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Facial Assessment and Injection Guide for Botulinum Toxin and Injectable Hyaluronic Acid Fillers: Focus on the Midface

de Maio, Maurício M.D.; DeBoulle, Koen M.D.; Braz, André M.D.; Rohrich, Rod J. M.D.on behalf of the Alliance for the Future of Aesthetics Consensus Committee

Plastic and Reconstructive Surgery: October 2017 - Volume 140 - Issue 4 - p 540e–550e
doi: 10.1097/PRS.0000000000003716
Cosmetic: Original Articles
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Summary: This second article of a three-part series addresses techniques and recommendations for aesthetic treatment of the midface. Injectable fillers are important for rejuvenation of the midface by replacing lost volume and providing structural support; neuromodulators play a smaller role in this facial region. Fillers are used for volumization and contouring of the midface regions, including the upper cheek and lid-cheek junction and the submalar and preauricular areas. Also, treatment of the frontonasal angle, the dorsum, the nasolabial angle, and the columella may be used to shape and contour the nose. Neuromodulators may be used to treat bunny lines and for elevation of the nasal tip. The midface is considered an advanced area for treatment, and injectors are advised to obtain specific training, particularly when injecting fillers near the nose, because of the risk of serious complications, including blindness and necrosis. Injections made in the midcheek must be performed with caution to avoid the infraorbital artery.

Supplemental Digital Content is available in the text.This and Related “Classic” Articles Appear on Prsjournal.Com for Journal Club Discussions.

São Paulo, Brazil; Aalst, Belgium; Rio de Janeiro, Brazil; and Dallas, Texas

From the Clinica Dr. Maurício de Maio; the Aalst Dermatology Clinic, private practice; and the University of Texas Southwestern Medical Center.

Received for publication April 13, 2016; accepted February 21, 2017.

Disclosure: Dr. de Maio is an Allergan plc consultant for speaking events and marketing strategy. Dr. DeBoulle is an Allergan plc consultant for speaking events and marketing strategy. Dr. Braz is an Allergan plc, Galderma, Merz, Loreal, La Roche Posay, Palomar, Skinceuticals, and Vichy consultant. Dr. Rohrich receives instrument royalties from Eriem Surgical, Inc., and book royalties from Thieme Medical Publishing. No funding was received for this article.

Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s website (www.PRSJournal.com).

Maurício de Maio, M.D., Clinica Dr. Maurício de Maio, Avenida Ibirapuera, 2907 cj 1202, Moema EP 04029200, São Paulo, Brazil, mauriciodemaio@uol.com.br

This second part of a three-part series describes techniques in the midface with a focus on alert areas. Table 1 illustrates the recommended needles by product. The midface is the most important supporting area for both the upper and lower face. In this area, the use of fillers is much more important than the use of a neuromodulator. Recommended Allergan plc (Dublin, Ireland) portfolio products and volumes/doses are listed in Table 2. Other filler and neuromodulator options are available and can be used in the treatment areas described; good results are dependent as much on injector technique as on the product used. We provide detail specific to Allergan products because of our extensive experience with these products in clinical practice.

Table 1

Table 1

Table 2

Table 2

Treatment of the lateral cheek may indirectly improve the tear trough, nasolabial fold, upper lip oral commissure, marionette lines, and jawline, and also provide support for the eyebrow. Injections into the midcheek should be handled with caution because of the presence of the infraorbital artery. Injections in and near the nose require specific training and experience because of the risk of blindness and necrosis with inadvertent injection into the angular and dorsal nasal arteries.

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AESTHETICS OF THE PERIORBITAL AREA AND CHEEKS

The midface contains important hallmarks of facial beauty and a youthful appearance; specifically, the malar projection and full cheeks.1 The youthful midface exhibits a smooth convexity from the lower eyelid down to the nasolabial fold and buccal region. The junction between the lower eyelid and cheek should be smooth and short.

