Simplifying Injectables for Volumetric Rejuvenation of Face

Aging changes

Depletion in fat compartments, resorption of bone, and loss of skin elasticity as well as thickness define age-related changes, which along with the loss of muscle tone leads to sagging.[123]

Volumetric restoration should precede the enhancement of an aging face. Bone resorption in aging reflects as changes in the skeleton, mostly in the orbital, periorbital, malar, submalar, and mandibular areas.[45]

Racial variation and diversity in the features and anatomy have gained emphasis because of structural skeletal differences. The Indian faces have comparatively smaller bones, wide malar angles and mandibles, rounded and high cheeks, and heavier lower faces with descent downward and medial while aging, which are accentuated by the already short lower one-third and middle one-third of the face in the Indian skin. The periorbital area ages fastest in the Indian skin, reflecting prominent tear trough by mid-20s to 30s, thus defying the Greco-Roman standards of facial proportions.[36]

Respecting the Indian anatomy that is characterized by small bones and more fat pads on the face and their subsequent depletion, one has to use techniques to restore and enhance in step with patient-derived desires of beauty, ensuring that there is no crowding of volume anteriorly to make the face heavier centrally [Figure 1].

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Figure 1

Indian face

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Facial fat compartments

A cadaveric study showed that the subcutaneous facial fat is highly compartmentalized, and not only a change in volume but also a change in the position of these compartments with age is observed.[123]

A few important aspects that need to be considered while understanding the depletion patterns of facial fat have led to important insights, which are as follows[789]:

• Facial subcutaneous fat is compartmental—superficial and deep layers [Figure 2A and B]

• Each compartment is independent, and its depletion is not en masse

• Contour changes with individual compartment depletion reflect variable expression of age, which changes from person to person

• Ligaments confine fat areas. Retaining ligaments anchor and stabilize the skin and facial fascia. Lateral laxity of ligaments is predominant than the central because of strong fixation points

• Surface anatomy reflects grooves because of volume depletion and ligament fixation

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Figure 2

(A) Superficial pads of fat on the face.

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The fat pad depletion pattern makes the single crucial evaluation point needed for volumetric restoration. This emphasizes the aging curve for a particular patient and leads to predictive filler outcomes, if properly analyzed. The deep plane of fat in supraperiosteal layer is the first to deflate in orbital zone laterally and medially; medial cheek and chin fat is subsequently lost.[48] Superficial pad fat compartment shows more lateral, temporal, and preauricular fat loss than that of the middle and medial cheeks.[381011] The nasolabial and jowl fold accentuation is more because of the loss of ligament strength than the fat loss, which happens much later[8] [Diagram 1]. The pattern of fat loss is thus predictable, and the volume restoration should follow the pattern of fat depletion.

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Diagram 1

Pattern of fat depletion

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Retaining ligaments reflect grooves and confine fat loss to compartments and not en masse[12] [Figure 3].

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Figure 3

Retaining ligaments of face.

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Patient assessment

Patient evaluation constitutes the key steps carried out before restoring volume with fillers. A face map needs to be generated, incorporating physician and patient goals with a realistic consideration. The assessment includes consideration of age, race, gender, medical history, previous treatments, and so on. One must consider medical history, especially psychiatric illnesses, allergies, diabetes, hypertension, blood thinners and antiviral medications, history of cancer and hypertrophic scars or keloids potential, and so on, before conducting a filler rejuvenation. Previous injections used and their duration are of utmost importance; the previous need for hyaluronidase, usage of toxins, energy-based devices, and lasers are very important factors considered before conducting a filler treatment.

The patient’s desire to improve a fold/line should be considered if realistic, and a restoration plan to alleviate the problem should be scientifically and logistically considered, for example, if prominent nasolabial fold is a concern for the patient, a physician has to work on the midface area at cheek, and the submalar area helps to efface the nasolabial fold. Understanding the vectors is important, and the patient has to be counseled for the same.

A physical examination is mandatory, especially to check for filler or toxin effects, preexisting brow ptosis, asymmetry, and so on.

Racial variations in the anatomic features and landmarks make for different techniques in the volumetric restoration, keeping in mind the requirements and trends for rejuvenation. Important topographical landmarks that help one in defining the safe implementation of filler injections are available.

Recent trends and techniques revolve around the deposition of the filler supraperiosteally, which is associated with safety. Swift and Remington[13] have proposed the following anatomical bony landmarks that need to be identified [Figure 4]:

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Figure 4

Anatomical landmarks.

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• Orbital rim

• Temporal crest

• Supra- and infraorbital notch

• Inferior maxillary border

• Zygomatic arch

• Pyriform fossa, gonial angle

• Medial and lateral limbus (parallel line from the edge of the cornea, where it joins the sclera, medially and laterally) constitutes the soft tissue landmarks with anterior border of masseter that makes the muscle landmark

The gender differences for male and female faces are considered before injections[1415] [Table 1].

Table 1 Aesthetic difference in male and female face

The action of light and shadow on the face helps one to assess and rejuvenate. Observation commands assessing the aging face by viewing the deflation of volume, observing the deterioration of soft tissue, and analyzing the descent of soft tissue as a result of deflation and disproportion with dynamic discord of muscle action before injecting.[13]

Vascular landmarks should be considered while conducting facial filler treatment. The potentially most serious side effect of a filler injection is vascular occlusion. Sheer vigilance and sound technique enable safer injection. The knowledge of key vessel pathway on the face is essential to practice safe injections. Important anatomic landmarks that help one to track the pathway of blood vessels are crucial [Figure 5].

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Figure 5

Course and important branches of facial artery.

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The following arteries in the zones below have an important bearing while conducting a filler injection:

Glabella: Supratrochlear and supraorbital arteries. Injecting filler in this zone should be avoided, or the injection should be superficial.

