effective_rejuvenation_with_hyaluronic_acid 46

Prévia do material em texto

Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. 
www.PRSJournal.com 1277e
Hyaluronic acid rejuvenation therapy can 
offer an improvement for patients who 
present too early for aesthetic surgery, 
those who do not want surgery, or those who 
have undergone surgery but would benefit from 
further subtle facial enhancements. Fat compart-
ments of the face deflate gradually like a slow-
leaking tire, often without the patient noticing.1,2 
“Reflation” of these areas, as opposed to “infla-
tion,” reinforces the concept that volume has been 
diminished with age, and is now being restored 
with hyaluronic acid filler. Stiffer hyaluronic acid 
fillers can add support and lift features that have 
descended, including the nasal tip or eyebrows, 
for example, and restore tissue resistance. Softer 
hyaluronic acid fillers can change the contour 
and shape of facial features, such as the jawline or 
forehead. Modern hyaluronic acid rejuvenation is 
more than just chasing lines and folds. With more 
sophisticated treatments and finer sculpting tools, 
it becomes increasingly necessary for the clinician 
to perform a detailed facial analysis for each indi-
vidual patient.
As surgeons, we tend to focus on a problem 
and the solution, but can at times miss the oppor-
tunity for full facial rejuvenation. As in restoring 
a painting or a car, one does not just restore the 
front third and leave the rest unfinished—this 
would appear peculiar. Also as in restoring a 
painting, the project is outlined and can require 
several stages, and smaller maintenance enhance-
ments in perpetuity (Fig. 1). For a comprehen-
sive facial analysis, younger patient photographs 
in various facial poses can offer an abundance of 
helpful information. For example, if the patients 
Disclosure: Dr. Swift is a consultant/clinical in-
vestigator for Allergan, Merz, and Galderma. Dr. 
Remington is a consultant and advisory board 
member for Galderma and Allergan. Dr. Comstock 
is a consultant and advisory board member for Al-
lergan, Galderma, Colorescience, Skinceuticals, Re-
vance, and skinbetter science. Drs. Mckee, Lambros, 
and Lalonde have no financial interest in any of the 
products mentioned in this article.
Copyright © 2019 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000005607
Daniel Mckee, M.D.
Kent Remington, M.D.
Arthur Swift, M.D.
Val Lambros, M.D.
Jody Comstock, M.D.
Don Lalonde, M.D.
Vancouver, British Columbia; Calgary, 
Alberta; Montreal, Quebec; and Saint 
John, New Brunswick, Canada; New-
port Beach, Calif.; and Tucson, Ariz.
Learning Objectives: After studying this article, the participant should be able 
to: 1. Process several patient-specific factors before reaching an optimal treat-
ment strategy with appreciation for facial balance. 2. Define the advantages 
and disadvantages of various hyaluronic acid preparations and delivery tech-
niques, to achieve a specific goal. 3. Perform advanced facial rejuvenation 
techniques adapted to each facial zone, combining safety considerations. 4. 
Prevent and treat complications caused by inadvertent intraarterial injections 
of hyaluronic acid.
Summary: The growing sophistication and diversity of modern hyaluronic acid 
fillers combined with an increased understanding of various delivery tech-
niques has allowed injectable filler rejuvenation to become a customizable 
instrument offering a variety of different ways to improve the face: volume 
restoration, contouring, balancing, and feature positioning/shaping—beyond 
simply fading skin creases. As more advanced applications for hyaluronic acid 
facial rejuvenation are incorporated into practice, an increased understanding 
of injection anatomy is important to optimize patient safety. (Plast. Reconstr. 
Surg. 143: 1277e, 2019.)
From the University of British Columbia; Remington Laser; 
McGill University; private practice; Skin Spectrum; and 
Dalhousie University.
Received for publication August 29, 2018; accepted Janu-
ary 11, 2019.
Effective Rejuvenation with Hyaluronic Acid 
Fillers: Current Advanced Concepts
Related Video content is available for this ar-
ticle. The videos can be found under the “Re-
lated Videos” section of the full-text article, or, 
for Ovid users, using the URL citations pub-
lished in the article.
RELATED VIDEO CONTENT IS AVAILABLE 
ONLINE.
CME
D
ow
nloaded from
 http://journals.lw
w
.com
/plasreconsurg by B
hD
M
f5eP
H
K
av1zE
oum
1tQ
fN
4a+
kJLhE
Z
gbsIH
o4X
M
i0
hC
yw
C
X
1A
W
nY
Q
p/IlQ
rH
D
3i3D
0O
dR
yi7T
vS
F
l4C
f3V
C
4/O
A
V
pD
D
a8K
2+
Y
a6H
515kE
=
 on 11/01/2023
Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. 
1278e
Plastic and Reconstructive Surgery • June 2019
never had a full upper lip, a pronounced Cupid’s 
bow, a peaked eyebrow, or full upper eyelids in 
their youth, they would not benefit from any of 
these enhancements at a later age. Respect their 
genetics (Fig. 2). In older faces, the changeable 
features such as lip size, eyebrow position, and 
cheek volume should be only partly restored in a 
subtle nature to their youthful proportions, limit-
ing the restoration to comply with the surround-
ing irreversible effects of age.3 Do not attempt to 
return older faces to appear the way they did in 
their twenties. Instead, make them appear the 
best for their age. Some patients young and old 
are not wired for aesthetics, so do not let them 
pull you in to distorted results.