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AGING OF THE PERIORBITAL AREA AND CHEEKS

The first signs of aging are noticed around the eye region, with excess skin and eye bags.2 With aging, fat redistribution, skin laxity, and connective tissue weakness affect transitions from the periorbital area to the cheek.3 Eye bags result from laxity in the orbital septum and pseudoherniation of orbital fat.3 With aging, a depression or concavity may develop at the junction of the thin eyelid skin above and the thicker nasal and cheek skin below, which is associated with a reduction in subcutaneous tissue overlying the maxillary bone.1 Initially, the depression is seen in the medial aspects of this area, but with continued aging, volume loss may become evident laterally. Volume loss is seen in the cheek area, with cheek wrinkling facilitated by dermal atrophy and lack of fat pads.1,4 The convex contour of the upper cheek region may flatten or become concave with age.5 A 2- to 3-cm depression extending inferolaterally from the eyelid, known by various names including the nasojugal groove, tear trough, or lid-cheek junction, may be evident.4 The loss of midfacial cheek support contributes to deep nasolabial folds and may lead to a skeletonized appearance of the cheekbones.1,2 Midfacial fat redistribution occurs with aging, including accumulation of anterior and inferior cheek fat and loss of lateral and superior fat.1 These changes cause a depression in the submalar area, which is an inverted triangular area limited superiorly by the zygomatic prominence, medially by the nasolabial fold, and laterally by the masseter muscle.1 The loss of lateral cheek fat with aging may lead to volume depletion in the preauricular area.1

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ASSESSMENT OF THE PERIORBITAL AREA AND CHEEKS

Midfacial assessment should be made at rest and during animation (i.e., while smiling).6 Assess the skin surface contour and shadowing, and assess the presence of dermal and fat pad atrophy, increased dynamic and static lines, loss of malar projection, and loss of bone volume and structure.1,6 Identify the point of maximal projection of the cheekbone; the ideal location is 10 mm lateral and 15 mm inferior to the lateral canthus.1

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ANATOMY OF THE PERIORBITAL AREA AND CHEEKS

The infraorbital artery originates from the infraorbital foramen [6 to 8 mm inferiorly to the arcus marginalis (orbital rim)], runs through the infraorbital foramen, and emerges onto the face, where it supplies the lower eyelid, lateral nose, and upper lip.6 It branches into the anterior superior alveolar artery that supplies the anterior teeth and maxillary sinus, and terminates in anastomoses with the transverse facial, angular, and buccal arteries and branches of the ophthalmic and facial arteries. The fat pads in the midface include the deep infraorbital fat pad and the medial and lateral suborbicularis fat pads.7 Volumizers are used to address loss in these fat pads.

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FILLER INJECTION TECHNIQUE FOR INDICATIONS IN THE PERIORBITAL AREA AND CHEEKS

Upper Cheek

Volume replacement in the upper cheek can be achieved with Voluma. There are three potential injection sites: lateral cheek, anterior cheek, and medial cheek (Fig. 1, left). Voluma should be administered at these sites as needed, paying particular attention to ethnic differences in bony anatomy. For each site, aspiration is necessary before injection. Massage after the injection to distribute the filler evenly.

Fig. 1

Fig. 1

In the lateral cheek, Voluma is administered by means of a supraperiosteal small-bolus injection. If up to 0.5 ml per side of Voluma is needed, treatment should be divided into two bolus injections. Injectors should be alert to avoid the zygomatic facial vessels and nerves (Fig. 1, right), and they should use a finger to avoid upper and lower displacement of the filler into the temporal area. [See Figure, Supplemental Digital Content 1, which shows injection technique for upper cheek. Injections must be below the orbital rim in the anterior and medial cheek (left). Inject by periosteal small-bolus injection at the lateral cheek and anterior cheek (right). Inject slowly at each site. Use fingers to avoid inadvertent displacement of filler to the temporal area during treatment of the lateral cheek, and to the lower eyelid during treatment of the anterior cheek. Aspiration before injection is mandatory at each site, http://links.lww.com/PRS/C362.] Inject slowly, and exercise care to avoid scratching the periosteum.

In the anterior cheek, Voluma may be administered by means of a deep subcutaneous small-bolus injection or, alternatively, by means of a supraperiosteal small-bolus injection. The latter should be considered when there is a lack of bone projection. If more than 0.3 ml per site is required, it should be divided into small-bolus injections. Injectors should be alert to avoid the infraorbital artery and vein, and they should ensure that injections are made below the orbital rim (arcus marginalis). Inject slowly and use a finger to avoid displacement to the lower eyelid. After treatment, the cheek volume should be natural at rest and with animation. Do not overvolumize to erase nasolabial folds, as these can be treated directly.

