Navigating the Temple: The First High-Risk Move
The temple is a high-risk zone because of the sheer volume we're placing there. That's why I take extra precautions. For example, I never prime my needle beforehand. I recommend this same approach anywhere you're delivering a large bolus—it's just safer that way. Now, as I slide the needle in, I'm watching for a specific angle. It's slightly more superior than it appears on the screen, but from my vantage point, I can see it clearly. I'm aiming for the point furthest away from where those crucial vessels should be. I aspirate, give it a second, and confirm no blood return. Then I begin to deliver the product.
Now, here's the critical part: I'm watching my patient's face like a hawk for any reaction. Some of the worst occlusions I've ever heard about were extremely painful during the injection itself. So if anyone ever winces or suffers, I stop immediately, pull out, and find another point. I also apply a little pressure just anterior to the injection site to control the flow and prevent the product from spreading backward.
Experience has taught me to go slowly. I'm not putting much force into the plunger at all. I already know from her initial photo that she had zero temple volume before, so I'm confident I can completely correct this. But if the product flows too easily—like some softer formulas that don't lift well—it just won't give us that projection we need. So patience is key.
Now, a bleed can happen. When it does, I hold firm pressure for at least a minute. Peaking too soon always backfires; I've learned that the hard way. My typical approach is half to one milliliter at a time. And you know, I've sat on expert panels where we debate safety limits and throw around numbers about how much is safe to inject in one area. My experience tells me there's no real data behind those numbers. There aren't documented cases of someone putting in two milliliters and causing an artery blockage, while patients with just one milliliter never have that problem. It's simply unknown. So what often happens is we gravitate toward the volume we're comfortable with, the range we operate in day to day.
I nearly always use a needle for temples because I can place it deeper, right on the periosteum. I do use cannulas sometimes, but there's a slight risk of bogginess—the skin is quite thin there, and you can end up with a puffy, boggy look that patients complain about. That said, it's a low risk overall. So I use an unprimed needle, feel for any pulsation, and repeat the process on the left side. Sometimes the left temple is a bit more painful. I go into that little V-shape by the bone, angled toward it. If I go too deep, I'm still safe. I aspirate, confirm it's negative, and start delivering. I don't move my tip once I've started injecting. I'm monitoring Lindsay's response closely.
The Cannula Question and the Cheek Lift
As for the cannula question: I've used it multiple times for temples, but I wouldn't try to build a whole temple with one right now, in my current practice, because of that bogginess issue. However, I might use it over the top to smooth in the final bit of the result. How does the temple affect the eyebrows? You can sometimes get a subtle lift—it's that stretching effect we discussed. Expanding the tissue here can even relax the orbicularis oculi, releasing some fibers and giving a slight lift to the eyebrow in some people.
Now, I can see this side is less risky thanks to her cheek support. The product is flowing more gently, so I can move to the next phase. I'm switching to Voluma with a long 25-gauge cannula. I'm going to layer the first foundation for her cheek, replacing that lateral fat pad. I create a pilot hole, aiming in the direction my cannula will travel. I only need to go through the dermis—that's enough. Now I'm in the hypodermis, the fat layer.
I've seen people use all sorts of techniques to get the cannula in—this stirring motion with a needle, going round and round. My understanding of what's happening there is that the sharpest part of the needle is doing damage underneath, while the blunt end is just stretching the skin ineffectively. It's rarely that effective. My advice: you don't need to do much more than aim properly. I'm known for being unusually gentle compared to many practitioners. I hate the idea of tearing through tissue to get somewhere. I prefer to find an easy route. So I try lots of different angles, maintaining my overall direction, and try to sneak through without causing trauma.
And there we are. Right where I need to be—the superior surface of the zygoma. This is where a cannula shines; it's very sculptural. It's a lot like being a sculptor chipping away at bone, except it's additive. I'm adding little bits, checking the result, shaping it, gradually increasing the volume. I'm also keeping the temple in mind. I can see a slight shadow connecting the cheek and temple, and I think I'll smooth that slightly. But I'm constantly referencing my aesthetic goal: I want this to project out a little but not too much.
I use the visibility of the cannula under the skin to guide me. As it bulges, I think, "Yes, that's what I want." So I do a little smoothing. Next, I move to the anterior cheek projection—this is harder to see, but I know from her anatomy that this area needs more projection forward. This is part of what will help lift the lower face. I prefer to do this deep, on the anterior surface of the zygoma. I can feel the angle of the bone. In my mind's eye, I see the alignment with the zygoma, and I'm trying to build there. The facial artery runs medial to it, and the transverse facial artery runs beneath. This is a relatively safe place to go deep, touch bone, and aspirate. Then I do some molding to shape it in.
The Lateral Cheek Junction and the Tear Trough
Now we do the same on the other side. Your supporting hand is critical with cannulas—you feel where the product is going and adjust the tissue as you slide, finding that easy route. I often paint the product, layering evenly to sculpt the shape. Most cannula procedures are in the hypodermis, either deep or superficial. That's why I sometimes prefer needles to get a bit deeper. Where is it good to be deep? Especially where puffiness might be a concern, like in the tear trough. So I go a little deeper there.
Next, I'm going to inject a bit into the lateral cheek junction using VYC (a filler like Vycross), right on the periosteum. This is safer in terms of puffiness. The lateral cheek junction is a crucial part of periorbital restoration. I still see many practitioners treating the tear trough as a separate entity—they improve the medial aspect but neglect the lateral part. That's a training gap, because in my opinion, the lateral cheek junction usually shows more aging than the tear trough itself. So I'm going to address that little shadow I can see—that line is really important for overall restoration.
I'm aiming in such a way that if I go too deep, I won't hit an eye. One of the cases of temporary blindness I know of happened on a tear trough course where the injector missed the medial border of the bone and hit the infraorbital artery. So I angle so that only bone is ahead of me. I use an unprimed needle, inject very superficially—maybe 0.05 ml as my first pass. Then I change angle, trying not to bruise by going through the same hole. Remembering the slight downturn to her eye, I might attempt a tiny lift to the lateral part. There's a little shadow there—if I can get it to project slightly more, it will give her a more positive aura instantly with just a tiny amount of product.
I look for small superficial veins, enter carefully, confirm I'm on the periosteum—you absolutely must touch bone around here—and inject 0.05 ml. Then I shape it. For the first pass, I use a finger for sensory feedback, then a cotton bud to roll it more precisely. This area is prone to bruising. Some people have a little notch in the bone here—it can look like you're about to hit the orbital rim, but there's actually a dip. I've had patients where that dip is essentially pronounced into a V-shape. If you feel above and below, you'd expect bone, but there's none underneath. It's not common, but it's very important to know about.