[Dr. Belleview Column 67.] Which area is the most difficult for filler procedures?

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Areas with a high level of difficulty for filler procedures

When performing filler procedures, which area is actually the most difficult? Today, let’s talk about that. Patients may not know, but those who are quite interested usually have a general idea. In general, the area under the eyes, the nose, the forehead, and the temples are known to be more difficult areas for treatment. Why is that? It is because these areas have many risk factors that require caution during the procedure. The difficulty of a filler procedure can be said to depend on the density of blood vessels and the anatomical characteristics of the area. When injecting filler into areas with many nerves and blood vessels, the procedure must be performed carefully while avoiding damage to them. Even if the same amount of filler is injected, areas with a greater distribution of nerves and blood vessels require more focused and cautious work, which also takes more time. Let’s take a look by area.

1. Under the eyes (tear trough filler)

• Skin characteristics: The skin under the eyes is very thin, sensitive, and has a complex distribution of blood vessels and nerves.

• Procedure difficulty: Because the skin is thin, if too much filler is injected or the depth is not properly controlled, it can easily become uneven or show the Tyndall effect, where a bluish tint appears through the skin. In addition, if the blood vessels around the eyes are damaged, bruising or swelling can be severe.

• Risk: Since important blood vessels pass around the eyes, there are reports that incorrect treatment can block blood vessels and lead to serious side effects such as blindness.

2. Nose (nose filler)

• Skin characteristics: The nose is a narrow area where bone and cartilage structures are intricately intertwined, and the blood vessel distribution is also very dense.

• Procedure difficulty: To achieve a natural result, the amount and depth of filler must be precisely adjusted according to the treatment area, such as the bridge, tip, and alae of the nose. In particular, the tip of the nose has thick skin and low elasticity, making it difficult to shape with filler.

• Risk: The blood vessels around the nose are connected to important vessels leading to the eyes and brain, so incorrect treatment can block blood vessels and cause serious side effects such as skin necrosis, blindness, and stroke. In fact, there have been reports of blindness after nose filler procedures.

3. Forehead (forehead filler)

• Skin characteristics: The forehead skin is relatively broad, but it is thin and close to the bone, so controlling the depth of injection is important. The forehead has a dense concentration of important blood vessels and nerves, so filler must be injected while avoiding them. Incorrect treatment can lead to serious side effects such as skin necrosis or, in rare cases, blindness. Because of these structural characteristics, a high level of skill is required of the practitioner.

• Procedure difficulty: The forehead is one of the widest areas and varies greatly in curvature from person to person, so it is truly difficult to naturally fill hollow areas and create a smooth curve. The result must be achieved through very meticulous work. To provide a natural volume, filler must be injected evenly across the broad area, and if it is injected too superficially it may look uneven, while if it is injected too deeply the effect may be minimal. Also, because the fatty and muscle layers of the forehead are quite thin, there is a high risk that the filler will clump near the surface or look abnormal, so it is important to inject it at the proper depth.

• Risk: Since blood vessels also run through the forehead, incorrect treatment can cause bruising or swelling due to blood vessel damage. In rare cases, skin necrosis due to vascular occlusion is also reported. Although opinions may differ among doctors, the forehead is often mentioned as one of the most difficult areas for filler procedures.

4. Temples

• Skin characteristics: The temple area has thin skin, is close to the bone, and important blood vessels and nerves pass through it.

• Procedure difficulty: Because the temples are a curved area, it is difficult to inject filler evenly, and excessive injection can lead to unnatural results.

• Risk: If the blood vessels around the temples are accidentally affected, side effects such as skin necrosis due to vascular occlusion and decreased vision may occur.

How to avoid blood vessels and nerves during filler procedures

• The most important thing is to accurately identify the location of blood vessels and nerves in the treatment area. This allows filler to be injected into a safe layer while avoiding major blood vessels and nerves.

• Before injecting the filler, gently pull back on the syringe to check whether it is inside a blood vessel. If blood does not flow back, it can be considered that the needle is outside the blood vessel.

• Using a blunt-ended cannula can reduce the possibility of directly damaging blood vessels. This is especially useful when injecting filler into deeper layers.

• Filler should be injected slowly, in small amounts, and at low pressure. This is effective in reducing the risk of filler entering a blood vessel due to excessive pressure.

• Filler should be injected into the deep fatty layer rather than the fibromuscular layer. This layer has a lower density of blood vessels, making it relatively safer, and the filler can remain stable without migrating.

• Areas that have previously experienced trauma or surgery are more likely to have altered blood vessel and tissue structures, so it is better to avoid treatment there.

• Including a vasoconstrictor in local anesthesia before the procedure can reduce blood vessel damage and lower the likelihood of side effects.

Although it may seem like a relatively simple procedure, filler is something that requires a precise understanding of the skin characteristics and blood vessel distribution of each facial area in order to achieve safe and satisfying results. Please remember that it is important to receive treatment from medical staff with extensive experience in difficult areas and a strong knowledge of anatomy, and I will end today’s post here.

That is all for today.

Thank you for reading.

This has been Dr. Belleview.

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