The Art of Precision: A Mentor's Guide to Safe Filler Injections
There is a beautiful sophistication in the way we approach the aging face, especially when it comes to treating those stubborn fine lines. I have found that one of the most effective treatments involves a very specific technique, using a very specific product. You see, if you use a thick product for these delicate creases, you will see the filler—it will be obvious. That is not the goal. The goal is seamless, natural integration.
Take, for example, the crease that runs along the lower eyelid, just below the eye. We use a product like Juvederm Volbella. We place a tiny, almost imperceptible line of it directly into that crease. This is a difficult area to treat with Botox because some of the muscle movement comes from the zygomaticus major, and the crease itself is often far from the orbicularis oculi. So, we place a little line straight under that crease, very superficial. We are working in the dermis, but the dermis here is very thin, so we are edging in. You watch the path of the needle: no blanching at rest, but a little blanching when you lift off. That is the right depth. With a good product, it blends beautifully. I would never treat the lower eyelid itself with this type of filler; it is far too thin. This is good for the cheek and lateral canthus.
Three Levels of Depth for the Nasolabial Fold
When we move to the nasolabial fold, we are dealing with a different anatomy. There are essentially three levels at which you can treat it. First, we can go deep onto the periosteum to project the deepest part of the shadow anteriorly—that is what we do first. Then, we can fill the fat layer in between, but we only do that with a cannula because that is often where the artery is at that level. Finally, we can treat the crease itself superficially, if there is a crease. So, for a comprehensive treatment, we do two levels: the deep projection at the base, and then the crease on top.
This injection requires you to think about your angles very carefully. The angle of your needle affects the proximity you are likely to get to the important arteries. We have the infraorbital artery, which is usually parallel with the mid-pupillary line, and the facial artery, which runs in the cheek fat pad. If we are medial to the facial artery and the needle is pointing away from it, we should be safe. Similarly, with the infraorbital artery, we want to point either neutral or slightly inferior. The more you go lateral, the more risky it gets. So, I need to be in the nasolabial fold but pointing in directions that do not cause unnecessary risks. An angle of approximately 90 degrees to the nose and 45 degrees to the surface of the skin should land me in the preperiosteal space at a position where there is no artery. Slide in nice and slowly, kiss the bone, then aspirate. Give it a second to validate, then slowly start injecting, looking for a response. There is a nerve here, so it tends to be sensitive. Then a little molding. I picture the infraorbital artery, angular artery, lateral nasal artery, superior labial artery, and facial artery in my mind's eye. I see a clear path to avoid them. Touching the periosteum with the correct angle is vital. New injectors often feel safer when they are not touching the bone, but that is not the right way.
Now for the superficial crease. This is significantly more superficial than where the artery should be. Just edge in and stay in the superficial hypodermis. You can see how that crease unfolds easily—a very promising prognostic sign. With the needle underneath, aspirate, then a little line, usually 0.05 ml. I might go slightly more superficial for another little pass, stacking two injections on top of each other.
The Nose: Risk and Reassurance
Noses are obviously risky areas, but the biggest risk is actually above the halfway point. From the glabella up, the blood supply comes from the internal carotid. Where we are injecting in the lower nose, it comes from the external carotid blood supply—from the facial artery and the lateral nasal artery. This means that if we did have a problem, it should be localized. What we worry about most is blindness, or even a stroke, which is incredibly rare and almost impossible with the amount of product we use, but it is on the list. It is reassuring to know that in the lower nose, you are far less likely to cause that. Theoretically, it is possible because all these vessels are connected, but we are safer than doing a normal non-surgical nose job. I also point the needle in the opposite direction as much as possible so that the flow of product is in a safer direction. I aspirate a lot. I use a product that aspirates extremely well—I have tested it. Juvederm Volift, the softer G-Prime product, also protects me from one of the side effects: pressure causing redness. If you get redness that does not go away, it could mean there is a little too much pressure, and the body accommodates by dilating the vessels. That is more likely with a thicker product.
We are trying to blend the little V-shape around each of the crura of the cartilage so they meet in the middle. I often do one injection that runs right along the midline. As you get close to the tip of the nose, there are fewer and fewer vessels, but they are capillaries. So I do not move very much. I aspirate, give it time, then do a little bolus. I watch the skin very carefully. Then I come out. That already reconnects the shape a little. I point away from the lateral nasal artery. Vessels are getting smaller. A nice long aspiration, a little squirt to fill it, then come back out. Aspirate again, and again a little squeeze to get the shape. Nearly done. Filler came out of the pore, which is quite common in noses. The one thing I like about that is it means it is not going into a blood vessel—that is reassuring. Check capillary refill as we go. Everything is fine.