Injection technique in neurotoxins and fillers: Planning and basic technique

The Patient Journey in Facial Aesthetics: Findings from a European Consensus Meeting on Improving the Quality of Life for Patients Receiving Botulinum Toxin Injections

Purpose

Successful treatment of facial lines with botulinum toxin is largely dependent on patient satisfaction; thus, a structured treatment journey that uses patient-reported outcomes (PROs) is helpful for maximizing botulinum toxin results. To develop a patient-centric approach for botulinum toxin injections in facial aesthetics, a group of clinicians met to provide opinions on an optimal treatment journey that uses PROs to quantify treatment benefits on patient quality of life.

Patients and Methods

A multidisciplinary panel of 9 clinicians with expertise in facial aesthetic procedures convened for an advisory board that was preceded by and followed up with a structured, multistep consensus discussion. Based on current literature, the panel's expertise, structured questions, and group discussion, panelists assessed, reconciled, and agreed upon on a patient journey for botulinum toxin treatment in facial aesthetics.

Results

Panelists agreed that an optimal patient journey includes screening, assessment, treatment, posttreatment, and follow-up visits. A compact, easy-to-complete, and digital PRO questionnaire should be provided before the visit. During screening, thorough assessments are integral for a successful patient journey because they provide an opportunity to understand treatment goals, address patient concerns, discuss risks and benefits, obtain medication lists/medical history, and take pretreatment photographs. Treatment strategies should include discussing and educating on the approach/choice of botulinum toxin and ensuring patients are comfortable. Posttreatment, clinicians should request intense muscle movements to enhance product uptake and be available to address patient concerns. Finally, during follow-up, PRO questionnaires can be provided to gauge patient satisfaction with treatment, and pretreatment photographs can be provided to allow patients to track their progression. Follow-ups should be scheduled with new patients or those reporting low satisfaction.

Conclusion

Establishing a relationship, being aware of the patient's goals, and developing an individualized care plan allows for a structured, patient-centered treatment journey that promotes positive aesthetic outcomes.

Precision of Soft-Tissue Filler Injections: An Ultrasound-Based Verification Study

BACKGROUND

Uncontrolled product spread is an important issue to consider in facial filler injections. Lack of precision can result in reduced effectiveness and surface projection, as well as irregularities and product visibility.

OBJECTIVES

The authors sought to assess the precision of soft-tissue filler injections in the face by employing a cannula.

METHODS

This single-center observational study investigated soft-tissue filler distribution utilizing real-time non-invasive ultrasound imaging. Outcome parameters included (1) the tissue plane of product distribution, (2) the extent of horizontal as well as vertical product spread at the injection site, and (3) the product surface area taking into account the multifactorial influence of several independent variables. Participants were followed up to 30 days post-injection.

RESULTS

A total 100 facial injections were performed in 8 patients (2 males, 6 females) with a mean age of 37.20 (±6.34) years and a mean BMI of 22.21 (±1.39) kg/m.2. The plane of product distribution remained constant in approximately 90% of cases at day 0 (d0), d14, and d30. Mean horizontal product spread was higher compared with vertical spread, and both significantly decreased over all time points (P < .001). Mean product surface area was 22.51 ± 16.34 mm2 at d0, 15.97 ± 11.28 mm2 at d14, and 12.9 ± 9.15 mm2 at d30. Analysis employing generalized linear models revealed that injection volume and injection depth significantly influenced product surface area.

CONCLUSIONS

Injection of soft-tissue filler employing a cannula allows precise application of the product within the intended tissue plane. Precision can be improved by injecting less product into deeper tissue layers.

LEVEL OF EVIDENCE: 5

How Much Does Filler Apparatus Influence Ease of Injection (and Hence, Potential Safety)?

PURPOSE

To document the relative contributions of intrinsic filler fluid dynamics versus delivery systems for ease of injection-specifically, to measure extrusion force variability across different syringes and needles (with the characterization of intrinsic rheological fluid properties vs. delivery apparatus contributions to ease of injection).

