Comprehensive Guide to Dermal Filler Injection Training

Comprehensive Guide to Dermal Filler Injection Training

History of Dermal Fillers

The advent of dermal fillers traces back to the late 19th century, with Dr. Neuber’s groundbreaking fat auto-grafting procedure in 1893. A substantial leap forward occurred in the 1970s with the development of bovine collagen, and the subsequent FDA approval of the Zyderm implant in 1983. Nevertheless, skin testing was necessary as 2-3% of patients exhibited hypersensitivity reactions to bovine collagen. The landscape of dermal fillers underwent a transformational shift in 2003 with the introduction of hyaluronic acid (HA) into the U.S. market, specifically with the product Restylane®. Since then, various HA-based fillers have dominated the aesthetic industry, including prominent brands like Juvederm, RHA, Versa, and Belotero.

Hyaluronic Acid

As a principal polysaccharide in the extracellular matrix, hyaluronic acid (HA) is instrumental in maintaining skin elasticity and fullness. Age-associated HA loss results in skin laxity and volume deficit. Crosslinked HA forms the basis of most contemporary dermal fillers, which are predominantly produced by gram-positive bacteria. This innovative development has led to the creation of non-animal sourced hyaluronic acid (NASHA) gel.

Crosslinked HA is characterized by its remarkable versatility, facilitating the customization of its physical properties, such as hardness, lift, duration of survival, and resistance to heat and degrading enzymes. It is a stable, cost-effective, safe, and tissue-compatible biomaterial. Furthermore, HA’s tissue residency is significantly prolonged due to cross-linking.

G Prime is a measure of the viscosity and elasticity of a dermal filler. It is a dimensionless quantity that is calculated using the following formula:

G’ = shear stress / shear rate

Shear stress is the force that is applied to the filler to make it flow.

Shear rate is the rate at which the filler flows.

A higher G Prime value indicates a more viscous and elastic filler. This means that the filler will be more difficult to inject and will be more likely to hold its shape once it is injected.

G Prime is an important factor to consider when choosing a dermal filler. The G Prime value will affect the way the filler flows and how it holds its shape. For example, a filler with a high G Prime value would be more suitable for volumizing and lifting, while a filler with a low G Prime value would be more suitable for filling fine lines and wrinkles.

The G Prime values for dermal fillers vary depending on the type of filler and the brand. In general, hyaluronic acid based dermal fillers have a lower G Prime value than calcium hydroxyapatite based dermal fillers.

The G Prime value of a dermal filler can affect the results of injections in a number of ways. For example:

• A filler with a high G Prime value will be more difficult to inject and may cause more pain. Conversely, a filler with a low G Prime value will be easier to inject and may cause less pain.
• A filler with a high G Prime value will be more likely to hold its shape, which can lead to longer results. Conversely, a filler with a low G Prime value will be less likely to hold its shape, which can lead to more temporary results.

Differences in Hyaluronic Acid-Based Dermal Fillers: A Deep Dive into the Restylane Family

Restylane is a comprehensive line of hyaluronic acid (HA)-based dermal fillers developed by Galderma, each with its unique properties to address different cosmetic concerns. Understanding these differences allows providers to choose the most appropriate product for each patient’s unique needs. Below is a comparative exploration of Restylane products: Restylane, Restylane L, Silk, Lyft, Refyne, Defyne, Kysse, Contour, and Eyelight.

1. Restylane: Restylane is the flagship product with 20mg/ml of HA and a moderate G Prime. It’s versatile, suitable for moderate-to-severe wrinkles, facial contouring, and lip enhancement. The moderate particle size provides both lifting and smoothing properties.

2. Restylane L: This is similar to the original Restylane but includes 0.3% lidocaine, a local anesthetic, for improved patient comfort during the injection. The inclusion of lidocaine doesn’t alter the HA concentration or the G prime.

3. Restylane Silk: Restylane Silk contains smaller, smoother particles (around 500 microns) than its counterparts, making it perfect for subtle lip augmentation and smoothing fine lines, especially around the mouth. It also has 20mg/ml HA but a lower G prime due to its smoother consistency.

4. Restylane Lyft: Formerly Perlane, Lyft has larger gel particles and a higher G prime, offering more substantial volumizing and lifting capacity. It’s excellent for enhancing cheeks and correcting volume loss in the midface. The HA concentration is 20mg/ml.

