COSMETIC

Facial Assessment and Injection Guide for

Botulinum Toxin and Injectable Hyaluronic
Acid Fillers: Focus on the Midface
Maurício de Maio, M.D.
Koen DeBoulle, M.D.
André Braz, M.D.
Rod J. Rohrich, M.D.
on behalf of the Alliance
for the Future of Aesthetics
Consensus Committee
São Paulo, Brazil; Aalst, Belgium; Rio
de Janeiro, Brazil; and Dallas, Texas
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 pro-
viding structural support; neuromodulators play a smaller role in this facial
region. Fillers are used for volumization and contouring of the midface re-
gions, 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 fill-
ers near the nose, because of the risk of serious complications, including blind-
ness and necrosis. Injections made in the midcheek must be performed with
caution to avoid the infraorbital artery.  (Plast. Reconstr. Surg. 140: 540e, 2017.)

T
his 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 vol-
umes/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 expe-
rience with these products in clinical practice.
Treatment of the lateral cheek may indirectly
improve the tear trough, nasolabial fold, upper
lip oral commissure, marionette lines, and jaw-
line, and also provide support for the eyebrow.
Injections into the midcheek should be handled
with caution because of the presence of the infra-
orbital artery. Injections in and near the nose
From the Clinica Dr. Maurício de Maio; the Aalst Derma-
tology Clinic, private practice; and the University of Texas
Southwestern Medical Center.
Received for publication April 13, 2016; accepted February
21, 2017.
Copyright © 2017 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000003716
require specific training and experience because
of the risk of blindness and necrosis with inadver-
tent injection into the angular and dorsal nasal
arteries.
AESTHETICS OF THE PERIORBITAL
AREA AND CHEEKS
The midface contains important hallmarks
of facial beauty and a youthful appearance; spe-
cifically, the malar projection and full cheeks.1
Disclosure: Dr. de Maio is an Allergan plc consul-
tant for speaking events and marketing strategy. Dr.
DeBoulle is an Allergan plc consultant for speaking
events and marketing strategy. Dr. Braz is an Aller-
gan plc, Galderma, Merz, Loreal, La Roche Posay,
Palomar, Skinceuticals, and Vichy consultant. Dr.
Rohrich receives instrument royalties from Eriem Sur-
gical, 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).

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 Volume 140, Number 4 • Injection Guide for Midface

Table 1.  Recommended Needle Sizes for Delivery of the depression is seen in the medial aspects of this
Injectable Fillers and OnabotulinumtoxinA area, but with continued aging, volume loss may
Product Needle Size
become evident laterally. Volume loss is seen in
the cheek area, with cheek wrinkling facilitated
Injectable fillers
 Ultra 30-gauge, ½-inch (13 mm)
by dermal atrophy and lack of fat pads.1,4 The
 Ultra Plus 27-gauge, ½-inch (13 mm) convex contour of the upper cheek region may
 Volbella 30-gauge, ½-inch (13 mm) flatten or become concave with age.5 A 2- to 3-cm
 Volift 30-gauge, ½-inch (13 mm) depression extending inferolaterally from the eye-
 Voluma 27-gauge, ½-inch (13 mm)
OnabotulinumtoxinA 30-gauge, ½-inch (13 mm) lid, known by various names including the naso-
jugal groove, tear trough, or lid-cheek junction,
may be evident.4 The loss of midfacial cheek sup-
The youthful midface exhibits a smooth convex- port contributes to deep nasolabial folds and may
ity from the lower eyelid down to the nasolabial lead to a skeletonized appearance of the cheek-
fold and buccal region. The junction between bones.1,2 Midfacial fat redistribution occurs with
the lower eyelid and cheek should be smooth and aging, including accumulation of anterior and
short. inferior cheek fat and loss of lateral and superior
fat.1 These changes cause a depression in the sub-
malar area, which is an inverted triangular area
AGING OF THE PERIORBITAL AREA limited superiorly by the zygomatic prominence,
AND CHEEKS medially by the nasolabial fold, and laterally by
The first signs of aging are noticed around the the masseter muscle.1 The loss of lateral cheek fat
eye region, with excess skin and eye bags.2 With with aging may lead to volume depletion in the
aging, fat redistribution, skin laxity, and connective preauricular area.1
tissue weakness affect transitions from the perior-
bital area to the cheek.3 Eye bags result from lax-
ity in the orbital septum and pseudoherniation of ASSESSMENT OF THE PERIORBITAL
orbital fat.3 With aging, a depression or concavity AREA AND CHEEKS
may develop at the junction of the thin eyelid skin Midfacial assessment should be made at rest
above and the thicker nasal and cheek skin below, and during animation (i.e., while smiling).6 Assess
which is associated with a reduction in subcutane- the skin surface contour and shadowing, and
ous tissue overlying the maxillary bone.1 Initially, assess the presence of dermal and fat pad atrophy,

