2018 Hassan Galadari (Auth.) - Soft Tissue Augmentation - Principles and Practice

Hassan Galadari
Soft Tissue
Augmentation
Principles and Practice
123
Soft Tissue Augmentation
Hassan Galadari
Soft Tissue
Augmentation
Principles and Practice
Hassan Galadari
Department of Medicine
College of Medicine and Health
Sciences
Al Ain
United Arab Emirates
ISBN 978-3-662-55842-3 ISBN 978-3-662-55844-7 (eBook)

https://doi.org/10.1007/978-3-662-55844-7
Library of Congress Control Number: 2017960849
© Springer-Verlag GmbH Germany 2018

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To my ladies, Leena and Sarah. Thank you for
your support, your patience and your endless love.
“You made me believe that with honey and lemon,
you can make sugar.”
Foreword
The appreciation of volume restoration in the aging human

face is something that has come to medicine over the last half
century. It has been a marriage of technology and commercial
application that began with the treatment of scars and a two-
dimensional view of the skin’s lines and creases and evolved
into a three-dimensional concept of the face as an evolving
number of changing facial volumes. What began with the use
of bovine collagen and silicone to treat acne scars and a few
wrinkles has blossomed into a market where hundreds of
products have been introduced to treat all kinds of facial
aging related to the gradual loss of soft tissue volume over
time. But the introduction of all of these injectable materials
into the aesthetic marketplace has come with some barriers
to mastery.
The reality is that the mechanics of governmental approval,
in the United States at least, required that the manufacturers
generate products with rather narrow and specific definitions
of indication and appropriate use. A given product arrives on
the market with usually one defined purpose. However the
so-called “off-label” corollary leads to initial tentative use of
the product in other sites and indications. We are then, as
physicians, left with anecdotal reports of success and failure
to guide our future choices. Clinical experience then becomes
the sine qua non that expands the professional breadth of
practice. Interestingly, the widespread clinical use of a prod-
uct “off-label” eventually becomes acknowledged by the
formal governmental approval process, e.g., botulinum toxin,
while the clinicians continue to drive the utility of the product
forward into new indications.
vii
viii Foreword
The clinical masters then frequently pause to sum up and

reflect upon their hard earned expertise and provide us all
with the benefit of their experiences, both good and bad, in
order to help us find our way through the maze of clinical
therapeutic options. Soft Tissue Augmentation: Principles and
Practice by Dr. Hassan Galadari is such a book. He has been
very active in the field of injectable fillers for over a decade
since his time with us in San Francisco and has had the advan-
tage of being at the frontier of new products to use in his
practice in Dubai, UAE. He has been a prodigious teacher
and shared generously both his time and knowledge with his
colleagues and has neatly organized this experience for us
here. I recommend it for you enjoyment as well as profes-
sional enhancement. May it continue to carry all of us
forward.
Richard G. Glogau
Clinical Professor of Dermatology
University of California San Francisco
San Francisco, CA, USA
Contents
Part I Introduction
1 The History of Fillers�� 3
2 Rheology: The Study of the

Physical Properties of Filler Materials�� 9
3 Differences in Men and Women�� 15
Part II Rule of Thirds
4 Upper Third�� 21

Forehead�� 22
Procedure�� 24
Eyebrows�� 31
Temples�� 32
5 Middle Third�� 39

Cheeks�� 44
Tear Troughs�� 55
Nose�� 61
6 Lower Third�� 67

Lips�� 68
Chin�� 79
Jawline�� 85
Index�� 89
ix
Part I
Introduction
Chapter 1
The History of Fillers
The first case of soft tissue augmentation was performed on

a patient who had cutaneous tuberculosis in the late nine-
teenth century. The condition caused destruction of the soft
tissues of his face. At that time, the surgeon used the patient’s
body fat as the filler of choice. Fat was transferred from the
abdomen to the face. While the patient did not survive the
procedure, this spoke on many levels the importance of soft
tissue augmentation as a method to enhance facial aesthet-
ics. To this day, fat is still considered to be a popular natural
filler in the plastic surgery world and advances in its transfer
and injection still continue. It is readily preferred over the
synthetic materials when injecting the body or other larger
areas. Its use in the face has waned, however, with the rise of
synthetic fillers.
Given that fat was such an unpredictable filler in the pro-
cess of soft tissue augmentation, as it was a comprised of
viable biologically active cellular components, it was impor-
tant to find an alternative synthetic form that was readily
available and much more stable when it came to injecting.
This paved the way for silicone and paraffin to be used.
These material gained wide popularity in the mid-1900s. The
essence of the procedure became popular, though it was
soon realized that these permanent fillers, though at first
were inert, have begun to cause long-standing inflammatory
reactions.
© Springer-Verlag GmbH Germany 2018 3

H. Galadari, Soft Tissue Augmentation,
https://doi.org/10.1007/978-3-662-55844-7_1
4 Chapter 1. The History of Fillers
The use of collagen began in the early 1980s with the intro-
duction of bovine collagen in the market. This was revolutiu-
onary at the time as these fillers were biologically based
albeit being xenografts. The materials were tested for immu-
nogenicity initially and when a reaction failed to occur, the
procedure was performed 2 weeks after. It became popular
with the main area of injection being the nasolabial fold. That
area, along with collagen based fillers, became the gold stan-
dard where all subsequent fillers were compared.
Collagen synthesized from human cadavers followed
suit and negated the need to perform an immunologic test-
ing of the material. While these fillers did their job very
well and the results were generally accepted, they did not
last long. This created a need for repeated injections on a
rate of every 2–3 months. This process was not something
that was attractive to patients who would need to undergo
this on a regular basis, especially with those who are needle
averse.
For a filler to be accepted for use on a massive scale, the
material should be of lower immunogenicity, relatively long-
standing and may be reversible if needed. It wasn’t until 1996
that such a filler utilizing hyaluronic acid (HA) from a non-
animal source became approved. The first use of HA was a
few years earlier when the material was cultivated from
rooster combs. The filler was made up of essentially a poly-
saccharide that comprised the ground substance of the extra-
cellular matrix of tissues. It was a ubiquitous material that
was found in nearly all living organisms. In addition, given
that it was synthesized from a non-animal source, HA caused
the least immunogenicity of all. Twenty years later and
although with many other fillers, the so-called collagen stimu-
lating, named because of their ability to produce a controlled
inflammatory response, hyaluronic acid remains the bench-
mark amongst which all other fillers are compared to.
Many changes have been introduced to hyaluronic acid.
These changes were along the line of the technology on
which it was synthesized. This has led to longer lasting HA
fillers on the market and products of different physical
1 The History of Fillers 5
properties. These soft and thick fillers may be injected in

different parts of the face depending on the indication.
These changes were so robust and of significance that even
the nasolabial fold, which has been the area of standardiza-
tion to compare fillers since modern injections were first
made popular, changed. Currently, a three-dimensional
paradigm exists and the face is looked on as a whole.
Standardized scales to look at the cheeks and their volume
have been formulated and currently that is what is being
used when comparing fillers.
In 2008, lidocaine was introduced with HA fillers. Studies
pointed that the anesthetic did not cause a decrease in the
longevity of the material nor its clinical effect. As a matter of
fact, these same studies indicated that patients seemed to do
better, tolerating the procedure more and were more content
with lidocaine incorporated with the filler. Lidocaine’s effect
is more or less immediate and the stinging that is usually
caused by the HA filler’s physical expansion into the tissue is
made much less apparent when lidocaine is introduced.
Though there are some people who may be allergic to the
substance, given the general rare occurrence of allergenicity
to an amide anesthetic, it is much more common to be allergic
to the HA filler than the anesthetic.
Other fillers that came along the way included calcium
hydroxylapatite (CaHA). Filler using this material was
approved in Europe in 2004 and received FDA approval in
2006. Comprised of calcium microspheres, the filler elicits a
controlled immune response or foreign body reaction when
it is taken up by the macrophages. The cytokines produced
by these cells affect fibroblasts to lay down new collagen.
The process of collagenesis provides volume not essentially
caused by the filler itself as in the case of HA, but by the
production of the body’s own collagen. The initial volumetric
change is caused by a gel comprised of carboxymethylcel-
lulose, which makes up 70% of the filler by volume, but that
effect usually lasts less about a month’s time to which then
the CaHA microspheres start taking effect. While most
clinical studies indicate that the filler lasts for about
9–12 months, histologic findings find that collagen produced

by CaHA may last up to 72 weeks. This longevity is corrobo-
rated in clinical practice, when introduction of a cannula in
an area that has been repeatedly injected with the material
will be met with resistance many year after the last injec-
tion, indicating possible fibrosis or collagen synthesis in that
area. This does not translate into clinical relevance as
patients may not show volume enhancement at the time of
the injection. CaHA may be injected anywhere with the
exception of the tear troughs and lips. It is the only filler
that is FDA approved for the hands and has also recently
been approved for the treatment of HIV associated facial
lipoatrophy. Recently, many practitioners advocate the use
of the material for facial and neck rejuvenation, that is
made possible when reconstituting the material with lido-
caine at a ratio of 3:1 or 5:1 and injected superficially. This
works by not filling the area per se, but enhancing collagen
synthesis from fibroblasts.
Poly-l-lactic acid (PLLA) is another filler that causes
new collagen synthesis produced by a foreign body reaction.
The filler itself is initially a powder that needs to be recon-
stituted, usually with saline and lidocaine 24 h prior to injec-
tion. The volume of reconstitution is varied as initially it was
about 5 ml. At this dilution, there was a higher chance of
causing lumps upon injection. This was later revised and
now authors advise about 10–12 mL to be reconstituted
with the filler prior to injection. PLLA is an area filler,
meaning it is great when it’s being injected for volume
replacement and was first approved in cases of HIV associ-
ated facial lipoatrophy. For fine lines in addition to lips or
tear trough injections, the filler needs to be avoided. Given
that collagen synthesis can take time, patients may not be
content with the initial results as repeated injections and
visits are necessary. Some injectors advocate the use of an
HA filler at the same time in the same area. This can give an
immediate response caused by the HA filler until the PLLA
takes full effect. The use of an HA filler in addition to a
filler that causes neocollagenesis, such as CaHA or PLLA,
1 The History of Fillers 7
does not lead to adverse events that is greater to when using

