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Lee et al. Plast Aesthet Res 2018;5:43 I http://dx.doi.org/10.20517/2347-9264.2018.39 Page 5 of 9

A

B

Figure 3. A: Botulinum toxin injection for lateral brow lift and pretarsal orbicularis injection to widen the palpebral fissure. Volumes
referenced are independent of neurotoxin variety and assume dilution as specified in the body of the text (i.e., 1 mL saline per 100 unit vial
of Botox® or Xeomin® and 3 mL per vial of Dysport); B: proper technique and position for the pretarsal orbicularis injection. While these
figures offer a guide, dosing may vary between patients according to their musculature and anatomy

of products, and Belotero®, each of which offer multiple formulations that vary in concentration, particle size,
and cross-linking. In general, products with a higher concentration of hyaluronic acid and higher degree of
[10]
crosslinking are thought to have a higher viscosity and stiffness (G’) and greater duration of effect .

Preparation and administration
3
Most dermal fillers come preloaded in a 1 cm syringe and include the appropriate needle size. Most are
made with powder lidocaine to minimize discomfort, but the addition of topical anesthetic for 15-20 min
prior to injection is beneficial for the patient.

Injection techniques
There are four basic techniques commonly used when injecting dermal filler. Choice of technique
depends on the location of injection and the complaint being addressed. The first, threading, is the linear
application of a continuous line of filler, typically (although not exclusively) injected in a retrograde fashion.
Two additional methods build upon this fundamental technique. The crosshatching technique employs
continuous lines applied in an overlapping horizontal and vertical pattern to build volume. Fanning is
another technique utilizing multiple continuous lines of filler, this time in a fan shaped projection, where
multiple lines emanate from a single point of entry as the needle is advanced repeatedly in a radial fashion
without withdrawing from the skin. Finally, the serial puncture method involves the delivery of multiple
[11]
discreet aliquots of product, each with a separate injection . Threading may be the best choice for discrete
linear rhytids, such as those in the frontalis or glabellar area. Addressing deeper deformities such as the
tear trough may be best approached with a serial puncture technique. Larger areas of treatment such as the
temple or forehead may require fanning or cross-hatching to build volume, depending on the patient.

Techniques and tips by location
Tear trough [Figure 4] - this prominence of the lid/cheek junction (also known as the nasojugal or palpebral-
malar groove), has historically been very difficult to address with satisfactory results. The development of
this deformity is commonly thought to involve both volume loss at the level of the cheek/lid junction as well
[12]
as increasing prominence of the overlying fat pad . The goal of filler injections in this region is to smooth
this transition. This area is the most unforgiving area to inject, so care and conservative measures must be