Table 2.  Recommended Allergan plc Portfolio Product and Volume/Dose for Individual Areas
Region Product Volume/Dose Range
Hyaluronic acid filler
 Lateral cheek Voluma 0.1–0.3 ml per site; total, 0.3–05 ml per side
 Anterior cheek Voluma ≤0.3 ml per site; total, 0.5 ml per side
 Medial cheek Voluma ≤0.3 ml per site
 Lid-cheek junction Volbella ≤0.1 ml per site; total, 0.6 ml per side
Ultra ≤0.05 ml per site; total, 0.5 ml per side
 Submalar area Volift ≤0.25 ml per site; total, ≤1.0 ml per side
Ultra Plus
Voluma
 Preauricular area Voluma 0.1–0.2 ml per site; total, ≤1.0 ml per side
Volift
Ultra Plus
 Frontonasal angle Ultra Plus 0.1–0.2 ml per site; for Asians, 0.2–0.3 ml per site
Voluma
 Dorsum Ultra Plus 0.1–0.2 ml per site; for Asians, 0.2–0.3 ml per site
Voluma
 Cartilaginous dorsum Ultra Plus 0.1–0.2 ml per site
Voluma
 Nasolabial angle Ultra Plus 0.1–0.3 ml
Voluma
 Columella Ultra Plus 0.1–0.2 ml
Voluma
Neurotoxin
 Bunny lines OnabotulinumtoxinA 2.0 U per site; total dose, 4.0–6.0 U
 Elevation of the nasal tip OnabotulinumtoxinA 2.0–4.0 U
Please note the differing occurrences of the terms “side” and “site” in the Volume/Dose Range column.

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 Plastic and Reconstructive Surgery • October 2017

increased dynamic and static lines, loss of malar
projection, and loss of bone volume and struc-
ture.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
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 supe-
rior alveolar artery that supplies the anterior teeth
and maxillary sinus, and terminates in anastomo-
ses 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 lat-
eral suborbicularis fat pads.7 Volumizers are used
to address loss in these fat pads.
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 poten-
tial 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.
In the lateral cheek, Voluma is administered
by means of a supraperiosteal small-bolus injec-
tion. If up to 0.5 ml per side of Voluma is needed,
treatment should be divided into two bolus injec-
tions. Injectors should be alert to avoid the zygo-
matic 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 perios-
teal 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 treat-
ment 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 admin-
istered 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 injec-
tions are made below the orbital rim (arcus mar-
ginalis). Inject slowly and use a finger to avoid

Fig. 1. Volume replacement in the upper cheek using Voluma. Potential injection sites in the upper cheek: lateral cheek
(designated by site 1), anterior cheek (site 2), and medial cheek (site 3) (left). Areas of caution: avoid zygomatic facial
vessels and nerves in the lateral cheek, infraorbital artery and vein in the anterior cheek, and angular and infraorbital
arteries and veins in the medial cheek (right). a., artery; v., vein.