5. Restylane Refyne: Using XpresHAn technology, Refyne has a flexible gel consistency, providing subtle correction of laugh lines while maintaining natural expression. It has 20mg/ml of HA, but the G prime varies due to the crosslinking process, enhancing flexibility.

6. Restylane Defyne: Also using XpresHAn technology, Defyne has more crosslinking than Refyne, offering more support for deeper laugh lines while still allowing natural facial movement. It also contains 20mg/ml of HA.

7. Restylane Kysse: Tailored for lip augmentation and the smoothing of upper perioral lines, Kysse also uses XpresHAn technology for flexibility and naturalness. It has 20mg/ml of HA, but its unique cross-linking gives it a different G prime, ensuring longevity and a softer feel.

8. Restylane Contour: Designed specifically for cheek and chin augmentation. It uses a novel crosslinking method (XpresHAn technology), creating a product with variable G prime, allowing for excellent lift and longevity. It also has 20mg/ml of HA.

9. Restylane Eyelight: This specific filler is designed for tear troughs, with a lower HA concentration (15mg/ml) and a lower G prime. Its softer gel consistency is ideal for delicate areas like under the eyes. It also contains lidocaine for added comfort during injection.

Each Restylane product is tailored to different needs, with variations in HA concentration, G prime, particle size, and the presence of lidocaine. Some newer products leverage XpresHAn technology for different crosslinking levels, affecting their consistency and allowing for a more natural look while maintaining volume and lift. Knowledge of these differences will enable providers to optimize treatment outcomes.

Differences in Hyaluronic Acid-Based Dermal Fillers: A Detailed Review of the Juvederm Family

The Juvederm range of dermal fillers, developed by Allergan, is well-regarded for its specialized products, each addressing different aesthetic needs. A deep understanding of their individual characteristics enables providers to select the best-suited filler for their patients. The discussion below explores Juvederm Ultra, Ultra XC, Ultra Plus XC, Voluma, Volbella, Vollure, Volux, and Skinvive.

1. Juvederm Ultra: With 24mg/ml of HA, Ultra provides versatility in treating moderate to severe wrinkles and folds, particularly nasolabial folds. Its moderate G Prime and Hylacross technology, which provides a high degree of cross-linking, offer a balance between volume and spreadability.

2. Juvederm Ultra XC: Like Ultra, Ultra XC offers 24mg/ml of HA and the same degree of cross-linking. The difference lies in the inclusion of 0.3% lidocaine, intended to increase patient comfort during and after injection.

3. Juvederm Ultra Plus XC: Ultra Plus XC has a higher G Prime than Ultra and Ultra XC due to a more robust cross-linking process, resulting in a more substantial lift and higher viscosity. It’s ideal for addressing more severe wrinkles and folds.

4. Juvederm Voluma: Voluma is tailored for deep injection in the cheeks to correct age-related volume loss. It has a high G Prime due to its proprietary Vycross technology (which involves cross-linking low and high molecular weight HA) and offers 20mg/ml of HA.

5. Juvederm Volbella: Volbella is designed for lip augmentation and correction of perioral lines. It uses Vycross technology, has a low HA concentration (15mg/ml), and a lower G Prime for a smooth consistency suitable for delicate areas. 

6. Juvederm Vollure: Vollure uses Vycross technology and offers an HA concentration of 17.5mg/ml. Its moderate G Prime makes it an excellent option for moderate to severe facial wrinkles and folds.

7. Juvederm Volux: Designed for the lower face, Volux is used to sculpt the chin and jawline. It uses Vycross technology, has a high G Prime and an HA concentration of 25mg/ml, ensuring longevity and a significant lift.

8. Juvederm Skinvive: Skinvive is designed for superficial dermal injection to improve skin quality, texture, and elasticity. Its HA concentration is lower, and it includes a unique blend of antioxidants, amino acids, and vitamins for overall skin health.

In summary, the differences among the Juvederm fillers range from variations in HA concentration, G Prime, the inclusion of lidocaine, to the use of proprietary technologies like Hylacross and Vycross. The specific characteristics of each product are designed to optimize outcomes for different cosmetic needs, and a detailed understanding of these is beneficial to treating your patient.

Differences in Hyaluronic Acid-Based Dermal Fillers: A Detailed Review of the RHA Family

Developed by Teoxane Laboratories, the Resilient Hyaluronic Acid (RHA) fillers are the first dermal fillers designed for dynamic areas of the face, adapting and stretching to work with facial movements. The family consists of RHA Redensity, RHA 2, RHA 3, and RHA 4. The specific details and key differences of these products are explored below.