Traditionally, surgeons define their aesthetic 
surgical treatment endpoints (e.g., brow position) 
using a discrete measurement based on an aver-
age obtained from the literature, or their own 
experience. Symmetry is often a goal. However, 
the pinpoint nature of hyaluronic acid rejuvena-
tion has allowed further refinement toward more 
ideal treatment endpoints, which are more often 
based on facial proportions.4,5 When it comes to 
treatment endpoints, one size fits none. Recog-
nizably beautiful faces all have a convergence of 
beauty and facial proportions that appear quite 
similar within all races, in addition to similar facial 
shape, delicacy of features, balance, and symme-
try.6–8 One goal of syringe therapy is to make the 
patients more blended toward their ideal propor-
tion, but also limiting changes by their relatively 
constant features (e.g., intercanthal distance, 
forehead height, anterior nasal spine position) 
and their genetics, age, and ethnic features.9
Everyone’s facial muscles and features age 
differently, at different rates, with different com-
pensatory effects from neighboring supporting 
structures. Some facial muscles become stronger 
in time because of a lifetime of overactivation. 
Accordingly, the brow can elevate or descend with 
age. The aperture of the eye can widen or constrict. 
Facial muscles of expression (especially in overly 
animated patients) with time can overpower the 
surrounding tissue resistance, creating unwanted 
creases and wrinkles. This is called dynamic dis-
cord and is observed mostly in the periorbital and 
perioral zones. Focused individualized treatment 
Fig. 1. Top 25 facial aesthetic zones for comprehensive analysis and hyaluronic acid rejuvenation. 
Zones can overlap and are often affected by treatment of adjacent zones.
D
ow
nloaded from
 http://journals.lw
w
.com
/plasreconsurg by B
hD
M
f5eP
H
K
av1zE
oum
1tQ
fN
4a+
kJLhE
Z
gbsIH
o4X
M
i0
hC
yw
C
X
1A
W
nY
Q
p/IlQ
rH
D
3i3D
0O
dR
yi7T
vS
F
l4C
f3V
C
4/O
A
V
pD
D
a8K
2+
Y
a6H
515kE
=
 on 11/01/2023
Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. 
Volume 143, Number 6 • Rejuvenation with Hyaluronic Acid Filler
1279e
to restore balance by using neuromodulator and 
hyaluronic acid combination maintenance ther-
apy may partially prevent this regression. Injected 
hyaluronic acid product lasts 1 to 2years, depend-
ing on patient and treatment variables. However, 
facial restoration effects can be long lasting, as 
hyaluronic acid stimulates neocollagenesis, elas-
tin, and ground substance, through tension and 
direct stimulation to fibroblasts.10 There may also 
be persistent positive effects on surrounding mus-
cle efficiency and soft-tissue elasticity.
PREPARATION AND TECHNIQUE
An advanced injector should be comfortable 
with using both microcannulas and needles, as 
both have their advantages and disadvantages—
often specific to facial location. In anatomical 
danger zones, a blunt-tip microcannula is safer 
in the subcutaneous plane but must still be used 
with caution. Long microcannulas can be used to 
contour large surface areas, or gently break up 
creases and scars, with little discomfort, trauma, or 
bruising. Microcannulas require a needle for skin 
entry and often a second pair of hands to assist, so 
there is a learning curve. The needle is typically 
one or two gauges larger than the microcannula 
(e.g., a 25-gauge ½-inch trocar for a 27-gauge 1.5-
inch microcannula). The 30-gauge microcannu-
las are especially useful for delicate areas such as 
the tear trough or upper lip. Microcannulas can 
be difficult to maneuver around dense tissues or 
retaining ligaments. Where lift is desired, needles 
are better for creating structural pillars on bone. 
Transferring product under sterile technique into 
smaller 3-cc syringes can offer better tactile feed-
back and control of injected volume—like a finer 
paint brush (off-label). (See Video, Supplemental 
Digital Content 1, which displays how to decrease 
Fig. 2. This 54-year-old patient of Dr. K. Remington who presents with an old photograph at age 23 (left), bringing attention to her 
underlying genetics—mild lip volume, subtle Cupid’s peaks, and blunted upper eyebrow peaks. (Center) Before treatment, the patient 
has supraorbital hollowing, deflated midface, deflated earlobes (yellow line), downturned unsupported oral commissures, retruded 
upper lip, deflated vermillion lips, obscured jawline, and weak chin (white line). (Right) Three weeks after full facial rejuvenation with 
hyaluronic acid and neuromodulator, the above age-related changes are improved. The injector is careful not to overtreat the upper 
vermillion lip and philtral columns, matching her native lip genetics. The upper eyebrow peak remains gradual, as in her youth.
Video 1. Supplemental Digital Content 1, which displays how to 
decrease the discomfort of the needle with filler injections, can 
be found in the “Related Videos” section of the full-text article at 
PRSJournal.com or at http://links.lww.com/PRS/D495.