METHODS

Six different fillers were tested: Belotero balance (Bel), Juvederm Voluma XC (Vol), Revanesse Versa (Rev), Restylane Lyft (Res), Radiesse (Rad), and Teosyal RHA3 (RHA). Extrusion force was measured in Newtons (N) for each by testing using the provided injection apparatus (needle + syringe), and also by standardizing all fillers to the same syringe and then varying needle sizes (30-ga, 27-ga, 25-ga/1.5-inch, 25-ga/2-inch, and 22-ga). Five trials were conducted for each scenario, with comparison via t -test (2-tailed, unpaired, assuming unequal variance).

RESULTS

The following results were noted: (1) in order of least to highest extrusion force in box-provided syringe + needle at 0.2 ml volume, the following were noted: Vol < RHA = Bel (27-ga) < Bel (30-ga) < Rev < Res = Rad; (2) for each filler (except for Vol which was similar), the box-provided syringe involved greater extrusion force than the standardized syringe used in this study (each 1-cc, p < 0.05); (3) for 27-ga and 30-ga needles, after standardization of delivery syringe at 0.2 ml volume, a significant difference was noted (proportional to increasing resistance): Bel = Vol = RHA3 < Res < Rev < Rad (for needles of 30-ga [ p < 0.05] and 27-ga [ p < 0.01]); (4) for testing cannulas after standardization of syringes no reproducible order was noted with increasing resistance when using 25-ga/1.5-inch long, 25-ga/2-inch, and 22g/2-inch cannulae; and (5) confirming expectation (validating study technique), the extrusion force was significantly higher for smaller needles and longer needles.

CONCLUSIONS

The delivery apparatus appeared to be the most influential contributor to filler injection extrusion force, with significant changes in ease of injection correlated to the filler's intrinsic rheological properties, such as viscosity (when standardized to the same syringe for needles tested). Knowledge of such data could influence the injector's ability to maximize patients' safety and clinical results.

Five-point liquid rhinoplasty: Results from a retrospective analysis of a novel standardized technique and considerations on safety

BACKGROUND

Nonsurgical aesthetic improvement of the nose with hyaluronic acid (HA) fillers is becoming increasingly popular but comes with important safety considerations.

AIMS

To assess the safety and effectiveness of the standardized "five-point liquid rhinoplasty" approach.

METHODS

This was a retrospective, single-center analysis of consecutive adult patients undergoing nonsurgical aesthetic treatment of the nose. All had one of the three main indications (insufficient nasal projection, nasal hump, or deep glabella) and were injected using HA fillers with high elastic modulus. Treatments were given using some or all of the injection points of the "five-point liquid rhinoplasty" technique: P1 (nasal tip, 0.2-0.3 ml supracartilaginous); P2 (nasal root, 0.1-0.2 ml supraperiostal); P3 (cartilaginous dorsum, 0.1-0.2 ml supracartilaginous/supraperiostal); P4 (subnasal, 0.1-0.2 ml supraperiostal); and P5 (nasal alar, 0.1-0.2 ml per side supraperiostal). The risk of complications was minimized by injecting deep and staying in the midline as far as possible.

RESULTS

Twenty patients were enrolled (n = 15 female [75%]; mean age: 37.8 ± 11.7 years). The mean volume of filler used was 0.66 ± 0.35 ml per patient. Nineteen subjects (95%) said they were "very satisfied" with results, and the physician was also "very satisfied" with outcomes in 19 patients (95%). Two individuals experienced hematoma, which was managed conservatively; there were no other significant complications.

CONCLUSIONS

The "five-point liquid rhinoplasty" is a simple and effective method designed to maximize safety. It offers a good alternative to surgery in selected patients.

Anatomical Basis for Malar Augmentation Injection With the Zygomatic Ligamentous System

BACKGROUND

The malar augmentation injection has gained popularity in recent years, but the exact location of each injection site has not been clearly identified.

OBJECTIVE

To discover ideal injection sites by comprehensively considering the distributions of ligaments, muscles, and vessels.

MATERIALS AND METHODS

Eighteen cadaver heads were dissected to investigate the zygomatic ligamentous system and to measure the position of muscles. Sixty-six cadaver heads were subjected to computed tomographic scanning and three-dimensional vessel reconstruction. Radiological evaluation of the fillers was performed before and after experimental injection in one hemiface and dissected to confirm safe delivery. Five patients were enrolled in a prospective clinical study. 2D and 3D photographs were taken before and after the injections for comparison.

