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How To Prevent The Challenging Filler Face
David J. Goldberg, MDSkin Laser & Surgery Specialists of NY and NJ
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Facial Fillers
• Perhaps the most versatile non‐surgical means of facial rejuvenation
• Several million treatments performed every year
• Expanding indications, anatomic areas, and product development
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Fillers Can Induce Collagen, Elastin and Proteogylcan Formation • Tensile Strength (Collagen)• Structural Support (Collagen)• Elasticity (Elastin) • Hydration (Proteoglycan)• Swelling Pressure (Proteoglycan)
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Collagen Formation
• HA• Biostimulation (The Others)
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PLLA Neocollagenesis
5
12 mo
Hematoxylin‐eosin stain, 400x, shows PLLA microparticles with adjacent aggregation of giant cells, histiocytes, and
collagen fibers
Vleggaar D. Dermatol Surg. 2005;31(11 pt 2):1511‐1518. Reprinted with permission from the author.
30 mo
Hematoxylin‐eosin stain, 400x, shows lack of PLLA microparticles and the
abundance of collagen fibers
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CaHA Neocollagenesis
6
32 wk 78 wk16 wk4 wk
Canine histology 40–60x, collagen matrix stained with picosirius red1
Top, with permission from Coleman K et al. Neocollagenesis after injection of calcium hydroxylapatite composition in a canine model. Dermatol Surg. 2008;34:S53‐S55. Bottom, from Marmur ES et al. Clinical, histologic and electron microscopic findings after injection of a calcium hydroxylapatite filler. J Cosmet Laser Ther. 2004;6(4):223‐226. Reprinted by permission of Taylor & Francis Ltd (www.tandfonline.com)
Thick section light microscopy at 1 mo and 6 mo postinjection2
6 mo1 mo
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PMMA‐Collagen Neocollagenesis
7
3 mo
At 3 mo, microspheres are completely encapsulated and surrounded by fibroblasts and collagen fibers (40x)
At 10 y, histology shows mature connective tissue, active fibroblasts,
microencapsulation of each microsphere (40x)
10 y
Lemperle G et al. ArteFill permanent injectable for soft tissue augmentation: I. Mechanism of action and injection techniques.Aesthet Plast Surg. 2010;34(3):264‐272. With permission of Springer.
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Elastin and Proteoglycan
• 20 Middle Aged Women • Injected with CaHA• Biopsy before and 6 months later
Goldberg DJ, et alDermatol Surg: 2019
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Proteoglycan: Alcian Blue Staining
Before 6 months
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Elastin: Immunohistochemistry Staining
Before 6 months
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Van Gieson Stain for Elastic Fibers
Before 6 months
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So Why are There So Many Filler Mistakes and Unfortunate Results?
• Many injectors received no formal training
• Filler treatments can be deceptively difficult to execute properly and master
• Use of products that carry higher risk
• Poor or basic understanding of facial anatomy, dynamics, and aesthetics
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What Do I See in My Practice?
• I regularly see bad filler outcomes
• These are usually due to poor technique
• Can these mistakes be fixed/addressed?
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Want To Focus on Good Technique
• Not on Biofilms• Not on Necrosis• Not on Nodules
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Common Filler Mistakes:General Mistakes
• Injecting too much volume in each setting• Especially true in lips and tear trough
• Not staging treatments when necessary
• Choosing the wrong product
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Staging Treatments Leads to Better Outcomes
• More natural results can be achieved by staging multiple treatments• Less bruising, swelling, patient anxiety• Facilitates more natural expansion of tissue• Allows you to address minor asymmetries
• Most over‐injected patients are injected in one session
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Common Filler Mistakes:Lip Augmentation
• Injecting filler too far inside lip
• Using permanent filler
• Creating nodules and irregularity
• Not paying attention to lip shape and balance
• Injecting philtral columns inaccurately
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Lip Augmentation Mistake:Injecting filler too far inward
• The most common technical error on lips
• Lip loses shape and definition
• Creates anterior projection
• Abnormal look when smiling
• Creates visible filler outside of the lip with a ‘puffy’ look
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Lip Augmentation Mistake:Injecting filler too far inward
• The most common technical error
• Lip loses shape and definition
• Creates anterior projection
• Abnormal look when smiling
• Creates visible filler outside of the lip with a ‘puffy’ look
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Lip Augmentation Mistake:Using Permanent Filler
• Most common are silicone and bio‐gel
• Inflammatory response of silicone
• Filler walls off, creating an implant look (i.e. no true tissue integration)
• Only surgery can fix
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Lip Augmentation Mistake:Using Permanent Filler
• Patient comes in with previous unknown filler treatment
• Reports long‐standing bumps and nodules
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Lip Augmentation Mistake:Using Permanent Filler
• Unknown soft material expressed
• Culture negative• Patient healed without incident
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Lip Augmentation Mistake:Creating Nodules & Irregularity• Patient treated previously with ‘micro‐droplet’ silicone and HA filler
• Her injector once treated her during an active HSV‐1 outbreak
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Lip Augmentation Mistake:Creating Nodules & Irregularity• What are the problems here?
• Use of permanent filler and HA• Poor technique – not properly distributing filler
How to address? Firm massage Carefully placed hyaluronidase HA filler injected unevenly (to blend with the silicone)
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Lip Augmentation Mistake:Creating Nodules & Irregularity• Patient treated with an unknown filler substance
• This was the result of one treatment session (i.e. a massive amount of product)
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Lip Augmentation Mistake:Creating Nodules & Irregularity• What is the cause here?
