Facial Assessment and Injection Guide for Botulinum Toxin and Injectable Hyaluronic Acid Fillers

Focus on the Upper Face

Maurício de Maio, M.D.; Arthur Swift, M.D.; Massimo Signorini, M.D.; Steven Fagien, M.D.


Plast Reconstr Surg. 2017;140(2):265e-276e. 

In This Article

Abstract and Introduction


Techniques for the administration of injectable fillers and neuromodulators for facial aesthetic rejuvenation and enhancement continue to evolve. As the number of physicians with limited experience in providing aesthetic treatments expands, the need for guidance and training from more experienced injectors has become apparent. The use of a slow, careful, and methodical injection technique is imperative in all treatment settings and for all facial areas. Constant attention to local anatomy, particularly arteries, veins, and nerve bundles, is critical for minimizing complications. This first article of a three-part series addresses techniques and recommendations for aesthetic treatment of the upper face. Traditionally, the upper face has been considered a basic area for treatment with neuromodulators but an advanced area for treatment with fillers. Injectable fillers may be used for temple volumization, eyebrow shaping, and forehead contouring. Neuromodulators are well suited for diminishing the appearance of dynamic facial lines such as forehead, glabellar, and crow's feet lines, and eyebrow lifting and eye-aperture widening. These techniques may be used independently or together, sequentially or concurrently, to address rejuvenation of individual or multiple facial regions. Overall, this series provides a practical framework of techniques for physicians who desire to perform safe and effective aesthetic treatments using a multimodal approach.


Currently, the use of injectable neuromodulators is the leading facial aesthetic procedure, and use of injectable fillers is the second leading procedure.[1,2] Year after year, increases in the number of these procedures attest to their popularity. The techniques for administering neuromodulators and injectable fillers are constantly evolving—what was originally considered state of the art 5 to 10 years ago no longer represents the standard approach. This underscores the need for a more updated consensus, particularly in light of the increase in available products and delivery devices. The aim of this series of articles is to present the practices and techniques that the authors, as physicians with extensive experience, agree are important principles for the delivery of injectable fillers and neuromodulators to provide optimal aesthetic outcomes. In many aspects, the authors have reached agreement on techniques and recommendations; however, in some cases, reaching consensus has proven difficult and is confounded by the fact that not all products and devices (i.e., cannulas versus needles) are available in each country. Furthermore, the authors acknowledge that the use of minimally invasive techniques for aesthetic enhancement is not an exact science. Other experienced practitioners may have developed treatment principles and practices that achieve equally optimal outcomes. This series of articles is not meant as a comprehensive review of the literature and scientific evidence supporting the use of fillers and neurotoxins for facial rejuvenation. The following is meant as a guide to less-experienced practitioners as a starting point in expanding their experience with these techniques.

With the improvements in injection techniques and the introduction of new products, additional facial areas are now amenable to nonsurgical intervention. Although we illustrate where and how these products should be injected, these guides do not replace greater understanding of the different product characteristics of each of the available products and proper hands-on training. The majority of the recommended injection techniques are directed toward the novice injector who has little experience with the targeted treatment area. However, some of the treatment areas are considered advanced and require significant injection expertise. Therefore, we emphasize the importance of obtaining specific hands-on training. The recommended techniques are applicable to the majority of patients, but alternative techniques may benefit some patients to achieve optimal results. For teaching purposes, the recommendations involve learning injection techniques using the needle provided in the product packaging. However, changing the needle to one with a different size or to a cannula may be more appropriate, depending on the injector's experience or when used in challenging areas of the face or areas in which extreme caution is necessary. The techniques and volume/dose ranges recommended are appropriate for most patients; however, the range of volumes/doses should be individualized depending on severity, age, and ethnicity.

This consensus will focus on the Juvéderm (Allergan plc, Dublin, Ireland) family of hyaluronic acid filler products that use Vycross or Hylacross technologies (Allergan) and on onabotulinumtoxinA for neuromodulator injections (Botox; Allergan). Table 1 illustrates the recommended needles by product. The recommended volumes of hyaluronic acid filler and the recommended doses of onabotulinumtoxinA are specific to the products discussed and are not interchangeable with other hyaluronic acid fillers or botulinum toxin products. Moreover, the volumes and doses cannot be compared or converted to those of any other products by using volume or dose ratios. Table 2 illustrates the dose range for each Allergan plc portfolio product for specific injection areas. When a patient is to be treated with both a neuromodulator and an injectable filler, yet at separate sessions, the neuromodulator is more commonly used in the first session to address the dynamic component of the wrinkle, and the injectable filler should be used in the second session. However, if both products are used in the same session, the authors more commonly suggest that the filler should be injected first and then properly massaged, and only then should the neuromodulator be injected.