Not long ago, the most common salutation between dermatologists — before even, “hello” — was, “What’s your Botox dilution?” Now, with the explosion of fillers in the past 2 years, the discussion has transitioned to, “What is your preferred filler for a given region?”
While we are very fortunate to have such a full palate of soft-tissue augmentation agents available, it can be confusing to some dermatologists new to the cosmetic arena. My practice has focused on cosmetic dermatology and cosmetic clinical trials, and I have enjoyed the opportunity of using many of these available agents.
By far and away, I think it is the injector that matters more than the specific injected product. There are a lot of great products on the market, and learning how to use one or two of them well will give most physicians great results. However, it is detailed knowledge of anatomy and tissue planes that are integral to success, as is understanding how to avoid, recognize and treat complications. Clearly, dermatologists have been at the forefront in the development of these products — how to use them safely and effectively and how to treat potential adverse events.
The Right Filler for Specific Regions
When injectors expand their treatment regions to inject many different areas, preferences often start to become more clear. Many who began injecting the nasolabial folds and oral commissures only a short time ago, are now enjoying success in treating their patients in many different regions including the lips, infra-orbital hollows, mid-cheek regions, dorsal hands, lateral brows, earlobes and depressed surgical scars.
Infra-Orbital Area. The infra-orbital area is one particular area that has garnered much attention in the never-ending quest for periocular rejuvenation. Knowledge of anatomy here is key in placing the product well, so as to restore youthful volume and avoid superficially placed nodules. For this area of prominent hollowing or tear troughs, hyaluronic acid products are wonderful agents to be placed deeply, usually below the orbicularis oculi.1 I favor Juvéderm Ultra in this area. The flow is very steady and predictable, and to me it seems that less swelling occurs than with other products in this area, which is already quite prone to the possibility of significant bruising and swelling. When treating this area, if you inadvertently inject too superficially or get any persistent areas of nodules or even bluish nodules, hyaluronidase can be used to dissolve unwanted hyaluronic acid product.2
Lip Augmentation. For lip volume augmentation, I have the same preference. Juvéderm Ultra has a nice flow, feels soft and natural, and in my opinion, often results in less swelling than some other products. Pay careful attention to proportions when treating for lip volume. We have all seen people with “plunger lips” walking around town, and regardless of what part of the country you live in, this is not an “aesthetic-look.” The lower lip should have more volume and have a central pout, while the upper lip should have a distribution of volume with tubercles as well as accentuation of the perimeter of the lip and often a Cupid’s bow.
Though Juvéderm Ultra is packaged with a 30-gauge needle, I often change to a 32-gauge needle for the infra-orbital hollow and for perioral lines. In the nasojugal fold, the smaller 32-gauge needle really helps you slow your injection and at the same time place tiny aliquots of product. This technique helps you accurately place the product, and the slower injection rate can often avoid significant bruising and swelling. For etched-in perioral lines, a 32-gauge needle with Juvéderm Ultra can be helpful for some of the deeper lines. For the thin and shallow lines around the mouth, I still prefer CosmoDerm and often use this in conjunction with erbium laser resurfacing or a series of TCA peels. Similarly, my filler of choice for an imprinted glabellar crease or even forehead etched-in lines is CosmoDerm as well.
Nasolabial Folds. For the nasolabial fold, I use both Restylane and Juvéderm products. At the inferior aspect of the fold and the oral commissure, I think Perlane and Restylane give very nice support to the lateral mouth, where we desire a bit more stiffness. Don’t forget to fill the pre-jowl sulcus down to the mandibular line, as this can really soften the appearance of redundant facial skin and sometimes even give the appearance of weight loss.
Juvéderm Ultra Plus can give a nice correction, especially at the superior aspect of the fold, with its fairly uniform dispersion.
For very deep folds, Radiesse can often provide an excellent correction as well. If patients have significant oral commissures, along with a downturned smile due to depressor anguli oris prominence, the combination of properly placed Botox along with a stiffer product like Restylane or Perlane can really help to soften the downturned smile into a more neutral/horizontal smile.3
I try to place the Botox at the posterior aspect of the muscle and aim my needle laterally using small dosages of 3 to 5 units per side. Too medial a placement can diffuse to the depressor labii inferior and result in slurred speech for up to a few months — something I have seen from non-physician medi-spa injectors quite a few times.