any one of the fillers alone. PLLA’s result may last up to
2 years.
The latest filler to be gain popularity in Europe is polycap-
rolactone (PCL). This filler, which is a hybrid of CaHA in that
it is made up of 30% microspheres of PCL with the remaining
being a gel material, also takes up after PLLA as it is made
up of material that induces collagen in the long-term.
Numerous studies have compared it to HA and it has shown
superiority in that regard in terms of longevity. The filler is
comprised of chains of PCL attached to each other. With
time, these chains are cleaved and the filler loses its effect.
Many formulations exist with some that may last for up to 4
or 5 years. Unlike HAs where the longevity of the filler may
affect its viscosity, PCLs remain constant throughout as the
only difference occurrence being a longer chain to correlate
for a longer time for the material to be bioresorbed.
Indications are very similar to CaHA with the contraindica-
tions including the tear trough and lips.
The only permanent filler to be approved by the FDA is
poly-methyl methacrylate (PMMA). The PMMA spheres
exist surrounded by bovine collagen and testing for immuno-
genicity is recommended. The filler has been approved for
the treatment of the nasolabial folds and has received
approval for treating acne scars. There are many case reports
for its use in the cheek volumization, though that may poten-
tially run the risk of causing permanent problems if correct
placement is not performed.
Fillers still continue to be an important part of the aes-
thetic tool box. A treatment that when combined with the
other modalities such as neuromodulators, energy based
devices and peels continues to enhance patients’ looks. They,
especially HA injections, continue to be the second most
popular procedures in the USA after botulinum toxin injec-
tion and the most popular in Europe. With more to come in
the pipeline, people should rest assured, that we will be see-
ing longer lasting products in the market that will also pro-
vide more natural results.
Brief History of Dermal Fillers

Human fat first
used as a
dermal filler First HA dermal First HA dermal filler
Silicone emerges, filler launched in range to incorporate
adverse events Europe CaHA approved lidocaine
were reported in Europe
1890 1900s 1940 1981 1996 2004 2007 2008 2009
Paraffin becomes
popular as a filler Allergan acquires Polycaprolactone
Hyaluronic acid is Bovine collagen was
Inamed and Corneal approved
discovered the first dermal filler
leading to new in Europe
approved by US FDA
focus on dermal
filler R&D
Chapter 2
Rheology: The Study
of the Physical Properties
of Filler Materials
There are many physical properties that should be taken into

consideration when choosing the right filler for the right area.
The study of such properties or rheology is an important con-
cept that needs to be explained and understood for any seri-
ous injector.
Fillers as mentioned earlier are divided into simple, tem-
porary ones that simply “fill” a given area, such as hyaluronic
acid, or biostimulatory fillers, that enhance the production of
collagen. These include calcium hydroxylapatite, poly l lactic
acid, and polycaprolactone. The final class are the permanent
fillers such as silicone and polymethylmethacrylate.

https://doi.org/10.1007/978-3-662-55844-7_2
10 Chapter 2. Rheology: The Study of the Physical Properties
<< Static >> measurement: Dynamic measurement:

Small oscillation test compression test
Rheometer Rheometer
ω, φ
Sample
Sample (2,5g)
→ G’ (elastic modulus) → Cohesivity index
Physical Properties of Fillers—Differences between the elastic

modulus and cohesivity index
No matter the type of filler, the basic physical property

that the material elicits on the tissue remains the same. The
ability of the filler to withstand outside forces that include the
movement of the overlying tissue and external pressure
forces is known as the G′ of the filler or the elastic modulus.
The G′ is calculated in vitro by using an oscillation instru-
ment that exerts pressure on the material to calculate its
stiffness or smoothness and thus immediate volume creation.
Stiffness, contrary to popular belief, does not translate into
the filler’s “lifting capacity.” It does not imply resistance of
the gel. This property is known as cohesivity and has to do
with both the filler’s resistance to degradation in vivo. For
example, biphasic HA fillers are quite stiff owing to their high
G′. These fillers during production pass through a mesh of a
certain size and thus are dependent on their particle size in
2 Rheology: The Study of the Physical Properties 11
their final form. These particles are not adherent to one

another when compared to the monophasic materials.
Biphasic fillers are not cohesive, thus are more susceptible to
degradation. These fillers provide immediate filling capacity,
but may not have great “lifting capacity” as those with lower
G′ but higher cohesivity. In summary, a filler’s lifting capacity
is dependent on both the G′ and the cohesivity of the
material.
1,600
Measured at 0.7 Hz
1,400
1,200
1,000
G’ (Pa)
800
600
400
200
0
RADIESSE Restylane Perlane Restylane Juvéderm Juvéderm Juvéderm
Filler SubQ Voluma Ultra Plus Ultra
Differences in elasticity between different filler materials. Sundaram

H, Voigts B, Beer K, Meland M. Comparison of the rheological
properties of viscosity and elasticity in two categories of soft tissue
fillers: calcium hydroxylapatite and hyaluronic acid. Dermatolsurg.
2010;36:1859–1865
12 Chapter 2. Rheology: The Study of the Physical Properties
1. FULLY DISPERSED 2. MOSTLY DISPERSED 3. PART-DISPERSED,

PART-COHESIVE
4. MOSTLY COHESIVE 5. FULLY COHESIVE
Cohesivity scale of different filler materials as formulated by

Sundaram
Both elasticity (G′) described above and viscosity (G″) of

the filler are properties that are used to look into where the
material may safely be injected. The ratio of G″:G′ is known
as delta (δ). Fillers with lower δ, where they are more viscous
than elastic, are injected in areas of high tension such as the
cheeks, chin, and temples (deep) and mainly in deeper planes.
If these fillers are injected superficially, they may create
lumps. Fillers of higher δ, where they are more elastic and less
viscous, are usually injected relatively superficially or areas of
lower tension, such as the tear troughs, glabella, or forehead.
The lips remain the only area where a combination of high
and low may be injected depending on the volume required
during the augmentation process.
2 Rheology: The Study of the Physical Properties 13
Physical Properties of Fillers—Delta aids the injector in choosing

the correct filler for the right area based on its physical properties
Chapter 3
Differences in Men
and Women
There are many intricate anatomical differences between

men and women. These changes are seen in both skeletal and
muscular aspects and are translated clinically in the areas of
focus during augmentation. A man’s skeleton is larger, its
surfaces rougher, and the edges are more angular in nature. A
woman’s skeleton has a more pronounced zygoma and zygo-
matic arch. A man’s muscles are also thicker compared to a
woman’s, which accounts for the skeleton’s rougher surface.
If the face is divided into thirds, an upper, middle, and third,
these will be highlighted accordingly.
The upper third consists of the forehead, which includes
the glabellar complex and eyebrows as well as the temples.
Though augmentation is not commonly performed in the
forehead of men, fillers are more readily injected in women
owing to the apparent decrease in volume in that gender.
For the eyebrows care should be taken as augmentation in
women is made by injecting the area above the eyebrow.
This causes a lift of the eyebrows that is considered attrac-
tive. For men, that look may be feminizing and thus injec-
tion should be performed lower on the eyebrow to enhance

https://doi.org/10.1007/978-3-662-55844-7_3
16 Chapter 3. Differences in Men and Women
the skeletal prominence. The glabella and the temples for

both sexes are injected in the same fashion.
The major differences between men and women are seen
when injecting a volumizing filler in the middle and lower
third. The difference in the middle third is mainly in the area
of the zygoma and mid cheek. Zygomatic prominence is
attractive in women and should be enhanced when necessary.
This is performed by injecting a highly robust and thick filler.
That very area should be avoided in men with the main point
of focus being the mid cheek. This mid cheek deflation tends
to be a male trait caused by the effect of testosterone. This
area tends to become more deflated mainly during high vol-
ume exercise and weight loss. This is the main point of injec-
tion in men and facial rejuvenation in that particular point
can lead to enhancement of the tear troughs and the nasola-
bial fold. Tear trough injection may not be necessary in men,
but is a demanded procedure in women. This provides a more
convex look that is attractive, while a more angular skeletal
feature is a masculine trait.
The lower third is where the major differences between
the sexes are most apparent. Utmost care should be taken
when treating those areas as masculinizing a woman can
occur much easier than feminizing a man if injections are
performed poorly. Take for example, the chin. Augmentation
of the chin in women is mainly in the midpoint and extends
laterally to no more than a line drawn vertically down from
the nasal ala. Extension of augmentation beyond this point
causes a more square shaped chin and is a manly feature
that is undesired in women. Lateral extension in women
should be performed only if there is an apparent prejowl
sulcus bilaterally. In men, chin augmentation extends to a
vertical line drawn down from the corners of the mouth.
Another important difference is the angle of the jaw. Men’s
jaws appear more angular and this can be made even more
prominent when injecting the area to create a stronger, right
angle. Masseteric injections may also be performed. On the
contrary, this procedure should be performed with care in
3 Differences in Men and Women 17
women as fillers to augment the angle of the jaw may lead

to a very muscular jaw. The angle in women is more obtuse
and wider. As for the lips, though not commonly performed
in men, if required, anatomically the lips should be injected
to a minimum to achieve a natural shape without a pout that
is desired in women.
These differences highlight the characteristics between
men and women and should be taken into consideration by
any injector during the facial assessment and injection of fill-
ers. In addition to ethnocentric aspects, when taken, the injec-
tion process yields to high satisfaction and subsequent patient
retention.
Part II
Rule of Thirds
Chapter 4
Upper Third
The upper third of the face is made up of the forehead, gla-

bella, where one may argue are part of the forehead and the
temples. Given the rule of thirds, the distance between the
upper third should equal that of the middle and third. The
area transcends the hairline superiorly to the root of the nose
inferiorly. Changes that occur with time cause the upper third
to appear more concave with the thinner skin leading to tex-
tural changes as well as the formation of lines that run per-
pendicular to the muscles underneath the skin.
The upper third’s major function is to display emotions.
Anger, happiness, and fear can easily be conveyed through
seeing just the forehead of that person without the need to
see the rest of the face. It is highly dynamic owing to the
muscles that originate and insert themselves in the same area
as compared to middle thirds where muscles, though originat-
ing from that location, insert themselves in structures in the
lower face, another highly dynamic part.
Treatment of the upper third is essential when taking care
of a person requesting volume rejuvenation. When combined
with botulinum toxin, the result is highly satisfactory for both
the patients and the injectors. The upper third, however, is
recipient to the least amount of filler injections when all three
domains are taken into consideration.