Infraorbital: While injecting malar zone, one must stay lateral to infraorbital foramen to avoid the infraorbital vessels.

Nasolabial fold: Angular branch of facial artery/lateral nasal artery. In the lower part of nasolabial fold it is important to stay superficial while injecting and in upper 1/3 of the fold deep or periosteal injections are safest.

Nasal tip: Angular artery. Vessels here are superficial, while injecting on the nasal tip, it is best to carry out on the bone or cartilage to avoid the lateral nasal artery.

Temple: Temporal artery connected to internal carotid system and central retinal artery.

Lips: Labial artery—superior and inferior branch. In lips, injections should be less than 3-mm deep, subcutaneous at commissures.

The potential risk zones for vascular complications with fillers are identified as the nasolabial folds, where the angular artery or lateral nasal artery can be occluded, the alar groove and nasal tip that have less subcutaneous tissue may reflect pressure occlusion from filler material. The glabellar region has arteries with smaller caliber and is a watershed area with minimal collateral circulation.[1617]

In the temporal fossa, the temporal artery traverses the temporoparietal fascia, and it may be blocked during an inadvertent injection. Thus, the injections at temple should be in the superficial, subcutaneous plane or bone deep.[1819]

Depth of injection

The injections can be placed superficial to bone deep, and this depends on the volume loss and fat pad depletion as well as anatomic landmark in that particular area. General rule depends on the amount of volumetric lift required as well as the presence of vascular structures in that area. The approach to filler treatment simplifies when the physician is aware of the depth of placement of the filling agent [Table 2].

Table 2 Depth of filler placement at different sites

Needles versus cannulas

Usage of a needle or cannula depends on the depth of the filler injection and vascular network in the area. The cannulas are generally considered nontraumatic and safer, but not always. The cannulas may be large bore or small bore and flexible or rigid [Table 2]. Large bore canulas are used for large size particle fillers and smaller ones for cohesive gel fillers. The choice of needle or cannula is largely injector dependent [Table 3].

Table 3 Cannula specifications for different zones

Cheek augmentation, nose reshaping, and tear troughs can be carried out with rigid cannulas, whereas the areas that need manoeuvring, such as lips, nasolabial folds, and Marionette lines, can be treated with flexible cannulas.

Filler techniques and sequence of injection

For the ease of assessment, the face is divided into three zones: the upper one-third from the hairline to the nasion of the glabella, the middle one-third from the glabella to the nasal tip, and the lower one-third from the subnasal columella unit to the chin [Figure 6].

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Figure 6

Three zones on the face.

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For the upper one-third restoration, periorbital forehead, glabella, and temples are addressed; whereas for middle one-third—periorbital, cheeks, nasolabial folds, and preauricular; and for lower one-third—marionette, chin, jawline, and neck.

Techniques

After a full pre-treatment consultation and a decision for the appropriate filler is taken, A 30 gauge needle or a 27 gauge is chosen, if filler is large particle sized depending on gel hardness it maybe easy or difficult to inject. Key focus is to inject slowly and without pressure. The key focus is to inject slowly and without pressure.

Some syringes are prefilled with lidocaine; however, mostly for deeper and large volume injections, an infiltrative anesthesia as field block injections may be advocated. Talkasthesia may work for small area treatments in compliant patients. Upright/slight semi-tilt posture with head rest is good to minimize the effects of gravity.

Injection techniques include linear threading, serial puncture and fanning, and bolus injections. Although serial puncture is most commonly used for injections, retrograde linear threading is the most appropriate. Serial puncture may be used on forehead and eyelids and linear threading in nasolabial and mentolabial folds or during crosshatching. Bolus injections are used for cheek, chin, temple, and point lifts, while treating submalar area or pyriform fossa in the nasolabial folds. Fractional microdepot is another technique, which is used where large bolus needs to be avoided and generally carried out in the periorbital zone.[2021]

Point lifts

The position and sequence of the small bolus injections in certain sites will anchor and bring support to the face. By injecting in a pattern in sequence, the volume of product used can be minimized, and still achieve maximum effect. Point lifts in filler techniques are more often used because of the various advantages as follows:

• Specific and focal injection points

• Small volume, graded buildup, long-term work

• Deep or supraperiosteal filling with more longevity

• More economical

• Point lift injections are generally conducted always with sharp needles and not cannulas, are always bolus single or multiple, large or small, and are placed largely supraperiosteal or deep dermal

• Point lift sequence of injections [Figure 7]: Deep restoration is first followed by superficial placements. The depth of injection placement is thus relocated from superficial to deeper planes. This builds deep support to the overlying structures and achieves volume repletion of subcutaneous fat compartments. This technique is used with respect to the Indian faces and their aging reflections to achieve a pattern of repletion with fillers using less volume, high G prime, and strategic placements of lateral to medial, superior to inferior, and deep to superficial to create liquid lift

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Figure 7

Sites of injection for point lifts. 1-8 = injection points for point lift

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When evaluating the areas to inject, creating structure and volume in one area of the face may lead to improvement in another, adjacent part.

Deep infraorbital injections that are used in injecting the infraorbital zone efface medial tear trough and nasojugal fold, creating a seamless lid cheek junction. Deep orbital plane is injected, as deep and supraperiosteal. Points chosen are lateral and middle and central infraorbitals [Figures 8–10].

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Figure 8

Points for infraorbital restoration

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Figure 9

Points for periorbital and middle malar restoration

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Figure 10

(A) Before periorbital and malar restoration. (B) After periorbital and malar restoration with fillers

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The orbital-retaining ligament and the thin nature of orbicularis oculi fibers should be kept in mind while working in this zone. Superficial placements may generate Tyndall effect.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.