D
ow
nloaded from
 http://journals.lw
w
.com
/plasreconsurg by B
hD
M
f5eP
H
K
av1zE
oum
1tQ
fN
4a+
kJLhE
Z
gbsIH
o4X
M
i0
hC
yw
C
X
1A
W
nY
Q
p/IlQ
rH
D
3i3D
0O
dR
yi7T
vS
F
l4C
f3V
C
4/O
A
V
pD
D
a8K
2+
Y
a6H
515kE
=
 on 11/01/2023
http://links.lww.com/PRS/D495
Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. 
1280e
Plastic and Reconstructive Surgery • June 2019
the pain of the needle with filler injections. This 
video can be found in the “Related Videos” sec-
tion of the full-text article at PRSJournal.com or 
at http://links.lww.com/PRS/D495.)
There are technical ways to reduce the pain of 
injection in addition to merely decreasing the size 
of the injection needle, or using microcannulas 
for contouring of large surface areas. As with the 
principles of local anesthesia infiltration,11 inject-
ing any fluid very slowly allows the tissue to equili-
brate, resulting in less injury, swelling, and pain. 
Prevent the needle from wobbling, and inject per-
pendicular to the skin. Sensory noise with vibra-
tion or a flick movement distracts the brain from 
registering the pain signals. Similarly, allowing the 
skin to fall into the needle, rather than pushing 
the needle into the skin, reduces pain. Pretreat-
ment with a cooling mechanism may reduce pain.
Knowing the characteristics and personalities of 
each hyaluronic acid product will help the injector 
decide where and how to use each product to its maxi-
mal effect. Some basic hyaluronic acid characteristics 
include the following: (1) stiffness G′ (stiffer products 
have a tendency to lift, but are also more prone to skin 
irregularities, especially when applied to thin skin), (2) 
cohesivity (optimal for smooth contouring), (3) lon-
gevity, (4) water absorption (highly absorptive prod-
ucts are prone to edema issues around the orbit), (5) 
crosslinking variations, and (6) response to hyaluroni-
dase (higher doses of hyaluronidase are required to 
dissolve more robust crosslinking technology).
Under sterile technique, filler can be mixed 
with normal saline or dilute lidocaine/epineph-
rine using a female-to-female Luer-Lock connector 
(Becton, Dickinson & Co., Franklin Lakes, N.J.) (off-
label). Ratios include 2:1 and 1:1 mixtures. Inject-
ing blended filler promotes a thin film of product to 
be layered smoothly in an area of desired contour. 
Blended hyaluronic acid is especially useful in areas 
with thin skin that are prone to irregularities (e.g., 
lips, orbit, temple, and forehead).12
After the injections are complete, a lubricat-
ing gel can be used to lightly and briefly mold and 
massage over the skin to help reduce lumps and 
irregularities. Some areas only require subtle mold-
ing (such as the lips) compared to other areas 
which require more assertive massaging (such as the 
cheeks). Also, have the patient animate their face to 
further expose any irregularities. Ice packs can be 
applied to areas prone to swelling, such as the lips.
UPPER FACE
Signs of forehead aging include slight concav-
ity in the lower third of the forehead, increased 
forehead lines throughout, and flattening of the 
brow and glabella. Placing hyaluronic acid on 
periosteum to contour the lower third of the fore-
head improves contour and also tents up the skin 
to fade creases.13 This technique can also elevate 
the eyebrows through improved efficiency of the 
frontalis muscle, given the restoration of the pivot 
support for its lever arm.14 An attractive forehead 
has a very mild prominence at the glabella and 
supraorbital rim where the eyebrows perch. An 
attractive female eyebrow starts medially at the 
orbital rim in line with the medial canthus, and 
slants upwards at 10 to 20 degrees. The intercan-
thal distance is measured, and the eyebrow peak is 
typically situated the same distance from the head 
of the brow. The eyebrows may either descend 
or become elevated with age (elevation can be 
due to the effects of dynamic discord). Microcan-
nulas inserted from the lateral side of the brow 
can restore volume on the supraorbital rim to 
improve contour, and help support the eyebrow. 
This technique does not work if the eyebrows 
have fallen below the rim, as volume placed on 
the rim in this case will only push the eyebrows 
lower—similar to a waterfall breast deformity with 
high implant placement. With this microcannula 
technique, one hand props the brow up, and the 
other hand directs the hyaluronic acid to support 
the desired position of the brow. An assistant can 
place a finger under the supraorbital rim to block 
dispersion of hyaluronic acid into the upper eye-
lid. The brow peak can be defined by depositing 
extra hyaluronic acid at the peak. At the level of 
the supraorbital rim and glabella, the supraorbital 
and supratrochlear arteries course on periosteum 
and are therefore vulnerable to hyaluronic acid 
injections even when the needle is directly on 
bone. The supratrochlear artery courses just deep 
to the medial corrugator crease; thus, if a perioste-
ally placed needle is necessary to restore the gla-
bella, injecting medial to this crease is safer.
