With Botox there are standard doses that most practitioners use as their starting point. Adding more as a “top-up” if required and taking note of the full dose needed for a given result so that it can be reapplied later, Botox doses are relatively straightforward. But with filler we don’t tend to have these “standard” doses. On our training courses I often explain that Botox administration is a scientific method whereas dermal filler treatments are much more of an art-form. So how do I answer this common question, “how much filler should I use?”
Firstly, there is a facetious answer. Teachers and lecturers I’d venture, will always have this answer in mind, and will dream of bursting out with the answer that makes their student look or feel stupid for asking. The vanity from within me, wants me to guffaw, “how long is a piece of string” then drop the proverbial mic to the applause of the other students. I also keep wanting to ask in retort, “how deep are the lines?” Of course, the answer to both is tricky and not unilateral- exactly my point. But wait, I’m supposed to know the answer to this- that’s why people pay me to teach them! Of course, the questioner is asking a specific question about a poorly-defined hypothetical scenario, but in this reply, you can see that knowing how deep the lines are doesn’t
really even help decide on the volume you should use. A better question might be – “what volume has been lost”. For an accurate answer you are likely to need to use expensive 3D imaging in the form of an MRI or 3D Ultrasound – I’m not aware of any aesthetics clinics offering this currently and even then, the answer will be mathematical and won’t take into account, how much volume you should be replacing in an X year old who also has Y skin quality and Z other issues requiring treatment. In reality, I know that on a one-day or even a 4-day training course, this concept of choosing doses can be a little intimidating. To make matters worse for students, the decision as to how much filler to use, usually needs to be made before the treatment has begun and it usually involves a complex balance between patient expectations, practitioner experience and patients’ budget.
“If you can’t explain it simply, you don’t understand it well enough.”
I’m not likening myself to Albert Einstein – I don’t think that injecting dermal filler is as complex as special relativity but, the answer to the question posed here (how much filler should I use) cannot be answered universally or even theoretically without bearing in mind patient expectations, practitioner experience and the patient’s budget. But, as a trainer, it’s my role to rethink what I already know and do instinctively so that I can teach others. In simplifying down my techniques and clarifying what it is that I actually do whenever I administer filler, I have realised that it is relatively simple and can be learnt relatively easily by someone who wants to learn.
Technique for treating Nasolabial & Marionette lines & folds – the “comet head”
The nasolabial (nose-to-mouth) lines and folds are similar in many ways, to the marionette lines and folds. They are both formed whenever, through the natural ageing process, the central part of the face loses soft-tissue volume whilst the fad pads from the lateral parts of the face thin and drop downwards with gravity, contributing to the folds of the nasolabials and marionettes.
So we have a few issues to deal with whenever we treat these features with dermal filler; 1) Volume loss and 2) Folds. Let’s deal with them one at a time.
Lift up the lower step to meet the higher step. It’s the shadow cast by the step down that causes the dark line that we notice whenever someone has nasolabial or marionette lines. Reduce the step, which reduces the shadow and you’ll reduce the appearance of the lines themselves. It’s virtually the same with nasolabials and with marionettes.
How do you do that? Two techniques; bolus injections- best given at the proximal (top) end where there tends to be the greatest volume loss and linear injections- given either deeply or superficially along the lines themselves, always ensuring that filler is not injected above or lateral to the lines, as doing so would potentially increase the size of the step. Think of the nasolabial or marionette line as a comet, with the top end, where we administer bolus injections as the “head” of the comet and the rest of the lines, where we use linear injections, as the “tail” of the comet.
To return to our original question – “how much filler should I use?’, my rule-of-thumb is to start by giving around half of the total volume
you eventually plan to use, into the head and then seeing how much of an improvement is achieved before deciding how to use the remainder. The remainder will be administered using any combination of deep linear, superficial linear, cross-hatching (see below) or further bolus injections. Give these bolus injections slowly and only after aspirating the syringe. Anytime you move the needle tip, aspirate again (or else’).