https://doi.org/10.1007/978-3-662-55844-7_4
22 Chapter 4. Upper Third
Forehead
Augmentation of the forehead, albeit uncommonly per-
formed is something worth looking into and understanding. It
is not a region that is injected by the novice, as understanding
the anatomy is key as well as realizing the right indication.
Perhaps the most important part of the forehead that may be
treated is the glabella. Although the part is fairly and readily
injected with botulinum toxin, there are times that filler
should be used to help remove etched lines caused by many
years of frowning or non-treatment. In addition, fat compart-
ments in the forehead do exist and those can atrophy with
aging.
Patients do not generally present asking for augmentation
of the forehead. Most will come to discuss the glabellar lines
and the horizontal creases. The physician should inform
patients especially those in their mid to late 40s that their
forehead may benefit from fillers and the expected results will
be softening of the lines as well as decreasing the concavity of
the forehead head that occurs with time due to the loss of the
fat compartments. The process also gives a youthful look and
shine when performed, as the skin is brought back to its taut,
original self. This is a holistic approach each and should be
discussed during the consultation process. As a rule, patients
will not come asking that their forehead be injected.
When treating the glabella, the injector should be aware of
the major vasculature, pertinent to the area, most impor-
tantly, the supratrochlear artery. Damage to this artery can
lead to neurovascular compromise affecting the forehead,
with backwash embolism into the vessel, potentially also
leading to the blindness. The vessel lies medial to the supra-
orbital foramen. Cadaveric studies show that the vessel lies in
the general area of the vertical creases caused by contraction
Forehead 23
of the corrugator supercilli muscle. This is exactly the same

area that is injected with fillers when treating the glabellar
lines, meaning the injector is injecting right over the vessel. It
is important to understand that though this may be the case,
the supratrochlear artery originates deep from the bone, at
roughly 1 o’clock in the right eye and 11 o’clock in the left.
The vessel continues to lie below the corrugators till about
2 cm from of the superior orbital rim, where it then pene-
trates the frontalis and lies more superficial.
The other major vessel in the area is the supraorbital
artery. This vessel lies more lateral to the suptratrochlear and
can be readily palpated by feeling for the supraorbital fora-
men on the superior orbital rim. Damage to this vessel is
uncommon as augmentation is not something that is readily
performed in that area. Advanced injectors may use fillers
and the best matter to avoid the penetrating the vessel and
leading to a potential complication is to use a blunt tipped
cannula, but the area is generally avoided. Damage to both
vessels may occur to their branches higher up on the fore-
head when both vessels penetrate the frontalis muscle and
are more superficial.
Other matters that need to be taken into consideration
when injecting the area of the forehead are knowing the type
of filler injected and knowing the level these fillers are
injected. When injecting the forehead fat compartments and
taking into consideration the stiffness and G′, fillers of low to
medium G′ should be considered. This allows the fillers to be
fairly distributed in the area without leaving any major lumps
in the area. That being said, it is not recommended that the
horizontal line be injected. Those lines tend to become less
apparent with subsequent injections and not through injec-
tions of the lines themselves as the vessels are in the superfi-
cial plane in that area.
Procedure
Glabella:
1. Identify the area to be injected by asking the patient to
frown. If the patient is unable to frown, you may push the
skin medially to elicit the movement and be able to visu-
alize the lines.
2. Discuss with the patient the need of neuromodulation.

This will help in decreasing the line initially in addition to
increasing the longevity of the filler itself.
3. If the patient has had the area treated with a neuromodu-
lator, assess the glabellar lines if they are actually
apparent.
4. Mark the areas to be treated.
5. It is recommended that injection should be performed
using a hyaluronic acid (HA) filler. HA fillers can be
readily dissolved if a neurovascular complication occurs
immediately or later.
6. Needles (recommended to be 30G or smaller) are pre-
ferred over than cannulas.
Forehead 25
7. Injection should be performed superficially. This is done

by introducing the needle parallel to the skin at about
10–15°. The injector is able to visualize the silhouette of
the needle.
8. It is recommended that the injections be performed away

from the orbital rim towards the hairline as that also help
ensure that the filler, if inadvertently injected into the
blood vessel moves away from the eye and thus decreas-
ing the chance of blindness.
9. When pushing the filler in, the injector is able to see

blanching of the area injected. This is not caused by the
embolism of the major vessels, but due to the pressure of
the filler on the tissue, mainly the capillaries of the
dermis.
10. Retrograde or anterograde injection may be performed.
11. Aspiration may be performed, though unnecessary, as a

lack of blood in the hub does not necessarily mean that
the needle is in the vessel lumen.
12. Massage the area after treatment.
Forehead 27
Forehead Horizontal Lines:

1. It is not recommended that these lines be treated as the
vessels lie in the superficial plane.
2. If treatment is needed, the injection should be performed
in the deeper compartments (supraperiosteal).
3. Both needles and cannulas may be used in this indication.
Cannulas of 25G size may be performed safely in the area
4. Identify the area to be injected.
5. Insert the needle deep by injections of small aliquots per-
pendicularly until bone is felt.
Forehead 29
6. Massage the area after treatment.

Forehead:
1. Three way approach is recommended; two from the lateral
and the one superiorly from the hairline.
2. 25G cannulas are preferred.
3. When introducing the filler from the lateral side, it is rec-
ommended that injection commence from the temporal
fusion line at the temporal crest and injection is made
across towards the midline.
4. Filler is injected in a fanning technique.

5. Cannula is then introduced at the hairline at the mid fore-

head. Cross hatching will occur with the material intro-
duced on the lateral sides and this will provide an
accentuated effect without the need to inject a high vol-
ume of filler.
6. Soft fillers may be injected although a slightly firmer prod-

uct may be used. In general, volumizers, such as products
injected for the cheeks and temples, should be avoided to
prevent lumpiness.
Eyebrows 31
Eyebrows
The eyebrows play an important role in facial recognition
and expression. Elevation may show signs of surprise and
depression can show anger or disdain. Botulinum toxin has
long been the mainstay of injecting the eyebrow. Controlling
the right elevator and depressor muscles can help provide a
youthful appearance. With age, however, increased use of
botulinum toxin in the area, combined with a loss of volume,
can leave the area, when treated with unnatural results. It is
important in this sense to combine treatment with fillers if
elevation of the brow is desired.
The level of injection is important to take into consider-
ation. When injected superior to the brow, the filler is able to
elevate the eyebrow. If injected on the brow, the filler allows
for outward bossing. This is a masculine feature and may dis-
tort a woman’s face when she is injected. Lower injection of
fillers can leave the eyebrow appear depressed and this pro-
cedure is rarely performed and should be avoided. This
approach may be performed only if there is hollowness in the
medial superior orbital rim that is apparent in elderly
patients. This procedure is highly technical and should be
avoided by the novice.
Managing patient expectation is key in this procedure.
Although elevation of the eyebrow can occur, it is not drastic
and patients expecting a lift akin to that produced by a brow
lift will be disappointed. It is important to inform patients
that a filler when combined with a toxin may help elevate the
brow to provide a youthful look, but this procedure does not
substitute for surgery when indicated.
Procedure:
1. 25G cannulas are preferred.
2 . Introduction of the cannula is at the tail of eyebrow at the
level 1 cm superior to the orbital rim at the level of the
inferior temporal fusion line. A more superior approach
may be used but care should be taken as the further up a
filler is injected, the less significant the eyebrow lift
achieved and the more material will be needed.
3. Insertion needle of the cannula should reach all the

way to the bone as filler introduced should be on that
plane.
4. Filler should not cross over the most upper part of the eye-
brow (area of maximum superior deflection). If injected
medial to that area, there is a possibility of penetrating the
supraorbital vessel. This area may be injected and treated
when treating the forehead.
5. Soft fillers are recommended to avoid lumps in the area.
The eyebrow and forehead are areas of high dynamism
and the filler should be able to withstand changing forces
of motion.
6. If injection of the medial aspect of the superior orbital rim
is required and indicated due to hollowness, it is important
to approach this area from the lateral point. No more than
0.2 mL should be injected at a given time to avoid unneces-
sary swelling.
Temples
One of the most neglected upper third facial areas are the
temples. This is partly due to the fact that women, who are
the major recipients of temporal augmentation are unaware
of the temporal atrophy due to wearing their hair down.
This, in turn, covers the temples and makes them less visible
and apparent. However, when performed, temporal aug-
Temples 33
mentation allows for a very satisfied patient. Unlike the

