CONTINUINGEDUCATION
NON-SURGICAL FACIAL REJUVENATION PART 2:
Dermal Fillers
and jawline enhancement. T ere is also a reversal agent, hyaluronidase, should results be undesirable or complications arise. At least fi ve companies produce over 20 types of HA fi ller FDA-approved for use in the U.S. Regardless of the selected product, it is essential the practitioner understands the manufacturing process, administration techniques, physical properties, and potential complications associated with use. For the purposes of this article, we will primarily focus on the HA-type fi llers.
DR. ELIZABETH FLOODEEN, DDS
In the fi rst part of this series, we discussed the uses of Botox to prevent the transition of dynamic to static rhytids. However, Botox isn’t ideal for patients with moderate signs of aging and facial folds. For these individuals, dermal fi llers off er a non-surgical option for facial rejuvenation or minor augmentation. Fillers are injectable substances used to restore volume, reduce wrinkles, and enhance contours by supporting the skin.
Types of Fillers T ere are many materials classifi ed as dermal fi llers including autologous products and manufactured products (see table 1). Hyaluronic acid (HA) has become especially popular as a fi ller for several reasons. T e physical properties of HA fi llers can be controlled based on manufacturing and molecular cross-linking. T is allows for soſt and viscous fi llers ideal for volumizing the lips all the way to very fi rm and cohesive fi llers which are better suited for cheek
56 | Sept 2025
Injection Technique HA fi llers are intended for subcutaneous administration and generally, low viscosity fi llers are best for superfi cial injections and high viscosity fi llers are ideal for deeper planes. T ere are a multitude of injection techniques, of which we will cover the four most common (fi gure 1). With any technique, aspiration is mandatory prior to injection, ensuring material is not deposited intravascularly. For this reason, blunt-tipped cannulas are generally safer than needles. Aſt er administration, massage the area to evenly distribute and shape the fi ller. • Linear retrograde: Insert the cannula at a low angle through skin and into the subcutaneous tissues. Advance the cannula to full length in the subdermal plane. Once fully inserted, aspirate and inject the fi ller in a smooth motion while withdrawing the cannula.
• Fanning: Similar to the linear retrograde technique, insert the cannula at a low angle through the skin to full length and inject while withdrawing the cannula. Before removing the cannula fully, pause injection and rotate 15-20 degrees to then thread the cannula to full length again and resume fi ller deposit in a retrograde fashion. T is allows for broad area coverage with only one injection point.
• Vertical column: Insert the cannula through skin at a 90-degree angle and advanced to bone. Withdraw so the tip
of the cannula is in the supra-periosteal plane, aspirate, and inject fi ller while withdrawing the cannula.
• Supra-periosteal bolus: T e cannula is inserted at a 90-degree angle to the skin and advanced to the supra-periosteal plane. An aliquot of fi ller is then deposited in the supra-periosteal plane while the needle remains in the deep position.
Common Areas of Treatment
LIPS Lips are a popular area for enhancement. Ideal lips have a defi ned vermillion boarder, fullness, and an upper-to-lower lip ratio of about 1:1.6. Fillers for the lips should be soſt , bendable, and of low viscosity. T ere are many described techniques for lip injections; however, one of the straightforward and universally pleasing is the linear retrograde technique. Typically, four injection points are used for the upper lip and two to four for the lower lip (Figure 2). T e cannula is inserted near the commissure or at the peak of cupid’s bow and the oriented parallel to the vermillion boarder. Filler is administered into either the subcutaneous plane or muscle depending on the selected fi ller.
NASOLABIAL FOLDS Nasolabial folds, or smile lines, can be camoufl aged with selectively placed fi ller. A moderate, fl exible fi ller is recommended. Using a linear retrograde technique, insert the cannula near the oral commissure and thread parallel to the fold, with the tip directed toward the alar base. For best results, remain slightly medial to the fold. Use caution in this area, as the angular artery runs parallel to the nasolabial fold.
MELOMENTAL FOLDS Also known as marionette lines, these extend from the commissure and curve around the chin. Use a linear retrograde technique, inserting the cannula near the mandible’s inferior border, just medial to the fold. Direct the tip superiorly toward the commissure in the subcutaneous plane. A second injection point may be used just below the commissure, employing a vertical column technique to improve the contour at the mouth’s corner.
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