Temporal hollowing should be restored in 
female patients only to a subtle concavity com-
pared to male temples, which are more flator 
slightly convex.15 By reflating the temple, the lat-
eral eyebrows swing back into plain sight. The 
temporal zone is fraught with vessels. Supraperi-
osteal placement of hyaluronic acid on bone 
with a needle or subcutaneous placement of 
hyaluronic acid using a microcannula are safer 
techniques (Fig. 3). When injecting on bone, the 
hyaluronic acid tends to spread upward along the 
needle track and into the subcutaneous hollow-
ing. (See Video, Supplemental Digital Content 2, 
which displays temple contouring with periosteal 
D
ow
nloaded from
 http://journals.lw
w
.com
/plasreconsurg by B
hD
M
f5eP
H
K
av1zE
oum
1tQ
fN
4a+
kJLhE
Z
gbsIH
o4X
M
i0
hC
yw
C
X
1A
W
nY
Q
p/IlQ
rH
D
3i3D
0O
dR
yi7T
vS
F
l4C
f3V
C
4/O
A
V
pD
D
a8K
2+
Y
a6H
515kE
=
 on 11/01/2023
http://links.lww.com/PRS/D495
Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. 
Volume 143, Number 6 • Rejuvenation with Hyaluronic Acid Filler
1281e
placement of hyaluronic acid. This video can be 
found in the “Related Videos” section of the full-
text article at PRSJournal.com or at http://links.
lww.com/PRS/D496.)
In the infrabrow region, subcutaneous tissue 
can deflate with age, causing a degree of orbital 
hollowing, especially medially.16 Redundant skin 
is the symptom, but the cause can be partially 
treated with low-G′ hyaluronic acid that lightly 
coats the plane between skin and orbicularis 
muscle. Use of a 27-gauge microcannula with an 
approach from the lateral position is among the 
safest approaches. Similarly, crow’s feet can be 
faded with a similar approach and plane, which 
can also include a light subcision using the micro-
cannula directed perpendicular to the creases.
MIDFACE
Although partially contained by relatively 
fixed facial retaining ligaments, soft-tissue com-
partments of the face deflate, descend, and/or 
wrinkle with time.17 The troughs and creases from 
the retaining ligaments become more prominent 
as an indicator of slow deflation of the immedi-
ately adjacent soft tissue.
The cheek has several overlapping aesthetic 
zones for consideration, at times concurrent with 
known fat compartments.18 The malar mound is 
often one of the first areas treated, as surround-
ing areas are frequently improved after restoring 
this area. Treatment of the cheek can be done 
efficiently by using stiff hyaluronic acid pillars 
positioned on bone, which tent up a fanned-out 
subcutaneous layer of soft hyaluronic acid—like a 
canopy’s frame holding up the lighter top (Fig. 4). 
The shadow inferior to the malar mound (form 
shadow) narrows the face by contrasting the lesser 
fullness of the cheek’s form shadow, found just 
inferior to the malar mound and mostly within 
the submalar zone. A well-contrasted form shadow 
is slightly concave relative to the malar mound. 
The shadow is often accented with makeup and 
is a sign of youth. The extent of contrast is less 
tolerated by Asian faces, aged faces, or postsurgi-
cal faces.19 In these exceptions, the submalar zone 
Fig. 3. Images showing a patient of Dr. V. Lambros who received hyaluronic acid rejuvenation injections to the temples. 
(Left) Before injection, the patient demonstrates significant hollowing over the temples. Each side received 1.5 cc of hyal-
uronic acid diluted in 5 cc of normal saline. (Right) After injection, there is only subtle youthful concavity over the temples. 
The lateral tail of the eyebrows are brought back into plain view. A 25-gauge microcannula was used to infiltrate blended 
hyaluronic acid into the subcutaneous plane.
Video 2. Supplemental Digital Content 2, which displays temple 
contouring with periosteal placement of hyaluronic acid, can be 
found in the “Related Videos” section of the full-text article at 
PRSJournal.com or at http://links.lww.com/PRS/D496.
D
ow
nloaded from
 http://journals.lw
w
.com
/plasreconsurg by B
hD
M
f5eP
H
K
av1zE
oum
1tQ
fN
4a+
kJLhE
Z
gbsIH
o4X
M
i0
hC
yw
C
X
1A
W
nY
Q
p/IlQ
rH
D
3i3D
0O
dR
yi7T
vS
F
l4C
f3V
C
4/O
A
V
pD
D
a8K
2+
Y
a6H
515kE
=
 on 11/01/2023
http://links.lww.com/PRS/D496
http://links.lww.com/PRS/D496
http://links.lww.com/PRS/D496
Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. 
1282e
Plastic and Reconstructive Surgery • June 2019
(especially medially) requires less contrast with 
the malar mound. The malar mound itself should 
be gradual, smooth, and rounded—accenting the 
natural ogee curve on the oblique facial view.4 
The position of the mound varies from face to 
face depending on the position of other facial 
features. The apex of the malar mound is eccen-
tric, and sits slightly superior and medial on the 
mound. Compared with a Caucasian female malar 
apex, the male and female Asian apex is broader 
and sits more inferior and medial. The male malar 
mound itself is also broader. (See Video, Supple-
mental Digital Content 3, which displays cheek 
analysis and volume restoration with hyaluronic 
acid. This video can be found in the “Related Vid-
eos” section of the full-text article at PRSJournal.
com or at http://links.lww.com/PRS/D497.)
The medial cheek deflates earlier in male sub-
jects, Asians, and patients with negative vectors. 
