Facial Fillers 101 The Basics of Injection Techniques

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Facial fillers are one of the most popular in-office cosmetic treatments on the market. While the word “filler” is typically used as a broad, catch-all term, there are actually a wide range of different filler types and brands aside from Juvéderm® and Restylane®, the most well-known names. For each type of filler and target area, there are various injection techniques depending on the specialist and patient goals. Ideally, the practitioner will administer the ideal filler using the optimal technique for each treatment goal. Facial fillers can address many different skin issues, helping patients reduce and prevent visible signs of age.

While fillers are best known as a treatment to help reduce the appearance of wrinkles and fine lines, they are an ideal treatment for facial volume loss. While facial volume loss may not be discussed as frequently as wrinkles, volume deficits cause stereotypical patterns of facial shadowing that can lead to a patient to look aged.

Depending on patient goals, area of treatment and doctor preference, not only will a particular filler product be chosen, but a specific injection technique will be used, as well. Before receiving treatment, it can be helpful for a patient to understand these different techniques. The patient will know what to expect and have a sense of why a particular technique was chosen.

Before reviewing the various facial filler injection techniques and common application regions, below is a very brief overview of filler basics and expectations.

Classic Injection Techniques

The classic injection techniques listed below are some of the most commonly used facial filler injection techniques. While certain regions and specific cases may require a different type of injection technique, in most cases facial filler will be administered using a combination of the tunneling, point, stretching, or dual plane techniques. These techniques should not be considered as isolated, single techniques, as they are commonly used together within a single treatment area.

Tunneling Technique

The tunneling technique is the preferred injection technique for most cosmetic specialists and doctors to address straight wrinkles and fine lines. This versatile injection technique is suitable for the treatment of both superficial skin wrinkles, deep-set lines, or areas of diffuse volume loss, and is generally considered the safest and most natural way to administer facial filler. The key to the tunneling technique is the angle at which the needle or cannula is inserted into the skin. For best results, the needle or cannula will be inserted at a slanted, 30-to-45 degree angle, following the direction of the wrinkle (if addressing a specific wrinkle).

No filler is injected during needle or cannula entry, or while placed at its endpoint. Instead, all filler is injected during the withdrawal process. Injecting filler while withdrawing is also known as “retro-trace” or “retrograde” injections. This technique is effective because it ensures that the filler is placed safely and evenly into the correct plane, and not within any dangerous areas.

The tunneling technique is precise and safe, which are the main reasons it is the preferred injection technique of facial filler specialists.

Point Technique

The point technique, also known as the “droplet”, “serial”, or “multi-puncture” technique, involves the injection of several small droplets of filler into the deeper layers of the outer skin, also known as the “deep dermis”, or below the skin, also called the “subcutaneous” area. Instead of injecting all of the filler at once, the point technique uses numerous microinjections in close vicinity to each other. By positioning several injections close together, the drops of filler coalesce to lift the wrinkle up and make its contours less visible.

While the point technique can be used to address individual wrinkles and fine lines, it tends to be more effective when trying to improve the overall quality and hydration of the skin, or when filling a large, hollow area in a deep plane. The downside to the point technique is that it has the potential to look less natural and it is more susceptible to complications. For these reasons, the point technique is usually only employed by injectors in very particular circumstances.

Stretching Technique

With the stretching technique, before injecting the filler, the skin surrounding the targeted wrinkle will be put on tension in order to isolate the area of treatment. This combination of stretching and application of pressure will allow the needle placement and angulation to be easier and more precise, allowing better visualization through the skin. All of this can help to ensure that the filler is being placed in the exact location needed.

For obvious reasons, the stretching technique is most commonly used in areas with more skin redundancy or laxity, such as when addressing the superficial wrinkles around the mouth.

The Dual Plane Technique

The dual plane technique is when facial filler is administered within two different levels of the skin in a single area. Most commonly, one of these areas is the dermis, or middle layer of the skin. Then, to augment this initial injection, the filler will also be administered to the subdermal plane, which is a level directly below the skin. In some situations, two different types of filler will be used for the two different planes. For the superficial, skin level injection, a thinner filler will be used, while a thicker filler will be used for the injection into the subdermal plane.