Mid-Cheek Region. For age-related atrophy in the mid-cheek, my patients usually want an immediate and reliable correction. I prefer Perlane and Radiesse in this area, and usually try to place them deeply, so I find it helpful to use a 27-gauge 1.25-inch needle.
For HIV patients with lipoatrophy, however, a gradual correction is usually desired, so I start with two sessions of Sculptra spaced about 6 to 8 weeks apart, and then fill residual areas with Radiesse a few months later. This way, the patient’s colleagues and friends don’t notice a dramatic change.
Dorsal Hands, Lateral Brows, Earlobes and Scars. Finally, the dorsal hands, lateral brows and earlobes are becoming more popular areas of treatment in my practice. Juvéderm Ultra and Restylane in the dorsal hands adjacent to prominent veins can help “lift” the skin and make the veins less prominent.
For extensive soft-tissue loss in this area, Radiesse can be a wonderful high-volume filler, as it has proven to be in the mid-cheek. For the lateral brows, I prefer Restylane to lift up some lateral redundancy and soften some degree of dermatochalasis.
Restylane also gives very nice volume to shrunken earlobes, and many patients have become big fans after initial skepticism. For post-surgical depressed scars after skin cancer removal and reconstruction, fillers can be very helpful to restore normal contour.4
For bound-down scars on the helical rim or nose, Radiesse can be molded nicely into place. For cheek scars, Perlane after subcision is my preference.
Not long ago, the most common salutation between dermatologists — before even, “hello” — was, “What’s your Botox dilution?” Now, with the explosion of fillers in the past 2 years, the discussion has transitioned to, “What is your preferred filler for a given region?”
While we are very fortunate to have such a full palate of soft-tissue augmentation agents available, it can be confusing to some dermatologists new to the cosmetic arena. My practice has focused on cosmetic dermatology and cosmetic clinical trials, and I have enjoyed the opportunity of using many of these available agents.
By far and away, I think it is the injector that matters more than the specific injected product. There are a lot of great products on the market, and learning how to use one or two of them well will give most physicians great results. However, it is detailed knowledge of anatomy and tissue planes that are integral to success, as is understanding how to avoid, recognize and treat complications. Clearly, dermatologists have been at the forefront in the development of these products — how to use them safely and effectively and how to treat potential adverse events.
The Right Filler for Specific Regions
When injectors expand their treatment regions to inject many different areas, preferences often start to become more clear. Many who began injecting the nasolabial folds and oral commissures only a short time ago, are now enjoying success in treating their patients in many different regions including the lips, infra-orbital hollows, mid-cheek regions, dorsal hands, lateral brows, earlobes and depressed surgical scars.
Infra-Orbital Area. The infra-orbital area is one particular area that has garnered much attention in the never-ending quest for periocular rejuvenation. Knowledge of anatomy here is key in placing the product well, so as to restore youthful volume and avoid superficially placed nodules. For this area of prominent hollowing or tear troughs, hyaluronic acid products are wonderful agents to be placed deeply, usually below the orbicularis oculi.1 I favor Juvéderm Ultra in this area. The flow is very steady and predictable, and to me it seems that less swelling occurs than with other products in this area, which is already quite prone to the possibility of significant bruising and swelling. When treating this area, if you inadvertently inject too superficially or get any persistent areas of nodules or even bluish nodules, hyaluronidase can be used to dissolve unwanted hyaluronic acid product.2
Lip Augmentation. For lip volume augmentation, I have the same preference. Juvéderm Ultra has a nice flow, feels soft and natural, and in my opinion, often results in less swelling than some other products. Pay careful attention to proportions when treating for lip volume. We have all seen people with “plunger lips” walking around town, and regardless of what part of the country you live in, this is not an “aesthetic-look.” The lower lip should have more volume and have a central pout, while the upper lip should have a distribution of volume with tubercles as well as accentuation of the perimeter of the lip and often a Cupid’s bow.
Though Juvéderm Ultra is packaged with a 30-gauge needle, I often change to a 32-gauge needle for the infra-orbital hollow and for perioral lines. In the nasojugal fold, the smaller 32-gauge needle really helps you slow your injection and at the same time place tiny aliquots of product. This technique helps you accurately place the product, and the slower injection rate can often avoid significant bruising and swelling. For etched-in perioral lines, a 32-gauge needle with Juvéderm Ultra can be helpful for some of the deeper lines. For the thin and shallow lines around the mouth, I still prefer CosmoDerm and often use this in conjunction with erbium laser resurfacing or a series of TCA peels. Similarly, my filler of choice for an imprinted glabellar crease or even forehead etched-in lines is CosmoDerm as well.
