Facial Fillers

Chapter 43. Facial Fillers

Bernard T. Lee, MD, MBA; Jason S. Cooper, MD

INDICATIONS

Redistribution of subcutaneous facial fat results in volumetric deflation and signs of facial aging (ie, creases, folds, and wrinkles). Facial rejuvenation with soft-tissue fillers has been used to treat atrophy of the upper and lower lips, down-turning at the corner of the mouth, malar soft-tissue descent, and deepening of the nasolabial folds.

PREOPERATIVE PREPARATION

Patients should be provided with an informed consent form specifically related to soft-tissue fillers. The area to be treated is photographed and corroborated by the patient with a handheld mirror after makeup is removed. Both patient and surgeon should be well versed in the fillers intended to be injected. Before soft-tissue augmentation, it is recommended that patients refrain from medication that can inhibit platelet aggregation and potentiate ecchymosis for approximately 2 weeks prior to injection. Immediately prior to injection, the patient’s vital signs should be checked, along with a recent history of medications taken and review of systems. The treatment area should be assessed with respect to its aesthetic deformity and the patient’s goals for treatment. The surgeon should choose a filler based upon the anatomic area being treated; consideration should be given to type of filler, duration of effect, and intended depth of injection. For example, the lips are evaluated for fullness, tightness of upper lip relative to maxillary arch, projection, and degree of eversion. Youthful lips demonstrate a certain amount of vermilion bulk, whereas thin lips are exaggerated by bony retrusion and changing dentition. The marionette lines, mental groove, and the anterior jowl line must be assessed similarly to optimize lip and perioral aesthetics.

ANESTHESIA

Adequate cutaneous anesthesia can be obtained with various topical preparations. Local anesthesia and nerve blocks may be unnecessary in collagen products that they already contain lidocaine in the syringe. The majority of patients receive a combination of topical, local, and regional anesthetic prior to filler injection. Topical anesthetic creams include lidocaine, tetracaine, and benzocaine. Regional anesthesia includes infraorbital and mental nerve blocks with 1% lidocaine and 1:200,000 epinephrine. It is our experience that after injection of filler, ice-saline gauze can be applied topically to soothe the treated area and reduce pain.

POSITION AND MARKING

Dynamic wrinkles caused by muscle action (ie, glabellar, crow’s feet, nasolabial, and forehead) are marked after asking the patient to activate those muscles. This action accentuates wrinkles and enables an outline of the intended treatment sites. Static wrinkles caused by sun damage, smoking, and gravity are marked with the patient sitting.

DETAILS OF PROCEDURE

Various facial filler techniques have been described and familiarity with the different techniques and soft-tissue filler products improves aesthetic results (Fig. 43-1).

Figure 43-1 A. Preoperative photograph of a patient presenting for upper-lip rejuvenation. B. Enhancement of vermilion and philtral column with 1 mL of Juvederm.

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