25 Dermal Fillers

Soft-tissue augmentation, commonly referred to as dermal filler treatment, reduces facial lines and improves contour defects by temporarily restoring volume to the dermis and soft tissues through the use of injectable products.¹ With the use of appropriate techniques and volumes, dermal filler treatments can enhance appearance in a subtle, natural way. Treatments require short recovery times and can be safely performed in the outpatient setting.^2,³

Dermal filler treatments have become the second most commonly performed minimally invasive cosmetic procedure in the United States, according to statistics from the American Society for Aesthetic Plastic Surgery.⁴ The popularity of this procedure is largely due to increased patient demand for less invasive cosmetic treatment options and to recent product innovations that have prolonged treatment results.

Numerous dermal fillers (DFs) are available, each varying in composition, duration of action, palpability, ease of administration, complications, and other factors.⁵ In addition to the provider’s knowledge of DF products and injection skill, an appreciation for aesthetic facial proportions and symmetry is required to achieve desirable outcomes. Injection of dermal fillers has a steeper learning curve than botulinum toxin injections and requires practice to achieve desirable results.⁶ This chapter is intended to assist aesthetic providers in getting started with products and techniques that consistently achieve good results and have a low risk of complications. The focus is on the use of hyaluronic acid DF products for the FDA-approved treatment of nasolabial folds (NLFs).

Cosmetic Indications

• Dermal filler treatments with hyaluronic acid are approved by the U.S. Food and Drug Administration (FDA) for injection in the mid to deep dermis for correction of moderate to severe facial wrinkles and folds, such as nasolabial folds.

• Dermal filler treatment for lip enhancement, marionette lines, oral commissures, cheek augmentation, acne and chicken pox scars, and other cosmetic areas are off label.

Alternative Therapies

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

Products Currently Available

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

TABLE 25-1 Dermal Fillers in Common Use ⁷^–⁹

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

Contraindications

• Pregnancy or nursing

• Active infection (e.g., herpes simplex and pustular acne) or inflammation in the treatment area

• Hypertrophic or keloidal scar formation

• Bleeding abnormality (e.g., thrombocytopenia or anticoagulant use)

• Accutane use in the previous 6 months due to impaired healing

• Skin atrophy (e.g., chronic steroid use or conditions such as Ehlers-Danlos syndrome)

• Impaired healing (e.g., due to immunosuppression)

• Dermatoses such as vitiligo and active psoriasis or eczema in the treatment area

• Uncontrolled systemic condition

• Previous anaphylactic reaction to anything at any time

• Multiple severe allergies

• Previous allergic response to dermal filler products or gram-positive bacterial proteins (which are commonly found in hyaluronic dermal fillers)

• Body dysmorphic disorder

• Unrealistic expectations, intolerance of bruising.

Advantages of Dermal Fillers

• Immediate results.

• Most undesirable outcomes spontaneously resolve with temporary fillers.

Disadvantages of Dermal Filler

• Post-treatment swelling and bruising is common.

• Repeat treatments are necessary to maintain results.

Anatomy

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

FIGURE 25-1 Wrinkles and folds of the face.

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

Handling and Storage

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

Procedure Preparation

1. Review the patient’s medical history and perform an aesthetic evaluation and consultation (see Chapter 19, Aesthetic Principles and Consultation).

2. Obtain informed consent (see Chapter 19; also see Appendix A for an informed consent form and patient information handout titled Dermal Filler Treatments).

3. Pretreatment photographs at rest and with the patient actively contracting muscles in the intended treatment area are advisable (see Chapter 19).

4. Document and discuss any notable asymmetries prior to treatment.

5. Schedule treatment well in advance of social events.

6. Minimize bruising by discontinuation of aspirin, vitamin E, St. John’s wort, and other dietary supplements including ginkgo biloba, evening primrose oil, garlic, feverfew, and ginseng for 2 weeks prior to treatment. Discontinue other nonsteroidal anti-inflammatory medications and alcohol consumption 2 days prior to treatment.

7. Prophylactic antiviral medication (e.g., valacyclovir 500 mg 1 tablet twice daily) may be given 2 days prior to procedure and continued for 3 days postprocedure for a history of labial or facial herpes simplex, or varicella zoster.

8. Discuss the estimated volume of dermal filler necessary for treatment and cost with patient prior to treatment.

Dermal Filler Treatment for Nasolabial Folds: Steps and Principles

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

General Treatment Technique

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

• Feel of the needle moving through tissue

• Plunger resistance during injection

• Visibility of the needle tip.

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

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

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

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

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

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

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

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

Planning and Designing

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

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

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