For treatment of the medial cheek, Voluma can be injected through a supraperiosteal or deep subcutaneous small-bolus injection. Make sure that the infraorbital foramen is marked correctly. Voluma should be injected lateral to the midpupillary line by means of a supraperiosteal small bolus in either case. Avoid the angular and infraorbital arteries and veins, and ensure that injections are made below the orbital rim. Inject very slowly, and use the middle and index fingers to protect the eye and the infraorbital foramen. The use of a 25-gauge blunt microcannula rather than a needle is recommended if Voluma is injected medial to the midpupillary line and close to the nose. It is important to recognize that this is an area of risk for severe vascular damage; therefore, we emphasize that use of a needle is not recommended.

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Lid-Cheek Junction

Volume replacement in the medial and lateral lid-cheek junction may be achieved using either Volbella or Ultra. Both products are delivered by means of very small supraperiosteal bolus injections at two to three sites in the medial lid-cheek junction and/or two to three sites in the lateral lid-cheek junction (Fig. 2, left). Injections at the lid-cheek junction should be attempted only by experienced injectors.8 This area is at high risk of bruising, and the injections carry significant risk of persistent eyelid edema, embolization, asymmetry, lumps, and double vision (see areas to avoid in Fig. 2, right).9 Alternatively, use of 25- or 27-gauge blunt microcannulae may avoid bruising and embolization.

Fig. 2

Fig. 2

Avoid the orbit by performing injections 1 to 2 mm below the orbital rim. For the first injection, have the patient close their eyes for protection. Aspirate before injection, and inject slowly. Move to the second injection and then the third injection. [See Figure, Supplemental Digital Content 2, which shows injection technique for volume replacement along the lid-cheek junction. For the first injection (left), have the patient close their eyes for protection, aspirate before injection, and inject slowly. For the second (center) and third (right) injections in each region, stay deep along the inferior orbital rim, aspirate before injection, and inject slowly. Massage after each injection and avoid overcorrection, http://links.lww.com/PRS/C363.] Again, aspirate before injection, and inject slowly. Massage after each injection to distribute the product evenly, and avoid overcorrection.8 Injectors should be alert to avoid the infraorbital nerve, artery, and vein at site 1 and the angular artery and vein during injection at site 3. Optimal correction can be delivered when using Volbella. However, when using Ultra, partial correction down to 50 percent is recommended to avoid development of late edema following treatment because of its greater hydrophilicity.

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Submalar Area

Volume replacement in the submalar area can be achieved with Volift, Ultra Plus, or Voluma. Two different techniques are recommended. With both, injectors need to be alert to avoid the facial artery and vein and the parotid duct, and to be careful near the buccal branches of the facial nerve. With the first technique, a small bolus of filler is administered at four sites per side by means of subcutaneous injection (Fig. 3, above, left). Volift or Ultra Plus is recommended for use in minor submalar volume replacement, and Voluma is recommended in cases of severe volume loss. With the second technique, the filler is administered by means of a superficial subcutaneous injection at a single medial site in the submalar area using a fanning technique (Fig. 3, above, right). The needle is inserted through a single insertion point and pivoted to create a series of linear tunnels in a fanlike pattern. The submalar area is prone to bruising. To avoid injecting into deep vessels and nerves (Fig. 3, below), pinch the skin, aspirate before injection, and inject slowly. (See Figure, Supplemental Digital Content 3, which shows injection technique for volume replacement in the submalar area. Both techniques require pinching the skin during injection, aspiration before injection, and slow injections. With the second technique, it is important to promote even distribution of the product during injections. An intraoral massage should be used to distribute product evenly. When Voluma is injected by the second technique, the skin surface should also be massaged, http://links.lww.com/PRS/C364.) Injections of Volift or Ultra Plus should be more superficial than those with Voluma. With the latter, overinjection may lead to an undesirable bulge. Apply intraoral massage to distribute product evenly for both techniques. Promote even distribution of product during the injection. Proceed from lateral to medial when pivoting the needle. For safety reasons, the use of blunt microcannulae is advisable when treating the submalar area.

