Injection Techniques and Cosmetic Applications for Soft Tissue Fillers

Injection Techniques and Cosmetic Applications for Soft Tissue Fillers. Authored by Doctors Jill Foster, Craig Czyz, Kelly Everman, and Allan Wulc.

This video describes various types of soft tissue fillers and their applications throughout the face. Prior to injection of the currently available hyaluronic acid soft tissue fillers, topical anesthetic is applied. Topical anesthesia may be augmented or replaced by local anesthetic injections for some areas, such as the lips. Polylactic acid gel is mixed with local anesthetic, and in the future, hyaluronic acid fillers mixed with lidocaine will be available. In this case, it is a mixture of tetracaine, lidocaine, and benzocaine. The mixture is left in place for 20 minutes or longer to diminish injection pain.

Comfort of injection can be improved by placement of topical anesthetic on the mucosal surfaces prior to injection. This can be accomplished with cotton-tipped applicators. Infiltrative injections are also a valuable tool to decrease filler injection pain. These are usually given in the form of infraorbital and mental nerve blocks. The infraorbital block is performed by injection into the superior labial sulcus at the apex of the canine fossa. Likewise, injection for a mental nerve block is given into the inferior labial sulcus at the apex of the first bicuspid.

Hyaluronic acid products are soft tissue fillers that can be used in many areas throughout the face. The first patient is receiving Restylane injections into the temporal brow region to treat brow deflation. The hyaluronic acid gel is delivered in the preperiosteal plane just below the cilia of the brow. The material injected should increase the anterior projection of the eyebrow. After injection, the material is molded with palpation to smooth over any irregularities.

Juvederm is also a hyaluronic acid derivative. It is shown being injected into the tear trough deformity of this patient. Hyaluronic acid products are very useful in this area. Like the eyebrow injection, treatment in this area is also layered deeply in the preperiosteal plane or just below the orbicularis. The technique shown here is to advance the needle forward until periosteum is encountered. Threading is then performed along the periosteum. Given the unique nature of eyelid skin in this area, it is important not to inject too superficially. It may be more difficult to judge the volume of product when local anesthetic has been used as a nerve block.

The next demonstration shows the use of Radiesse. Radiesse is made of calcium phosphate microspheres. The calcium phosphate microspheres are a more rigid and firm material than the hyaluronic acid gels. The material performs best when placed deeply into the subdermal tissue and placed in small threads of material rather than pools or depot deposits. This material should not be placed superficially or in areas where soft and mobile tissue is desired, such as the lips. In this patient, the nasolabial folds are filled using a combination of two techniques: linear threading and fanning. This is particularly useful in the region adjacent to the nasal ala.

As we direct our attention towards treatment of the lips, the demonstration material switches back to one of the hyaluronic acid derivatives. When injecting the lips, infiltrative anesthesia is often preferred. The general approach is to use a linear threading technique to fill the vermilion border first. Once the border has been adequately inflated, attention can turn to the body of the lips. Finally, we see vertical injections into the philtral pillars.

Additional support and volume can be given in the marionette lines using the same principles of prior injection techniques. Again, placing the material in the mid to deep dermal location is desired, with a combination of fanning and linear threading techniques. Gentle massage of the material can be applied at the time of injection.

The next dermal filler shown is Sculptra. This material is different than the other fillers. It is not designed to fill wrinkles, but rather as a volumetric filler. The polylactic acid gel results in an inflammatory reaction in the native tissue that is ultimately responsible for the desired results by increasing collagen production. Unlike the other materials, it typically requires two to three planned sequential injection sessions spaced 2 months apart before significant change occurs. It is important to be clear to patients that noticeable improvement will not occur immediately as with the other soft tissue fillers.

The polylactic acid gel is reconstituted 2 days or more prior to injection. In the temporalis region, a depot-type injection may be given underneath the temporalis muscle, as seen here. This is the only location on the face where a depot-type injection would be appropriate.

The remainder of the injections are given in the subcutaneous tissue using a linear crosshatching technique. In this video, a half-inch needle is being used. In most areas, a one-and-a-quarter-inch needle is a better choice for this application. Multiple areas can be filled using this material with the same techniques being applied here. As shown, large-volume areas are being addressed. Postinjection treatment for the polylactic acid gel requires patient massage five times per day for 5 minutes for 5 days to help prevent inflammatory nodules from forming.