How To Prevent The Challenging Filler Face David J. Goldberg, MD Skin - - PDF document

How To Prevent The Challenging Filler Face

David J. Goldberg, MD Skin Laser & Surgery Specialists of NY and NJ

Facial Fillers

• Perhaps the most versatile non‐surgical means of facial

rejuvenation

• Several million treatments performed every year
• Expanding indications, anatomic areas, and product

development

Fillers Can Induce Collagen, Elastin and Proteogylcan Formation

• Tensile Strength (Collagen)
• Structural Support (Collagen)
• Elasticity (Elastin)
• Hydration (Proteoglycan)
• Swelling Pressure (Proteoglycan)

1 2 3

Collagen Formation

• HA
• Biostimulation (The Others)

PLLA Neocollagenesis

5 12 mo

Hematoxylin‐eosin stain, 400x, shows PLLA microparticles with adjacent aggregation of giant cells, histiocytes, and collagen fibers

Vleggaar D. Dermatol Surg. 2005;31(11 pt 2):1511‐1518. Reprinted with permission from the author. 30 mo

Hematoxylin‐eosin stain, 400x, shows lack of PLLA microparticles and the abundance of collagen fibers

CaHA Neocollagenesis

6 32 wk 78 wk 16 wk 4 wk

Canine histology 40–60x, collagen matrix stained with picosirius red1

Top, with permission from Coleman K et al. Neocollagenesis after injection of calcium hydroxylapatite composition in a canine model. Dermatol Surg. 2008;34:S53‐S55. Bottom, from Marmur ES et al. Clinical, histologic and electron microscopic findings after injection of a calcium hydroxylapatite filler. J Cosmet Laser Ther. 2004;6(4):223‐226. Reprinted by permission of Taylor & Francis Ltd (www.tandfonline.com)

Thick section light microscopy at 1 mo and 6 mo postinjection2

6 mo 1 mo

4 5 6

PMMA‐Collagen Neocollagenesis

7 3 mo

At 3 mo, microspheres are completely encapsulated and surrounded by fibroblasts and collagen fibers (40x) At 10 y, histology shows mature connective tissue, active fibroblasts, microencapsulation of each microsphere (40x)

10 y Lemperle G et al. ArteFill permanent injectable for soft tissue augmentation: I. Mechanism of action and injection techniques. Aesthet Plast Surg. 2010;34(3):264‐272. With permission of Springer.

Elastin and Proteoglycan

• 20 Middle Aged Women
• Injected with CaHA
• Biopsy before and 6 months later

Goldberg DJ, et al Dermatol Surg: 2019 Proteoglycan: Alcian Blue Staining Before 6 months

7 8 9

Elastin: Immunohistochemistry Staining Before 6 months Van Gieson Stain for Elastic Fibers Before 6 months

So Why are There So Many Filler Mistakes and Unfortunate Results?

• Many injectors received no formal training
• Filler treatments can be deceptively difficult to execute

properly and master

• Use of products that carry higher risk
• Poor or basic understanding of facial anatomy,

dynamics, and aesthetics

10 11 12

What Do I See in My Practice?

• I regularly see bad filler outcomes
• These are usually due to poor technique
• Can these mistakes be fixed/addressed?

Want To Focus on Good Technique

• Not on Biofilms
• Not on Necrosis
• Not on Nodules

13 14 15

Common Filler Mistakes: General Mistakes

• Injecting too much volume in each setting
• Especially true in lips and tear trough
• Not staging treatments when necessary
• Choosing the wrong product

16 17 18

Staging Treatments Leads to Better Outcomes

• More natural results can be achieved by staging

multiple treatments

• Less bruising, swelling, patient anxiety
• Facilitates more natural expansion of tissue
• Allows you to address minor asymmetries
• Most over‐injected patients are injected in one session

Common Filler Mistakes: Lip Augmentation

• Injecting filler too far inside lip
• Using permanent filler
• Creating nodules and irregularity
• Not paying attention to lip shape and balance
• Injecting philtral columns inaccurately

