Table 1: Types of fi llers available for use in the United States.


Figure 1: Several techniques for administration of dermal fi llers including a) linear retrograde, b) fanning, c) vertical column, and d) supra- periosteal bolus.


Figure 2: Injection patters of dermal fi ller for the treatment of a) lips, b) nasolabial folds, c) melomental folds, d) cheek enhancement, e) nasal dorsum and bridge, and f) tear trough deformity. Arrows represent pathway for use of the linear threading technique and circles represent supra-periosteal bonus or vertical column techniques.


CHEEKS Select a fi rm, robust fi ller for this area. Injections are typically made in the deep planes using a supra-periosteal bolus technique. Use caution in the malar region around the mid-pupillary line, as the infraorbital neurovascular bundle exits here.


NASAL DORSUM & BRIDGE T e nose is a defi ning facial feature, and small augmentations can be achieved with a fi rm fi ller. Start with small, precise amounts, as there is little margin for error. Overfi lling can create an unnatural appearance. T e dorsum may be defi ned, or a small hump masked, using a linear retrograde technique or several small aliquots placed in the supra- periosteal plane. Additional defi nition can be added to the bridge using a supra-periosteal deposit, but caution is warranted, as this is a highly vascular area.


TEAR TROUGHS A tear trough deformity presents as a sunken appearance of the globe, creating shadows under the eyes and a fatigued look. A soſt , low-viscosity fi ller can help mask this. Avoid fi rm fi llers here, as the skin is extremely thin.


Use multiple supra-periosteal deposits or a linear retrograde technique in the same plane. Shallow injections should be avoided to prevent bluish discoloration known as the Tyndall eff ect.


Complications Minor issues include discomfort, bruising, or palpable lumps. To help with injection pain, apply a topical anesthetic such as LET or EMLA prior to administration and select a fi ller manufactured with lidocaine. Bruising can be minimized with the use of ice packs. To avoid lumps, use smooth administration technique followed by massage of the area to evenly distribution the fi ller. Rarer, but serious complications include


granuloma formation, tissue necrosis, and blindness. Granuloma formation is due to a foreign body reaction, which may arise months or even years aſt er fi ller administration and can result in disfi guring, painful nodules around treatment. Unfortunately, there is no way to predict who will be prone to granuloma formation and there is no cure. Most


recommend treating with intra-lesional steroid injections, which has variable success. Tissue necrosis results from vascular compromise due to occlusion of an artery by inadvertent intravascular fi ller injection or compression of an artery from too much fi ller volume immediately adjacent to the vessel. Patients oſt en experience immediate pain and blanching of the skin in the region supplied by the aff ected artery. If this occurs, immediately stop administration, reverse with hyaluronidase, and consider oral aspirin or nitroglycerine paste to increase blood fl ow. Finally, there have been several case reports of vision loss resulting from accidental intravascular fi ller injection. T is is due to a bleb of fi ller migrating from one of the facial vessels to the ophthalmic artery, which is a natural narrowing point, and if this artery becomes occluded blindness may result. Should this occur, immediately administer hyaluronidase and place an emergent referral to an ophthalmologist. T e best practice to avoid vascular complications is to practice the safe habit of aspirating prior to each deposit of fi ller.


Conclusion T is article outlined popular uses for dermal fi llers, injection techniques, and potential complications. Dermal fi llers are valuable tools for non-surgical facial rejuvenation, and dentists, experts in facial anatomy, are well- suited to provide this service. With proper training, attention to detail, and a respect for the complexities of facial anatomy, dental professionals can confi dently and safely off er dermal fi llers to enhance both function and aesthetics for their patients.


1


De Maio M, Swift A, Signorini M, Fagien S. Facial assessment and injection guide for botulinum toxin and injectable hyaluronic acid fi llers: Focus on the upper face. Plast Reconstr Surg. 2017;140(2):265e-276e. doi:10.1097/PRS.0000000000003544


2


De Maio M, Wu WTL, Goodman GJ, Monheit G. Facial assessment and injection guide for botulinum toxin and injectable hyaluronic acid fi llers: Focus on the lower face. Plast Reconstr Surg. 2017;140(3):393E-404E. doi:10.1097/PRS.0000000000003646


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De Maio M, DeBoulle K, Braz A, Rohrich RJ. Facial assessment and injection guide for botulinum toxin and injectable hyaluronic acid fi llers: Focus on the midface. Plast Reconstr Surg. 2017;140(4):540E-550E. doi:10.1097/PRS.0000000000003716


4 5


Quach B, Clevens RA. Complications of Injectables. Atlas Oral Maxillofac Surg Clin North Am. 2024;32(1):57-63. doi:10.1016/j.cxom.2023.10.005


Fagien S, Bertucci V, Von Grote E, Mashburn JH. Rheologic and Physicochemical Properties Used to Diff erentiate Injectable Hyaluronic Acid Filler Products. Plast Reconstr Surg. 2019;143(4):707E-720E. doi:10.1097/PRS.0000000000005429


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Sattler G. The tower technique and vertical supraperiosteal depot technique: novel vertical injection techniques for volume-effi cient subcutaneous tissue support and volumetric augmentation. J drugs dermatology. 2012;11(8):s45-s47.


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