Achieving natural and lasting facial rejuvenation with dermal fillers requires a strategic approach grounded in anatomical understanding and precise injection techniques. As bone and fat pads age in predictable patterns, a standardized sequence for volume restoration is crucial. This guide delves into the dual-plane injection technique, a methodology that addresses age-related volume loss by targeting both deep and superficial facial compartments. This approach, often implemented across multiple sessions, ensures a comprehensive and harmonious full-face rejuvenation.
Soft tissue fillers, including hyaluronic acid (HA) fillers which are commonly associated with brands like Tesoro (though specific Tesoro filler information should always be verified with the manufacturer’s guidelines), are characterized by their unique rheological properties. Understanding viscoelasticity and cohesivity is paramount for optimal filler selection and placement.
Viscoelasticity, encompassing both elasticity (G’) and viscosity (G”), dictates the gel’s firmness and its ability to maintain shape under pressure. A higher viscoelastic modulus (G) signifies greater resistance to deformation and enhanced lifting capacity. Cohesivity, on the other hand, describes the gel’s tendency to stick together, influencing its integration within tissues and resistance to fragmentation by facial movements. For deep plane injections aiming for structural support, fillers with high G are typically preferred.
Deep Plane Injection Strategy
The foundational step in the dual-plane technique involves deep injections targeting the periosteal layer. This deep placement provides structural support and lift, addressing foundational volume loss.
Deep Malar Plane Augmentation
The deep malar plane is a critical area for restoring youthful facial contours. High G* hyaluronic acid fillers are ideal for this region, providing significant lifting with controlled volume. The targeted compartments, injected sequentially, are the lateral suborbicularis oculi fat (SOOF), medial SOOF, and deep medial cheek fat. The injection sites are carefully marked, as illustrated in Figure 4.
Using a 29 G or 27 G needle (25 mm length) to reach the periosteum, small boluses (0.1-0.2 mL) of filler are deposited in each compartment, totaling 0.3-0.4 mL per compartment. This bolus technique minimizes pressure on lymphatic vessels. The lateral-to-medial injection sequence creates a “tenting” effect, optimizing material efficiency. Augmenting the deep medial cheek fat enhances anterior projection, softens the nasolabial fold, and restores youthful cheek volume within natural anatomical boundaries, as visualized in Figure 6.
Deep Orbital Plane Correction
Similar to the malar region, the deep orbital plane benefits from high G* fillers injected deeply onto the periosteum or infraperiosteally. A 25 G cannula (40 mm length) is recommended to minimize bleeding and to navigate ligamentous areas, such as the orbital retaining ligaments. Two access points are strategically chosen:
- Lateral to the lateral canthus, targeting the palpebromalar groove by directing the cannula inferomedially.
- Inferior to the zygomaticocutaneous ligament, targeting the tear trough by directing the cannula superomedially, cephalad to the tear trough ligament.
Typically, 0.3-0.4 mL of filler is used for the palpebromalar groove and 0.1-0.2 mL for the tear trough, administered in small aliquots to prevent overfilling and the “sausage” effect, as shown in Figure 7.
Mandibular and Chin Contouring
The mandibular plane also necessitates deep, periosteal injections. Vertical boluses of high G filler are placed along the inferior border of the mandible using a 29 G or 27 G needle (25 mm length). The jowl area, between the masseteric and mandibular ligaments, is avoided due to underlying facial vessels. Similarly, the chin is augmented with deep, periosteal vertical pillars. The use of high G fillers in these areas maximizes vertical tissue expansion with minimal lateral spread, crucial for defining the jawline.
Superficial Plane Injection for Refinement
Following deep plane volumization, the superficial subcutaneous plane is addressed, typically in a subsequent session 25-45 days later. This phase focuses on refining contours and addressing superficial volume deficits in specific compartments.
Temporal Fossa Filling
The temporal area is injected superficially within the subcutaneous tissue above the temporoparietalis fascia using a 25 G cannula (40 mm length). The cannula entry point is anterior to the hairline, carefully avoiding the superficial temporal artery. The cannula is advanced in a plane parallel to the skin, using fan-like movements to deposit filler within the temporal fossa, extending from the temporal fusion line to the zygomatic arch. This superficial cannula technique minimizes risk to vessels and the temporal branch of the facial nerve located beneath the fascia. Cohesive fillers with moderate G’ and G” are preferred for this area, allowing for even distribution and a natural filling effect, potentially enhanced with gentle massage. The goal is to eliminate temporal hollowing and achieve a smooth or slightly convex contour, as illustrated in Figure 8.
Superficial Cheek Fat Pad Augmentation
The lateral compartment of the superficial cheek fat pad is addressed with a similar superficial injection pattern as the temporal area. The preauricular area often experiences significant volume loss and requires systematic treatment to restore facial ovality. A 25 G cannula (40 mm or 50 mm length) is inserted anterior to the tragus, just below the zygomatic arch. Filler is deposited in the subcutaneous layer, parallel to the skin, using fan-shaped movements extending to the mandibular angle inferiorly and the parotidocutaneous ligament anteriorly. For extensive areas, a second entry point anterior to the earlobe might be necessary. In this region, fillers with both high G’ and G” are beneficial for volumizing and tightening effects, as visualized in Figure 9.
The middle compartment of the superficial cheek fat pad, located medially to the parotidocutaneous ligament, is injected superficially in the subcutaneous layer. The cannula entry point is medial to the parotidocutaneous ligament. Filler is delivered in a fan-shape pattern. Often, addressing the preauricular area sufficiently repositions this compartment, minimizing the need for direct injection. Cohesive fillers with moderate G’ and G” are suitable for even distribution without heaviness.
The medial compartment of the superficial cheek fat pad may not require direct injection, as the tenting effect from treating lateral and middle compartments may suffice. If injection is needed, the entry point is distal, near the corner of the mouth, lateral to the nasolabial fat compartment. A small amount of cohesive, softer filler with moderate G’ and G” is used.
Nasolabial Fold and Superficial Chin
The nasolabial fold is selectively treated, primarily in its cephalad aspect, into Ristow’s space. Deep injections with high G* fillers are used to avoid the facial artery. The caudal aspect is addressed superficially only if a significant skin impression exists, using a 30 G needle or 25 G cannula.
The superficial chin compartment is injected with a 25 G cannula (40 mm length) from the mandibular ligament towards the midline, requiring minimal augmentation to tighten the area and reduce the labiomental fold.
Conclusion: Achieving Harmonious Facial Rejuvenation
The dual-plane injection technique offers a systematic and anatomically informed approach to facial volume restoration. By addressing both deep structural support and superficial contour refinement, this method aims to achieve natural, balanced, and long-lasting rejuvenation. Practitioners utilizing fillers, including options like Tesoro fillers, can adapt this placement guide, always considering individual patient anatomy and product-specific guidelines, to optimize outcomes and enhance patient satisfaction. Further detailed resources and potentially PDF guides on specific filler placement techniques can offer additional support for mastering this advanced approach.