forehead, where the area is difficult to visualize due to
front view manner of an area that is generally skeletal in
nature, the temples are surrounded by bony landmarks that
do not change with time. Recession of the soft tissue is then
much more readily apparent.
The anatomical temples are different than the temples
that are visualized. The anatomical temples extend all the
way posteriorly to the occiput to make a large expanse of
space. What is seen from the temples is bordered by the
zygomatic arch inferiorly, the temporal fusion line, superi-
orly, the hairline posteriorly, and the orbital rim anteriorly.
The mass is mainly made up by the temporalis muscle, a
strong muscle of mastication. In addition, there are fat
compartments, temporal fascia, and neurovascular bundles
in the area. The most important blood vessel is the superfi-
cial temporal artery. A vessel that when penetrated may
inadvertently lead to blindness and other further complica-
tions. The superficial temporal artery is a terminal branch
of the external carotid artery. The other being, the maxil-
lary. Branches of the artery supply areas near the orbit and
are labeled the anterior temporal, zygomatic, and trans-
verse facial arteries. The anterior temporal artery supplies
the skin and muscles of the forehead and anastomoses with
branches of the supraorbital and supratrochlear arteries.
Any filler injected into these vessels can potentially cause
embolism and neurovascular compromise. Before reaching
the temples, the superficial temporal artery runs in the pre-
auricular area, in front of the tragus, makes its way over the
zygomatic arch, and then moves into the temporal fascia
crossing over the temples diagonally till it reaches the tem-
poral crest, where it then gives off the frontal branch and
an orbital branch. As its namesake, the artery is quite
superficial and a pulse may be palpated closer to the bony
landmarks of the skull after crossing the temples.
To understand further injectrions of the temples and to do
so safely, one must need to understand the different layers of
its underlying anatomical structures. This will help realize the
correct approach and right filler type for volume
replacement.
The layers are:

1. Skin
2 . Fat
3. Temporal fascia
4. Temporalis muscle
5. Supraperiosteal (subgaleal space)
There are two ways into which augmentation may be
achieved. The first is through a direct approach using a bonus
technique, where the filler is placed underneath the t emporalis
muscle. The second is the placing of the filler over the muscle
in a fanning technique. Both have their pros and cons.
Procedure (deep bolus):
1. Correct placement is underneath the temporalis muscle.
2. Filler that is used is of the volumizing type. It should be
thick and heavy to withstand the mechanical forces pro-
duced by the temporalis muscle.
3. Injector should avoid any visible veins. This can be
achieved further by stretching the skin of the area. Good
lighting is also essential.
4. The area of injection that is generally accepted as to cause
the least damage exists 1–2 cm lateral to the orbital rim
and 1–2 cm up. Beyond that area, damage to the vessels in
the area increases.
5. Some injectors argue that as long as you are in the right
plane (deep, under the muscle in the supraperiosteal
plane), then you may inject safely on the area of maxi-
mum depression.
6. Needle is used in this case. The needle should be long
enough to penetrate all the layers and touch the bone. Most
manufacturers do not provide such needles with the prod-
uct. One must make sure that the length of the needle is
appropriate. If the needle does not reach bone of the skull
due to its short length, one may assume that there is a
potential to cause damage to the superficial temporal artery.
7. Given that the vessel crosses the temples diagonally as it
comes through the zygomatic arch, it is difficult to predict
where they may occur alongside the temples. This makes
Temples 35
augmentation difficult as damage when a needle is intro-

duced may happen.
8. Mark the area of injection.
9. Introduce the needle at a 90° angle.
10. The needle will penetrate the areas easily, with some
resistance as it goes through the muscle.
11. There will be an immediate release of such resistance and
the injector will have reach the supraperiosteal area. It is
important that the novice touch a bit of bone with the
needle, pull up slightly and inject the filler slowly.
Advanced injectors may not need to do this step as they
are able to tell once the resistance of the temporalis has
given way.
12. Rapid injection of filler may cause a headache as the

expansion of the space leads to discomfort. Slow injection
is key for satisfactory results.
13. When pulling out, injector should be slow to do so.
14. Massaging after does not need to be performed as the
muscle will do so during regular activities of mastication
and speech.
Pros of this procedure:
1. Safe injection in the correct plane
2 . Filler in the deep compartments allows for a much more
natural result as it is covered by the body’s own soft
tissue.
Cons of this procedure:
1. Huge amount of filler will need to be injected to achieve a
satisfactory result as the temple is essentially a bowl and
filler will dissipate from the area of injection downwards to
cover the area of defect.
2. Perceived pain as the needle essentially touches bone

when introduced.
3. Headache may occur.
Procedure (superficial fanning):
1. The filler is placed superficial to the temporalis.
2. Injection may occur either from the superior border or the
inferior border of the temples. The former being the more
popular approach as it is easier to inject from the temporal
crest rather than the zygomatic arch given that the soft tis-
sue in the area is much more accessible with less resistance.
3. Filler to be placed is soft. A highly volumizing filler will
cause lumps as movement of the temporalis muscle may
make the thicker filler more apparent in the soft tissues.
4. Cannulas, preferably 25G, are used during the procedure.
Needles should be avoided as they may damage the super-
ficial temporal artery as this is the plane where the artery
runs.
5. Massage the area after completion.
Temples 37
Pros of this procedure:

1. Less amount of filler is injected.
2 . Much more harmonious immediate result.
3. No headache.
Cons of this procedure:
1. Learning curve is needed as cannulas are not universally
used.
2. Wrong filler may lead to lumpiness.
Chapter 5
Middle Third
If there ever was one area on the face that will give you the
most when it comes to facial augmentation with fillers, it
would have to be the middle third of the face. Fillers when
injected in that area help showcase the most commonly visu-
alized part, the eyes, and subsequently the area under them.
Thus, it is important to understand the anatomy in addition to
the safe zones where the material may be injected.

https://doi.org/10.1007/978-3-662-55844-7_5
40 Chapter 5. Middle Third
Areas of convexities that need to be enhanced during the process of

soft tissue augmentation
The middle third is made up of the peri-ocular area, the

cheeks and the nose. Each of those areas is injected differ-
ently than the other with different fillers needed depending
on the indication. The middle third of the face is also different
in men and women. In men, due to the effect of testosterone,
the mid cheek is slightly more depressed and volume
enhancement happens in that area with lateral extension
onto the zygomatic arch generally avoided. As a matter of
fact, injecting that area in men can lead to feminizing fea-
tures. By injecting the mid cheeks, the tear troughs may not
necessarily require any enhancement, as most hollowness
that are perceived as tear trough deformities are caused by
5 Middle Third 41
atrophy of the mid cheeks. Augmentation of the tear troughs

in men may lead to an increase in the convexity of the mid
cheek, which is also a feminine feature. In women, there are
three very important areas that are usually injected to
enhance the middle third. These are the mid cheeks, the lat-
eral cheeks (area of the zygomatic arch), and the tear troughs
with priority dependent on the individual indication.
Lateral Temporal-Cheek Middle forehead

(forehead)
Central
Lateral orbital
Medial
Superior
orbital
Middle
Inferior
orbital
Nasolabial
Lateral
temporal-cheek
Jowl
Pre-platysma fat
Deep fat compartments of the face
Anatomically the layers of the middle third are com-

prised of the skin, fat compartments, both superficial and
deep, muscles and bones of the skeleton. With aging many

changes occur in those areas. Both superficial and deep fat
compartments tend to undergo volumetric changes with a
decrease in the size of those compartments. That being said,
not all compartments undergo the same volume loss with
time. The nasolabial fold (NLF) fat compartment, for
example, does not decrease with time when compared to its
neighboring compartments and may show a relative
increase. This is important to realize as this negates the old
age adage of injecting the NLFs. As a matter of fact, this
proves that injecting the NLFs will cause a much more
unnatural result.
Blood circulation in the area is restricted to the middle
part of the middle third and compromises of branches of the
facial artery, mainly the angular which tends to branch off to
feed the nose and the transverse facial artery. In addition
the infraorbital artery also comes off of the infraorbital
foramen. Though difficult to palpate, the foramen is found
slightly medial the supraorbital foramen and opens at a
downward angle from the maxilla about 1 cm from inferior
orbital rim. This is important as injection in that area can be
perpendicular at a 90° when placing a bolus, but an angled
injection introduced from the lower part of the cheek
upwards should be avoided as to not lacerate the artery.
Thus, when it comes to filler injection and this artery being
the most prominent in the mid cheek, it is important to
inject from the lateral end to the medial with the injection
point being on the zygoma and moving medially to the max-
illa. This will insure that any potential damage to the vessel
is avoided.
The angular artery passes by the pyriform fossa, a
depression lateral to the nose. While this vessel is deep at
first, it starts moving further superficial and in that area it
is relatively found lying just in the subdermal plane. This is
important to know because though the NLFs may be
injected with fillers in the dermal/subdermal plane, once
the superior part that is lateral to the nose is augmented,
5 Middle Third 43
injection should be placed deeply onto bone to avoid any

potential complication, as neurovascular compromise into
the area will lead to potential necrosis across the side of
the nose and above it. This may be avoided with the use of
cannulas.
The vessels feeding the nose are branches of the angular
artery and anastomose with those arising from the infraor-
bital and supratrochlear arteries. This makes this location
the most sensitive in terms of potentially causing adverse
events. The nasal arteries lie on the lateral walls and anasto-
mose on the bridge of the nose and dorsum. This clinically is
translated into injections needing to be made strictly on the
midline and in the deeper plane. It is important to know that
even when injecting with a cannula, injections should be
made along that midline as much as possible to avoid pos-
sible damage to the vessels.
Internal carolid
Ophthalmic
Lacrimal
Supraorbital
Supratrochlear
Middle
Infratrochlear
temporal
Superficial Infraorbital
temporal
Angular
Transverse
facial
Intemal
Superior
maxillary
labial
Inferior
labial
External Facial
carotid
Anatomy of the blood circulation of the face

