There are no standard doses for cosmetic procedures such as dermal fillers — the volume of filler required, and the desired treatment outcome varies greatly among patients. In this article, we will discuss the doses of dermal fillers used in the treatment of marionette lines and nasolabial folds. We will also discuss the different techniques for administering dermal fillers to achieve specific, desired outcomes.

Marionettes lines and nasolabial folds

Marionette lines occur between the lips and the chin, and nasolabial lines occur between the nose and the mouth. Despite this difference in facial location, 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/middle face is lost. With this loss of volume, 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 inevitable formation of lines.

To determine the quantity 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 reviewed, as well as the experience of the doctor.

Technique

There are several important aspects to consider during the treatment of nasolabial and marionette lines with injectable filler.

1. Folds

Generally speaking, the cross-hatching treatment technique is effective to treat folds. Inspired by an engineering principle called “bracing,” this technique involves the injection of dermal filler perpendicular to the fold. The lines of dermal filler hold and support the tissues, thereby minimizing unwanted movement in dynamic areas. To prevent seeing lines of the dermal 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.

2. Loss of volume

There are two main methods for correcting general volume loss, which are linear injections and bolus injections. Linear injections are typically administrated superficially or deeply along the lines, whereas bolus injections are performed at the proximal end – where the volume loss tends to be greatest.

Selection of Product

For the treatment of nasolabial or marionette lines, it is recommended to use a firmer or more thick dermal filler that contains cross-linked hyaluronic acid (for example, Juvederm Ultra 2). Fillers formulated using cross-linked hyaluronic acid are usually more resistant to the effects of gravity. While they claim to last for 9–12 months, many have a much longer duration of action when they are administrated into the nasolabial folds.

The first treatment of these areas typically requires around 2 to 4ml of product, while follow-up treatments generally only require half the volume (1 to 2ml) to achieve similar effects.

Complications

As with all procedures, dermal filler treatments are associated with a risk of complications. The most common complications associated with dermal fillers are injected-related reactions. This includes ecchymosis, itching, pain, and edema. Being mild and self-limiting in nature, these side effects will normally resolve themselves within 1 week. Local anesthetics, such as lidocaine, can be used to relieve pain and discomfort related to the injection. Also, ice packs can be applied before and after the procedure for symptomatic relief.

To prevent adverse events, it’s recommended to administer bolus injections slowly after aspirating the syringe. Make certain 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 dermal filler treatment, such as vascular occlusion leading to skin ischemia and blindness. However, some inexperienced practitioners may not be able to control the location of the needle tip accurately.

Keep in mind that any injections come with a risk of infection. Hyaluronic acid-based dermal fillers are associated with a small risk of allergic reaction, characterized by redness and swelling. Patients should seek medical attention if this occurs.

The process

Ultimately, the amount of 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 should be used. While it may be awkward to discuss treatment priorities and budgets (particularly if patients expect unrealistic results while spending 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 – patient education is key.

Summary

When choosing the correct filler dosage, consider all the important factors, such as the patient’s budget and the depth of lines. To ensure the best 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 therefore, a smaller amount of filler), can often lead to mediocre results. Patients are more likely to return and recommend the treatment to others if they witness the “wow” factor.