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 Volume 140, Number 4 • Injection Guide for Midface
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 midpupil-
lary 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 nee-
dle 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 empha-
size that use of a needle is not recommended.
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 injec-
tions 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, asym-
metry, lumps, and double vision (see areas to
avoid in Fig. 2, right).9 Alternatively, use of 25- or
Fig. 2. Volume replacement along the lid-cheek junction using Volbella or Ultra. Injections are made at three main loca-
tions (two injections per location; up to six total aliquots) (left). Areas of caution: avoid the orbit by making injections 1
to 2 mm below the orbital rim (right). a., artery; v., vein.
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
27-gauge blunt microcannulae may avoid bruising
and embolization.
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 injec-
tion. [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.
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
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 Plastic and Reconstructive Surgery • October 2017

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 rec-
ommended 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 fan-
ning technique (Fig. 3, above, right). The needle is
inserted through a single insertion point and piv-
oted 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 injec-
tion, 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 dur-
ing injection, aspiration before injection, and slow
injections. With the second technique, it is impor-
tant 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 prod-
uct evenly for both techniques. Promote even dis-
tribution 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.
Preauricular Area
Volume replacement in this lateral cheek area
may be achieved with Voluma, Volift, or Ultra Plus.
Superficial subcutaneous small-bolus injections

Fig. 3. Volume replacement in the submalar area using Volift, Ultra Plus, or Voluma. Two techniques may be used: small-
bolus, deep subcutaneous injections at four sites per side (above, left) or a superficial subcutaneous injection at one site
using a fanning technique (above, right). Areas of caution: avoid the facial artery and vein; avoid the parotid duct; and be
careful near the buccal branches of the facial nerve (below). a., artery; v., vein.

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 Volume 140, Number 4 • Injection Guide for Midface
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 man-
datory (Fig. 4, right). Aspirate before injection,
insert the needle in a superficial subcutaneous
plane angled upward, and inject slowly. (See Fig-
ure, 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 vol-
umes are required, inject a small bolus and mas-
sage, 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.
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 nasola-
bial 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 pro-
jecting nose compared with Caucasians.11 How-
ever, among Asians, a good dorsum height, narrow
alar base, and tip projection are considered pref-
erable.11 The use of fillers and neuromodulators
in combination offers a minimal approach for
Fig. 4. Volume replacement in the preauricular area can be delivered with Voluma, Volift, or Ultra Plus. Injections are
made at three to five sites in the lateral cheek region (left). Areas of caution: avoid the parotid gland and the transverse
facial artery and vein (right). a., artery; v., vein.
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
reshaping the nose and midface area, address-
ing both the loss of volume and structure and the
wrinkles that develop with aging.12
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
ASSESSMENT OF THE NOSE
The frontal assessment should include evalu-
ation 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 colu-
mella.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.
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 anas-
tomoses with the supratrochlear artery; this anas-
tomosis is a point of high risk that can lead to
serious complications such as blindness.1,6 Filler
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 Plastic and Reconstructive Surgery • October 2017
or neurotoxin injections in the nose for postrhi-
noplasty deformities may dramatically increase
the risk of complications. These deformities
should be addressed only by experienced injec-
tors or, preferably, by the surgeon who performed
the original surgery.
FILLER INJECTION TECHNIQUE FOR
INDICATIONS IN THE NOSE
Frontonasal Angle
Filling the frontonasal angle to reduce the con-
cavity of the dorsum may make the nose appear
smaller. This procedure is particularly suited for
patients whose frontonasal angle is too deep.1 Fill-
ing the frontonasal angle may be achieved with
Ultra Plus or Voluma using a single supraperios-
teal 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 Con-
tent 5, which shows injection technique for fill-
ing 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.) Mas-
sage 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. Filling the frontonasal angle with Ultra Plus or Voluma. Injections are made by means of a supraperiosteal small-
bolus injection at one site (left). Area of high caution: presence of anastomosis of periorbital vessels in the subcutaneous
plane (right). a., artery; v., vein.
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Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
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 iden-
tical 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 mid-
line, http://links.lww.com/PRS/C368.)
For the cartilaginous dorsum, a single injec-
tion 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 manda-
tory 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 injec-
tion and precautions for administering filler in
the cartilaginous dorsum are the same as those for
the frontonasal angle and bony dorsum. (See Fig-
ure, Supplemental Digital Content 7, which shows
 Volume 140, Number 4 • Injection Guide for Midface

Fig. 6. Filling the bony dorsum with Ultra Plus or Voluma. A supraperiosteal injection is made by means of linear retro-
grade technique or as a small bolus (left). Area of caution: avoid the dorsal nasal artery and vein (right). a., artery; v., vein.