The dual plane technique is used in two different, specific circumstances. First, if a patient has a target area that tends to be in constant movement, the dual plane technique can create a more natural result across all potential facial expressions. The dual plane technique is also useful when trying to address an area of the face that has both superficial wrinkling and deeper volume loss.

The Upper Face

The forehead is a tricky region to navigate. While many individuals have forehead wrinkles and lines that they would like to eradicate, there is also an unacceptable level of risk associated with filler injections into the region. This is due to the vast array of blood vessels in this area which, if impacted by filler, can cause devastating complications with blood supply. In addition, because of the tight skin and extensive movement of this area, forehead filler injections can often lead to unnatural looking results. As such, experts generally do not recommend injecting this area with filler.

The periorbital region is a broad term that refers to various areas around the eyes. Although the area to the side of the eye (the “crows feet”) is a problem area for many patients, this area is not treated with filler for similar reasons to the forehead: there are significant safety concerns and it would prove difficult to get results that appear natural. Instead, this region is a perfect place to apply Botox®. Botox® can not only reverse the appearance of wrinkles, but it also can prevent future wrinkles from forming around the eye.

The most common filler injections in the periorbital region occur in the area just above the eye (the brow), to treat a low or devolumized brow, and the region just below the eye (infraorbital region), to camouflage bags or fill hollows, called “tear troughs”. These issues can lead to a tired and aged appearance that can take away from a patient’s natural beauty. For the periorbital region, particular care must be taken to choose the correct filler. Specifically, because of the water properties of this area, a filler that doesn’t absorb too much water should be used. Injecting that filler using the tunneling cannula technique can result in a refreshed and rejuvenated appearance above and below the eye.

The Midface Region

The center of the face is called the midface region. This region encompasses two main problem areas: the nose and cheekbones. What is considered to be beautiful in the midface region can also vary wildly based on the patient’s culture and perspective. For example, Asian patients tend to want a fuller central midfacial area in relation to their cheekbones out to the side, whereas Caucasian patients tend to want the opposite: more pronounced cheekbones when compared to the central midface region. The same unique and personal preferences are also at play when it comes to the nose. Although the ideal nose is one that harmonizes the face by tying together all the other surrounding facial features, most patients will have very specific desires for nasal fillers.

It is essential to take these unique preferences into account before proceeding with facial fillers, and that is why a comprehensive consultation is an essential part of the filler process. During a consultation, the injection specialist will have an open line of communication with the patient in order to make sure they understand the patient’s exact goals. Patients should make an effort to understand all of the different filler treatments and techniques so that during the consultation they can have an informed viewpoint.

The nose in particular presents a unique challenge in filler placement. Filler is generally used to hide otherwise undesired features of the nose, or sculpt its overall shape. Because the nose is complex anatomically, it is especially critical to go to a facial expert when seeking out nasal injections, also referred to as “liquid rhinoplasty”. A comprehensive consultation, sometimes with photographic imaging and digital morphing, can be used to ensure that the patient and injector are aligned in the goals and expectations are set appropriately. It is even higher risk to have filler injections placed into the nose if a patient has had previous surgery to the nose, as this creates a situation where the anatomy, including blood supply, of the nose is less predictable.

The Lower Face

The lower one-third of the face encompasses the area around the mouth, the lips, jawline and chin. All of these areas can be dramatically improved in the right hands with the right fillers.

For the jawline and chin, thicker, more-structured fillers can be placed in deeper locations to powerfully smooth out contour, and project the chin so it is proportionate with the patients lips and nose. In addition, these treatments can create an optical illusion that makes an otherwise aged neck appear more youthful.

Thin, delicate fillers can be used, along with a gentle, needle tunneling technique, to fill in the fine wrinkles around the mouth.

The lips themselves, however, must be treated while carefully considering the patient’s specific goals. Some patients are looking for slight reshaping of the lips, while others want significant volumization. It is important that the injector guide the patient while listening to his or her goals, as this will determine the type and amount of filler, along with the technique used. Lips, like the nose, are very personal and a successful treatment requires careful consideration of patient desires along with a highly trained practitioner.