RESULTS

Site 1 was defined along the zygomatic arch, except the first 1/4 length and the midline of the arch. Site 2 was on the body of the zygoma, superior to the level of the infraorbital foramen and medial to the jugale. Site 3 was defined in the anteromedial midface approximately 30 mm below the lateral canthus.

CONCLUSION

Injections at these 3 sites can be performed within the range of the ligaments to achieve effective lifting effects and minimize potential complications.

Tear Trough Filler Techniques Utilizing Hyaluronic Acid: A Systematic Review

BACKGROUND

Hyaluronic acid soft-tissue augmentation fillers are commonly injected into multiple areas of the face, including the tear trough. Despite well-documented risks, there is no standardized, evidence-based approach to inject filler in this area, be it using a hypodermic needle or a microcannula. The authors, therefore, sought to establish a preference between the two methods to facilitate progression toward standardization and prevention of adverse events.

METHODS

This is a systematic review of articles discussing hyaluronic acid tear trough injection techniques performed in vivo and related outcomes. Searches were conducted across The Cochrane Library, PubMed, Scopus, Web of Science, and Embase to yield relevant articles published before February of 2020. All selected articles incorporated discrete patient cases and were analyzed by a variety of variables assessing evidence strength, outcomes, technique, and patient safety.

RESULTS

After appraisal, 42 articles met eligibility criteria: 20 using needles, 12 using cannulas, and 10 focusing on adverse events. Level III was the most commonly awarded evidence grade, corresponding to retrospective, nonexperimental descriptive studies. There were no statistically significant differences in reported aesthetic results, patient satisfaction, or incidence of adverse events across the needle-based and cannula-based articles. Some technique trends, such as targeted anatomical plane and needle position, emerged in subsequent articles.

CONCLUSION

Given that there were no statistically significant differences in patient safety or outcomes, an evidence-based preference for needle or cannula injection into the tear trough cannot be made at this time. Current inconsistencies make tear trough injection procedures difficult to replicate, making standardization based on avoidance of adverse events not feasible.

Lip Reshaping with LOVE Approach: A Prospective Analysis Based on Two Hyaluronic Acid Fillers

Aesthetic improvement of the lips with hyaluronic acid fillers is a popular procedure. A comprehensive, modular, and highly individualizable method has been developed: the Lip Omnicomprehensive Volume Enhancement (LOVE) approach. The present study assessed the safety and effectiveness of LOVE across different patient age groups.

Injectable Filler Technique for Face Lifting Based on Dissection of True Facial Ligaments

BACKGROUND

Strengthening weakened ligament tissues with injectable fillers to improve their supportive effect may achieve the aesthetic goal of face lifting.

OBJECTIVES

The aim of the study was to design an injectable technique for enhancing the true facial ligaments and dissect the ligaments to provide anatomical guidance for effective injection.

METHODS

Six true facial ligaments were chosen as target anatomical sites for injection. Specimens were dissected, and 3-dimensional (3D) images were reconstructed to confirm the exact location of each injection site and to confirm that the proposed injection routes will not cause dangerous vascular damage. A total of 5 patients received the injections; 3D images were taken before and after the injections for comparison and clinical outcome assessments.

RESULTS

The injection technique was designed to target 6 true facial ligaments, as follows. Site 1 targeted the temporal ligamentous adhesion region to lift the lateral ends of the eyebrows. Site 2 targeted the region of the lateral orbital thickening to lift the lateral canthus. Site 3 and site 4 targeted the zygomatic retaining ligaments and zygomatic cutaneous ligaments, respectively, to augment the soft tissues of the midface. Site 5 targeted the region of the maxillary ligament to lessen the nasolabial folds, and site 6 targeted the mandibular ligament to reduce the marionette line.

CONCLUSIONS

This site-specific injection technique targeting the true ligaments may lead to increased efficiency and accuracy of face rejuvenation and exert a lifting effect.

LEVEL OF EVIDENCE: 4

Rates of Vascular Occlusion Associated With Using Needles vs Cannulas for Filler Injection

Importance

Soft-tissue augmentation with skin fillers can be delivered with needles or microcannulas, but unwanted vascular occlusions are possible.