These are the overhanging part of the nasolabials and marionettes. Not everyone who has lines has folds and potentially, someone might have folds and not an underlying line but generally, folds come after the development of lines. Folds call for a different technique. I use “cross hatching”. This is when filler is injected perpendicular (at right angles to) the direction of the fold. It’s a principle borrowed from engineering. Lines of filler can hold and support the tissue they are injected into, reducing the amount of unwanted movement in that tissue. Cross-hatching therefore, can also be used for lines worse on movement, but here we are sticking to nasolabials and marionettes. Obviously we don’t want to see lines of filler through the skin, so these injections are generally given a little deeper than those of the linear injections mentioned above. If we can see the lines though, it’s easy to remedy this by applying gentle pressure to the lines within a few hours of administration (best done by the practitioner at the time of treatment, before showing the client the final result). As a general rule for this – “how much filler should I use?”, the answer is that the longer each line of cross-hatching, the larger the volume in each line, the closer together the lines are and the thicker the product, the stronger the cross-hatching will be at withholding the pressures applied to it, such as gravity of facial muscle movement.
So, what’s the answer? How Much Filler Should I Use?
A Method for Deciding
Here’s my thought process:
- What is the patient’s budget? If they haven’t told me outright, i’ll need to sensitively find out
- What are their treatment priorities? Is it just their nasolabials, just their marionettes, is it just one side or one line? Are they wanting my opinion or do they want me just to do what they want without questioning?
- What can I realistically expect to achieve with 1ml, 2mls, 3mls, 4mls?
It can be awkward discussing budgets and treatment priorities, especially whenever some patients will expect you to do perform miracles with tiny budgets, but it’s far more uncomfortable to end up with an unhappy client who has spent several months saving for a treatment which they don’t see as giving any significant benefit. As we all know, we don’t always have a budget in mind when we enquire about a service, so it can be an annoying question to be asked outright. Most of us will be prepared to pay more for a better quality product or service, but we would need to have some confidence that it will be worth it.
To land on what the patient’s budget really is, I recommend giving two extreme options then “reeling them back in” once the conversation begins and you start to see what their budget is. For example, “I think to treat these nasolabial and marionette lines fully, would take 1ml each side for the nasolabials and 1ml each side for the marionettes, and that would cost £xxx <pause for reaction to price, then continue> BUT I think that you’d see a significant improvement if we used <2ml> overall”. Here’s my second tip – if in a situation, similar to the above, the patient then states outright that they have only £300 to spend (what I charge for 1ml), I then advise that we focus on the area that bothers them the most. I push them to choose between the nasolabials and marionettes and we decide together to treat that area within their budget. It is far better for them and for your repeat business that you do a good job on a focussed area rather than doing a minimally impressive, shoulder-shruggable job on many areas. It’s “wow-factor” that brings clients back and entices them to tell their friends what they’ve had done and it’s also the “wow-factor” that makes clients satisfied that they made a wise decision in choosing you as their practitioner. So, how much filler should you use? How long is a piece of string?!
Dr Michael Aicken
Dermal Revolution (DEEP) Feature (£40-49/ML)
Is a new product from Dermal revolution specifically designed for trouble areas that need more filler such as the cheeks, nasolabial folds and marionette lines. This product provides a lift which will last 9-12 months and is CE marked & ISO registered.
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Frequently Asked Questions
Q: What treatments can be performed with Dermal Revolution (DEEP)?
A: We recommend that this product is used for the following treatments: cheek augmentation, deep injections to the nasolabial folds & marionette lines.
Q: How long does this product last once injected?
A: Typically this product lasts 9-12 months. This varies due to anatomical position of implant, frequency of movement in that location, injection technique and patient factors.
Q: Does this product contain lidocaine?
A: No; it is recommended that an anaesthetic cream is applied to the skin surface prior to injection to improve patient comfort.
Q: Is it CE marked?
A: Yes. The registered mark is 0434. The CE quality standards have been verified via an independent 3rd party. Their address is ZCube Medical Consulting Co. Semmel str 38 97070, Wurzburg, Germany.
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Q: Will my medical indemnity insurer cover me to use this product in my daily practice?
A: Yes, but you’ll need to tell them. Hamilton Fraser, Lonsdale Insurance and Cosmetic Insure have granted Dermal Revolution the endorsement to be a named hyaluronic acid on their medical indemnity policy schedule. Please ask your insurer to add Dermal Revolution to your own individual or corporate policy. If they require any clarification of product details, please ask them to contact email@example.com