Cheeks
Injection of the cheeks has become the gold standard of soft
tissue augmentation procedures. When performed, the cheeks,
tear troughs, and also the nasolabial folds are corrected. Thus,
it is a procedure that is not only desirable, but required when
assessing and treating any patient with fillers. There are dif-
ferences in the cheeks and bony prominences of both men
and women and differences when it comes to injecting fillers
do exist between the two sexes. In addition, there are also
ethnic differences. The Asian skull has slightly more promi-
nent zygomatic arches when compared to the Caucasian
skull. This leads to an apparent flattening of the mid face in
the former. Thus, injection of fillers is usually performed in
the mid cheek in the Asian population and the zygomatic
arch is not augmented to avoid further lateral projection. In
the Caucasian population, both areas are readily injected.
Injection of the mid cheek corrects the tear trough allowing
for less filler to be used. Thus, it is important to inject the
cheeks first and then inject the tear trough after reassess-
ment. The zygomatic arch may also be injected to increase
lateral projection. The arch should be slightly fuller than their
area underneath it. This is observed as a shadow effect that
gives the cheek a three-dimensional look. Makeup artists use
blushers to enhance that effect and this can be performed
with filler material to give a much more youthful
appearance.
Cheeks 45
Superior temporal septum

Interior temporal septum
Orbicularis retaining ligament
Medial canthus
Lateral canthus
Zygomatic
ligament
Lateral cheek
septum
Superior cheek
septum
Masseteric
Platysma-auricular ligaments
ligament
Mandibular ligament
Retaining ligaments and septae
When injecting the cheeks, it is important to be aware of

the correct level of placement of the filler. Thicker fillers
may be injected in the deep fat compartment and that may
be performed by injecting the filler using a cannula in a
linear threading method or bolus. Needles may be used to
do the same, though they are safer when injecting a bolus

into the correct compartment. A filler once placed in the
deep compartment will not migrate. In the midface, the sub-
orbicularis oculi fat and deep cheek fat represent deeper fat
compartments that provide volume and shape of the face.
The deep fat compartments are divided by septae or an
extensive network of retaining ligaments. It is these that
prevent the filler from moving from one compartment to
the other very similar to a partition in a room. Unlike other
retaining ligaments, the zygomatic retaining ligament is a
true ligament that connects the inferior border of the zygo-
matic arch to the dermis and is found just posterior to the
origin of the zygomaticus minor muscle. This is clinically
seen as a groove in the cheeks of some people. Augmentation
of that groove may prove challenging for two reasons. The
first is that injecting into it will not make it disappear given
that injectors are injecting an area where the zygomatic liga-
ment runs through. The second challenge is avoiding the
facial vein, which also lies in that groove. This can cause for
a significant hematoma if it bleeds. Another true ligament is
the lateral orbital thickening that appears on the superolat-
eral orbital rim and meets the orbital retaining ligament,
which surrounds the orbit in a circular fashion. The ligament
also acts as the superior border of the suborbicularis oculi
fat compartment. Augmentation of that area underneath it
helps decrease the tear trough deformity.
The superficial fat compartments, although separated by
septae, allow for communication of the filler from one point
to the other and it is important to realize that only thinner or
more dynamic fillers, those that become readily integrated
into the soft tissue, should be placed in that area as this plane
is notorious in causing bumps.
Cheeks 47
With aging, the retaining ligaments under the eye become

weaker. In addition to volume loss in the superficial and deep
fat compartments, this results in visible folds and grooves in
the cheeks and under the eye.
Orbicularis retaining ligament
Zygomatic ligament
(McGregor’s patch)
Platysma-auricular
ligament
Masseteric ligament
Mandibular ligament
Retaining ligaments and septae1
Procedure:
1. Identify the area to be injected (in most circumstances, it
is the mid cheek).
2. There are many points that may be safely identified when
it comes to injecting the cheeks and all depend on the
region of augmentation. The mid cheek compartment is
where the bulk of augmentation will happen and this may
be accessed laterally (least chance of an adverse event

occurring), inferiorly (risk of penetrating through the
infraorbital foramen and vessels), or at a 90° angle with a
needle.
3. If only the cheeks will be injected, a straight line is drawn
from the lateral orbital rim to about 1–2 cm inferior. This
point may be used.
Only volume:
Lateral Orbit Line (LOL)
4. If both cheeks and tear troughs are to be injected, this line

should be slightly more medial and the landmark used in
this case is the lateral canthus of the eye. This point has
been coined as the Redka/Galadari (RG) point and pro-
vides for a safe, relatively vascular poor area to inject the
whole face; cheeks, tear trough, palpebromalar groove
and depending on the length of the cannula, the corners
of the mouth and chin.
Cheeks 49
Volume & tear trough and/or palpebromalar groove:

Lateral Canthus Line (LCL)
5. It is important to differentiate the lines described in

points 3 and 4. The former is lateral and does not take into
account the convexity of the area of the tear trough and
should only be used predominantly for the cheek aug-
mentation. If that point is used for the tear troughs, there
is a risk for superficial injection of the filler, which may
lead to a Tyndall effect or swelling of the area under the
eyes.
6. Upon identifying the point of injection, an introducer
needle is used to create the passage for the needle. If the
deep plane is where the filler will be injected, then the
needle should be pressed as deep as possible in that area
(to at times hitting the periosteum). If this is not per-
formed, then the cannula will meet resistance when
introduced.
7. Depending on the filler to be injected, a 22 G or a 25 G

cannula is passed through the point.
8. Pinching the cheeks with the nondominant hand will

cause the cannula to pass through the deep fat compart-
ments. Stretching the skin will allow it to move into the
superficial compartment.
Cheeks 51
9. If the deep plane will be injected, then filler may be placed

as a bolus or through linear threading (retrograde or
anterograde).
10. When moving the cannula the injector might encounter
resistance produced by retaining ligaments. If that does
occur, then simply stop pushing the cannula and slowly
ease it through and gently rotate it on its axis. Forceful
movement may work, but runs the risk of causing discom-
fort to the patient. The process is not painful, but the can-
nula may prove to be awkward for some and it is important
to distract the patient by either communicating with them
or giving them a stress ball.
11. If there is sudden pain, then injections should be stopped

in that area and then slowly commenced again once the
pain or discomfort subsides.
12. A cannula will not sever the nerve, but may run next to it
and produce a sharp stabbing pain. At other times, the
sheering effect of a thick filler on the tissue may cause
certain discomfort. Most fillers contain lidocaine and
injecting slowly does help because it allows time for the
lidocaine to work in addition to decreasing the pressure
effect of the filler.
13. Fillers that may be used in this area are of thicker proper-
ties and with higher G′ in addition to being cohesive. This
will allow for a better lifting effect. A thinner filler may be
used to inject the superficial plane. A sandwich technique
by which both the superficial and deep fat compartments
are injected provides a very natural looking overall result
when performed.
14. When treating the mid-cheek groove, the material should
be placed in the superficial compartment as this groove is
caused by the zygomatic retaining ligament and deeper
injections may accentuate it.
15. When moving the cannula back and forth, if the injector
wants to change the plane of injection, it is prudent that
they pull the cannula back as if near drawing it out. They
will feel a sudden decrease in resistance. The cannula then
may be turned and reintroduced into the tissue. If this
Cheeks 53
process is not performed and the cannula is turned whilst

it’s inside then it pulls with it the fat from the same fat
compartment and the filler will remain in that area despite
the injector thinking it is being injected in another. In
addition, if this is not performed, patients will feel very
uncomfortable as there is a great deal of tugging.
16. Upon completing the cheek, the injector may need to
inject the area of the zygomatic arch.
17. The cannula is pulled out till resistance decreases, the

direction of the cannula changes so that it faces the lateral
aspect of the face.
18. Injection is best performed in the areas above and below

the bony zygomatic arch and also avoiding overcorrec-
tion of the area below as that will increase the roundness
of the patient and inadvertently cause the face to look
smaller.
19. Depending on how bony the patient’s facial structure, the

zygomatic arch may slightly be injected. Care should be
made so as to not overcorrect it as it may increase lateral
projection of the face.
Tear Troughs 55
20. Gentle massage is performed in the end in an upward

motion to ensure an overall lifting effect.
Tear Troughs
The tear troughs are one of the most common areas that are
treated with fillers. Tear trough deformity happens for many
reasons and it is important to identify that injections with
filler material only works for if there is actual atrophy, which
appears as hollowness clinically, of the fat compartment in
the area, namely the suborbocularis oculi fat compartment
(SOOF). The SOOF, in itself, is divided into medial and lat-
eral compartments, with the lateral moving unto the palpe-
bromalar groove and towards the lateral orbital rim. The
SOOF is an important structure that is adherent to the under-
lying skull and is a tightly compacted compartment. Filler
placed in that area will stay there for a great deal of time
given the relative immobility of the plane. The tear trough
deformity exists from an area medial to the mid pupillary
line. Hollowness on the lateral aspect is known as the palpe-
bromalar groove. When augmenting the area, both should be
assessed and both should be corrected if necessary.
Tear trough Orbital septum

Orbicularis retaining
ligament
Preperiosteal fat Orbicularis oculi
Sub-orbicularis oculi
Zygomatic retaining fat (SOOF)
ligament Prezygomatic space
Nasojugal
groove
Nasolabial
fold
Relationship between the SOOF and the orbital retaining ligament