Objective

To determine whether filler-associated vascular occlusion events of the face occur more often with injections performed with needles than with microcannulas.

Design, Setting, and Participants

This retrospective cohort study included a random sample of board-certified dermatologists deemed eligible based on membership in relevant professional societies and attendance at relevant national professional meetings. Participants completed detailed forms in which they could enter deidentified data and volume statistics pertaining to patients undergoing filler procedures in their practices. Data were collected from August 2018 to August 2019.

Exposures

Injectable fillers approved by the US Food and Drug Administration delivered via needles or microcannulas.

Main Outcomes and Measures

The primary outcome measure was intravascular occlusion. Occlusion events were graded by severity (no sequelae, scar, and ocular injury or blindness).

Results

A total of 370 dermatologists (mean [SD] years in practice, 22.3 [11.1] years) participated and reported 1.7 million syringes injected. The risk of occlusion with any particular filler type using needle or cannula never exceeded 1 per 5000 syringes injected. Overall, 1 occlusion per 6410 per 1-mL syringe injections was observed with needles and 1 per 40 882 with cannulas (P < .001). Of the 370 participants, 106 (28.6%) reported at least 1 occlusion. Multivariate analysis found that injections with cannula had 77.1% lower odds of occlusion compared with needle injections. Participants injecting fillers for more than 5 years had 70.7% lower odds of occlusion than those who were less experienced. For each additional injection per week, the odds of occlusion decreased by 1%, and 85% of occlusions had no long-term sequelae. Nasolabial folds and lips were most likely to be occluded, with mean severity level of occlusions highest at the glabella.

Conclusions and Relevance

In this cohort study, filler injections with either needles or cannulas were associated with a very low risk of intravascular occlusion events. Moreover, the vast majority of such events were minor and resolved without scar or other injury. Injections with microcannulas were less often associated with occlusion events than injections with needles. Occlusion risk per syringe appeared decreased after the first few years of clinical practice and was also lower among those who more frequently inject fillers. Whether a needle or cannula is most appropriate for injection may depend on patient factors, anatomic site, and the type of defect being treated.

Nonsurgical reshaping of the nose, chin, and jawline: A retrospective analysis using experience-based eligibility criteria

BACKGROUND

Nonsurgical reshaping of the nose, chin, and jawline with hyaluronic acid fillers is becoming increasingly popular. Appropriate patient selection is essential.

OBJECTIVES

To assess the safety and efficacy of nonsurgical treatment of these facial areas using experience-based eligibility criteria and injection of the high G' filler, VYC-25L.

METHODS

This was a retrospective analysis of patients undergoing aesthetic improvement of the nose, chin, and/or jawline with VYC-25L, selected based on detailed criteria derived from extensive experience and imaging assessments. In a subgroup of subjects, high-resolution 3D imaging was used to assess nasal angles, nasal hump height, and chin projection.

RESULTS

A total of 135 patients were included (n = 106 females; mean age, 43.4 ± 14.3 years; n = 44 nose treatment only, n = 24 chin/jawline only, n = 67 both). Mean treatment volume was 3.3 ± 2.0 ml. In total, 111 individuals (82.2%) were injected in the nose (mean volume: 0.9 ± 0.2 ml) and 91 (67.4%) in the chin/jawline (mean volume: 3.8 ± 0.8 ml). Most complications were injection site-related (bruising, n = 27 [20.0%]; pain, n = 1 [0.7%]). One patient (0.7%) experienced lip herpes, successfully managed with antiviral therapy. Thirty-two individuals underwent 3D imaging, which showed substantial mean changes from baseline in nasofrontal angle (3.5 ± 1.6 degrees), nasofacial angle (2.2 ± 0.8 degrees), and nasolabial angle (3.9 ± 2.6 degrees); decreases in nasal hump height (1.7 ± 0.9 mm); and increased chin projection (2.7 ± 1.5 mm).

CONCLUSIONS

Nonsurgical reshaping of the nose, chin, and jawline was safe and effective using experience-based eligibility criteria and VYC-25L.