Fig. 3

Fig. 3

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Preauricular Area

Volume replacement in this lateral cheek area may be achieved with Voluma, Volift, or Ultra Plus. Superficial subcutaneous small-bolus injections are delivered at three to five sites on each side (Fig. 4, left). Injectors should be alert to avoid the parotid gland and the transverse facial artery and vein; therefore, subcutaneous injection is mandatory (Fig. 4, right). Aspirate before injection, insert the needle in a superficial subcutaneous plane angled upward, and inject slowly. (See Figure, Supplemental Digital Content 4, which shows injection technique for volume replacement in the preauricular area. Aspirate before injection, and deliver a superficial subcutaneous small-bolus injection. Inject slowly, and massage robustly after injection with Voluma, http://links.lww.com/PRS/C366.) This area is prone to irregularity if large volumes of filler are injected per site. If large volumes are required, inject a small bolus and massage, and repeat until full correction is obtained. Some defects may be difficult to correct because of parotid fascia attachments. Robust massage after injection is recommended. In patients with a skeletonized facial appearance, the use of Volift with a blunt cannula is recommended.

Fig. 4

Fig. 4

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AESTHETICS OF THE NOSE

The nose is an important landmark in facial beauty; even slight modifications may produce dramatic changes in appearance.6,10 The nasolabial angle should be 95 to 100 degrees in women and approximately 90 to 95 degrees in men.6 Asians typically have a shorter, wider, and less projecting nose compared with Caucasians.11 However, among Asians, a good dorsum height, narrow alar base, and tip projection are considered preferable.11 The use of fillers and neuromodulators in combination offers a minimal approach for reshaping the nose and midface area, addressing both the loss of volume and structure and the wrinkles that develop with aging.12

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AGING OF THE NOSE

Aging may alter the shape of the nose. Changes include a drooping of the nasal tip, increasing prominence of the dorsal hump, and a decrease in the width of the body and cartilaginous dorsum.6 With the relative shortening of the lower third of the face combined with a relative elongation of the nose, there is the appearance of a drooping tip and accentuated dorsal convexity.6,13

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ASSESSMENT OF THE NOSE

The frontal assessment should include evaluation of the straightness and symmetry of the nose and whether any deviations are present, the width of the bony and cartilaginous dorsum, the width of the nasal tip, and the visibility of the columella.1 On a side profile, measure the frontonasal angle, nasolabial angle, and height of the nose, and assess for irregularities on the dorsum and for the presence of a supratip break.1 Avoid treating patients with prior nasal surgery, as they may have increased potential for adverse events.

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ANATOMY OF THE NOSE

The blood supply derives from the facial artery; important branches are the lateral and dorsal nasal arteries. The dorsal nasal artery anastomoses with the supratrochlear artery; this anastomosis is a point of high risk that can lead to serious complications such as blindness.1,6 Filler or neurotoxin injections in the nose for postrhinoplasty deformities may dramatically increase the risk of complications. These deformities should be addressed only by experienced injectors or, preferably, by the surgeon who performed the original surgery.

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FILLER INJECTION TECHNIQUE FOR INDICATIONS IN THE NOSE

Frontonasal Angle

Filling the frontonasal angle to reduce the concavity of the dorsum may make the nose appear smaller. This procedure is particularly suited for patients whose frontonasal angle is too deep.1 Filling the frontonasal angle may be achieved with Ultra Plus or Voluma using a single supraperiosteal small-bolus injection (Fig. 5, left). Injectors should be alert to the presence of anastomosis of periorbital vessels in the subcutaneous plane (Fig. 5, right). Pinch the skin around the injection site and keep your fingers in place to avoid lateral displacement of the filler, touch the bone, aspirate before injection, and inject deep and very slowly with low pressure, maintaining the needle in the midline. (See Figure, Supplemental Digital Content 5, which shows injection technique for filling the frontonasal angle. Pinch the skin during the injection, aspirate before injection, and inject very slowly with low pressure, staying deep and in the midline, http://links.lww.com/PRS/C367.) Massage softly after the injection to evenly distribute the filler. Pain is not common with this injection.1 If there is a change in skin color or severe pain, stop the injection immediately.