Fig. 4. Cross-sectional anatomy demonstrating deflation of the cheek with age, and “reflation” of 
the cheek with hyaluronic acid. (Left) The young cheek skin is supported by thick deep fat and the 
zygomatic cutaneous retaining ligaments, and a full superficial fat layer. (Center) The aged cheek 
shows deflation of the deep fat and ptosis of the retaining ligaments. The unsupported superficial 
soft tissue of the cheek droops over the nasolabial fold ligamentous structure. (Right) Restoring 
volume to the superficial fat compartment using soft hyaluronic acid causes the cheek skin and 
cutaneous ligaments to plump up. Stiffer hyaluronic acid placed on malar bone restores volume 
to the deep compartment and acts like poles or pillars to support and lift the canopy top.
Video 3. Supplemental Digital Content 3, which displays cheek 
analysis and volume restoration with hyaluronic acid, can be 
found in the “Related Videos” section of the full-text article at 
PRSJournal.com or at http://links.lww.com/PRS/D497.
D
ow
nloaded from
 http://journals.lw
w
.com
/plasreconsurg by B
hD
M
f5eP
H
K
av1zE
oum
1tQ
fN
4a+
kJLhE
Z
gbsIH
o4X
M
i0
hC
yw
C
X
1A
W
nY
Q
p/IlQ
rH
D
3i3D
0O
dR
yi7T
vS
F
l4C
f3V
C
4/O
A
V
pD
D
a8K
2+
Y
a6H
515kE
=
 on 11/01/2023
http://links.lww.com/PRS/D497
http://links.lww.com/PRS/D497
Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. 
Volume 143, Number 6 • Rejuvenation with Hyaluronic Acid Filler
1283e
Restoring volume to the medial cheek and 
 sub–orbicularis oculi fat in a deep plane can 
support the lower eyelid structures. The medial 
cheek should be treated before treating the tear 
trough, or else the negative vector will be exac-
erbated. Use of a blunt-tip microcannula and 
approaching from the lateral aspect of the face 
are favored to avoid piercing the infraorbital and 
angular vessels. (See Video, Supplemental Digital 
Content 4, which displays the medial cheek using 
a microcannula injecting in the deep subcutane-
ous layer. This video can be found in the “Related 
Videos” section of the full-text article at PRSJour-
nal.com or at http://links.lww.com/PRS/D498.)
Restoring volume under the thin delicate skin 
of the tear trough can lead to skin irregularities and 
a bluish hue from the Tyndall effect.20,21 The Tyndall 
effect can be caused by too much hyaluronic acid 
injected into the subdermal plane or in the der-
mis—especially superficial dermis. Hyaluronidase 
may be used to reverse deformities caused by hyal-
uronic acid. (See Video, Supplemental Digital Con-
tent 5, which displays using hyaluronidase to treat 
the Tyndall effectin the tear troughs. This video 
can be found in the “Related Videos” section of 
the full-text article at PRSJournal.com or at http://
links.lww.com/PRS/D499.) Medially, the orbicularis 
retaining ligaments have multiple attachments to 
bone, so a periosteal placement of hyaluronic acid 
using a microcannula is difficult. Microdeposit of 
hyaluronic acid on the rim using a needle has been 
described. Blended soft hyaluronic acid can be 
used to thinly coat the layer between skin and orbi-
cularis with a 30-gauge microcannula.22 It is safest to 
undertreat the tear troughs, as hyaluronic acid will 
absorb water over time. The more hydrophilic the 
hyaluronic acid molecule is, the more problematic 
it can be in this area. The lower lateral eyelid crease 
can be softened with an identical approach. The 
lateral orbicularis is not as fixed to bone; therefore, 
a bilayer approach can be achieved with a micro-
cannula. When examining more laterally on the 
cheek, a flattened preauricular cheek is often a tell-
tale sign of a previous face lift and can be corrected 
with fanning subcutaneous hyaluronic acid but 
should not be overcorrected because of the risk of 
masculinizing the face.23 (See Video, Supplemen-
tal Digital Content 6, which displays tear trough 
Video 4. Supplemental Digital Content 4, which displays the 
medial cheek using a microcannula injecting in the deep sub-
cutaneous layer, can be found in the “Related Videos” section 
of the full-text article at PRSJournal.com or at http://links.lww.
com/PRS/D498.
Video 5. Supplemental Digital Content 5, which displays using 
hyaluronidase to treat the Tyndall effect in the tear troughs, can 
be found in the “Related Videos” section of the full-text article at 
PRSJournal.com or at http://links.lww.com/PRS/D499.
Video 6. Supplemental Digital Content 6, which displays tear 
trough rejuvenation with hyaluronic acid, can be found in the 
“Related Videos” section of the full-text article at PRSJournal.
com or at http://links.lww.com/PRS/D500.
D
ow
nloaded from
 http://journals.lw
w
.com
/plasreconsurg by B
hD
M
f5eP
H
K
av1zE
oum
1tQ
fN
4a+
kJLhE
Z
gbsIH
o4X
M
i0
hC
yw
C
X
1A
W
nY
Q
p/IlQ
rH
D
3i3D
0O
dR
yi7T
vS
F
l4C
f3V
C
4/O
A
V
pD
D
a8K
2+
Y
a6H
515kE
=
 on 11/01/2023
http://links.lww.com/PRS/D498
http://links.lww.com/PRS/D499
http://links.lww.com/PRS/D499
http://links.lww.com/PRS/D498
http://links.lww.com/PRS/D498
http://links.lww.com/PRS/D499
http://links.lww.com/PRS/D500
Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. 