Lip Augmentation Mistake: Injecting filler too far inward

• The most common

technical error on lips

• Lip loses shape and

definition

• Creates anterior

projection

• Abnormal look when

smiling

• Creates visible filler
• utside of the lip with a

‘puffy’ look

19 20 21

Lip Augmentation Mistake: Injecting filler too far inward

• The most common

technical error

• Lip loses shape and

definition

• Creates anterior

projection

• Abnormal look when

smiling

• Creates visible filler
• utside of the lip with a

‘puffy’ look

Lip Augmentation Mistake: Using Permanent Filler

• Most common are

silicone and bio‐gel

• Inflammatory

response of silicone

• Filler walls off,

creating an implant look (i.e. no true tissue integration)

• Only surgery can fix

Lip Augmentation Mistake: Using Permanent Filler

• Patient comes in

with previous unknown filler treatment

• Reports long‐

standing bumps and nodules

22 23 24

Lip Augmentation Mistake: Using Permanent Filler

• Unknown soft

material expressed

• Culture negative
• Patient healed

without incident

Lip Augmentation Mistake: Creating Nodules & Irregularity

• Patient treated previously with ‘micro‐droplet’ silicone

and HA filler

• Her injector once treated her during an active HSV‐1
• utbreak

Lip Augmentation Mistake: Creating Nodules & Irregularity

• What are the problems here?
• Use of permanent filler and HA
• Poor technique – not properly distributing filler
• How to address?
• Firm massage
• Carefully placed hyaluronidase
• HA filler injected unevenly (to blend with the silicone)

25 26 27

Lip Augmentation Mistake: Creating Nodules & Irregularity

• Patient treated with an unknown filler substance
• This was the result of one treatment session (i.e. a

massive amount of product)

Lip Augmentation Mistake: Creating Nodules & Irregularity

• What is the cause here?
• Too much filler at once, creating a ‘tissue expander’

effect

• How did I address this?
• Firm massage
• Large amounts of hyaluronidase (multiple sessions)
• A small amount of HA (to fill in the massive skin excess)
• Recommended surgical excision of excess skin

Lip Augmentation Mistake: Not paying attention to lip shape/balance

• Injectors often create imbalance between upper/lower lip
• Border of lip and definition often ignored
• Usually straightforward solution

28 29 30

Lip Augmentation Mistake: Not paying attention to lip shape/balance

• An entire syringe of HA was injected into her upper lip
• 150U hyaluronidase dissolved all of the filler

Lip Augmentation Mistake: Injecting Philtral Columns Poorly

• Augmenting or creating philtral columns can improve

lip balance

• Attributes of a beautiful philtrum
• A slight diagonal tilt (15 degrees)
• Slightly narrow inter‐philtral distance
• More fullness inferiorly
• Many injectors create fat philtral columns in a wide,

vertical orientation

Lip Augmentation Mistake: Injecting Philtral Columns Poorly

• Too wide
• Asymmetric
• Too vertically oriented
• Can this be fixed?
• Good separation
• Symmetric
• Slight inward orientation

& curvature

31 32 33

Common Filler Mistakes: Tear Trough

• Using the wrong filler
• Placing filler too far inferiorly
• Placing filler too superficially
• Ignoring the lateral component

Tear Trough Mistake: Using the Wrong Filler

• Higher concentration HA fillers can

lead to long‐term edema

• Highly resistant to enzyme

degradation

• Tissue expander effect
• Calcium‐based fillers should never

be used

• Create visible white nodules

Tear Trough Mistake: Placing Filler Too Far Inferiorly

• Typically due to two causes
• Cannula use by an

inexperienced injector

• Inferior approach to the tear

trough

• Avoided by using needles and

entering perpendicular to the skin overlying the tear trough

34 35 36

Tear Trough Mistake: Placing Filler Too Superficially

• More commonly seen in patients treated with cannulas
• Inexperienced users place filler in wrong tissue plane
• This cosmetic deformity is more prominent in patients with

poor skin elasticity

• Almost always requires enzyme degradation
• Can create a ‘tissue expander’ effect

