Antoine J. Panossian¹ and Christopher J. Haggerty²

¹Panossian Oral and Maxillofacial Surgery, Massapequa, New York, USA

²Private Practice, Lakewood Oral and Maxillofacial Surgery Specialists, Lees Summit; and Department of Oral and Maxillofacial Surgery, University of Missouri–Kansas City, Kansas City, Missouri, USA

Injection of autogenous, synthetic biodegradable and permanent soft tissue fillers for facial aesthetic augmentation and rejuvenation.

• Autogenous fat: A semipermanent filler for all forms of facial soft tissue augmentation, in particular for patients undergoing liposculpting procedures and with previous hypersensitivity to injectable fillers
• Temporary synthetic fillers: Juvederm (Allergan, Irvine, California, USA) (hyaluronic scaid {HA}), Perlane (Medicis Aesthetics Inc, Scottsdale, Arizona, USA) (HA), and Restylane (Medicis Aesthetics Inc, Scottsdale, Arizona, USA) (HA)
• Semipermanent synthetic fillers: Radiesse (Merz Aesthetics Inc, Franksville, Wisconsin, USA) (calcium hydroxylapatite [CaHa]) and Sculptra (Valeant Pharmaceuticals Inc, Laval, Quebec, Canada) (ploy-L-lactic acid [PLLA])
• Permanent fillers: ArteFill (Suneva Medical Inc, Santa Barbara, California, USA) (polymethyl methacrylate microspheres [PMMA]), which is currently the only US Food and Drug Administration–approved permanent injectable filler for facial soft tissue augmentation

Facial Aesthetic Indications

1. Lip augmentation
2. Effacement of nasolabial folds
3. Perioral rhytids and marionette lines
4. Cheek enhancement
5. Defining lower jaw
6. Elevation of lateral brow
7. Glabellar lines
8. Horizontal forehead lines
9. Temporal fossa wasting
10. Asymmetrical facial features
11. Scars
12. HIV lipoatrophy

Contraindications

1. Hypersensitivity to injectable material and ingredients
2. Infection at the proposed injection site

Anatomy

• Epidermis: Layers, from superficial to deep, are the stratum corneum, stratum granulosum, stratum spinosum, and stratum basale.
• Dermis: Layers, from superficial to deep, are the papillary dermis and reticular dermis.
• Hypodermis: Contents include fat, connective tissue, neural tissue, and blood vessels.

Injection Technique

1. Patients are advised to avoid anticoagulant substances or medications prior to facial soft tissue augmentation procedures.
2. For lip augmentation, local anesthesia in the form of mental and infraorbital nerve blocks are employed. Care must be taken to minimize local anesthetic distortion of the anatomy of the site to be injected. For areas not amendable to local anesthesia, topical anesthetic (EMLA) cream can be applied 10–30 minutes prior to the procedure.
3. Makeup is removed, and injection sites are prepped with an alcohol pad.
4. Patients are positioned seated and upright.
5. Depth of injection (dermis, mid-dermis, and hypodermis) is dependent on the type of filler used. In general, nonpermanent fillers are injected more superficially, whereas semipermanent and permanent fillers are injected deeper.
6. Injection of filler is slow, deliberate, and in a retrograde fashion with aspiration. The filler is injected with the needle bevel facing superiorly.
7. The noninjecting hand is used to feel and mold the filler as it is injected into the appropriate tissue plane.
8. Patients are allowed to visualize and make recommendations during the procedure. The surgeon always has the final determination of the amount of filler used.

Postoperative Management

1. Cold compresses are immediately applie/>
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