1284e
Plastic and Reconstructive Surgery • June 2019
rejuvenation with hyaluronic acid. This video can 
be found in the “Related Videos” section of the full-
text article at PRSJournal.com or at http://links.lww.
com/PRS/D500.)
Nasal rejuvenation with hyaluronic acid filler 
is very risky.24 It is safest to remain exactly midline 
and on periosteum/perichondrium when redefin-
ing the radix or nasal dorsum.25 Caudal support 
decreases with age because of deflation of caudal 
soft tissues and retrusion of the piriform fossa. The 
nasal tip drops, the nasolabial angle decreases, the 
nasal length appears longer, and the nasal bases 
splay, resulting in larger nares. A high-G′ hyal-
uronic acid can be used to correct these deformi-
ties by structurally reinforcing the columella base 
at the anterior nasal spine, in addition to filler 
placement under the nasal bases, directly on bone. 
(See Video, Supplemental Digital Content 7, which 
displays nasal rejuvenation with hyaluronic acid. 
This video can be found in the “Related Videos” 
section of the full-text article at PRSJournal.com 
or at http://links.lww.com/PRS/D501.)
High-G′ filler injected in the aged earlobe can 
improve firmness of the earlobe and counteract 
descent with age. A pixie ear deformity following 
face lift can be improved by injecting hyaluronic 
acid filler into the preauricular cheek just adja-
cent to the earlobe. Injecting the adjacent skin 
with stiff filler can add support to the skin and 
prevent it from pulling down on the earlobe. (See 
Video, Supplemental Digital Content 8, which dis-
plays earlobe rejuvenation with hyaluronic acid. 
This video can be found in the “Related Videos” 
section of the full-text article at PRSJournal.com 
or at http://links.lww.com/PRS/D502.)
LOWER FACE
The nasolabial fold becomes more defined 
with age.26 This is a partly caused by descent of 
the midface as it droops over a relatively perma-
nent facial ligament. The nasolabial fold benefits 
when the deflated midface is propped up with 
structural hyaluronic acid filler. Obliterating 
this anatomical structure should not be the goal. 
Adjunct techniques to soften the fold include 
(1) gentle subcision with a microcannula run-
ning longitudinally with the fold and then a light 
sheeting of cohesive filler, or (2) multiple needle 
deposits along the fold aimed at the superficial 
subcutaneous layer in the lower two-thirds of the 
fold, and the subdermal layer in the upper third. 
The tortuous facial artery runs parallel to the 
Video 7. Supplemental Digital Content 7, which displays nasal 
rejuvenation with hyaluronic acid, can be found in the “Related 
Videos” section of the full-text article at PRSJournal.com or at 
http://links.lww.com/PRS/D501.
Video 8. Supplemental Digital Content 8, which displays ear-
lobe rejuvenation with hyaluronic acid, can be found in the 
“Related Videos” section of the full-text article at PRSJournal.
com or at http://links.lww.com/PRS/D502.
Video 9. Supplemental Digital Content 9, which displays naso-
labial fold rejuvenation with hyaluronic acid, can be found in 
the “Related Videos” section of the full-text article at PRSJournal.
com or at http://links.lww.com/PRS/D503.
D
ow
nloaded from
 http://journals.lw
w
.com
/plasreconsurg by B
hD
M
f5eP
H
K
av1zE
oum
1tQ
fN
4a+
kJLhE
Z
gbsIH
o4X
M
i0
hC
yw
C
X
1A
W
nY
Q
p/IlQ
rH
D
3i3D
0O
dR
yi7T
vS
F
l4C
f3V
C
4/O
A
V
pD
D
a8K
2+
Y
a6H
515kE
=
 on 11/01/2023
http://links.lww.com/PRS/D500
http://links.lww.com/PRS/D500
http://links.lww.com/PRS/D501
http://links.lww.com/PRS/D502
http://links.lww.com/PRS/D501
http://links.lww.com/PRS/D502
http://links.lww.com/PRS/D503
Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. 
Volume 143, Number 6 • Rejuvenation with Hyaluronic Acid Filler
1285e
fold and becomes more superficial in the upper 
third of the crease as the skin thins. (See Video, 
Supplemental Digital Content 9, which displays 
nasolabial fold rejuvenation with hyaluronic acid. 
This video can be found in the “Related Videos” 
section of the full-text article at PRSJournal.com 
or at http://links.lww.com/PRS/D503.)
Like the nasolabial fold, most signs of aging in 
the lower face are partly influenced by soft-tissue 
deflation and skeletal resorption of the midface27 
(Fig. 5). The jowl is partly caused by descent of fat 
and skin relative to the fixed prejowl sulcus. The 
jowl is also partly caused by tissue deflation of adja-
cent supporting zones including the prejowl sulcus, 
the marionette zone, and the lateral oral commis-
sure. With age, the skin and subcutaneous tissue 
surrounding the perioral region lose elasticity and 
resistance compared to the surrounding facial 
muscles. Several consequences of this dynamic 
discord include increased lateral teeth show with 
smiling (which becomes a grin), down-turned oral 
commissures, and increased perioral skin creases. 
