Dermal Filler Doses & Treatment Guide

What are the differences between dermal filler and botulinum toxin treatments?

Dermal fillers refer to injectable medical devices that are formulated to easily treat various aesthetic issues, like wrinkles, loss of skin volume, and asymmetrical facial contours. The soft tissue fillers could be manufactured from different types of materials, such as temporary collagen gel or polymethyl methacrylate (PMMA) polymer with permanent residence time. One of the most popular types of aesthetic implant is hyaluronic acid based-fillers. These fillers are designed using hyaluronic acid molecules that are either harvested from animal sources (e.g. rooster combs) or non-animal sources (e.g. bacterial fermentation). On the other hand, botulinum toxin is an effective neurotoxic drug that is extracted from Clostridium botulinum bacteria. In the field of aesthetic medicine, the muscle-relaxing drug is usually intended to soften the appearance of dynamic wrinkles associated with muscle movements. Administration of botulinum toxin solution is relatively straightforward. Physicians are usually provided with standard injection doses to use as starting point according to different brands of botulinum toxin. But dermal fillers generally do not have their own specific injection protocols. The exact volume of filler required, or the best injection technique will depend on the concern being treated. The purpose of this article is to elucidate the best treatment approach to correct marionette lines and nasolabial folds.

How do nasolabial folds and marionette lines develop?

Nasolabial folds—also known as nasogenian furrows, smile lines, and laugh lines—are the skin folds that extend from the corners of the nose to the corners of the mouth. Marionette lines, on the other hand, refer to the long vertical lines that run downwards from the corners of the mouth and laterally circumscribe the chin. Both of these vexing aesthetic imperfections develop due to the natural aging process whereby the quantity and quality of dermal cells dwindle rapidly. Aging brings about an unavoidable loss of soft tissue volume in the central part of the face and loss of fat pads from the lateral parts of the face. Not only that, the dermis skin layer also loses its elasticity, resulting in the eventual downward shifting of the skin.  

What are the pre-procedural considerations?

For an aesthetic procedure to be successful, there are some important issues that require careful consideration from both the patients and the physician(s). The first consideration should be the budgets of patients. Though it can be quite awkward to discuss one’s financial capability, especially with patients who are looking for affordable treatment options, it is still an important aspect to consider. This is to allow the aestheticians to perform only the necessary procedures that will significantly benefit the patients. The second consideration is the treatment priorities of patients. When dealing with patients who want to correct both their marionette lines and nasolabial folds but have limited budgets to do so, it is imperative that the physicians focus on correcting the most problematic and bothersome area(s). This way, the chosen cosmetic imperfection can be realistically and effectively corrected with a certain amount of filler. A pre-procedural consultation session with an in-depth discussion and facial assessment will help to determine patients’ treatment priorities. Patients and physicians can decide together to treat the problematic area within a narrow budget. Not only that, consultation sessions will also help the aesthetic practitioner(s) to determine the best treatment approach to deliver aesthetic outcomes that will be appreciated by the patients without causing an unnatural imbalance in the facial features.

How to choose the appropriate dermal filler

Besides injection techniques, the success rate of dermal filler procedures greatly depends on the type of implants chosen. Both marionette lines and nasolabial folds should be corrected using cross-linked hyaluronic acid fillers with thick gel texture. This is because a firm injectable gel can withstand the effects of gravity. Some examples of hyaluronic acid-based fillers with highly viscous texture are Belotero Intense, Restylane Perlane, and Juvederm Ultra 4. Though these fillers are touted by the manufacturers to last for about 9–12 months once injected into the marionette lines and nasolabial folds; however, they can actually resist degradation longer than the residence time outlined by manufacturers. Most of the time, patients require much smaller volume of filler during their repeated treatment session. For example, patients who require 2ml to 4ml of filler to correct the deep nasolabial folds during their first session may only require half of that volume when they return for maintenance treatment approximately a year (or more) later. The protection provided by the zygomatic arch, chin, and the nose from pressure applied unconsciously on the face while sleeping could have played a part in the long-lasting residence time of the filler.  

What is the best dermal filler injection technique?

There are two major issues that need to be considered when correcting the nasolabial folds and marionette lines with soft tissue fillers. The two issues and the best dermal filler injection technique for each of them are explained below:

Aesthetic issues caused by volume loss – A loss of tissue volume may cause the more elevated lateral face to cast a shadow to the relatively less elevated medial face. This shadow will then result in prominent dark lines that are apparent in areas with marionette lines and/or nasolabial folds. By reducing the severity of the volume loss with cosmetic fillers, the shadowy areas will be brightened, and the skin creases will be smoothened away. The cosmetic filler can be administered using two appropriate techniques: bolus and linear injections. While the former is best done at the proximal end with the greatest volume loss, the latter can be done superficially or deeply along the dark lines themselves. During the injection, physicians must ensure that the filler is not administered above or lateral to the dark lines; failure to do so will only increase the discrepancy of height between the lateral and medial face and exacerbate the shadowing effect. For easy understanding, physicians should envision the nasolabial or marionette line as a comet, with the top end of the wrinkle as the head of the comet and the remaining wrinkle as the tail of the comet. Estheticians are also advised to administer bolus injections into the head of the wrinkle and then follow up with linear injections while moving downwards along the tail of the wrinkle. The general rule-of-thumb when determining the adequate volume of filler is by injecting half of the total filler volume into the comet head first. Aestheticians can then inject the remaining filler downwards along the facial line using any combination of superficial linear, deep linear, and/or cross-hatching techniques. If necessary, the leftover gel can even be administered into the comet head via bolus injections.

Aesthetic issues caused by folds: Skin folds refer to the overhanging part of the marionette lines and nasolabial furrows. Not all patients with facial lines will have skin folds, while some patients may have skin folds without any underlying lines. That being said, however, most folds progress from skin lines. The best technique to employ to correct folds is cross-hatching injection, which is done by injecting the filler in the direction that is perpendicular to the fold. Once injected, the lines of fillers help to hold and support the tissues, resulting in the reduction of unwanted movements in that particular tissue. Cross-hatching technique can also be used to treat other facial lines, like lateral forehead lines and perioral lines, that are made more obvious with movement. Compared to the linear technique, implants administered via cross-hatching technique must be injected deeper within the dermis to ensure that the lines of filler remain invisible. Filler lines that do appear visible through the skin can be remedied by applying slight pressure to the lines through the injection process. As the cross-hatching lines increase, there will be larger volume in each line, and the lines will also become closer with each other. The viscosity of a filler also determines the strength of the cross-hatching at withstanding the pressures applied to it, which includes the pull of gravity and/or movement of the facial muscles.

What are the possible complications?

Cosmetic filler injections, while seemingly uncomplicated, can still pose undesirable and potentially serious side effects. Indeed, some of the adverse health reactions are blindness and skin ischemia. The risk of these dangerous side effects can be greatly reduced when physicians administer the fillers slowly and only after aspirating the prefilled syringe, especially when using bolus injections. Physicians must aspirate the syringe every time the needle tip is moved. That being said, a group of experts still disagree over the regular aspiration method, as some blood vessels may collapse under the aspiration pressure. Also, some aestheticians may be unable to accurately control the position of the needle tip.

Summary

Treatment priorities, the budgets of patients, and injection techniques all play an important role in determining the adequate filler dosage. Physicians must concentrate on treating the primary areas of concern first before moving on to other less discernible imperfections to ensure that patients get significant aesthetic enhancements without exceeding their budgets. Patients will be satisfied with the results and may even return for further procedures in the future.