A Master’s Approach to Facial Aesthetics: The Art of the Cannula
Let me walk you through a procedure that is both precise and deeply intuitive—a series of injections that reshape the face not by brute force, but by understanding the subtle layers beneath the skin. We begin with the temples, a zone that often hollows with age or volume loss. I am using define and refine, two products chosen for their high integration and smooth results. I draw these into a 23-gauge cannula, mixing the filler with a small amount of lidocaine—one cc per one cc of product—to ease the patient’s comfort. The entry point is carefully chosen: below the visible vessels, because staying deep to them is the safest path. I glide the cannula into the space above the deep temporal fascia but below the superficial temporal fascia, all the way into the hairline. Then I perform a retrograde approach, pulling the cannula almost entirely out as I deposit a tiny thread of filler. This should be done swiftly and steadily; the longer it takes, the less pleasant it becomes for the patient. So there is the temple, filled and softened.
Next, the forehead. The plane here is fairly deep—deep to the Galea but superficial to the periosteum. I choose a point where there is no prominent vascularity, and I go down until I hit the periosteum. You must navigate carefully because the supratrochlear and supraorbital vessels lie above, and we want to stay below them as we fan out the filler. I move the cannula constantly for safety. The patient will temporarily not be able to raise their brows for about thirty minutes due to the lidocaine, but that is expected. I warn them about this. This injection fills the little divot above the orbit and addresses the fat loss that often occurs there.
For the tear trough—a tricky area—I again use a slightly diluted define and a 23-gauge cannula from Softfil. I insert it with two hands: one is the smart hand, guiding the cannula; the other is the dumb hand, stabilizing the tissue. I place just a small amount, not too much, right into the hollow.
Let me reinforce the logic: I choose an entry point halfway between the brow and the hairline, entering that superficial plane with a twist of the cannula, then advancing to the temple fusion line. I retrograde the filler as I withdraw, staying above the orbit. Then I go all the way back into the hairline and retrograde again. This gives the best, most even result. The define and refine products are ideal here because of their high integration—they create a smooth, natural look without lumps.
Now back to the forehead. I go down to the periosteum, which is slightly deeper. I am very deliberate with my retrograde strokes, all the way to the midline. Then I gently massage the area to smooth it out. Keep in mind that the vessels ascend from deep to superficial as you move up the forehead, so staying deep to them is key. I am on the periosteum, which is completely below the vessels, making this a risk-free, almost bloodless zone.
Let me shift to the preauricular area. The vasculature here is specific: the facial vessels run anteriorly, and posteriorly you have the retromandibular area. I inject into the subcutaneous tissue—superficial to the platysma. If you go too deep, the patient will feel it, and you risk hitting muscle or gland. I am in the superficial plane, above the platysma. Patients who have had facelifts often need this area because the lifting of the flap devascularizes some fat, leading to loss. Define works beautifully here, spreading out to restore that lost volume. The parotid gland is deep, so we are safe.
These injections should not take long. Speed is a kindness to the patient. I work the preauricular plane—subcutaneous tissue above the platysma—and spread the filler gently. This is a much better approach than widening the lower face or overfilling the marionette lines directly. Often, if you just treat this preauricular hollow, the marionettes improve dramatically without needing direct injection. The jawline also becomes firmer. In this case, the patient’s jawline was already good, so we did not need to widen it further. The lower face in a female should remain thin and refined.
Now let us look at her after the procedure, about 45 minutes later. The forehead and temples are much smoother. You can see the divots in the superorbital area are gone. She can raise her brows now—though she still needs a little Dysport for full movement, the lidocaine has worn off. The tear trough is also improved. When you look at her profile, the temples are fuller, and the hollows are filled. There is still a slight marionette line, but I did not inject directly into it. Instead, I addressed the hollow in the preauricular area. I believe that if I put filler directly in the marionette, it would make her face too full. By strengthening the jawline with the last bit of filler I had—using it to increase the posterior jaw and give the chin a little more projection—the lower face looks more sculpted. The chin gets a bit of definition from small boluses on the periosteum, using a cannula for safety.
This is the key insight: the marionette lines improved without me ever touching them. The placement of filler in the preauricular area and along the jawline lifted and tightened the lower face, smoothing those creases. It is a lesson in restraint and strategy. We do not always need to treat the wrinkle itself; sometimes, treating the surrounding structure restores the whole picture. That is the art of facial aesthetics—understanding the layers, respecting the vessels, and knowing that the best results come from a light, precise hand and a deep knowledge of anatomy.