• Too much filler at once, creating a ‘tissue expander’ effect
How did I address this? Firm massage Large amounts of hyaluronidase (multiple sessions) A small amount of HA (to fill in the massive skin excess) Recommended surgical excision of excess skin
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Lip Augmentation Mistake:Not paying attention to lip shape/balance
• Injectors often create imbalance between upper/lower lip• Border of lip and definition often ignored• Usually straightforward solution
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Lip Augmentation Mistake:Not paying attention to lip shape/balance
• An entire syringe of HA was injected into her upper lip• 150U hyaluronidase dissolved all of the filler
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Lip Augmentation Mistake:Injecting Philtral Columns Poorly• Augmenting or creating philtral columns can improve lip balance
• Attributes of a beautiful philtrum• A slight diagonal tilt (15 degrees)• Slightly narrow inter‐philtral distance• More fullness inferiorly
• Many injectors create fat philtral columns in a wide, vertical orientation
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Lip Augmentation Mistake:Injecting Philtral Columns Poorly
• Too wide• Asymmetric• Too vertically oriented• Can this be fixed?
Good separation Symmetric Slight inward orientation & curvature
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Common Filler Mistakes:Tear Trough
• Using the wrong filler
• Placing filler too far inferiorly
• Placing filler too superficially
• Ignoring the lateral component
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Tear Trough Mistake:Using the Wrong Filler
• Higher concentration HA fillers can lead to long‐term edema• Highly resistant to enzyme degradation
• Tissue expander effect• Calcium‐based fillers should never be used• Create visible white nodules
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Tear Trough Mistake:Placing Filler Too Far Inferiorly
• Typically due to two causes• Cannula use by an inexperienced injector
• Inferior approach to the tear trough
• Avoided by using needles and entering perpendicular to the skin overlying the tear trough
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Tear Trough Mistake:Placing Filler Too Superficially
• More commonly seen in patients treated with cannulas• Inexperienced users place filler in wrong tissue plane
• This cosmetic deformity is more prominent in patients with poor skin elasticity
• Almost always requires enzyme degradation• Can create a ‘tissue expander’ effect
After cannula treatment Post‐enzyme treatment Re‐treated with HA
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Master the needle, then the cannula
• Injecting in the correct plane (i.e. supra‐periosteal) is critical
• Much easier to stay in correct plane with needle• Though it is easy to learn cannula technique, you MUST understand anatomic planes to be successful
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Tear Trough Mistake:Ignoring the Lateral Component• Technically, the tear trough is only medial
• Continues laterally as palpebromalar groove
• Many injectors ignore the palpebromalar groove since it is often less prominent
• Lateral correction is necessary in >90% of patients treated, and is often more important than medial
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The Midface is the Among the Most Complex Areas of the Face• Anatomic variability is incredibly high among patients
• Must pay attention to adjacent areas to maintain balance• Lower cheeks• Temples• Parotid/pre‐auricular region
• Underlying bony anatomy impacts outcomes greatly
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Common Filler Mistakes:Mid‐face Augmentation• Too much emphasis on the medial cheek
• Reliance on a ‘cookbook’ approach
• Not paying attention to the lower cheeks and temples
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Mid‐face Mistake: Too much emphasis on the medial cheek
• Too much attention paid to medial cheek by inexperienced injectors
• Can worsen tear trough and decrease size of eyes
• Creates a ‘fat face’ look that can be difficult to correct
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How to Avoid an Over‐injected Medial Cheek
• Typically, place the LEAST amount of filler in the medial cheek
• Understand the limitations of treating the mid‐cheek Can never be fully corrected
• Diagnose carefully: Many patients don’t need ANY filler in the medial cheek (especially younger patients)
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How to Correct an Over‐injected Medial Cheek
• If large amount of filler has been injected (i.e. tissue expansion), enzyme is not advised creates excess skin
• Best to add filler laterally in an attempt to ‘lift’ the medial cheek
• If tear trough is apparent, treat this as well (conservatively)
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Mid‐face Mistake: Reliance on a ‘cookbook’ approach
• 1 – Lateral zygoma• 2 – Mid zygoma• 3 – Anteromedial cheek• 4 – Submalar
• Some protocols recommend injecting in this sequence to best economize product
• Creates unnatural result in patients with high cheekbones, hollow lower cheeks, or a narrow face
1234
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Mid‐face Mistake: Not paying attention to the lower cheeks and temples
• Once the mid‐face (cheeks) volume is restored, the temples and lower cheeks often appear volume‐deficient• Especially in patients with high cheekbones
• The temple can be the most powerful area to treat
• Lower cheeks can be treated one of three ways• PLLA/CaHA• HA directly (fanning technique)
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Avoid Hollow Lower Cheeks and Temples
• First must recognize patients with low volume and/or elasticity in the lower cheeks
• First stage of treatment may be PLLA to the lower cheeks and temples• Can then treat with more mid‐face augmentation
• Treating the jawline can often help
• When treating midface with HA, augment the inferior portion of the zygoma
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How to Treat Hollow Lower Cheeks and Temples
• Typically, these imbalanced patients desire a ‘quick fix’• Treat with HA
• Vollure• Restylane Refyne
• Prefer to treat temples with Sculptra/Radiesse
• Large temple deficits: treat first with HA for foundation, then Sculptra/Radiesse
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Prevent the Challenging Filler Face
• Poor filler outcomes can be attributed to:• Bad technique• Lack of anatomic expertise• Poor choice of filler/permanent filler• Not understanding aesthetic principles
• In many cases, these outcomes can be remedied
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Pro‐Nox and Injectables