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While some treatments, such as botulinum toxin, are fairly straightforward when it comes to standard dosing, there are no standard doses for cosmetic procedures like dermal fillers. The desired treatment outcome (and the volume of filler required) varies greatly among patients. Simply put, filler injections are more of an art form, while the administration of botulinum toxin is more scientific and technical in nature. In this article, we will discuss the doses of dermal filler used in the treatment of marionette lines and nasolabial folds. We will also discuss the different techniques for administering dermal fillers.
Marionette lines occur between the lips and the chin, while nasolabial lines occur between the nose and the mouth. Despite this difference in placement, they are quite similar. Often caused by the natural aging process, these lines and folds are formed when the soft tissue volume of the central face is lost. With this, the adipose tissue is altered, causing the dermis to lose elasticity. This causes the fat pads in the lateral facial regions to slide downwards, resulting in sagging and the formation of lines.
To determine the amount of dermal filler required to treat these wrinkles, the depth of the lines must be considered. In addition, the budget and expectations of the patient must be deliberated, as well as the experience of the doctor.
There are several important aspects to consider during the treatment of marionette and nasolabial lines with injectable filler.
Generally, the cross-hatching technique can be used to treat folds. Inspired by an engineering principle called “bracing,” this technique typically involves the injection of dermal filler perpendicular to the fold. The lines of filler hold and support the tissues, thereby minimizing unwanted movement in dynamic areas. To prevent seeing lines of filler through the skin, the filler should be injected slightly deeper into the dermis. Be aware that thicker fillers will result in stronger cross-hatching, helping the skin to better withstand pressure.
There are 2 main methods for correcting volume loss, which are linear injections and bolus injections. Linear injections are usually administrated superficially or deeply along the lines, whereas bolus injections are performed at the proximal end (where the volume loss tends to be greatest).
For the treatment of nasolabial or marionette lines, it is recommended to use a firmer or thicker dermal filler that contains cross-linked hyaluronic acid (for example, Juvederm Ultra, Restylane Perlane, Belotero Plus Intense, or Dermal Revolution DEEP). These fillers are usually more resistant to the effects of gravity. While they claim to last for 9–12 months, most of these fillers have a much longer duration of action when they are administrated into the nasolabial folds.
The first treatment of these areas usually requires around 2 to 4ml of product, while subsequent repeat treatments generally only require half the volume (1 to 2ml) to achieve similar effects. This may be due to the protective effects conferred by the nose, chin, and zygomatic arch, which shield the face from pressure while sleeping.
As with all procedures, dermal fillers are associated with a risk of complications. The most common complications associated with fillers are injected-related reactions. This includes ecchymosis, itching, erythema, pain, and edema. Being mild and self-limiting in nature, these side effects will usually resolve themselves within 1 week. Local anesthetics, such as lidocaine, can be used to relieve pain and discomfort related to the injection process. Alternatively, ice packs can be applied before and after the procedure for symptomatic relief.
To prevent adverse events, administer bolus injections slowly after aspirating the syringe. Make sure that the syringe is aspirated again after the tip of the needle is removed. In theory, regular aspiration should minimize the risk of severe complications related to fillers, such as vascular occlusion leading to skin ischemia and blindness. However, some inexperienced doctors may not be able to control the location of the needle tip accurately.
Keep in mind that all injections come with a risk of infection. Hyaluronic acid-based dermal fillers are associated with a small risk of allergic reaction, which is characterized by redness and swelling. Patients should seek medical attention if this occurs.
Ultimately, the amount of dermal filler required depends on various factors, such as the treatment priorities and the expectations of the patient. Budgeting also plays a role in deciding how much filler to use. While it may be awkward to discuss treatment priorities and budgets (particularly when patients expect miraculous results with minimal funds), it is worse to end up with unhappy patients. Most patients are willing to spend more on a better quality treatment, but they need to be confident that it will be worthwhile.
When choosing the right filler dosage, consider all the important factors, such as the patient’s budget and the depth of lines. To ensure optimal results, focus on one main area of concern rather than multiple regions—especially when the patient has a limited budget. Treating several areas with a small budget (and smaller amount of filler) often leads to mediocre results. Patients are more likely to return and recommend the treatment to others if they witness the “wow” factor.