Hyaluronic acid treatment can restore volume, tis-
sue resistance, and balance to the cutaneous lips, 
modiolus region, marionette zone, and prejowl 
sulcus. (See Video, Supplemental Digital Content 
10, which displays age-related retrusion of the 
lateral oral commissure, jowl, and marionette zone 
requiring hyaluronic acid rejuvenation therapy. 
This video can be found in the “Related Videos” 
section of the full-text articleat PRSJournal.com 
or at http://links.lww.com/PRS/D504.) Chin projec-
tion should not be restored without also addressing 
the other lower facial zones—at the risk of causing 
Fig. 5. (Left) This 67-year-old patient has midface and lower face retrusion from multizone soft-tissue deflation, and 
maxillary and mandibular bony resorption. Resulting signs of aging include fixed cheek creases, prominent nasola-
bial fold, jowls, labiomandibular creases, and obscured jawline. The jowl is amplified by the tethering effect of the 
osteocutaneous mandibular ligament, and deflation of the zones immediately adjacent. (Right) The patient is shown 
10 months after injection with hyaluronic acid by Dr. K. Remington, without surgery. Restoring structure and vol-
ume to the malar mound and medial cheek (marked in blue) improves all of the above-mentioned deformities by 
providing projection/lift. The cheek form shadow (marked in purple) becomes slightly more contrasted and concave 
relative to the restored malar cheek. The medial cheek droops less over the nasolabial fold, lightening the crease’s 
shadow. Injecting the lower facial zones (i.e., nasolabial fold, prejowl sulcus, marionette zone, lateral oral commissure, 
postjowl jawline, and chin) improves the above-mentioned lower face deformities. Jawline definition is restored, 
along with its shadow underneath (white line). The restoration project returns youthful shadow to the jawline and the 
cheek’s form shadow, and removes shadows from creases, folds, and hollows.
Video 10. Supplemental Digital Content 10, which displays age-
related retrusion of the lateral oral commissure, jowl, and mari-
onette zone requiring hyaluronic acid rejuvenation therapy, can 
be found in the “Related Videos” section of the full-text article at 
PRSJournal.com or at http://links.lww.com/PRS/D504.
D
ow
nloaded from
 http://journals.lw
w
.com
/plasreconsurg by B
hD
M
f5eP
H
K
av1zE
oum
1tQ
fN
4a+
kJLhE
Z
gbsIH
o4X
M
i0
hC
yw
C
X
1A
W
nY
Q
p/IlQ
rH
D
3i3D
0O
dR
yi7T
vS
F
l4C
f3V
C
4/O
A
V
pD
D
a8K
2+
Y
a6H
515kE
=
 on 11/01/2023
http://links.lww.com/PRS/D503
http://links.lww.com/PRS/D504
http://links.lww.com/PRS/D504
Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. 
1286e
Plastic and Reconstructive Surgery • June 2019
an overprojected central chin in proportion to the 
rest of the lower face. Deep hyaluronic acid depos-
its using a needle can address a retruded chin. 
Hyaluronic acid therapy is more customizable than 
using a surgical chin implant. However, hyaluronic 
acid does not replace the need for chin implants 
for patients with significant micrognathia. The pos-
terior jawline can be contoured using a microcan-
nula aimed posteriorly. A soft jawline and rounded 
projected chin is more feminine, whereas a square 
jawline and wider chin are more masculine.28
The vermillion lips are particularly sensitive to 
symmetry and balance, and it does not take much to 
achieve a noticeably unnatural result. The white roll 
border can be partly restored by adding extra prod-
uct to the vermillion peak if necessary, using a 27- or 
25-gauge microcannula. In a balanced lip, the dis-
tance between the philtral columns is equal to the 
height of the lower lip. The lower lip height is larger 
than the upper lip height in Caucasians by a factor 
of 1.618:1 (phi), but closer to 1:1 in Asians.4 With 
age, the lower lip vermillion deflates quicker than 
its counterpart. Restoration of volume should focus 
on the middle 80 percent of the lower vermillion lip 
(equal to the intercanthal distance). The thin skin 
of the lip is prone to lumps; therefore, a blended 
soft hyaluronic acid is often preferred. Injections 
at the wet-dry junction are typically performed in 
a plane between skin and superficial orbicularis 
muscle (subvermillion). The tortuous labial arteries 
have variable anatomy but are typically situated in 
deep orbicularis and oral mucosa (approximately 
4 mm deep to skin) adjacent to the vermillion bor-
der. (See Video, Supplemental Digital Content 11, 
which displays lip rejuvenation with hyaluronic acid. 
This video can be found in the “Related Videos” sec-
tion of the full-text article at PRSJournal.com or at 
http://links.lww.com/PRS/D505.)
SAFETY
Hyaluronic acid rejuvenation is reversible and 
therefore the safest currently available injectable 
filler.29 Acute complications are rare but can include 
pain from nerve injury, venous and lymphatic com-
promise, severe bruising from vessel injury, local 
skin pressure necrosis, and distal soft-tissue necro-
sis.30–33 Inadvertent intravascular injection of filler 
is responsible for distal soft-tissue necrosis affecting 
distant skin or the eye. If the arterial flow connects 
with the ophthalmic system, ophthalmoplegia or 
blindness can occur.34 Depositing filler external to 
vessels does not cause distal soft-tissue necrosis but 
can cause local temporary blanching of the skin 
that is responsive to massage and hyaluronidase.
