Another important aspect is the choice of the filler. Hard fillers will inevitably cause lumps in the forehead or temple. Even a highly skilled surgeon would not be able to prevent the lumps. Hard fillers are useful for creating a line or shape but soft fillers does not retain the initial shape and pulls the adjacent water and spreads. There is a drastic difference between soft and hard fillers. Therefore, for an evenly spread outcome, a soft filler with higher absorption should be used. However, one should be careful not to choose a filler that is too soft as it could cause indentation from a hat or a head band. The ideal choice would be somewhere between hard and soft, such as the Perlane line of Restylane.  

 

Combining filler with botulinum toxin can enhance the outcome. The forehead is subject to active muscular movement from facial expressions and this could affect the shape of the filler. As the filler should spread evenly, it would help to minimize the impact of the muscle movement.

 

Figure 1. Dermal filler in the forehead.

 

Koh`s Expanding Technique  

I have developed ‘Koh`s Expanding Technique’ for smooth placement of the filler over an extensive area. Most users create a volume with a short needle and move to the next area to continue the volume. This could create a gap between injected fillers, which is difficult to smooth over. Using ‘Koh`s Expanding Technique,’ one can inject the filler continuously without gaps.  

I advise using a long needle. Inject the filler into one site and withdraw the needle slightly without pulling out completely. Inject more filler into the middle of the first drop of filler. Be careful not to pull out the needle completely. Using the other hand, apply pressure on the side of the previous injection and inject the filler in the direction of where you want the filler to expand. It is important to inject a large amount of filler in a deep layer at a single shot. It is difficult to control the amount of filler across multiple injections. It is easier to induce smooth spread of the filler with light massaging after injection. Thick needles are ideal for this technique.

 

Cheek

 

Another extensive area of the face is the cheek. It is important to find the appropriate site of injection for the cheek volume enhancement. Some may say that a problem with this area is that the filler can droop downward due to the pull of gravity. However, this problem is rare unless you purposefully push the filler downward. This may be caused by choosing an injection site that is too low. For volume enhancement of the cheek, I advise injecting slightly above the indented area.  

It is important to create a smooth connection with the cheekbone. Inject the highest amount in the cheekbone area and gradually decrease the amount as you move down. This can help prevent the droopy appearance. However, most users place the largest amount of filler in the area of indentation and even inject some around it. This should be avoided as it can create a bull-dog like appearance.

Massaging with hand after injection should also be avoided in this area. Massaging with hand reduces the volume enhancement and take away from the desired outcome. Post-injection massaging is to be avoided as it carries many risks.

 

 

HELIOSⅡ/LOTUSⅡ/HYPERION – Manufacturer: LASEROPTEK(www.laseroptek.com)

 

Hand

 

Another extensive area that dermal filler could be used is the hand. This area requires entirely different techniques. Here, I advise massaging. Dilute the filler to increase the water content and inject large amounts into four sites. Then, smooth out the four lumps with fingers. The aesthetic outcome is not compromised even with massaging in this area. In the next article, we will discuss Making Shape procedure.