Fig. 7. Filling the cartilaginous dorsum with Ultra Plus or Voluma. A supracartilaginous
injection is made by means of a linear retrograde technique (left). Area of caution: avoid
the dorsal and external nasal arteries, external nasal nerve, and lateral nasal artery in the
alar groove (right).

injection technique for filling the cartilaginous
dorsum. Pinch the skin during the injection, aspi-
rate 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.
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 colu-
mellar branches of the superior labial artery and
vein. Pinch the skin around the injection site and
keep your fingers in place to avoid lateral dis-
placement of the filler, aspirate before injection,
and inject very slowly with low pressure, main-
taining the needle in the midline. (See Figure,
Supplemental Digital Content 8, which shows
injection technique for increasing the nasola-
bial angle. Pinch the skin during the injection,

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 Plastic and Reconstructive Surgery • October 2017
Fig. 8. Increasing the nasolabial angle with Ultra Plus or Voluma.
A supraperiosteal bolus injection is given into the anterior naso-
labial spine. Area of caution: avoid injecting in the cartilage of
the anterior septum, and avoid the columellar branches of the
superior labial vessels.
aspirate before injection, and inject very slowly
with low pressure, staying deep and in the mid-
line, http://links.lww.com/PRS/C370.) Pay atten-
tion to the injection volume to avoid elongation
of the upper lip. Massage softly after the injec-
tion. Stop the injection immediately if there is a
change in skin color or severe pain.
Fig. 9. Increasing the columella height with Ultra Plus or Voluma.
An injection is given in the anterior cartilaginous septum using a
linear retrograde technique or as a small bolus. Area of caution:
avoid injecting directly into the tip of the nose, and avoid the
columellar branches of the superior labial vessels.
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Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
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 colu-
mella 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.
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 advis-
able. However, even with this precaution, the above-
mentioned complications may occur. Proper training
and gentle technique are highly recommended.
ONABOTULINUMTOXINA INJECTION
TECHNIQUE FOR INDICATIONS IN THE
NOSE
Bunny Lines
Bunny lines may appear during facial ani-
mation, 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 pro-
cerus muscle lowers the medial aspect of the eye-
brow 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 onabotulinum-
toxinA into the transverse part of the nasalis
 Volume 140, Number 4 • Injection Guide for Midface
Fig. 10. Treatment of bunny lines with onabotulinumtoxinA.
Injections are made at two lateral sites, one on each side of the
nose and optionally at a medial site. Asterisks indicate depth of
injections, which should be one-third the needle depth.
muscle. (See Figure, Supplemental Digital Con-
tent 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.
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 ona-
botulinumtoxinA elevates the nasal tip at rest
and prevents it from drooping during smiling.
This is achieved by a transcutaneous medial injec-
tion at the columella base (Fig. 11). Insert the
needle to one-half of its depth and inject ona-
botulinumtoxinA into the depressor septi nasi
muscle. (See Figure, Supplemental Digital Con-
tent 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,
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Fig. 11. Elevation of the nasal tip with onabotulinumtoxinA. An
injection is made at a medial site at the columella base. X indicates
that depth of injections should be one-half the needle depth.
complete elevation of the nasal tip may not be
fully achieved with this technique.
CONCLUSIONS
Injectable fillers are much more important
than neuromodulators in the midface, where they
are used to correct volume loss and provide struc-
tural 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 addi-
tion, injections near the nose require specific train-
ing and experience because of the risk of serious
complications, including blindness and necrosis.
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
ACKNOWLEDGMENTS
This article was sponsored through an educational
grant from Allergan plc (Dublin, Ireland). Medical writ-
ing 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.
549e
 Plastic and Reconstructive Surgery • October 2017
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