Fig. 5

Fig. 5

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Dorsum

Injection of filler in the dorsum is appropriate for reshaping when the nose tip is adequate but the frontonasal angle and dorsum are low.1 Filling the bony dorsum and cartilaginous dorsum may be achieved with Ultra Plus or Voluma. For the bony dorsum, one supraperiosteal injection is delivered by a linear retrograde technique or as a small bolus (Fig. 6, left). Injectors should be alert to avoid the dorsal nasal artery and vein (Fig. 6, right). In Asian patients (and in Caucasians with a drooping nasal tip), consideration should be given to injecting the columella and anterior spine before injecting the dorsum. The injection and precautions for administering filler in the bony dorsum are identical to those described above for the frontonasal angle. (See Figure, Supplemental Digital Content 6, which shows injection technique for filling the bony dorsum. Pinch the skin during the injection, aspirate before injection, and inject very slowly with low pressure, staying deep and in the midline, http://links.lww.com/PRS/C368.)

Fig. 6

Fig. 6

For the cartilaginous dorsum, a single injection of Ultra Plus or Voluma is delivered above the cartilage using a linear retrograde technique (Fig. 7, left and center). The volume range depends on the severity of the defect. Aspiration is mandatory before injection. Injectors should be alert to avoid the dorsal and external nasal arteries, the external nasal nerve, and the lateral nasal artery in the alar groove (Fig. 7, right). Again, the injection and precautions for administering filler in the cartilaginous dorsum are the same as those for the frontonasal angle and bony dorsum. (See Figure, Supplemental Digital Content 7, which shows injection technique for filling the cartilaginous dorsum. Pinch the skin during the injection, aspirate before injection, and inject very slowly with low pressure, staying deep and in the midline, http://links.lww.com/PRS/C369.) In addition, care should be exercised to avoid supratip deformation caused by excessive filling of the cartilaginous dorsum.

Fig. 7

Fig. 7

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Nasolabial Angle

Increasing the nasolabial angle may be achieved by injecting Ultra Plus or Voluma into the anterior nasal spine.1 A supraperiosteal bolus injection is given at one site (Fig. 8). Injectors should be alert to avoid injecting filler into the cartilage of the anterior septum or into the columellar branches of the superior labial artery and vein. Pinch the skin around the injection site and keep your fingers in place to avoid lateral displacement of the filler, aspirate before injection, and inject very slowly with low pressure, maintaining the needle in the midline. (See Figure, Supplemental Digital Content 8, which shows injection technique for increasing the nasolabial angle. Pinch the skin during the injection, aspirate before injection, and inject very slowly with low pressure, staying deep and in the midline, http://links.lww.com/PRS/C370.) Pay attention to the injection volume to avoid elongation of the upper lip. Massage softly after the injection. Stop the injection immediately if there is a change in skin color or severe pain.

Fig. 8

Fig. 8

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Columella

Enhancing the columella height is performed in cases where the nostrils are flat or the columella is retracted.1 In treating the columella, Ultra Plus or Voluma may be used. An injection is given at one site in the anterior cartilaginous septum using a linear retrograde technique or as a small bolus (Fig. 9). Injectors should be alert to avoid injecting directly into the tip of the nose and to avoid the columellar branches of the superior labial vessels. As with the other injections of filler in the nose, pinch the skin during injection, aspirate before injection, and inject very slowly with low pressure. (See Figure, Supplemental Digital Content 9, which shows injection technique for increasing the columella height. Pinch the skin during the injection, aspirate before injection, and inject very slowly with low pressure, staying deep and in the midline, http://links.lww.com/PRS/C371.) Stay deep and maintain the needle in the midline. Avoid lateral displacement and avoid widening the columella. Inject into the space behind the columella itself, but in front of the anterior septum. Massage softly after the injection. Stop the injection immediately for skin color change or severe pain.

Fig. 9

Fig. 9

Injections into the nose should be attempted only by experienced injectors because of the high risk of necrosis and blindness. For Asians with very flat noses, the use of a blunt microcannula is advisable. However, even with this precaution, the above-mentioned complications may occur. Proper training and gentle technique are highly recommended.