Nasolabial Folds. For the nasolabial fold, I use both Restylane and Juvéderm products. At the inferior aspect of the fold and the oral commissure, I think Perlane and Restylane give very nice support to the lateral mouth, where we desire a bit more stiffness. Don’t forget to fill the pre-jowl sulcus down to the mandibular line, as this can really soften the appearance of redundant facial skin and sometimes even give the appearance of weight loss.
Juvéderm Ultra Plus can give a nice correction, especially at the superior aspect of the fold, with its fairly uniform dispersion.
For very deep folds, Radiesse can often provide an excellent correction as well. If patients have significant oral commissures, along with a downturned smile due to depressor anguli oris prominence, the combination of properly placed Botox along with a stiffer product like Restylane or Perlane can really help to soften the downturned smile into a more neutral/horizontal smile.3
I try to place the Botox at the posterior aspect of the muscle and aim my needle laterally using small dosages of 3 to 5 units per side. Too medial a placement can diffuse to the depressor labii inferior and result in slurred speech for up to a few months — something I have seen from non-physician medi-spa injectors quite a few times.
Mid-Cheek Region. For age-related atrophy in the mid-cheek, my patients usually want an immediate and reliable correction. I prefer Perlane and Radiesse in this area, and usually try to place them deeply, so I find it helpful to use a 27-gauge 1.25-inch needle.
For HIV patients with lipoatrophy, however, a gradual correction is usually desired, so I start with two sessions of Sculptra spaced about 6 to 8 weeks apart, and then fill residual areas with Radiesse a few months later. This way, the patient’s colleagues and friends don’t notice a dramatic change.
Dorsal Hands, Lateral Brows, Earlobes and Scars. Finally, the dorsal hands, lateral brows and earlobes are becoming more popular areas of treatment in my practice. Juvéderm Ultra and Restylane in the dorsal hands adjacent to prominent veins can help “lift” the skin and make the veins less prominent.
For extensive soft-tissue loss in this area, Radiesse can be a wonderful high-volume filler, as it has proven to be in the mid-cheek. For the lateral brows, I prefer Restylane to lift up some lateral redundancy and soften some degree of dermatochalasis.
Restylane also gives very nice volume to shrunken earlobes, and many patients have become big fans after initial skepticism. For post-surgical depressed scars after skin cancer removal and reconstruction, fillers can be very helpful to restore normal contour.4
For bound-down scars on the helical rim or nose, Radiesse can be molded nicely into place. For cheek scars, Perlane after subcision is my preference.
Not long ago, the most common salutation between dermatologists — before even, “hello” — was, “What’s your Botox dilution?” Now, with the explosion of fillers in the past 2 years, the discussion has transitioned to, “What is your preferred filler for a given region?”
While we are very fortunate to have such a full palate of soft-tissue augmentation agents available, it can be confusing to some dermatologists new to the cosmetic arena. My practice has focused on cosmetic dermatology and cosmetic clinical trials, and I have enjoyed the opportunity of using many of these available agents.
By far and away, I think it is the injector that matters more than the specific injected product. There are a lot of great products on the market, and learning how to use one or two of them well will give most physicians great results. However, it is detailed knowledge of anatomy and tissue planes that are integral to success, as is understanding how to avoid, recognize and treat complications. Clearly, dermatologists have been at the forefront in the development of these products — how to use them safely and effectively and how to treat potential adverse events.
The Right Filler for Specific Regions
When injectors expand their treatment regions to inject many different areas, preferences often start to become more clear. Many who began injecting the nasolabial folds and oral commissures only a short time ago, are now enjoying success in treating their patients in many different regions including the lips, infra-orbital hollows, mid-cheek regions, dorsal hands, lateral brows, earlobes and depressed surgical scars.