1. RHA Redensity: This product, also known as Teosyal Redensity (15mg/ml). Its low G Prime makes it ideal for injection into the dermis and superficial dermis of the face, for the correction of moderate to severe dynamic perioral rhytids, in adults aged 22 years or older

2. RHA 2: With an HA concentration of 23mg/ml, RHA 2 is intended to fill moderate facial wrinkles such as perioral, periorbital, or glabellar lines. It has a moderate G Prime, allowing it to balance between firmness and flexibility. The HA in RHA 2 is crosslinked with 1,4-butanediol diglycidyl ether (BDDE), which increases its viscosity and longevity.

3. RHA 3: RHA 3 also has an HA concentration of 23mg/ml but has a higher G Prime than RHA 2, making it firmer and more suited for filling severe facial wrinkles and folds, such as nasolabial folds. Like RHA 2, RHA 3’s HA is crosslinked with BDDE.

4. RHA 4: This product, with 23mg/ml HA, has the highest G Prime in the RHA series and is tailored for the correction of severe wrinkles and facial contours. RHA 4 is typically used for volumizing areas such as the cheeks and contouring the jawline. Like the other RHA products, the HA in RHA 4 is crosslinked with BDDE.

One key feature of the RHA series is its “Preserved Network” technology. Unlike traditional fillers that can lose their structural integrity upon injection, the RHA series preserves the native HA structure, resulting in a more natural look and feel.

In summary, the RHA family differentiates itself by varying degrees of G Prime, while keeping the HA concentration consistent. This enables the provider to tailor the product selection based on the severity of the wrinkles and the desired level of firmness and lift. Furthermore, the unique “Preserved Network” technology enhances the fillers’ performance in dynamic facial areas.

Differences in Hyaluronic Acid-Based Dermal Fillers: A Detailed Review of Versa and Lips+

The Versa lines of hyaluronic acid-based dermal fillers are each known for their unique manufacturing processes and properties. 

1. Versa: Manufactured by Prollenium, Versa is a homogenous, monophasic dermal filler that contains 24mg/ml of HA. The product is created using a proprietary wet milling technology, which produces spherical and uniform particles. These particles result in high-quality HA, reduced inflammation, and longevity. Versa has a relatively high G prime, giving it a good lifting capacity.

2. Versa+: Also part of Prollenium’s portfolio, Versa+ is similar to the original Versa but includes Lidocaine for enhanced patient comfort during the procedure. Versa+ also contains 24mg/ml of HA and has the same manufacturing process, properties, and G prime as Versa.

3. Lips+: Specifically designed for lip augmentation, Lips+ is another Prollenium product with 24mg/ml of HA. 

Differences in Hyaluronic Acid-Based Dermal Fillers: A Detailed Review of Belotero Products

Here we’ll explore the specific details and key differences between Belotero Balance, and Belotero Balance Plus.

1. Belotero Balance: Manufactured by Merz Aesthetics, Belotero Balance is unique due to its Cohesive Polydensified Matrix (CPM) technology, which produces a smooth, flexible gel. Belotero Balance has 22.5mg/ml of HA and a moderate G prime that offers a balance between lift and spread. This filler is suitable for moderate lines and wrinkles.

2. Belotero Balance Plus: Belotero Balance Plus is similar to Belotero Balance but contains 0.3% lidocaine hydrochloride to reduce pain on injection. 

