Juvederm Ultra Injection to NasoLabial Folds (laugh lines) by Reston Virginia Cosmetic Surgeon

Hi. We're going to do a filler injection for our volunteer patient here. We're going to inject her laugh lines, which are referred to as the nasolabial folds and the marionette areas. If you look at most patients starting in about the 20s and definitely getting worse with age, the line starts from the junction of the nose and it goes up laterally towards the outer portion of the lips. These are referred to as laugh line. If she smiles for us, or smile lines, you can see that they get deeper. Now, if you relax, you can see that this line is created by the descent of the cheek pad. This little bit of soft tissue here, a few years ago was up higher and what happens is it starts carrying on downwards and with age it gets worse and worse and worse. There are lots of different options for treating this area. A mid facelift takes this tissue pad and resuspends it up in a surgical fashion. Other options are filler injections, fat injection, if it's worse enough, subcision, which actually releases the scar tissue that's created between the skin and the deeper structures. But nine out of 10 times, most patients these days are getting filler injections or outpatient procedures. It takes just a few minutes to do very low risk and they get back to their regular activities and it looks very natural. There's lots of options. Juvederm, Purlane, Restylane, Radiesse, Artifalderol. Choices that are safe options in the United States, all FDA approved. What we're going to do is Juvederm, which is one of my favorite substances because of its texture and its longevity. We're going to prepare her. What I first do is I go ahead and take an alcohol wipe and I prep the area that I'm going to inject. Then we take the substance. It comes prepackaged with its own very small 30 gauge needle. The needle has to be placed on very tightly with Juvederm. With Restylane, you don't want to tighten it too much. With Juvederm, you have to tighten it. Those of you who have seen the needle pop out during the injection know why that is. We're going to start with two different techniques. The first technique that I like to use when I inject Juvederm or any filler really, is to fill the area in a longitudinal fashion. And go right under the skin. With Juvederm, it can be very close up to the epidermis itself. After I do a longitudinal filling, I like to do perpendicular, especially up high, close to the junction of the nose. It allows the tissue to be pushed away in a very natural fashion. And any filler, when I inject it, I massage it. And after I massage it, I don't feel any lumps or bumps. It's gone. A lot of times with age, patients start developing a little bit of a shadowing right here at the corner of the lip. That's called the marionette area. The best way to remove that is to fillet, which pushes the corner of the lip upwards. There's a little triangular zone depending on the age of the patient. Our volunteer patient is very young, so we don't need too much. But in older patients, you want to actually inject the entire triangular space in this area to fill it and push it up. But in the younger patients, such as this, just a few little blebs do the trick. Push the lip up nicely and I have them hold a little bit of pressure and I go to the other side. Start the same way. Start with the longitudinal serial injection. The depth with Juvederm is going to be different than the depth with, for example, Arrhenius or Artifil. You can be closer to the epidermis and you can actually see the location of your needle and the filler as you're injecting. With artiful and radius, you definitely are going to be deeper. If you see your needle drop too close to the skin, then you're going to have a bad outcome. So choosing the proper filler isn't all about longevity of the substance, how long it lasts, and the cost of the substance. The nature of the line and the fold is also very important. We're going back down here to the marionette area. Pushes the lip up really nicely. What I do now is I always save a little bit. After injecting a symmetric amount, I save a little bit. You can go and hold this, and I compare the sides and I do my fine contouring after I've compared the sides. Often you need a little bit more on one side than the other. Our patient's right side is deeper, and I knew this beforehand, so I've already put in a little bit more on the other side. But most of the time you do a symmetric amount and then you judge. So what I do is I take a look, I step back. Lift your head for me. Don't smile, just relax. Return it back. We'll just do a little bit of contouring here, Come back to the other side, And if you hold pressure about a minute or two, that reduces chances of bruising. Bruising in this area is really rare, even though with every needle stick we do see some oozing of blood. It's rare for patients to get a bruise, unlike the lips where bruising can happen. But again, they can be covered with lipstick or makeup immediately afterwards. So after she holds it for about a minute, we're going to take injection. She's held onto a little bit of pressure there for about a minute and a half. She's taking it off. I don't see any significant bruising. A couple of very small little particle spots which are really easy to cover with makeup, and that's the final result. It's very natural. Don't smile. Pull back. Okay. And you can see the final outcome. Now, what happens over the next several days? The substance is hydrophilic, so it actually attracts more water and more fluid, so it'll even fill in more over the next several days. Thank you. Thank you.