Tackling tough areas with fillers

Expanding one's filler horizons to more challenging areas allows dermatologists, plastic surgeons and other core aesthetic specialists to differentiate themselves from less skilled providers, says Kenneth Beer, M.D ., who spoke at The Cosmetic Bootcamp meeting recently in Aspen Colo.

Dr. BeerThe temples, chin, jawline, tear trough and frontalis are difficult to inject, but very rewarding for physicians who master these skills, Dr. Beer says.

"These new areas offer a point of distinction for us as the core aesthetic physicians. We cannot distinguish ourselves by filling areas that other providers can fill. These are the areas in which we need to excel," Dr. Beer saus. He is an associate clinical professor of dermatology at the University of Miami Miller School of Medicine, a consulting associate with Duke University and a clinical associate in dermatology, University of Pennsylvania Perelman School of Medicine.

The jaw offers much potential for aesthetic enhancement with fillers, he says.

"The jaw is going to be a big, exciting area. We will start seeing a lot of information about this in the near future," he says.

When the jaw angle gets blurred, "It makes a huge difference in how the person is perceived," Dr. Beer notes.

For this area, he suggests injecting hyaluronic acid (HA) or calcium hydroxylapatite (CaHa), preferably with a cannula. Injecting horizontally along the bottom of the mandible usually suits physicians with a medium skill level, Dr. Beer says, while injecting vertically on the jawline is "a bit more challenging. If you're going to do it, work with a mentor who's done many of these injections."

Regarding treatment volumes, "I would err on the side of caution – about 1 cc of product on each side, maybe a little bit more. Then I bring patients back in a month or two" to see if additional injections are needed.

For the chin, Dr. Beer says neuromodulator injections remain popular.

"I also believe that as we age, we start to lose a little projection, particularly in women," he says.

Women often benefit from a tapered appearance to the chin, Dr. Beer says. To avoid feminizing the male chin, "Give men a little more width than you would a woman."

When injecting fillers in the chin, "Stay low and away from the mental nerve and artery," he adds.

HA is popular for the chin, he says, "For fairly good reasons. It's very forgiving in this area. You can mold it. But I've also injected the chin with CaHa and gotten great results. I don't use poly-L-lactic acid (PLLA) here, but I don't see any reason why one couldn't."

Addressing age-related changes

Age-related changes in the temporal area include not only loss of fat from the retro-orbicularis oculi (ROOF) fat pad,¹ he says, but also loss of other soft tissues and bone. Additionally, patients can develop sun damage, skin laxity and muscle atrophy, he says. "We are trying to replace a three-dimensional, multi-structural loss with one injection."

When filling the temples, "The questions are, what material should we use and why? There are many different opinions. CaHa, HA and PLLA all are effective. Then there are technical considerations. I'm of the mindset that when I'm injecting in this area, I'm on the bone, as deep as possible. I inject very slowly and aspirate whenever possible. I also use my non-dominant hand to compress the area. I keep the needle relatively stationary and use my nondominant hand to guide the flow to different areas. I can usually get most of the temporal areas filled effectively with one or two sticks. That minimizes the risk of danger."

Avoiding the area within one centimeter of the suture line allows one to avoid the temporal artery, which courses across the forehead, says Dr. Beer, who uses cannulas for the temporal area about half the time.

"The cannula reduces risk to a minimal level - probably not zero, although I have not heard of anybody having a vascular incident with one," he says.

When injecting the tear trough, Dr. Beer says, avoiding the confluence of vessels and other subcutaneous structures is crucial. "I tend to use a small insulin syringe (BD) to inject HA right on the bone. When injecting, I use my nondominant hand to press the product where it's needed. With two or three sticks, I can fill most of the tear trough. My patients get very little if any bruising because I'm making very few pokes into the dermal layer."

According to a recent study of HA in the tear trough, if the distance from the skin's surface to the bone is 0.5 cm or greater, one should use the bolus technique rather than serial punctures.² This author's bolus technique involves a total of two needle sticks, versus three for the serial puncture technique. Dr. Beer says he considers the difference between two and three sticks here inconsequential.

"But Dr. El Garem is one of the few people who uses the depth from skin to bone as a rational basis for how to inject this area. I've also seen injectors use one stick with a cannula," which also can produce highly satisfactory results safely, he says.

On the forehead, "I'm very comfortable filling glabellar lines, but I use very small amounts of product with very low pressure,” he says. “I still have a healthy respect for the frontalis. Usually women – but sometimes men – can't stand having that lower forehead crease, just above the eyebrow, that persists after toxin use. I will fill it with a low-concentrate HA," or combine dilute HA across the face with minimally reconstituted or non-reconstituted HA in the frontalis. Here, he uses a superficial stick with a very fine-gauge needle.

A more comprehensive approach to the forehead involves three-dimensional forehead reflation.³ This approach differs drastically from simply filling lines because it requires placing fairly substantial amounts of HA on underlying bone while avoiding the vascular complex. "This is a challenging technique that can produce beautiful results," Dr. Beer says.

Disclosures: Dr. Beer is a partner in The Cosmetic Bootcamp and Theraplex and a trainer, speaker and clinical trial investigator for Allergan and Galderma.

References

1. Sykes JM. Applied anatomy of the temporal region and forehead for injectable fillers. J Drugs Dermatol. 2009;8(10 Suppl):s24-7.

2. El-Garem YF. Estimation of bony orbit depth for optimal selection of the injection technique to correct the tear trough and palpebromalar groove. Dermatol Surg. 2015;41(1):94-101.

3. Carruthers J, Carruthers A. Three-dimensional forehead reflation. Dermatol Surg. 2015;41 Suppl 1:S321-4.