Combined List of Contraindications

• Dermal fillers are contraindicated for patients with severe allergies manifested by a history of anaphylaxis, or history or presence of multiple severe allergies.
• Dermal fillers, which contain trace amounts of gram-positive bacterial proteins, are contraindicated for patients with a history of allergies to such material.
• Dermal fillers should not be used in patients with previous hypersensitivity to local anesthetics of the amide type, such as lidocaine.
• Dermal fillers should not be used in patients with bleeding disorders.
• Dermal fillers are contraindicated for use by anyone with a skin infection or a susceptibility to keloid formation or hypertrophic scarring.
• Dermal fillers should not be used by pregnant women or nursing mothers.
• People under the age of 22 should not be treated with certain types of dermal fillers.
• Patients with evidence of scars at the intended treatment sites should not be treated with dermal fillers.
• Patients with acne and/or other inflammatory diseases of the skin should not be treated with dermal fillers.
• Patients with unattainable expectations should not be treated with dermal fillers.
• Dermal fillers should not be used in patients who have plans to undergo desensitization therapy.
• Dermal fillers should not be used in patients with acute or chronic skin disease in or near the injection sites, or with any infection or unhealed wound of the face.
• Patients under concomitant anticoagulant therapy, antiplatelet therapy, or with a history of coagulation defects or connective tissue disorders should not use dermal fillers.
• Dermal fillers are not intended for intravascular use and must not be injected into blood vessels, as implantation into dermal vessels may cause vascular occlusion, infarction, or embolic phenomena.
• Dermal fillers should not be used in conjunction with a laser, intense pulsed light, chemical peeling or dermabrasion treatments, or with over-the-counter (OTC) wrinkle products or prescription wrinkle treatments within 4 weeks (28 days) prior to treatment.

Please note that this list is a combination of all contraindications from each product, and each individual product may not have every listed contraindication. Always refer to the specific product’s package insert.

Warnings

This is a consolidated list of all the specific warnings.

• Avoid injecting dermal fillers directly into blood vessels, as this may cause vessel occlusion, embolization, or infarction.
• Rare but serious adverse events associated with the intravascular injection of soft tissue fillers in the face have been reported and include temporary or permanent vision impairment, blindness, cerebral ischemia or cerebral hemorrhage, leading to stroke, skin necrosis, and damage to underlying facial structures.
• Use of these products on patients who are pregnant, breastfeeding, or under 18 years old has not been studied, and therefore is not recommended.
• The safety and effectiveness of these products for treatment in areas other than those specified in their respective FDA-approved labeling have not been established.
• Do not overcorrect (overfill) a contour deficiency because the depression should gradually improve as treatment continues.
• Do not mix these products with any other products before implantation.
• As with all skin injection procedures, there is a risk of infection.
• Injections of greater than 1.5 mL per lip (upper or lower) per treatment session significantly increases the occurrence of the severity of lip swelling.
• Dermal fillers should not be used in areas that have high vascularity as there is a risk of vascular embolization.
• Injection site reactions (for example: redness, temporary swelling, tenderness, or pain) have been observed and are short term in duration (less than seven days). Any reactions in excess of this anticipated reaction should be reported to a healthcare professional.
• If immediate blanching occurs, the injection should be stopped, and the area massaged until it returns to a normal color. Blanching may represent a vessel occlusion. If normal skin coloring does not return, do not continue with the injection.
• Patients should receive prompt medical attention and possibly evaluation by an appropriate healthcare practitioner specialist should an intravascular injection occur.
• This product should only be used by healthcare practitioners who have appropriate training, experience, and who are knowledgeable about the anatomy at and around the site of injection.
• Patients with adverse inflammatory reactions that persist for more than one week should report this immediately to their doctor.
• Health care practitioners are encouraged to discuss all potential risks of soft tissue injection with their patients prior to treatment and ensure that patients are aware of signs and symptoms of potential complications.
• Serious adverse events have been reported related to the use of dermal fillers in the area of the eye.
• Localized superficial necrosis and scarring may occur after injection in or near vessels, such as in the lips, nose, or glabellar area. It is thought to result from the injury, obstruction, or compromise of blood vessels.
• Delayed onset inflammatory papules have been reported following the use of dermal fillers. Inflammatory papules that may occur rarely should be considered and treated as a soft tissue infection.

These warnings provide important information for safe and effective use of dermal fillers and should be carefully considered by healthcare providers and patients alike. It is essential to reach out to the respective product manufacturers or healthcare providers for additional information.

Precaution

• Dermal fillers are intended for single use only. They should not be resterilized or used if the package is opened, damaged, or past its expiration date.
• The product should be used with caution in patients undergoing immunosuppressive therapy or patients who are using substances that reduce coagulation.
• The injection of dermal fillers into patients with a history of herpetic eruptions may lead to reactivation of the herpes.
• The patient should be informed that they should minimize exposure of the treated area to excessive sun or heat, UV lamp exposure, saunas, and extreme cold weather until any initial swelling and redness have resolved, and puncture sites have healed.
• Any syringe that shows signs of content separation or appears cloudy should not be used.
• If nodules or persistent papules occur, consider appropriate treatment, such as hyaluronidase injection or surgical removal.
• Prior to treatment, the patient should avoid taking aspirin, nonsteroidal anti-inflammatory medications, St. John’s Wort, or high doses of Vitamin E supplements, as these agents may increase bruising and bleeding at the injection site.