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ONABOTULINUMTOXINA INJECTION TECHNIQUE FOR INDICATIONS IN THE NOSE

Bunny Lines

Bunny lines may appear during facial animation, such as smiling, laughing, frowning, or speaking. In addition, they may appear in some patients after treatment of glabellar or crow’s feet lines with neurotoxins if the nasalis muscle is not also blocked.6 Bunny lines develop from contraction of the transverse fibers of the nasalis muscle on the dorsum.6 Contraction of the procerus muscle lowers the medial aspect of the eyebrow and can also contribute to horizontal lines in this area. Treatment of bunny lines is made at two lateral injection sites, one on each side of the nose (Fig. 10). In some patients, a third medial site is also treated. Insert the needle to one-third of its depth and inject onabotulinumtoxinA into the transverse part of the nasalis muscle. (See Figure, Supplemental Digital Content 10, which shows injection technique for bunny lines. Insert the upper one-third of the needle into the transverse part of the nasalis muscle, http://links.lww.com/PRS/C372.) Avoid far lateral injections because of the risk of lip ptosis caused by compromise of the levator labii superioris alaeque nasi muscle.

Fig. 10

Fig. 10

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Elevation of the Nasal Tip

The tip of the nose is drawn downward by contraction of the depressor septi nasi muscle during smiling.6 The nasal tip may also droop at rest as a result of aging.6 Treatment with onabotulinumtoxinA elevates the nasal tip at rest and prevents it from drooping during smiling. This is achieved by a transcutaneous medial injection at the columella base (Fig. 11). Insert the needle to one-half of its depth and inject onabotulinumtoxinA into the depressor septi nasi muscle. (See Figure, Supplemental Digital Content Figure 11, which shows injection technique for elevation of the nasal tip. Insert the needle to one-half of its depth into the depressor septi nasi muscle, http://links.lww.com/PRS/C373.) Avoid injecting in patients who have a very long upper lip. Sensitive patients may benefit from a topical anesthetic in this area. In certain cases such as volume loss in the maxillary complex with aging, complete elevation of the nasal tip may not be fully achieved with this technique.

Fig. 11

Fig. 11

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CONCLUSIONS

Injectable fillers are much more important than neuromodulators in the midface, where they are used to correct volume loss and provide structural support. Injections in the midface need to be performed carefully to avoid displacement of filler beyond the area to be treated. Specifically, injections into the midcheek region need to be performed with caution to avoid the infraorbital artery. In addition, injections near the nose require specific training and experience because of the risk of serious complications, including blindness and necrosis.

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ACKNOWLEDGMENTS

This article was sponsored through an educational grant from Allergan plc (Dublin, Ireland). Medical writing assistance was provided by Barry Weichman, Ph.D., of Peloton Advantage (Parsippany, N.J.) and funded by Allergan plc. No honoraria or other forms of payment were made for authorship.

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REFERENCES

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3. Glaser DA, Patel U. Enhancing the eyes: Use of minimally invasive techniques for periorbital rejuvenation. J Drugs Dermatol. 2010;9(8 Suppl ODAC Conf Pt 2):s118–s128.
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5. Small R. Dermal Filler Procedures. 2012.New York: Wolters Kluwer Health.
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9. Raspaldo H, Gassia V, Niforos FR, Michaud T. Global, 3-dimensional approach to natural rejuvenation: Part 1. Recommendations for volume restoration and the periocular area. J Cosmet Dermatol. 2012;11:279–289.
10. Swift A, Remington K. BeautiPHIcation: A global approach to facial beauty. Clin Plast Surg. 2011;38:347–377, v.
11. Bergeron L, Chen PK. Asian rhinoplasty techniques. Semin Plast Surg. 2009;23:16–21.
12. de Maio M. The minimal approach: An innovation in facial cosmetic procedures. Aesthetic Plast Surg. 2004;28:295–300.
13. Shaw RB Jr, Kahn DM. Aging of the midface bony elements: A three-dimensional computed tomographic study. Plast Reconstr Surg. 2007;119:675–681; discussion 682–683.

Supplemental Digital Content

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