Can 11 Syringes of Filler Still Look Natural?

Hi. We're going to do a total facial rejuvenation, and we're going to focus on neurotoxin as well as fillers. There are some longstanding frown lines. You can see the formation of these lines. It takes years for them to form, and the lines themselves don't disappear magically with neurotoxin. They do require lifting, and require a brow lift, but you can keep them from getting deeper. Also, with fillers injected properly, you can keep them from looking as deep. A lot of people are afraid of injecting this area because there have been some vascular occlusions. If you know the anatomy and do it properly and safely, it's perfectly fine. But for the average injector who just learned how to inject in a weekend course, please stay away from that area.

You're going to see the midface needs to be lifted, and you're going to have more contour, more of a heart-shaped face. Then ultimately, once this is done, we can work around the mouth, even the chin and lips. But first we're going to start with the upper part of the face, so hang tight.

We are using Daxxify for its longer-lasting results. It's a little bit less comfortable, but it lasts longer, and it's worth it. My assistant is going to use ice on the other side of the face for comfort. We are going to do Daxxify to the procerus muscle and the depressor supercilii. Compared to Botox and Dysport, it is a little bit less comfortable, but it does have longer-lasting results. As you see, this muscle is pulling the eyebrow down. You can actually watch the eyebrow pull down as I pull it up. Look, the muscle wants to pull it down. So by injecting it the right way, you actually release that pull and open up the eyebrows a little bit. What most average injectors do is paralyze the forehead, and they actually make this problem worse. We don't want that to happen. I barely treat the forehead, as you'll see in a second.

I also don't want a Spock eye, so I do a little drop here to prevent the Spock eye from forming. But as we get older, this gets heavier, so I don't want to overdo this, because we don't want to drop it. We go on the other side and do the same thing. You can see the active muscle. It's pulling in this direction, and in a few days it's going to open up. We're going to stay symmetric and do a little drop here to prevent the Spock eye, but I do want a little bit of a lateral lift.

Now, I'm leaving the forehead alone. I want her frontalis lifting. But I'm going to do one drop in the middle. This actually weakens the frontalis in the middle and allows the outside to lift even more. I'm going to come back here in the middle section, place a bigger drop and let it spread into the muscles that are really acting on her anatomy. Her anatomy is all about the procerus, depressor supercilii and corrugators pulling things down, so that's where I'm going to focus on her. Hold pressure. If you hold pressure, you will not bruise.

Then we're going to go to the outer eyes. In her, I'm doing one drop to the lateral canthus, and then one drop underneath her eyebrow, at the tail of it, and this gives her a little bit of lift. I'm not going underneath, because I don't want the eyes to look hollow. I'm doing the lateral canthus so when she smiles, the eyes stay more open. Daxxify does burn more than Botox. It is less comfortable than Botox. That's the downside of Daxxify, plus it costs more. The upside is quicker results and longer-lasting results.

So now we're going to focus on the midface. You can see that the midface is drawn down. It's hollow here, then you get the fullness here, and then the hollow there. So we're going to focus on refilling and revolumizing the midface. I am all the way down, vertical. I am on top of the bone. People say, "Well, are you going to withdraw and check for blood?" No, there's no need to. I'm right on top of the bone and I'm vertically down. There's absolutely no need to do that here. There are some places I'll do it. You'll see me do it at the tip of the nose. There are certain areas where it must be done, and when I'm there, I'll do it. But this area does not need it if you do it the right way.

You'll see me again going vertical, down on top of the periosteum. And what you'll see immediately: compare this side to that side. See the flatness, and then you see the lift on this side. Again, going vertically down. I have seen plenty of injection videos on Instagram where injectors are going in these areas. That's not the right way to do it. You don't want to inject in the soft tissue. You're going to make it heavier. Plus, if you go this way, you can thread it into a blood vessel. So you don't want to do it that way. Technique comes with safety.

All right, so that's one syringe, and immediately we got a lift right there. Now we're going to the second syringe. Again, straight down, top of bone, adding volume. Straight down. Very little bleeding. I don't see any bleeding yet. You're starting to see the lift. A lot of injectors go out here and start there. That youthful look comes from the midface, not out here. So you want to first volumize the midface and then start to work laterally and inferiorly. And I don't want just something large standing there. I want everything to be filled together.

Now we're going to do a little bit to the smile lines. Then a little through the jawline to give more definition here, better structure, and it'll blend into the jowls. The jowls are here. What we're doing is going in front of them and behind them. By doing that, we minimize the appearance of the jowls. These are down deep. These are not microdroplets. These are larger boluses, because we're trying to minimize the number of times we poke in and out. This is not an area where you want to use a cannula. You don't want to be going along the face. You want to go longitudinally and create lift.

