Dermal fillers, placed where the face has lost volume

Ageing in the midface is not simply a loss of volume from one place. The deep medial cheek fat compartment deflates, the superficial compartments descend over retaining ligaments that stay fixed, and the maxilla and pyriform aperture resorb underneath all of it. The nasolabial fold you see is often the visible edge of that descent rather than a problem in its own right.

Filling the fold directly, therefore, frequently makes a face look heavier without making it look younger. Restoring the deep compartment and the bony platform beneath it addresses the cause, uses less product, and is far less likely to produce that recognisable overfilled look. This is why the assessment maps compartments rather than lines.

• Bony platform — maxilla, pyriform aperture, mandibular angle and chin projection, since resorption here undermines everything above.
• Fat compartments — which are deflated, which have descended, and which are still where they should be.
• Skin quality — thin skin shows product that thicker skin conceals, and it changes both the plane and the choice of gel.
• Vascular anatomy — the course of the facial, angular and supratrochlear arteries relative to every intended injection point.
• What you have had before — old product persists longer than most people expect and must be accounted for.

1. Assessment

   Photographed in standard views and examined in three dimensions, seated upright. Bone is palpated. A plan is written for the whole face even when only one area is being treated, so that later work is coherent with this work.

2. Consent and planning

   Product, plane, volume and the specific risks including vascular occlusion are discussed before anything is drawn up. Hyaluronidase is kept on site.

3. Placement

   Cannula or needle depending on the site, chosen for the vascular anatomy rather than by habit. Aspiration and slow, low-pressure delivery throughout. You are shown the result seated and upright as it develops.

4. Review

   Seen at two to four weeks once swelling has fully resolved. Filler integrates and softens over that period, so what you see on day one is not the result.

These are discussed with you individually before consent is taken. The list is not exhaustive, and it is not a substitute for that conversation.

• Swelling, which is expected, and bruising, which is common — particularly around the eye and lip.
• Tenderness and firmness at the site for one to two weeks as the gel integrates.
• Visible or palpable lumps, which can usually be massaged or dissolved.
• Asymmetry, correctable at review.
• Vascular occlusion — filler entering or compressing an artery. This is rare but serious, can cause skin necrosis and, very rarely, blindness. Recognised early and treated with hyaluronidase, outcomes are far better, which is why you are told exactly what to look for.
• Delayed inflammatory nodules, occurring weeks to months later, sometimes triggered by infection or immune stimulation.
• Infection at the injection site.

When this treatment is not appropriate

• Pregnancy and breastfeeding.
• Active infection or inflammatory skin disease at the site.
• Known hypersensitivity to hyaluronic acid or lidocaine.
• Active autoimmune disease, which needs individual discussion.
• Anticoagulant therapy, which does not exclude treatment but substantially raises bruising risk.
• Recent or planned dental work, which is deferred by two weeks either side.