There are no major neurovascular anatomical structures in

the SOOF when it comes to injecting the tear troughs and
thus if that filler is placed in that plane, the risk of an adverse
event is low. There are many capillaries, however, which may
lead to bruising.
Procedure:
1. Identify the area to be injected.
2 . A soft filler with a low G′ is used.
3. Both a cannula or a needle may be used.
4. Needle:
a. A 30 G is preferred. The needle is inserted in a line drawn
from the lateral iris down to the orbital rim. The needle is
inserted anterior to the orbital bony rim. It is important
to feel for bone when injecting as to ascertain that the
correct plane has been attained. The needle is then passed
on that deep plane into the tear trough deformity. Small
aliquots of filler are placed in that area as small boli or in
a linear threading fashion parallel to the orbital rim and
running anterior to it. Further injections may be per-
formed slightly more medial to attain overall correction.
It is important to avoid overcorrection.
Tear Troughs 57
b. The palpebromalar groove may also be injected in a simi-

lar fashion with injection points being more lateral.
c. Whether both areas are injected, the key element is to

make sure that these injections are deep and into the
SOOF, with the best method to actually hit bone with
each subsequent injection to correctly realize that that
the right plane has been attained.
d. It may be necessary to change the needles as repeated
injections especially when hitting the periosteum will
dull the needle.
5. Cannula:
a. A 27 G or 25 G is preferred. A 30 G will behave like a
needle in terms of sharpness and may cause harm.
b. Insertion needle may be introduced deeply either in the
lateral iris line as above but slightly more inferior to the
orbital rim (at about 1–2 cm) as compared to the point
where the needle is placed.
Tear Troughs 59
Only tear trough and/or palpebromalar groove:

Lateral Iris Line (LIL)
c. Another insertion point is in the lateral canthal line (the

RG point), if cheek augmentation was performed prior
in the same setting.
d. The cannula may correct the tear troughs by placing a
small amount into the deformity and pulled laterally to
run along the palpebromalar groove and lateral orbital
rim to correct that area.
e. Resistance may be felt in that area as the cannula will

have to go through the point where the orbital retaining
ligament meets lateral orbital thickening described
earlier.
f. No matter the method, overcorrection is not recom-
mended as that may lead to swelling caused by the
hygroscopic property of the filler itself to actually physi-
cal blockage of the lymphatic drainage of the area.
Swelling may occur weeks post injection.
g. It is recommended to undercorrect that area and have
the patient follow-up if necessary for further
volumization.
Nose 61
Before and after treatment of the tear troughs
Nose
Nasal augmentation occurs for many reasons. Mainly it is a
procedure performed for:
1. Patients who are averse to surgical rhinoplasties and are
candidates to filler injections of the nose, such as depres-
sion of the nasal bridge or nasal bony prominence.
2. Patients with depressions post rhinoplasty.
3. Patients with a wide dorsum of the nose due to their ethnic
backgrounds, such as patients from Southeast Asia.
No matter the indication, proper assessment is key as the
nose may sound easy to perform but may result in potentially
deleterious adverse events.
Anatomically, the nose receives its blood supply from
branches of the maxillary and ophthalmic arteries. The sep-
tum and alar cartilages receive additional supply from the
angular and lateral nasal arteries, which are branches of the
facial artery. The angular artery is relatively superficial in the
pyriform fossa, the most superior part of the nasolabial fold.
If filler is placed there, it should be injected in the deep plane.
Filler deep in that area prevents the nasal ala from flaring and
can help in making the nose appear narrower by making the

nares smaller. The blood vessels on the nose then ride to the
side of the nasal walls as the lateral nasal arteries. They then
anastomose with branches of the maxillary and ophthalmic.
Procedure:
1. Nasal augmentation is better achieved from an inferior
approach when using a cannula as superior injection on
the nasal bridge may prove challenging due to the can-
nula’s length and the patient’s glabella being in the way.
When using a needle both inferior from the tip or supe-
rior from the bridge may be performed.
2. A combination technique where both cannulas and nee-
dles are used may be necessary.
3. A 25 G cannula is introduced into the midline of the nose.
This may be placed further up from the tip.
4. The cannula’s opening should also be in the midline to
make sure that the material does not deviate laterally.
Some cannulas have marks on them to indicate the direc-
tion of their opening.
5. If there is a bony prominence between cartilage and bone,
then another opening should be placed further up as
pushing the cannula over the prominence will cause the
skin near the end of the cannula to be pulled and the can-
nula to bend.
6. The area of injection should be pinched between the non-
dominant index finger and thumb to ensure the filler is
placed in the correct midline.
Nose 63
7. Slow injection should be performed and repeated mas-

sage by pinching the sides is key to ensure the material is
correctly placed.
8. Filler is places subdermally and deep lying immediately
over bone.
9. A needle maybe used in a similar fashion, though may

result in a higher chance of bruising or swelling.
10. Filler in tip is injected in the subcutaneous layer and thus
a needle is preferred. It is normal to visualize the filler
coming out of the pores when such a superficial injection
is performed.
11. The tip will slightly elevate once filler is injected in that
area.
12. Further elevation may be achieved by slow injection of
the columella.
13. The soft triangle of the nose may also be injected if defor-
mities exist.
14. Resistance may be expected if there are any prior surger-
ies and a cannula may not be introduced due to that. Care
should be taken in this case as this change in anatomy
may lead to possible emobolization of the blood vessels
of the nose.
Nose—before and after of filler augmentation of the nose
No matter the indication, the mid face is one of the most

important aspects of the face and volumetric cheek augmen-
tation has succeeded nasolabial fold augmentation as the
gold standard when comparing different fillers. The cheek is
Nose 65
also one of the safest areas to be injected and novice injectors

are encouraged to use that area when commencing their
career in facial aesthetics.
Before and after of filler injection in the upper and mid thirds
of face
Chapter 6
Lower Third
The lower third of the face is its most dynamic part. It encom-
passes soft structures such as the lips, as well as bony ones
such as the angle of the jaw and a mix of the two such as the
chin. In humans, that part is responsible for verbalization and
speech, in eating, in performing certain sexual functions such
as kissing and may be of importance depending on the per-
son’s profession, as in the case of musicians. In addition, parts
of the lower face can portray masculinity or femininity; a
strong jawline with squared chin or full rounded lips,
respectively.
Unlike the upper, where neuromodulator use is key and
is an essential part of facial rejuvenation, the use of that in
the lower can potentially lead to major adverse events when
injected inappropriately. Areas where botulinum toxin may
be injected in the lower face are the lips when injecting the
orbicularis oris, the softening of the marionette lines when
injecting the depressor anguli oris, softening of the chin by
injecting the mentalis and finally, decreasing the roundness
of the face or in cases of bruxism in those patients with
strong masseters. Thus, the lower third has always relied
more on the use of fillers for augmentation and to reverse
the signs of aging.

https://doi.org/10.1007/978-3-662-55844-7_6
68 Chapter 6. Lower Third
Blood vessels in the lower third run deep and injection of

fillers is generally performed more superficially. Branches
of the facial artery run in the deeper plane, with the only
superficial part of that the artery running along the mandi-
ble and palpable right anterior to the masseter muscle.
Neurovascular compromise in the area is highly unlikely,
given that the artery is quite large, but it can readily occur
in its branches, such as the superior and inferior labial arter-
ies. Another major vessel of the lower face is the mentalis
artery, which comes off from the mental foramen. Though
large, the vessel may be compromised and embolism may
lead to necrosis of the parts of the chin. That being said,
bruising is much more common in that area than neurovas-
cular compromise. This owes to the high dynamism of the
area where there are many arterial branches, venous tribu-
taries and capillaries present.
Lips
The lips are perhaps the most important structure of the
lower face. They have many uses and functions. Lips are
also an extremely popular indication for filler injection
for volume restoration and augmentation. The procedure
has increased in popularity recently due to the effect of
media with the younger population. Depending on who
you ask, the lips and to a slightly lesser extent, the tear
troughs, are the most popular area of injection across the
board when it comes to filler injections, especially
amongst the youth. This is especially true given that
major studies performed find that men are attracted to
women with fuller lips. This is attributed to the notion
that people with fuller lips have higher estrogen levels
and thus are seen to be more fertile. This has not only
been true in the field soft tissue augmentation, but also in
c osmetic products available in the market produced for
that part of the face.
Lips 69
When seeing and assessing the lips during the consultation

process, it is important to understand two things: the shape of
the upper lip and the volume of the lower. The upper lips
should retain its shape and augmentation in that area should
always respect that aspect and add more to it. Increasing the
upper lip volume can lead to unnatural results and is more
apparent when compared to changes of volume in the lower
lip, where that is expected. In addition to this, the upper lip is
slightly smaller than the lower. The change may be highly
visible in different ethnicities such as Caucasians, where the
difference in ratio can be up to 1:2. That, however, is not the
case in people of African origin where the upper and lower
lips have equal ratios. The lower lip provides the bulk of the
volume. Though that being said, there are volume differences
across the lip itself, with maximum volume occurring lateral
to a depressed midpoint, giving off a shape similar to that of
a dumbbell. In addition, the upper and lower lips lock onto
each other like a key and lock frame. The central part of the
upper lip fitting in nicely in the lower’s midline depression.
During the process of augmentation, the upper and lower lips
should both be treated, even though one may need slightly
more modification than the other. Failure to do that can
make the lips appear unnatural. If artistry is ever looked into
the soft tissue augmentation, the lips are the most important
part of that assessment.
The lips are identified as having both a cutaneous, or hair
bearing, component and a mucosal component. The vermilion
border separates the components apart. Interestingly, when
fillers are injected in the vermillion border, it is possible to see
filler move into the vermillion in an area further away from the
point of injection as if the filler was being injected in a tunnel
or passageway. Stiffer fillers, especially those that are biphasic
will do such a thing more readily than the softer monophasic
type. That being said, there is no discrete anatomical structure
in that area that does not allow the filler to move upwards or
downwards. Other parts of the lips include the oral commis-
sures, or the angles of the mouth. The commissures tend to
change with time as the angle moves from an upward slant to

a more horizontal to finally ending up in a more downward
slant and continuing as part of the marionette lines that sepa-
rate the chin and cutaneous lips from the cheeks. The Glogau-
Klein point of the upper lip is the point of maximum deflection
between the cutaneous and mucosal parts. This point is essen-
tially part of the vermilion. The central part of the upper lip has
a specific shape as the vermilion changes its angle from an
upper to slightly lower. That point usually coincides to a verti-
cal line or philtral ridge that goes up to the lateral side of the
columella of the nose. The central part, where the vermilion
border of one side meets the other, is known as the philtrum,
which is an outward protrusion of the upper lip and its area of
maximum projection. This philtrum sits on top of the lower
lip’s central depression. This whole structure of the upper lip is
commonly called the cupid’s bow given its shape.
Anatomically, the major vessels supplying the lips are the
labial arteries, the superior and inferior. Both are branches of
the tortuous facial artery as it goes up the cheeks towards the
middle third of the face and nose. The arteries run deep but
may be compromised if an injection into that area causes
embolization. This is uncommon, but can happen and should
be identified appropriately and in a timely manner to avoid
scarring. Bruising is much more common and is caused by
damage to the veins. Bruising may be extensive owing to the
mobile structure of the lips and can at times be seen in the
mucosal part of the lips too.
Lips 71
Procedure (Upper Lip):

