filler treatment. These typically resolve within a few days to a few weeks.^13,14 Specific side effects are associated with each filler product¹⁵ and the following discussion focuses on complications reported with hyaluronic acid fillers and their management.

Visible filler lumpiness occurring at the time of, or shortly after treatment, can usually be treated with aggressive compression by the provider. This may require local anesthetic infiltration prior to compression for patient comfort, and a bruise may form as a result of compression. In addition, hyaluronidase has been used by some providers for treatment of HA bumps, but it is not FDA approved for this use (see below).¹⁶ Some providers report lancing large filler collections with a scalpel and expressing the product.¹⁷

Prolonged or excessive swelling can be treated with regular use of ice, as described above, and oral antihistamines (e.g., cetirizine 10 mg, 1 tablet daily until swelling resolves). Severe swelling and allergic hypersensitivity reactions, such as angioedema, have been reported, and oral or intramuscular steroids are indicated in these rare cases.¹⁸

Prolonged erythema is often due to tissue hypervascularity above the dermal filler. Discrete telangiectasias may be present with the erythema. Hypervascularity may be due to vascular congestion from filling the tissue, or an inherent tissue response to the dermal filler product.¹⁹ Lasers or intense pulsed light devices specific for reduction of vascularities are useful treatment modalities to reduce erythema associated with hypervascularity. Prolonged erythema may also be due to irritation and/or inflammation in the treatment area, particularly when treatments are performed in highly mobile areas, such as the oral commissures.

Prolonged erythema may stimulate postinflammatory hyperpigmentation, which can be treated with topical lightening products such as hydroquinone (see Chapter 24, Skin Care Products).

Infection, such as reactivation of herpes simplex, can occur and may be prevented with prophylactic antiviral medications. Any time the skin barrier is breached, bacterial or fungal infection is possible.

Erythematous tender bumps and nodules (also called inflammatory nodules) are treated as bacterial infections. These can occur immediately after treatment or be delayed, up to a year or more.¹⁹ Management consists of empiric antibiotics with a macrolide (e.g., clarithromycin 500 mg BID) or tetracycline (e.g., minocycline 100 mg BID).^20,21 A 6-week course of antibiotics is common; however, the duration of treatment depends on the intensity of infection. If fluctuant, it is advisable to incise, drain, and culture the nodule. HA fillers may be degraded by injecting hyaluronidase into the nodular area (10 to 30 units, based on the volume to be removed). New evidence is emerging to suggest that late-onset inflammatory nodules (and perhaps granulomas) may be due to biofilms, which are aggregates of microorganisms within adhesive protective coverings that commonly adhere to foreign bodies, and can be elusive to standard culture methods and highly resistant to antibiotics. Once the dermal filler foreign body is gone, the biofilm is presumed to resolve.²⁰

Granulomas are a delayed complication, appearing 6 months to 2 years after dermal filler treatment, which are much more common with permanent and certain semipermanent fillers such as poly-L-lactic acid. A minority of granulomas spontaneously resolve, however, intralesional steroid injection or excision is often required.¹⁵

A Tyndall effect with bluish skin discoloration may occur with superficial placement of HA dermal fillers in thin-skinned areas.¹⁷ Product can either be reduced using compression, hyaluronidase, or expressed as described above.²²

Tissue ischemia, due to reduced blood supply to tissue, although rare, is a potentially serious complication. Blood flow can be compromised by overfilling tissue with filler product or injecting intravascularly.

Ischemia with possible impending tissue necrosis may present with pain or painlessly, and may be visible as a violaceous reticular pattern or white blanching. With NLF treatments, intravascular injection of the angular artery may occur (see Figure 25-2), with ischemic signs visible on the nose and/or nasolabial fold. Ischemia is managed urgently because it can rapidly progress to tissue necrosis. If ischemia occurs, attempt to revascularize by massaging the ischemic area, and if intravascular injection of the artery is suspected, apply heat packs, inject 10 to 30 units of hyaluronidase in the area, and administer aspirin 2 tablets of 325 mg orally. In addition, reports of applying of a vasodilator such as nitropaste to the affected area have also been used successfully.^12,23 It is advisable to contact the local emergency room and/or plastic surgeon if ischemia does not rapidly resolve.

Blindness due to retinal artery embolization has been reported with dermal filler treatment in the glabella.

Asymmetry, overcorrection, and undercorrection relate to the volume of product injected and their incidence usually decreases as injector skill improves. It is important to discuss these possible outcomes with patients prior to treatment, and inform them that additional product, incurring additional expense, may be required to correct an asymmetry or for undercorrection. A similar pretreatment discussion about the duration of correction (or persistence of the product) is also important because a product may not last as long as its FDA-approved duration, particularly if small product volumes are used, treatment areas are highly mobile, or the patient has a high metabolism. Overcorrection, as with product lumpiness, can often be corrected with compression to mechanically break down the product. Migration of filler product adjacent to the treatment area can occur if the treatment area is compressed shortly after treatment. For this reason it is advisable to instruct patients not to massage their filler product after treatment. If filler is tracked into the epidermis or superficial dermis upon withdrawal of the needle during injection, rarely, product may extrude spontaneously.

Keratoacanthomas, benign epithelial tumors, can arise in response to trauma and have been reported with DF treatments. These lesions can be refractory to treatment and it may be advisable to seek consultation for management.

Scarring is very rare with DF treatments, but may occur with any injection, particularly if treatment is complicated by an infection. Patients with a history of hypertrophic or keloidal scarring are also at increased risk of scarring.

Learning the Techniques

Dermal filler injection requires practice to obtain proficiency. Providers can practice the linear thread, fanning, and cross-hatching techniques using clear silicon packs or synthetic skin models (which dermal filler manufacturers may provide). However, to place filler in the correct level of the skin, providers must acquire a “feel” for intradermal injection, which can only be obtained by injecting patients. Initially, it is advisable to start with treatment of the nasolabial folds of staff and family, using small volumes. Additional volume for further correction may be added subsequently.

Current Developments

Many hyaluronic acid dermal fillers are being formulated with lidocaine to reduce treatment discomfort and the need for anesthesia. Advanced techniques involving layering of fillers in different levels of the skin may improve outcomes with wrinkle reduction. In addition, new approaches to facial rejuvenation focusing on restoration of facial contours, in combination with the traditional approach of filling wrinkles, are increasing the applications of dermal fillers in facial aesthetics.

Financial Considerations

Cosmetic dermal filler treatments are generally not covered by insurance. In rare instances, coverage for filler treatments to scars may be possible. Dermal filler fees are based on the type of filler used, size and number of syringes, injector skill, and vary according to local prices in different geographic regions. Prices range from $500 to $650 per syringe of hyaluronic acid filler (0.8 mL). Box 25-1 lists CPT codes for DF procedures.

Conclusion

Treatment of facial lines and wrinkles with dermal fillers is well tolerated by patients and can reliably achieve good results in the nasolabial fold area. Dermal fillers are an integral part of aesthetic care and are the treatments of choice for wrinkles in the lower two-thirds of the face. Once proficiency has been achieved with treatment of nasolabial folds, providers may choose to expand dermal filler use to other facial areas and aesthetic applications.

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