Aging Skin

The process of skin aging encompasses numerous interconnected and complex changes that occur within the skin and underlying tissues. These changes are typically observed as loss of subcutaneous volume, thinning of the skin, and modifications in bony structures, all of which contribute to the deterioration of youthful facial contours. Additionally, aging skin is characterized by a reduction in collagen and elastin, proteins integral to maintaining the skin’s elasticity and firmness. This loss, coupled with the relentless tug of gravity, results in skin laxity and a downward shift of the skin and underlying tissues. 

Dermal landmarks of aging skin include the pronounced laugh lines and marionette lines, a clear depiction of the loss of subcutaneous support. The lips, once plush and rounded, become thin, flat, and deflate, losing their characteristic curvature and fullness. The emergence of vertical lines both above and below the lips, often termed as ‘smoker’s lines’, become increasingly visible. The oral commissures, or corners of the mouth, gradually turn downward, giving the face a perpetual frown. 

Consultation

The crux of a successful practice hinges upon comprehensive patient selection and education. Often, patients tend to confuse neurotoxins like Dysport® or Botox® Cosmetic with Dermal Fillers, erroneously assuming they serve the same purpose. It is incumbent upon the medical practitioner to elucidate the fundamental differences between these two treatment options, particularly when a patient requests inappropriate treatments, such as Dysport® injections in the lips to enhance fullness.

Start your consultation by acquiring a full medical history and conducting a physical examination to rule out potential contraindications. This includes probing for any underlying health conditions or allergies that could impede the successful administration of dermal fillers.

Next, ask the patients about the specific areas they wish to correct or enhance. Assess these areas: nasolabial folds, marionette lines, smile lines, lips, and perioral lines, or vertical lines around the mouth. It’s also crucial to guide the patient through the process. Instead of pointing out perceived flaws, demonstrate the beneficial effects of dermal filler treatment.

Evaluate the depth and severity of wrinkles by performing a stretch test, using your thumb and index finger to see if the wrinkle can be flattened. Not all folds can be completely corrected due to excess sagging tissue or scar tissue, so it’s crucial to set patient expectations appropriately.

Timing of the treatment is another vital consideration. It is generally not recommended to initiate a new treatment, such as lip augmentation with Restylane, close to a major event like a wedding, especially if the patient has never had the treatment before.

Discuss the potential need for touch-ups in the future, the cumulative costs, and their pain tolerance. Offer information about various pain control options available. 

Practitioners should strive to foster a rapport with their patients, taking the time to listen, educate, and set realistic expectations. Some patients may have unrealistic treatment expectations, desiring too many areas to be treated with one syringe, which would lead to suboptimal results. In such cases, it might be preferable to defer treatment rather than risk dissatisfaction. 

Pre-Injection Checklist

Prior to any dermal filler injection, following a systematic pre-injection checklist ensures a smooth and safe procedure.

1. Photography: Maintain a photographic record of the patient’s pre-injection features. This documentation aids in managing any misdirected blame regarding treatment results.

2. Asymmetry Evaluation: Assess for any pre-existing asymmetry. If the patient desires a symmetrical result, ensure sufficient product quantity to treat each side evenly.

3. Pain Management: Offer a topical anesthetic or ice to cool and numb the area before injection to improve the patient’s comfort.

4. Cleanliness: Thoroughly cleanse the area with alcohol wipes to minimize the risk of infection.

5. Proper Equipment: Always use the needle provided by the vendor and ensure it is fully seated to the hub. This reduces the chance of needle disengagement from the syringe and prevents product waste or accidental spills.

6. Needle Position: Orient the eye of the needle upwards towards the skin surface, ensuring accurate and safe product delivery.

7. Air Purge: Push the plunger until a droplet appears at the tip of the needle, removing any air that might be inside the needle hub.

8. Preventive Measures: For patients with a history of cold sores, consider pretreatment with antiviral medication, as any injection around the mouth can trigger a recurrence.

Injection

Dermal filler injections require a meticulous technique to achieve optimal results and minimize complications. Always insert the needle into the middle to deep dermis for appropriate product placement. You can gently stretch the skin to aid needle insertion, which also helps visualize the treatment area better. 