Subdermal injections are safe from major 
intraarterial complications but can still cause local 
skin necrosis from increased pressure in areas with 
less elastic skin such as scarred tissue, or areas that 
have native terminal end-arteries such as the nose 
and glabella. If the needle inadvertently slips deep 
to the dermis, the plunger resistance decreases as 
a warning if using a small 3-cc syringe.
Supraperiosteal injections are typically the 
next safest plane, but have the added risk of (1) 
piercing nerves and vessels on the way down, 
and (2) intraarterial injections in select loca-
tions where major vessel are on bone. Piercing 
vital structures on the pathway down to bone can 
be minimized by choosing the shortest distance 
to bone: needle perpendicular to the skin. The 
supraorbital, infraorbital, and supratrochlear 
arteries all initially course on periosteum. The 
facial artery courses on periosteum as it crosses 
the mandible 1 cm medial to the medial edge of 
the masseter. All these vessels connect with the 
ophthalmic artery system as well (Fig. 6).
The injection plane between skin and bone 
(subcutaneous and muscle layer) is where the 
majority of arteries course, and where the major-
ity of risk lies. Advanced knowledge of injection 
anatomy is required to prevent complications. 
This knowledge must include location and depth 
of target tissue and vital structures as they relate 
to surface landmarks.33 (See Video, Supplemen-
tal Digital Content 12, which displays injection 
anatomy and safety techniques. This video can be 
found in the “Related Videos” section of the full-
text article at PRSJournal.com or at http://links.
lww.com/PRS/D506.)
Video 11. Supplemental Digital Content 11, which displays lip 
rejuvenation with hyaluronic acid, can be found in the “Related 
Videos” section of the full-text article at PRSJournal.com or at 
http://links.lww.com/PRS/D505.
D
ow
nloaded from
 http://journals.lw
w
.com
/plasreconsurg by B
hD
M
f5eP
H
K
av1zE
oum
1tQ
fN
4a+
kJLhE
Z
gbsIH
o4X
M
i0
hC
yw
C
X
1A
W
nY
Q
p/IlQ
rH
D
3i3D
0O
dR
yi7T
vS
F
l4C
f3V
C
4/O
A
V
pD
D
a8K
2+
Y
a6H
515kE
=
 on 11/01/2023
http://links.lww.com/PRS/D505
http://links.lww.com/PRS/D506
http://links.lww.com/PRS/D506
http://links.lww.com/PRS/D505
Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. 
Volume 143, Number 6 • Rejuvenation with Hyaluronic Acid Filler
1287e
In high-risk areas or planes, consider aspirat-
ing before injection, using a microcannula brought 
in perpendicular to the known course of the sur-
rounding artery, and avoid injecting in areas that 
are vasodilated (e.g., from earlier injection trauma). 
If a needle must be used, inject the hyaluronic acid 
directly on periosteum, or at a depth well away from 
the known vital structures in the area.
Regardless of injection depth, hyaluronic acid 
should be injectedin small aliquots (injections. Plast 
Reconstr Surg. 2017;139:1103–1108.
 32. Scheuer JF III, Sieber DA, Pezeshk RA, Campbell CF, 
Gassman AA, Rohrich RJ. Anatomy of the facial danger 
zones: Maximizing safety during soft-tissue filler injections. 
Plast Reconstr Surg. 2017;139:50e–58e.
 33. Swift A, Remington K. S.A.F.E.R. Technique. Fort Lauderdale, 
Fla: The Aesthetic Blueprint Seminar; 2016.
 34. Beleznay K, Carruthers JD, Humphrey S, Jones D. Avoiding 
and treating blindness from fillers: A review of the world lit-
erature. Dermatol Surg. 2015;41:1097–1117.
 35. Pessa JE, Nguyen H, John GB, Scherer PE. The anatomical 
basis for wrinkles. Aesthet Surg J. 2014;34:227–234.
 36. DeLorenzi C. Transarterial degradation of hyaluronic acid 
filler by hyaluronidase. Dermatol Surg. 2014;40:832–841.
 37. DeLorenzi C. New high dose pulsed hyaluronidase protocol 
for hyaluronic acid filler vascular adverse events. Aesthet Surg 
J. 2017;37:814–825.
 38. Cohen JL, Biesman BS, Dayan SH, et al. Treatment of hyal-
uronic acid filler-induced impending necrosis with hyal-
uronidase: Consensus recommendations. Aesthet Surg J. 
2015;35:844–849.
 39. DeLorenzi C. Complications of injectable fillers, part 2: 
Vascular complications. Aesthet Surg J. 2014;34:584–600.
D
ow
nloaded from
 http://journals.lw
w
.com
/plasreconsurg by B
hD
M
f5eP
H
K
av1zE
oum
1tQ
fN
4a+
kJLhE
Z
gbsIH
o4X
M
i0
hC
yw
C
X
1A
W
nY
Q
p/IlQ
rH
D
3i3D
0O
dR
yi7T
vS
F
l4C
f3V
C
4/O
A
V
pD
D
a8K
2+
Y
a6H
515kE
=
 on 11/01/2023