With the mid-face, it’s important to understand what’s going on. We can see age-related drooping and a gathering of tissues over the nasolabial fold. This also tends to pull eyelid tissue down resulting in an unmasking of the bony inferior orbital rim. This is an area that we want to pay attention to, which can benefit greatly with fillers. I tend to use Radiesse to augment the mid-face but something thinner like a hyaluronic in the tear trough. Radiesse lasts a year, takes 15 minutes to inject and the patients are happy.

Before, we could only get the same results with a cheek implant. But cheek implants frequently resulted in intraoral exposure and complications. Longer acting fillers work very well.

In the mid-face, you need to be mindful of what plane you’re in. I like the subdermal plane, injecting small amounts, then massaging and feathering it. This is why filler is superior to a solid implant. You have the ability to manipulate it endlessly and soften the effects.

In terms of the plane, I’ve had one serious complication with a filler. I was injecting over the bone, in the supraperiosteal level, and some of the filler tracked into the infraorbial foramen and caused a long-lasting numbness in the cheek and upper lip on that side which took almost a year to resolve. The subdermal plain is very safe. I keep the filler out of the orbit, away from the orbicularis, just in the cheek. I treat the orbital rim tear trough with just a light HA. You’re close to the eye so inject slowly while withdrawing the needle. I prefer using a longer needle—a one inch, 30G—and draw it back along the rim, leaving the filler right on the bone and under the muscle. This is an advanced technique so make sure you know what you’re doing and spend some time learning from someone experienced in this procedure.

Some patients who have a prominent medial compartment of the inferior orbital fat, who would otherwise have a blepharoplasty, can be treated with this technique using a light HA along the rim.

This can provide contour improvement in a non-invasive way. HAs tend to last six months on the inferior orbital rim, but I have seen results last up to a year.

For fine facial lines, a light to medium HA is the best bet. For superficial lines, take your time to fill them carefully. For medium to deep lines, a little Radiesse can provide dramatic improvement without any surgery, which patients appreciate.

Medium to large contour defects, whether in the bone or soft tissue, can be treated with Radiesse. If they’re small and superficial, such as acne scars, I usually go with an HA. You can use, for example, Beloltero and the tip of a half-inch 30G needle, using a subcision technique to get a nice effacement of the scar.

Fillers come into their own in the nasolabial fold. I tend to use calcium hydroxylapatite, or Radiesse. I can layer the product—if they have a well-defined line within the fold itself, I’ll layer the Radiesse deep and then apply an HA superficially.

This can be quite successful—a study investigating the use of Radiesse and HA in combination found that the patients were happier with the combination treatment than one treatment alone.

I mainly use calcium hydroxylapatite in the melolabial fold and prejowl sulcus jaw line, unless the tissues are very thin and then I’ll use an HA. Perioral lines, smoker’s lines or very thin lines can be treated with a very light HA.

Using very small amounts of a neuromodulator into the deep lines around the mouth works well. Large amounts interfere with the smile and ability to speak, so don’t get carried away—use it in very fine, small amounts. Some patients are happy with neuromodulator treatment for the depressor anguli oris, but others aren’t. I’m on the fence about that.