Keywords

Juvederm® is a well-accepted nonanimal-based hyaluronic acid that has the advantage of lower viscosity allowing for easier injection. The regular formulation of Juvederm is technically for filling minimal rhytides, particularly for perioral lines and for defining the vermillion border. It works very well to enhance deeper filling performed with Restylane®, Perlane®, Juvederm® Ultra, or Radiesse®. Superficial, fine lines may also be treated by first performing parallel “subcision” with an injection needle (e.g., 27 gauge) along the length of the rhytides, followed by injection of hyaluronic acid through a 32-gauge needle. The 32-gauge needle seems to thin the filler viscosity, enabling fine, superficial rhytid filling while avoiding lumps. Caution is needed with superficial filling to avoid skin color discoloration, and it is imperative to ensure that the needle is securely fastened to the Luer-Lok syringe to avoid accidental needle expulsion and potential ocular injury (Lin et al. 2006). Although theoretically safer, cannula use for fine lines does not work technically well owing to the larger size of the cannula and length as compared to a very fine and short 30- or 32-gauge needle, which allows very precise placement. Belotero Balance® is a recently available hyaluronic acid that is excellent for fine, superficial wrinkles. Because of its low viscosity and variable density, it is optimal for superficial injections with less risk of lumpiness and Tyndall effect. Each of the available hyaluronic acid fillers may be premixed with lidocaine (0.25 cc lidocaine per 1 cc of hyaluronic acid) for improved patient comfort.