After cannula treatment Post‐enzyme treatment Re‐treated with HA

Master the needle, then the cannula

• Injecting in the correct plane (i.e. supra‐periosteal) is

critical

• Much easier to stay in correct plane with needle
• Though it is easy to learn cannula technique, you MUST

understand anatomic planes to be successful

Tear Trough Mistake: Ignoring the Lateral Component

• Technically, the tear trough is only medial
• Continues laterally as palpebromalar groove
• Many injectors ignore the palpebromalar groove since it is
• ften less prominent
• Lateral correction is necessary in >90% of patients treated,

and is often more important than medial

37 38 39

The Midface is the Among the Most Complex Areas of the Face

• Anatomic variability is incredibly high among

patients

• Must pay attention to adjacent areas to

maintain balance

• Lower cheeks
• Temples
• Parotid/pre‐auricular region
• Underlying bony anatomy impacts outcomes

greatly

Common Filler Mistakes: Mid‐face Augmentation

• Too much emphasis on the medial cheek
• Reliance on a ‘cookbook’ approach
• Not paying attention to the lower cheeks and temples

Mid‐face Mistake: Too much emphasis on the medial cheek

• Too much attention paid to medial cheek

by inexperienced injectors

• Can worsen tear trough and decrease size
• f eyes
• Creates a ‘fat face’ look that can be

difficult to correct

40 41 42

How to Avoid an Over‐injected Medial Cheek

• Typically, place the LEAST amount of filler in the medial

cheek

• Understand the limitations of treating the mid‐cheek

Can never be fully corrected

• Diagnose carefully: Many patients don’t need ANY filler

in the medial cheek (especially younger patients)

How to Correct an Over‐injected Medial Cheek

• If large amount of filler has been injected (i.e. tissue

expansion), enzyme is not advised  creates excess skin

• Best to add filler laterally in an attempt to ‘lift’ the

medial cheek

• If tear trough is apparent, treat this as well

(conservatively)

Mid‐face Mistake: Reliance on a ‘cookbook’ approach

• 1 – Lateral zygoma
• 2 – Mid zygoma
• 3 – Anteromedial cheek
• 4 – Submalar
• Some protocols

recommend injecting in this sequence to best economize product

• Creates unnatural result

in patients with high cheekbones, hollow lower cheeks, or a narrow face

1 2 3 4

43 44 45

Mid‐face Mistake: Not paying attention to the lower cheeks and temples

• Once the mid‐face (cheeks) volume is

restored, the temples and lower cheeks

• ften appear volume‐deficient
• Especially in patients with high cheekbones
• The temple can be the most powerful area to

treat

• Lower cheeks can be treated one of three

ways

• PLLA/CaHA
• HA directly (fanning technique)

Avoid Hollow Lower Cheeks and Temples

• First must recognize patients with low volume

and/or elasticity in the lower cheeks

• First stage of treatment may be PLLA to the lower

cheeks and temples

• Can then treat with more mid‐face

augmentation

• Treating the jawline can often help
• When treating midface with HA, augment the

inferior portion of the zygoma

How to Treat Hollow Lower Cheeks and Temples

• Typically, these imbalanced patients desire a

‘quick fix’

• Treat with HA
• Vollure
• Restylane Refyne
• Prefer to treat temples with Sculptra/Radiesse
• Large temple deficits: treat first with HA for

foundation, then Sculptra/Radiesse

46 47 48

Prevent the Challenging Filler Face

• Poor filler outcomes can be attributed to:
• Bad technique
• Lack of anatomic expertise
• Poor choice of filler/permanent filler
• Not understanding aesthetic principles
• In many cases, these outcomes can be remedied

Pro Pro‐No Nox and and Inje Injectable les 49 50