1. Choose the right filler. The only filler that should be
injected in the lips is a hyaluronic acid. Lumps and bumps
may occur and fillers that may not be dissolved should be
avoided.
2. Stiffer fillers may be used to inject the vermilion border,
but should generally be avoided in volume replacement
as they may be felt. Highly cohesive fillers that are soft
are the materials of choice for volume enhancement
3. Needles (30 G or smaller) and cannulas (27 G) may be
utilized in the augmentation process.
4. The oral commissures and the angle of the mouth are the
first areas to be treated.
5. Injection is performed at a point 5 mm lateral to the oral
commissures.
6. The needle is inserted straight to the angle and a small
amount of filler is injected.
7. The needle is advanced to the lower lip and a small

amount is injected in the area of the vermilion.
8. A much smaller amount is injected in the upper vermilion
to produce what looks like a “C” shaped structure.
9. There will be an immediate visible lifting of the angle of
the mouth.
10. Further support of the angle may be achieved by injecting

perpendicular to the filler lateral vermilion towards the
lower lips. This buttresses the filler in the area.
11. The upper lip is treated by injecting the vermilion

0.5–1 cm medial the oral commissures. If the whole ver-
milion is enhanced with filler, the upper lips may appear
longer similar to that of a duck’s bill. This is quite unnatu-
ral and is a sign of poor technique.
Lips 73
12. When injecting the vermilion, one may see the filler mov-
ing across it and the subsequent injection will be slightly
more lateral. Given that most HA filler contain lidocaine,
that area will be numb when the needle is introduced.
13. When reaching the philtral ridge, angle of injection should

be changed as the vermilion runs lower.
14. The uppermost part of the upper lip, most inferior part of
the philtral ridge, may enhance further by injecting a
small aliquot of filler there at the level of the dermis.
15. The philtral ridge may also be injected, but care should be
taken as to the direction of where the needle is pointing
toward. It is important to inject medially towards the col-
umella of the nose with the philtral ridge pinched between
the index finger and thumb of the nondominant hand.
This not only ensures correct placement, but also pre-
vents widening the space between the two philtral ridges.
The needle runs parallel to the skin to inject the dermis.
Blanching may be visible and perhaps welcome to ensure
the correct plane of injection.
Lips 75
1 6. The other side is performed the same way.

17. Volume enhancement may be performed with filler injected
in the area of the wet/dry junction of the mucosal lip. The
filler should be placed intramuscularly avoiding deeper
submucosal injections to prevent the occurrence of lumps.
18. When using a cannula, the insertion of the cannula is

similar to that of the needle with the steps followed
being similar. The cannula may not readily move into the
vermilion and would need to be pushed in gently.
Changing the angle of injection will also allow volume
enhancement.
19. Cannulas are unable to enhance the philtral ridges as

injecting into that area is at the level of the dermis.
20. Massaging is important. The area of the vermilion is mas-
saged with the index finger and thumb on the area. The
area of the mucosal lip is massaged by pressing the small
bolus so as for it not to be felt anymore.
Lips 77
Procedure (Lower Lip)

1. Volume enhancement is key.
2 . The wet/dry junction is the area of choice to inject.
3. Volume injection is about 1–2 cm lateral to the midline.

4 . Avoid injecting the midline for volume restoration, though
the vermilion may be injected to provide a softer transition
between the enhanced areas.
5. The vermilion border is generally avoided in the lower lips,
but may be injected in the areas of volume enhancement to
provide an even more eversion and outward projection
especially in the central lower lip.
Procedure (cutaneous part of the lips):
1. This can be treated as part of the normal lip augmentation
process of the upper lips or when treating the vertical so-
called bar code lines.
2. During the upper lip augmentation process, a small amount
of filler should be injected in the area of the cutaneous lips
at the area where the vermilion was not treated. Treating
the vermilion will cause the lips to be longer and aestheti-
cally unpleasant and should be avoided. Not treating the
cutaneous part of the upper lip in that area will leave a
small depression.
3. The vertical or barcode lines are injected with a very soft

filler.
4. A needle (30 G) is best utilized and the line is injected
preferably after lip augmentation has been performed as a
much smaller amount will be needed when done.
5. Injection is performed superficially to cause blanching of
the skin.
6. Filler is later massaged.

7 . Combination treatment with botulinum toxin may be used
in this case, though an adept injector will use the toxin first
and then ask the patient to come back for filler enhance-
ment once the neuromodulator is in full effect.
Chin 79
Chin
The chin is a rather important structure in terms that it is
not readily sought by patients, but has one of the most
impressive impacts if done correctly in the right individual.
Chin augmentation can elongate the face, project it lower
third forward, and can also enhance femininity and
masculinity.
The chin proper is bordered superiorly by the cutaneous
lip and inferiorly by the tip of the bony jaw. The chin is later-
ally bordered by the marionette lines. The lines themselves
are made due to the effects of both the depressor anguli oris
and the mandibular ligament. The ligament is attached to the
mandible and separates the chin from the cheek. On the
bone, that area is known as the pre-jowl sulcus. While there
are many muscles that transpose the area and are responsible
for shortening the chin during certain facial expressions
mainly disdain, disagreement or disgust, there are some
muscles that also lower the lips and are responsible for enun-
ciation. The most important of these muscles is the mentalis,
a muscle that at most times has two bellies (similar to the
frontalis). It is quite deep and injecting botulinum toxin mid-
way in the belly can help decrease the crumpling effect that it
causes to the chin as well as elongating the chin and
subsequently the face. Any injection of filler is usually placed
under this muscle to prevent the filler from readily moving
and appearing lumpy. The mental foramen that contains the
neurovascular bundle in the area is also found in that area at
the level of the mid pupillary line. The vessel is not usually
ruptured or embolized, but that may occur if augmentation
was performed by a needle.
Filler use in the chin should be of the soft variety if it is
injected superiorly in the dynamic component, but along the
bone, thicker fillers may be used. Both hyaluronic acid may
be injected as well as other fillers such as calcium hydroxyl-

apatite. The latter, owing to its nature, is usually injected
along the bone and jawline.
Chin 81
Procedure:
1. The most important factor is assessing patients’ needs.
2. Augmentation of male patients is different than female
patients. In males, filler injection may be extended to the
plane of the oral commissures. This will cause patients to
have a more square jaw and thus appearing more mascu-
line. In females, augmentation should be limited only to
the area of the midline, preferably between the ala of the
nose.
3. Two things may be achieved during chin augmentation,
outward projection and downward elongation.
4. For outward projection, filler is placed in the midline of
the chin, directly to the bone.
5. Needles or cannulas may be used, but this is a deep injec-

tion and should be placed under the muscles.
6. Insert the needle or cannulas perpendicularly.
7. A bolus may be injected slowly and reassessment and
massage performed intermittently.
8. The needle or cannula may be moved to inject a small

amount of materials around the bolus. This allows for
softening of the main area.
Chin 83
9. For elongation of the chin and subsequently the face,

injection is performed from an inferior point onto bone.
10. A bolus is then injected slowly with reassessment

performed.
11. The needle or cannula may also be moved to inject a
small amount the area to soften the area around the main
point of entry.
12. Some chins have a dimple and the treatment described
above may cause it to disappear.
13. If this dimple is desired or a patient would like to have
one, then injection should be slightly lateral to the mid-
line on both sides.
14. Filler should be thick in order to create the dimple.
Male Patient:
1. When treating a male patient, injection is extended
towards the area of the oral commissures.
2. This will provide the patient a square looking jaw.
3. The injection occurs all the way onto bone.
4. The midpoint is not injected with a bolus, but in a linear
pattern along the chin. This will create the base, the side
of the square.
5. That should be extended across onto the mandible from

