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  • Serial puncture technique: Small aliquots of filler are injected close together so that they integrate continuously along a rhytid or fold. Postinjection massage further facilitates this blending.

  • Linear threading technique: The full length of the needle is introduced dermally or subcutaneously, and filler is injected linearly either retrograde (as the needle is withdrawn) or anterograde (as the needle is inserted), which creates a plane of blunt dissection.

  • Cross-hatching or radial injection technique: Regularly spaced, linear threads created by injecting in more than one direction to form a grid pattern.

  • Fanning technique: The needle is inserted at a single site then passed multiple times in different directions without fully withdrawing the tip from the skin.

  • Depot injection techniques: Boluses of filler are injected along the periosteum, usually to correct volume deficiency in the temporal, zygomatic cheek, and chin areas. Postprocedural massage helps prevent nodularity and smooth contour irregularities.

image Beginner Tips

  • Injection of commercially available hyaluronidase degrades hyaluronic acid filler if it is misplaced (i.e., too superficially), overinjected, or if it produces inflammatory reactions or occludes vasculature.

  • Differences in formulation and manufacturing techniques help impart the unique characteristics of each filler.

image Expert Tips

  • Because of its ability to decrease edema and, consequently, external vessel compression, some recommend hyaluronidase injection irrespective of filler type.

  • Sculptra is essentially pulverized polyglactin 910 and can be prepared with as much as 8 to 11 mL of sterile water in >24 hours.

  • Calcium hydroxyapatite is radiopaque, though it does not obscure radiographic findings.

image Don’t Forget!

  • Persistent papulonodules are more likely with Sculptra, Bellafill/Artefill, and silicone than other agents.

  • Both hypersensitivity and infection with or without biofilm can contribute to the formation of delayed nodules.

  • For fat grafts, massage and vigorous dynamic facial movement should be avoided postprocedure.

image Pitfalls and Cautions

  • Superficial HA can cause a temporary bluish tint due to the Tyndall effect.

  • If intralesional hyaluronidase is ineffective or nodules occur in the setting of non-HA augmentation, other reported medical therapies include oral antibiotics (antimicrobial and anti-inflammatory effects); topical, intralesional, or systemic corticosteroids; intralesional 5-fluorouracil; oral immunosuppressants such as cyclosporine; lasers; or combination therapies.

image Patient Education Points

  • All injectable fillers entail risk; while the risk of serious adverse events is low, it is not inconsequential.

  • Patients should have realistic expectations regarding potential outcomes and the need for repeated treatments. Many of the commercially touted before-and-after photos reflect patients treated with large volumes of filler; given the cost, many patients attempt treatment with significantly less volume and should be warned that their results may be less dramatic.

  • Though rare, potentially irreversible vascular complications are the most dreaded and serious adverse events following soft tissue augmentation, and patients should understand this possibility and alert the surgeon immediately in the event of any symptoms.



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