Infra-Orbital Area. The infra-orbital area is one particular area that has garnered much attention in the never-ending quest for periocular rejuvenation. Knowledge of anatomy here is key in placing the product well, so as to restore youthful volume and avoid superficially placed nodules. For this area of prominent hollowing or tear troughs, hyaluronic acid products are wonderful agents to be placed deeply, usually below the orbicularis oculi.1 I favor Juvéderm Ultra in this area. The flow is very steady and predictable, and to me it seems that less swelling occurs than with other products in this area, which is already quite prone to the possibility of significant bruising and swelling. When treating this area, if you inadvertently inject too superficially or get any persistent areas of nodules or even bluish nodules, hyaluronidase can be used to dissolve unwanted hyaluronic acid product.2
Lip Augmentation. For lip volume augmentation, I have the same preference. Juvéderm Ultra has a nice flow, feels soft and natural, and in my opinion, often results in less swelling than some other products. Pay careful attention to proportions when treating for lip volume. We have all seen people with “plunger lips” walking around town, and regardless of what part of the country you live in, this is not an “aesthetic-look.” The lower lip should have more volume and have a central pout, while the upper lip should have a distribution of volume with tubercles as well as accentuation of the perimeter of the lip and often a Cupid’s bow.
Though Juvéderm Ultra is packaged with a 30-gauge needle, I often change to a 32-gauge needle for the infra-orbital hollow and for perioral lines. In the nasojugal fold, the smaller 32-gauge needle really helps you slow your injection and at the same time place tiny aliquots of product. This technique helps you accurately place the product, and the slower injection rate can often avoid significant bruising and swelling. For etched-in perioral lines, a 32-gauge needle with Juvéderm Ultra can be helpful for some of the deeper lines. For the thin and shallow lines around the mouth, I still prefer CosmoDerm and often use this in conjunction with erbium laser resurfacing or a series of TCA peels. Similarly, my filler of choice for an imprinted glabellar crease or even forehead etched-in lines is CosmoDerm as well.
Nasolabial Folds. For the nasolabial fold, I use both Restylane and Juvéderm products. At the inferior aspect of the fold and the oral commissure, I think Perlane and Restylane give very nice support to the lateral mouth, where we desire a bit more stiffness. Don’t forget to fill the pre-jowl sulcus down to the mandibular line, as this can really soften the appearance of redundant facial skin and sometimes even give the appearance of weight loss.
Juvéderm Ultra Plus can give a nice correction, especially at the superior aspect of the fold, with its fairly uniform dispersion.
For very deep folds, Radiesse can often provide an excellent correction as well. If patients have significant oral commissures, along with a downturned smile due to depressor anguli oris prominence, the combination of properly placed Botox along with a stiffer product like Restylane or Perlane can really help to soften the downturned smile into a more neutral/horizontal smile.3
I try to place the Botox at the posterior aspect of the muscle and aim my needle laterally using small dosages of 3 to 5 units per side. Too medial a placement can diffuse to the depressor labii inferior and result in slurred speech for up to a few months — something I have seen from non-physician medi-spa injectors quite a few times.
Mid-Cheek Region. For age-related atrophy in the mid-cheek, my patients usually want an immediate and reliable correction. I prefer Perlane and Radiesse in this area, and usually try to place them deeply, so I find it helpful to use a 27-gauge 1.25-inch needle.
For HIV patients with lipoatrophy, however, a gradual correction is usually desired, so I start with two sessions of Sculptra spaced about 6 to 8 weeks apart, and then fill residual areas with Radiesse a few months later. This way, the patient’s colleagues and friends don’t notice a dramatic change.
Dorsal Hands, Lateral Brows, Earlobes and Scars. Finally, the dorsal hands, lateral brows and earlobes are becoming more popular areas of treatment in my practice. Juvéderm Ultra and Restylane in the dorsal hands adjacent to prominent veins can help “lift” the skin and make the veins less prominent.
For extensive soft-tissue loss in this area, Radiesse can be a wonderful high-volume filler, as it has proven to be in the mid-cheek. For the lateral brows, I prefer Restylane to lift up some lateral redundancy and soften some degree of dermatochalasis.
Restylane also gives very nice volume to shrunken earlobes, and many patients have become big fans after initial skepticism. For post-surgical depressed scars after skin cancer removal and reconstruction, fillers can be very helpful to restore normal contour.4
For bound-down scars on the helical rim or nose, Radiesse can be molded nicely into place. For cheek scars, Perlane after subcision is my preference.
