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  • The past several years have seen a paradigm shift to viewing facial aging and the development of rhytides as a three-dimensional process.

  • Rather than simply filling in facial creases, injectors now focus on volumizing and contouring the face to indirectly address the root cause of wrinkle formation.

  • Judicious combinations of neuromodulators and fillers provide patients with a minimally invasive—though not risk free—approach to wrinkle reduction and contouring that may ultimately lead to an aesthetically pleasing outcome.

image Beginner Tips

  • Combined use of sharp needle injections and blunt microcannulas, depending on the site and treatment goals, may be used to achieve a balance of safety and efficacy.

  • Beware overtreatment of lateral canthal rhytides with botulinum toxin in order to avoid creating an unusual smile with a shelf-like appearance and overprojection of the cheeks anteriorly.

  • Prior to injecting, palpate and avoid the temporal artery and slowly aspirate on the needle plunger to minimize the risk of intravascular placement; keep in mind that a negative aspiration test does not guarantee nonintravascular placement.

image Expert Tips

  • Deeper filler placement is less effective in the submalar area due to the lack of bony support.

  • BTX-A may be suitable for treating hyperdynamic “accordion” cheek lines with one to six units of intracutaneous BTX-A to each side. This can be achieved by one to two injection points over the mid-to-lateral malar eminence.

  • When injecting fillers in the tear trough, undercorrection is advocated, as the hygroscopic nature of HA fillers makes this area prone to edema, bulging, and the Tyndall effect.

image Don’t Forget!

  • The global aesthetics consensus recommends the following toolkit for managing HA filler complications: hyaluronidase, oral and intralesional steroids, empiric antibiotics (minocycline, ciprofloxacin, or clarithromycin), antiviral agents, topical nitroglycerin (1%), antihistamines, aspirin 325 mg orally, warm compresses, bacterial culture kit, and phone numbers of prearranged referrals (e.g., ophthalmologists, hyperbaric oxygen).

  • Err on the side of underdosing perioral BTX.

image Pitfalls and Cautions

  • With filler injections, the highest risk of blindness and changes is in the glabella (38.8%) followed by the nasal region (25.5%), nasolabial area (13.3%), and forehead (12.2%).

  • Avoid overcorrection of the jawline so as to prevent masculinization of the female face.

  • Avoid completely effacing the nasolabial folds, and preferentially augment the cheek prior to considering direct fold injection.

  • Extra care should be taken for nasal dorsum fillers.

  • BTX-A injections should be placed higher on the forehead to minimize the risk of eyebrow and eyelid ptosis.


The quest for beauty is an age-old human desire; indeed, this yearning is hardwired into the brain, partly to increase the likelihood of success in the search for a fertile mate for reproductive purposes and ultimately for overall species survival. This genetic drive, coupled with the influence of popular media on the perception of attractiveness, has contributed to the wish to enhance ...

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