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Page 6 of 10 Zein et al. Plast Aesthet Res 2020;7:44 I http://dx.doi.org/10.20517/2347-9264.2020.133

Table 1. Summary of hyaluronic acid dermal fillers currently commercially available in the United States
Product Site [HA] (mg/mL) G' (Pa) Duration (months)
Belotero Balance Superficial - mid-dermis 22.5 30 6
Restylane-L Superficial - mid-dermis 20 565 6
Restylane Medium - deep 20 544 9
Restylane Silk Superficial - sub-mucosal 20 344 6
Restylane Lyft Medium - deep 20 545 9
Restylane Refyne Medium - deep 20 47 12
Restylane Defyne Medium - deep 20 260 12
Restylane Kysse Superficial- sub-mucosal 20 156 12
Juvéderm Ultra XC Superficial - medium 24 207 12
Juvéderm Volbella XC Superficial - medium 15 274 12
Juvéderm Vollure XC Medium - deep 17.5 317 18
Juvéderm Voluma XC Medium - deep 20 353 24
Juvéderm Ultra Plus XC Medium - deep 24 244 12
Revanesse Versa Plus Medium - deep 28 130 12
Teosyal RHA 2 Superficial - mid-dermis 23 144 15
Teosyal RHA 3 Medium - deep 23 184 15
Teosyal RHA 4 Deep - sub-cutaneous 23 296 15
[HA]: concentration of hyaluronic acid, G’: elastic modulus. Values were obtained from manufacturer documentation and published
sources [56-60] . Exact G’ values varied between sources, but the relative differences between listed products were similar

be rapidly applied, and if available the patient can be referred for hyperbaric oxygen. Few reports suggest
sodium thiosulfate can be used to dissolve calcium hydroxylapatite [39,40] . However, apart from injection of
[41]
hyaluronidase, no other therapy has been proven effective . There is no consensus on how to treat vision
loss from filler-associated vascular occlusion, though anterior chamber paracentesis, ocular massage,
hyperbaric oxygen and retrobulbar hyaluronidase injection have all been tried [37,42] . Fortunately, with proper
attention to anatomy vascular complications are exceedingly rare.

AVOIDING BAD COSMETIC OUTCOMES
Strategies for filler placement
There are four basic injection techniques associated with dermal fillers. The most basic technique is
threading, which involves the application of a continuous line of filler injected in a retrograde fashion to
correct discrete rhytids. The crosshatching technique builds upon this and involves continuous overlapping
horizontal and vertical lines to build volume. The third technique is fanning, which involves drawing
filler lines in a fan-shaped projection. Finally, serial puncture involves the injection of discreet aliquots of
product to correct deep deformities.

Irregular surface contours
Superficial irregularities are commonly encountered in regions with minimal subcutaneous fat. To avoid
this complication, filler must be placed deeply. In the tear trough region, we use a serial puncture technique
to advance the needle to the periosteum along the inferior orbital rim and deliver small boluses of product
working from medial to lateral. Similarly, in the temporalis fossa, we inject deeply under the fascia of
the temporalis muscle in the area of maximal volume loss attempting to avoid vessels and nerves while
providing a nice contour. In areas that require more superficial injection such as along the nasolabial
[43]
groove, using hyaluronic acid fillers with higher cohesivity will diminish surface irregularities . Any lumps
or bumps noticed early on are addressed with manual massage, while persistent irregularities generally
must be dissolved with hyaluronidase.

Festoons
Festoons or chronic fluid collections often become more noticeable following filler injection with
particular hydrophilic hyaluronic acids. Tear trough filler is particularly prone to this complication and it