Recommendations for the treatment of tear trough deformity with cross-linked hyaluronic acid filler

Background

Recent years have seen a growing interest in the appearance of the eyes among the concerns expressed by patients in cosmetic clinics. This has led to an increase in the frequency of diagnosis of tear trough deformity, and, as a result, the number of treatments performed by specialized professionals has also risen. Hyaluronic acid filler injection is a rapid, nonsurgical technique that gives good long‐lasting, but not permanent, results. However, to achieve optimal results, the attending physician must have good anatomical knowledge of the area and involvement of the structures in the tear trough, carry out proper clinical assessment of the patient, and use an appropriate injection technique with the right product.

Aims

To support good practice among the professionals who carry out these procedures, this interdisciplinary consensus document describes the relevant issues and recommendations, in order to improve safety standards and to help successfully resolve this aesthetic problem.

Facial aesthetic injections in clinical practice: Pretreatment and posttreatment consensus recommendations to minimise adverse outcomes

Facial aesthetic treatment with injectable neuromodulators and hyaluronic acid fillers is well established, with favourable safety profiles and consistent outcomes. As with any medical treatment, adverse events and complications may occur. Adverse events associated with these products are typically transient and mild to moderate in severity. Serious adverse events, such as infection and intravascular occlusion, are rare. Proper patient selection, consent and counselling, preparation and impeccable injection technique are important risk reduction strategies. Both clinicians and patients must be alert to the signs and symptoms of complications so that appropriate treatment can be started promptly. In this article, the authors review the current literature and provide their consensus recommendations for minimising adverse outcomes when treating patients with botulinum toxin or hyaluronic acid fillers.

A new nonhydrophilic agarose gel as subdermal filler for facial rejuvenation: Aesthetic results and patient satisfaction

BACKGROUND

A wide range of fillers are already available for facial rejuvenation. Most of them are based on the use of reticulated or nonreticulated hyaluronic acid.

AIMS

The main objective of this study is to present the advantages, efficacy, and safety profile of a new agarose gel filler without reticulating agents, for different facial areas.

PATIENT/METHODS

A total of 41 patients were treated with different concentrations of the agarose gel filler (1%; 1,5%; 2,5% and 3,5%). Mean age of the participants was 44.62 years. 67.7% (31/41) of the patients were female. Typically, each anatomic area was injected with half of the syringe volume (0.7 + 0.1 mL of lidocaine 2%) per side. One week after one-session treatment, Global Aesthetic Improvement Scale (GAIS) was obtained and satisfaction surveys were filled by patients.

RESULTS

Clinical improvement was noted immediately, with no progressive volume gain over following days. In the GAIS, 90% of the cases scored as "significant or great improvement." Patient satisfaction was very high with 83% of them evaluating the results as 8 or higher in a scale 1-10. Only one late-onset nodule was observed some weeks after injection, that resolved completely with corticosteroid injection.

CONCLUSIONS

This new agarose gel filler represents an effective and safe alternative for facial rejuvenation with fillers. Among its advantages, it can be highlighted the absence of reticulating agents and its nonhydrophilic nature.

AbobotulinumtoxinA for Facial Rejuvenation: What Affects the Duration of Efficacy?

AbobotulinumtoxinA (Dysport) has a long history as a safe and effective treatment option for aesthetic rejuvenation. One of the key measures of botulinum toxin efficacy is the persistence of clinically meaningful results. The duration of efficacy depends on different factors, many of which can be controlled by the clinician to better achieve their desired results. In this review, we discuss how dose, individual patient variation, and injection technique affect the duration of botulinum toxins. Increased duration may result from increased dose or more precise placement of the toxin in the muscle. The varying anatomy and behavior of patients can affect duration as well. Measures of duration in clinical studies vary, but both a 1-grade improvement on the glabellar line severity scale and patient-reported outcomes are key measures. The clinical effects of Dysport can last up to 5 months, and patients in Dysport clinical studies remained satisfied with treatment for up to 6 months. Dysport has a legacy of safety, efficacy, and high subject satisfaction demonstrated through studies and clinical experience. Building on that legacy by correctly dosing the subject, properly accounting for the individual subject anatomy and behavior, and using specific injection techniques can help ensure that your patients have the longest lasting results.