Typically, most faces have a better shaped, more contoured left side than right side. Therefore, if you're doing cheek injections, you'll see that you need a little bit more volume on the right side than on the left side. Typically, the left side is more narrow and higher, so it looks better. The right side is typically wider and droopier. So to try to create more symmetry, I need to lift the right side more compared to the left side. But in her, we still want a little bit of a lift on the left as well. You don't want to create sharp lines, so you want to blend it and contour.

This is basically the piriform aperture, at the very top of the nasolabial fold. You're going to benefit from larger boluses on most people, and then we start working our way down. What I've done is swap the needle and put on a smaller needle than the one that comes with the filler. It takes more force from the injector's point of view, but it gives a better result and less bruising. And then we can come back in a week or so, when the swelling and bruising go away, to take more pictures.

The proper technique for frown lines: there are neurovascular bundles coming up here. The supraorbital and supratrochlear vessels are coming up there. You don't want to be injecting intravascularly, but you have to add some volume here. So what I do is first start with deep injections down to the bone. Again, I'm down to the bone, there are no blood vessels, and I'm pulling up. Now as I go here, the neurovascular bundle could be there, so I withdraw, then I fill, still drawing out. If you come around with the camera and look at these two sides, you can actually see how different they are. It's already filled in, without even the Daxxify kicking in. On this side you can see this deep line. If you tilt the chin up a little bit more, you can see this side is so smooth, and here you've got the line.

We're going to continue on and do the other side as well. I'm starting with a deep injection down to the bone in a safe area, drawing up to add volume. The next one is a little bit lower here. I'm going to withdraw, then come back and add volume as I go up. Now here is where you can really potentially thread into the blood vessels, and you don't want to do that. So if I'm doing it this way, I'm definitely drawing back, making sure there are no red blood cells, and then injecting retrograde. I'm going back here and doing the same thing: drawing back, making sure there are no blood vessels, injecting retrograde, pulling back. That is going to open up this area much better.

Now, you don't want to create too much bulge and fullness in women, because it's going to become masculine. But there's also a part here, the root of the nose, that's creating the depression. So I'm doing the root of the nose as well, and in combination, when the Daxxify kicks in, these will look like a brow lift. I'm not necessarily doing this for the nose itself. It is going to improve the dorsal hump, but what it's going to do is improve the frown. She will look like she's not frowning anymore, and it will look much better.

Thinning of the lips is one of the biggest signs of aging. A lot of people are afraid of duck lips or full, Instagram-style lips if they're older. But unless you actually add some volume to the lips, you really can't rejuvenate around the mouth. The mouth is not about lines. It's about a zone, and you've got to rejuvenate that zone. So we're going to do a subtle lip augmentation. We're not trying to make her into Kylie Jenner. We're simply trying to add a little bit of youthfulness back to the lips. You can already see definition to the vermilion border, because with age, we lose definition to the vermilion border. It thins out. If you look straight on, you'll see definition on the vermilion border here, and over here it's flatter. So that's going to improve, and we're going to continue doing that. Very subtle, very natural, but you just can't be afraid of it.

Now, how many syringes have we gone through? I think about eight or nine. We'll show you how many syringes we did at the end. But most patients are scared, because they've seen their sister, their neighbor, their cousin, somebody on Instagram look really weird, really puffy, really fake, and they don't want to do this. For a lot of other patients, it's cost prohibitive. Once you start doing this many fillers, it becomes quite expensive, so they just want to do one syringe or two syringes. And you cannot rejuvenate a face with one or two syringes. It just doesn't happen, unless all you need is truly a little bit. Typically, by the time we hit our 50s, 60s and beyond, you need quite a bit of volume. And I'm going to show you in a second that volume can be added in a very normal way. Lots and lots of volume, but it can still look super natural. It does not have to look fake. It does not have to look puffy. It does not have to look weird. I can put in 10 syringes, and I think we've done more, and it can still look extremely natural.

So the take-home message here is: don't be afraid. Do it the right way, but you have to go to a master injector. If you go to a place where all they're doing is filling you, without analyzing your face, without an understanding of what an age-appropriate face should look like... We're not going to make a 60-year-old's face look like a 16-year-old's. It just doesn't work that way. But if you do it the right way, you can get beautiful results and look very natural. This just reinflates an area that's been deflated. You can see there's looseness to the mucosa because she had full lips when she was younger, and it's settled down. So we're not trying to change her from what she was. We're just trying to take her back to what she was. Smile really big for me. Big smile. Relax. Perfect. Okay, done.