The contour of the needle should be barely visible or not at all, depending on the type of filler used and the severity of the wrinkle being treated. If utilizing a threading technique, apply even pressure on the syringe plunger while slowly retracting the needle. Ensure you stop the injection before completely removing the needle to prevent the product from oozing out or a superficial placement.

Superficial injections can cause a bluish hue on the skin due to the Tyndall effect. If this occurs, consider massaging the product deeper into the tissue, expressing it out, or dissolving with Hyaluronidase.

In fanning technique, keep the needle inside the skin while angling the syringe and reinserting the needle to the hub. Be aware of the potential for intravascular injection. If blanching occurs, immediately stop injecting and massage the area until normal skin color returns. 

Throughout the procedure, you should always feel the resistance of the dermis, indicating correct plane injection. If you encounter too much or too little resistance, you may be in the wrong plane. At the end of the treatment, the injected wrinkle should be visibly lifted and filled.

Post Injection

After administering the dermal filler, a careful evaluation is critical to ensure an optimal result. The treated area should feel smooth with no detectable empty spaces or lumps. Strive for a precise correction – neither under nor overcorrect. 

Gently massage the injection site to blend the product with surrounding tissue. If you feel any bumps or lumps, massage them until they flatten. In most cases, any protrusions will resolve naturally, but reassure the patient and schedule a follow-up appointment within a week. If a lump persists at this follow-up, consider using Hyaluronidase to dissolve the filler.

Symmetry assessment immediately post-injection can be challenging due to localized swelling and bruising. Invite the patient back after a week for re-evaluation once the swelling has subsided. 

Lastly, any post-injection swelling or internal bruising should resolve in a few days. To minimize these side effects, provide your patient with an ice pack, which can also help to reduce potential bleeding. 

This comprehensive approach to patient consultation, preparation, and treatment will facilitate optimal results when using dermal fillers like Restylane, Juvederm, RHA, Versa, and Belotero, and ensure your patients are satisfied with their treatments.

Injection Technique

The success of dermal fillers is not only dependent on the type of product used but also on the technique of injection. There are various injection techniques, each with its own set of advantages and potential pitfalls.

https://youtu.be/FAwQaoHB4YQ

Serial Puncture

The serial puncture technique involves multiple, closely spaced injections along a wrinkle. The key to this technique is the precise placement of the filler. If the filler is not accurately placed, gaps may be found between the injection sites. This technique is less desirable due to the multiple puncture wounds it generates. However, it can be effective for treating fine lines and wrinkles, provided that the practitioner has a steady hand and a keen eye for detail.

Linear Threading

Linear threading is a technique where the needle is fully inserted into the wrinkle up to the hub and the product is injected along the track as the needle is gradually withdrawn. This technique requires continual pressure and even distribution of the product. It is crucial to stop the injection several millimeters before completely removing the needle from the skin to avoid superficial placement or leakage of the product above the skin.

Some practitioners prefer the push-ahead technique, where the product is injected as the needle is being advanced through the skin. This requires a certain level of skill and dexterity, as the practitioner must simultaneously push the plunger of the syringe while pulling back the syringe from the skin. With practice, this technique can be mastered and can provide a smooth, even distribution of the filler.

Cross Hatching

Cross hatching is a technique that involves injecting a series of parallel linear threads at 5 – 10 mm apart, followed by a perpendicular series of parallel linear threads at the same distance. This creates a grid-like pattern and is particularly useful for adding volume to a larger area or when multiple wrinkles are close in proximity. The cross-hatching technique allows for a more uniform distribution of the filler, resulting in a more natural-looking result.

Fanning

The fanning technique involves puncturing the epidermis once, as in the linear threading technique, and before the needle is completely removed from the skin, the needle is moved in a fan pattern to create a triangular shape. Additional evenly spaced fanning injections may be performed without removing the needle from the skin, depending on the size of the triangular area to be filled. Care must be taken to avoid over-injecting at the proximal end of each “fan” as this can result in an overlap of the product in one region.

Ferning

Ferning is a technique that involves short linear threading perpendicular to the fold, followed by advancing a few millimeters away from the fold in either direction. This technique is typically used on dynamic facial lines that require stiffness of the skin on either side of the wrinkle. The ferning technique can provide a more structured support to the skin, helping to smooth out dynamic lines and wrinkles.

Originally published at Dermal Filler Training Austin