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.

Disclosures

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

In This Article

Hyaluronic Acid Filler Injection Technique for Contour Restoration in the Upper Face

Temple Volumization

Age-related volume loss in the upper face can result in hollowing of the temples.[12] Youthful temples are flat or slightly convex; temple volumization is indicated for temples that have become overly concave. Volumization of the temples can be achieved using Voluma, Volift, or Ultra Plus (Figure 1). For temple volumization with Voluma, identify the temporal artery and vein (Figure 1, above). Look for the junction of the temporal crest or fusion line with the orbital rim, and identify the area of greatest volume loss. Position the needle 1 cm superior to the lateral orbital rim and 1 cm lateral to the temporal crest. Insert the needle perpendicular down to bone, aspirate, and then inject very slowly using a supraperiosteal bolus injection (Figure 1, below). Moderate pressure with the index finger of the free hand placed superior to the needle along the hairline will prevent economic loss by spread of product under the hair. Injection speed is slow, maintaining the needle on bone throughout the injection. Once the needle is removed, pressure on the injection site for several minutes is warranted in the event that a deeper vein is pierced, to avoid a late-occurring bruise. Gentle molding of the temporal region may be required after injection of typical volumes in the 0.5- to 1.0-ml range for most temporal hollows. Severe volume loss may require up to 2 ml per side of Voluma and multiple treatment sessions may be needed. When using Ultra Plus, some injectors prefer to deploy injections at two sites (Figure 1, above). The first injection is made as described for Voluma. The second injection should be made along the lateral edge of the frontozygomatic arch, medial to the first injection. Gently pinch the skin at the tail of the eyebrow, and insert the needle at an anteromedial angle (Figure 1, below). Aspirate and then slowly perform a deep injection using retrograde linear threading. Apply finger pressure to avoid displacement of the product into the upper eyelid and massage to shape the gel. Voluma is preferred for moderate to severe volume deficiency in the temple. Ultra Plus may be indicated for mild to moderate volume deficiency, or when Voluma is not available.

Figure 1.

Temple volumization using either Voluma or Ultra Plus. Voluma is injected at site 1 only (above, left), whereas Ultra Plus is delivered by means of injections at sites 1 and 2. For the first injection, identify the temporal artery and vein (above, right). For the first injection, a full needle should be used, and aspiration is mandatory before injection (below, left). For the second injection, pinching of the skin is used to avoid inadvertent displacement of the product into the upper eyelid (below, right).

There are several areas of caution for temple volumization (Figure 1, above). By visual inspection and palpation, avoid the superficial temporal artery and vein that lie in the subcutaneous tissue.[12] Selecting a supraperiosteal location high in the temporal fossa (1 cm up the temporal fusion line and 1 cm lateral and parallel to the supraorbital rim) minimizes the risk of intravascular events because of the relative avascularity of this region and the thin fibers of the temporalis muscle of the upper region. Piercing of a branch of the artery or vein should result in deposition of product deeper beneath the deep temporal fascia lying on the muscle, which will protect the vessels. Again, once the tamponade effect of the needle is lost with its withdrawal, pressure on the area will prevent untoward bruising. The deep temporal arteries (anterior and posterior) and the middle temporal artery are located more posteriorly to this point, and their calibers are small, as they diminish in size from their origin at the second portion of the internal maxillary artery. Although not a guarantee of extravascular location, aspiration before injection is always warranted. Finally, avoid deep needle injections into the lower or posterior fossa above the zygomatic arch, as internal maxillary branches are present, with a risk of palate necrosis. Superficial cannula injection may be attempted with careful observation of cannula position. It should be noted that the deep periosteal injection high in the fossa may lead to temporary (24 to 48 hours) visible congestion of the temporal venous plexus lying in the subcutaneous tissue, whereas superficial injections may lead to surface irregularities that require massage over the ensuing days.

Eyebrow Shaping

The position and/or shape of the eyebrow may change with aging. Fillers can enhance eyebrow contour and volume, and may be used for improving the elevation of the eyebrow tail in cases where onabotulinumtoxinA provides insufficient eyebrow lifting.[12] Eyebrow shaping can be achieved using either Ultra Plus or Volift. With each product, injections are made at two sites (Figure 2, above). Identify the orbital rim to avoid inadvertent injection into the orbital cavity (Figure 2, above). For the first injection, position the needle and aspirate before injection. Insert the needle at the lateral end of the eyebrow, inject very slowly using a supraperiosteal bolus injection, and then massage upward to shape. Injections in the lateral aspect of the eyebrows are intended to promote support of the roof. Remember to palpate the orbital rim and protect with a finger to avoid migration of the filler into the upper eyelid (Figure 2, below). Avoid overcorrection of the eyebrow with filler, because it can result in an unduly prominent eyebrow appearance or cause eyelid edema.[12] The second injection should be made in the same manner medial to the first injection along the eyebrow. Be careful to avoid the supraorbital foramen when injecting lateral to it (Figure 2, above).

Figure 2.

Eyebrow shaping using either Ultra Plus or Volift. Each filler is delivered by means of injections at two sites (above, left). Identify the orbital rim to avoid inadvertent injection into the orbital cavity (above, right). Aspiration is mandatory before each injection, and a finger should be placed to avoid migration of the filler into the upper eyelid (below).

Forehead Contouring

Dynamic forehead lines are usually treated with a neuromodulator, but hyaluronic acid fillers are used to treat deep horizontal wrinkles to create a smooth contour across the forehead.[12] Forehead contouring can be achieved using Volift or Volbella; if these are not available, Ultra can be used. Each product is injected at six sites along the forehead wrinkle (Figure 3, left). For the first injection, position the needle near the lateral end of the wrinkle and at least 2 cm above the eyebrow, and aspirate before injection. Insert the needle fully, inject very slowly using a supraperiosteal bolus injection, and inject deeply to avoid the forehead and temporal vessels and nerves (Figure 3, left). The needle tip must be on bone beneath the galea to access this avascular plane. Moving medially along the forehead, the second and third injections are given on the same facial side at least 2 cm above the eyebrow, with aspiration before each injection. Again, inject very slowly using a supraperiosteal bolus injection, and inject deeply to avoid the supraorbital and supratrochlear vessel bundles (Figure 3, left). Continuing to the other side of the face, perform the other three injections in the same manner. Avoid scratching the periosteum to reduce pain and swelling. Remember that massage is mandatory for delivering a uniform and smooth forehead contour.

Figure 3.

Forehead contouring using either Ultra, Volbella, or Volift. Each filler is delivered by means of injections at six sites (three on each side of face) (left). Injections are made at least 2 cm above the eyebrow, and areas of caution are particularly relevant for the second, third, fourth, and fifth injections. Aspiration is mandatory before each injection. For the first and sixth injections, inject deeply to avoid the forehead and temporal vessels and nerves, and for the second, third, fourth, and fifth injections, inject deeply to avoid the supraorbital and supratrochlear vessel bundles (right).

There are several areas of caution for forehead contouring. Inject at least 2 cm above the eyebrow, and avoid not only the supratrochlear and supraorbital but also the superficial temporal vessels of the transverse frontal branch. In addition, always maintain deep injection to avoid the subcutaneous vessel bundles. It is also possible to use blunt cannulas to deliver these products for forehead contouring.

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