the middle laterally to the plane of oral commissures. This
may be injected using a needle or a cannula in a linear
fashion or perpendicularly onto bone using only a
needle.
6. The lateral sides are then created by injecting a thick filler
upwards in a line towards the oral commissures.
7. The final side of the square is made up of the lower lip
superiorly. Augmentation is not necessary at this point.
8. The dynamic area may be softened by injecting a softer
filler in the marionettes across the cutaneous lips and
mental crease.
9. Large volumes may be injected in the chin and repeated
injections may be necessary to achieve the right effect.
10. This may not necessarily be achieved in one setting and
subsequent visits are necessary.
11. The filler should not be injected in the dermis in this area
as it may affect hair growth of the beard leading to patchy
areas off hair loss.
Female patients:
1. Thick filler should be injected in the middle only and the
location depends on what is needed to be achieved.
2. Lateral extension may be performed if the patient has
marionette lines or prejowl sulci.
3. Care should be taken when that area is augmented as to
avoid masculinizing the patient.
4. Soft fillers should be used when performing this.
Jawline 85
Jawline
The jawline is the most dynamic structure of the face that
relies on movement of the bone rather than soft tissue and
muscles, such as in the case of the lips and eyes. During aug-
mentation, gender differences exist. This may be used to the
patient’s benefit. While feminizing a male patient is quite
difficult, it is much easier to do the opposite to the female
patient. Injection along the jawline and masseter muscle may
lead to this. The jawline is usually enhanced when injecting
the chin. It is considered an extension of treatment in that
area.
Anatomically, the most important blood vessel is the facial
artery. The artery can easily be identified by asking the
patient to clench their teeth and engaging the masseter
muscle. Just in front of the muscle, one can feel the pulse of
the facial artery along the jawline. The artery moves upwards
to give off the labial arteries that feed the lips and then enters
the mid face as the angular artery. It is important to realize
that the artery is quite deep in the lower face, but its branches
become more superficial as it moves to the middle third of
the face. While emobolization of the blood vessel is a possibil-
ity, the lumen is quite large and direct injection is uncommon.
To avoid this from happening, cannulas are preferred. Needles
may be used but care should always be taken to move them
while injecting and to inject in the superficial plane when
injecting the lower face.
Procedure:
1. After completing chin augmentation, filler may be used to
inject the jawline.
2. Needle or cannula may be used.
3. If a person has a prejowl sulcus on both areas, filler should

not extend laterally beyond those areas. Augmentation
along that line will simply cause the jowls to be more
apparent.
Jawline 87
4. Filler should be placed on the angle of the jaw.

5. Insert the needle directly onto the angle at the point
where you are touching the bone.
6. The needle should be pointing towards the angle and the

best way to approach this is to come from inferior auricu-
lar area. When injecting, the filler will enhance that angle.
7. The needle should not come straight from the face as the
filler may potentially move back to the area of the infraau-
ricular space and its primary effect lost.
8. Injection onto the angle will make for a much more eco-
nomical approach.
9. Keep an eye on the shadow that will be created when the
filler is injected.
10. Introduce the needle/cannula superiorly along the ramus

of the mandible and inferiorly on the jawline towards the
midline. An angle that is 90–100 degrees creates a more
masculine angle of the jaw, while a more feminine angle is
obtuse.
11. Masseter injection may be performed. Though a deep

injection is preferable, at times that could be painful given
the large body of the muscle. Filler may be placed over
the muscle, but should be spread and fanned evenly and
not in a bolus pattern as to avoid it from creating a lump
when the muscle contracts.
12. Masseter enhancement should be carefully used in female
patients as this will lead to a squarish face that may at
times be undesirable.
Index
A E
Angular artery, 25, 34, 44 Elastic modulus (G'), 8
External carotid artery, 20
Eyebrow(s), 11, 19, 20
B
Biostimulatory fillers, 7
Biphasic, 8, 38 F
Blindness, 16, 17, 20 Facial artery, 25, 34, 37, 38, 44
Botulinum toxin, 5, 15, 19, 37, 42 Facial vein, 27
Fat compartments, 15, 16, 20, 24,
27, 30, 31
C Forehead, 9, 11, 15–20
Calcium hydroxylapatite
(CaHA), 4, 7, 8, 42
Carboxymethylcellulose, 4 G
Cheek(s), 4, 5, 9, 11, 19, 24–31, 33, Glabella, 9, 11, 15, 16, 35
36, 38, 42 Glogau-Klein, 38
Chin(s), 9, 11, 12, 28, 37, 38, 42–44
Cohesivity index, 8
Collagen, 3–5, 7 H
Cupid’s bow, 38 HIV associated facial
lipoatrophy, 4
Hyaluronic acid (HA), 3, 4, 7, 8,
D 16, 38, 42
Deep fat compartment(s), 24, 27,
29, 30
Delta (δ), 9, 10 I
Depressor anguli oris, 37, 42 Infraorbital foramen, 25, 28

https://doi.org/10.1007/978-3-662-55844-7
90 Index
J R
Jawline, 37, 42, 44, 45 Redka/Galadari (RG), 28
Retaining ligament(s), 26, 27,
29–31, 34
L Rheology, 7–10
Labial arteries, 38, 44
Lidocaine’s, 4, 30, 39
Lips, 4, 5, 9, 12, 37–44 S
Silicone, 3, 7
Suborbicularis oculi fat, 27
M Superficial fat
Macrophages, 4 compartments, 27
Masseter(s), 37, 44, 45 Superficial temporal artery,
Maxillary artery, 34, 35 20–22
Mentalis, 37, 42 Superior and inferior labial
Microspheres, 4, 5 arteries, 37
Middle third(s), 11, 15, 23–36, 38, 44 Supraorbital artery, 16
Supraorbital foramen, 16, 25
Supratrochlear artery, 16
N
Nasal arteries, 34
Nasojugal groove, 27, 30 T
Nasolabial fold (NLF), 3–5, 11, Tear trough(s), 4, 5, 9, 11, 24,
24, 34, 36 26–28, 31–34, 37
Neuromodulators, 5, 16, 37, 42 Temples, 9, 11, 15, 19–22
Nose, 24, 25, 34–36, 38, 40, 42 Temporal fascia, 20, 21
Temporalis muscle, 21, 22
O
Ophthalmic arteries, 34 U
Oral commissures, 38, 39, 42, 43 Upper third, 11, 15–22
Orbicularis oris, 37
Orbital rim, 16, 17, 19–21, 25, 27,
28, 31–33 V
Vermilion border, 38, 39, 41
Viscosity (G), 5, 8, 9
P
Palpebromalar groove, 28, 31–33
Paraffin, 3 Z
Philtral ridge(s), 38, 40, 41 Zygomatic arch(es), 11, 20–22,
Philtrum, 38 24, 26, 27, 30
Polycaprolactone (PCL), 5, 7 Zygomatic ligament, 27
Poly-l-lactic acid (PLLA), 4 Zygomatic retaining ligament,
Poly-methyl methacrylate 27, 30
(PMMA), 5

2018 Hassan Galadari (Auth.) - Soft Tissue Augmentation - Principles and Practice

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2018 Hassan Galadari (Auth.) - Soft Tissue Augmentation - Principles and Practice

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Hassan Galadari

ISBN 978-3-662-55842-3 ISBN 978-3-662-55844-7 (eBook)

Library of Congress Control Number: 2017960849

© Springer-Verlag GmbH Germany 2018

Printed on acid-free paper

This Springer imprint is published by Springer Nature

The appreciation of volume restoration in the aging human

The clinical masters then frequently pause to sum up and

1 The History of Fillers����������������������������������������������������� 3

2 Rheology: The Study of the

3 Differences in Men and Women����������������������������������� 15

Part II Rule of Thirds

4 Upper Third��������������������������������������������������������������������� 21

5 Middle Third�������������������������������������������������������������������� 39

6 Lower Third��������������������������������������������������������������������� 67

The first case of soft tissue augmentation was performed on

© Springer-Verlag GmbH Germany 2018 3

properties. These soft and thick fillers may be injected in

9–12 months, histologic findings find that collagen produced

does not lead to adverse events that is greater to when using

Brief History of Dermal Fillers

1890 1900s 1940 1981 1996 2004 2007 2008 2009

There are many physical properties that should be taken into

© Springer-Verlag GmbH Germany 2018 9

<< Static >> measurement: Dynamic measurement:

→ G’ (elastic modulus) → Cohesivity index

Physical Properties of Fillers—Differences between the elastic

No matter the type of filler, the basic physical property

their final form. These particles are not adherent to one

Differences in elasticity between different filler materials. Sundaram

1. FULLY DISPERSED 2. MOSTLY DISPERSED 3. PART-DISPERSED,

4. MOSTLY COHESIVE 5. FULLY COHESIVE

Cohesivity scale of different filler materials as formulated by

Both elasticity (G′) described above and viscosity (G″) of

Physical Properties of Fillers—Delta aids the injector in choosing

There are many intricate anatomical differences between

© Springer-Verlag GmbH Germany 2018 15

the skeletal prominence. The glabella and the temples for

women as fillers to augment the angle of the jaw may lead

The upper third of the face is made up of the forehead, gla-

© Springer-Verlag GmbH Germany 2018 21

of the corrugator supercilli muscle. This is exactly the same

2. Discuss with the patient the need of neuromodulation.

7. Injection should be performed superficially. This is done

8. It is recommended that the injections be performed away

9. When pushing the filler in, the injector is able to see

10. Retrograde or anterograde injection may be performed.

11. Aspiration may be performed, though unnecessary, as a

Forehead Horizontal Lines:

6. Massage the area after treatment.

4. Filler is injected in a fanning technique.

5. Cannula is then introduced at the hairline at the mid fore-

6. Soft fillers may be injected although a slightly firmer prod-

3. Insertion needle of the cannula should reach all the

mentation allows for a very satisfied patient. Unlike the

The layers are:

augmentation difficult as damage when a needle is intro-

12. Rapid injection of filler may cause a headache as the

Pros of this procedure:

© Springer-Verlag GmbH Germany 2018 39

Areas of convexities that need to be enhanced during the process of

The middle third is made up of the peri-ocular area, the

atrophy of the mid cheeks. Augmentation of the tear troughs

1 The History of Fillers�� 3

2 Rheology: The Study of the

3 Differences in Men and Women�� 15

4 Upper Third�� 21

5 Middle Third�� 39

6 Lower Third�� 67