The field of aesthetic medicine has been experiencing rapid growth, with aesthetic procedures increasing by approximately 33% annually, according to the International Society of Aesthetic Plastic Surgery. Despite this surge, there is no universally accepted protocol for filler administration in the upper face.

Researchers from Brazil and Colombia conducted a comprehensive review which analyzed seven studies from global literature. The included studies—three narrative reviews, two literature reviews, and two anatomical studies—were identified through systematic searches.

Findings and Techniques

The review identified four primary techniques for the temporal region:

• Upper Third for Volume Technique: Application to the superficial fatty layer, indicated for mild volume loss in the anterior temporal region; use a 22 × 50 mm cannula with less than 0.7 mL of a low G′ product.

• Interfascial for Volume Technique: Application between the superficial and deep laminae of the superficial temporal fascia; uses a 22 × 50 mm cannula with retrograde fan-like administration, typically injected from access points 1 cm below the hairline, medial to the temporal crest, or from the scalp; recommended volume is less than 1 cc.

• Supraperiosteal Lower for Volume Technique: Application in the supraperiosteal plane as an intramuscular deposit; uses a 27G needle with aspiration before injection; typically uses less than 1 cc of a high G′ product; the access point is located 1 cm cranially and 1 cm laterally from the temporal crest.

• High Supraperiosteal for Volume Technique: Part of the “3-point full-face” approach; uses a 27G needle inserted 1 cm below the temporal crest and posterior to the lateral orbital rim, angled cranially at 45 degrees.

For the frontal region: 

• Syringe Technique: Offers precise filler placement for intricate areas but requires a steady hand; postmassage irregularities may persist temporarily.

• Cannula Technique: Preferred for reduced trauma; entry is near the frontotemporal crest next to the eyebrow tail, using a 25G × 38 mm or larger cannula, advancing beneath the frontal muscle toward the bone; product is dispersed using a fanning or retrograde technique.

Safety Considerations

According to authors Ligia Colucci, MD, and Jaime Rengifo, MD, common adverse events after filler injections included tenderness, bruising, accidental intravascular injections in critical areas such as the nasal dorsum (leading to skin necrosis), and risk of permanent blindness. The temple’s proximity to critical vascular territories—such as the internal and external carotid plexuses, the venous plexus, and the internal jugular vein— contributes to a higher risk of visual complications.

They recommended deep-space injections to reduce the likelihood of vascular injury, especially in high-risk areas such as the temporal region, glabella, nose, infraorbital region, nasolabial folds, nasal triangle, lips, and chin.

Need for Standardization

“We underscore the absence of a standardized approach to hyaluronic acid filler injection sites and techniques for the facial upper third,” wrote authors Ligia Colucci, MD, and Jaime Rengifo, MD. “Integrating anatomical knowledge with empirical evidence will be paramount in developing standardized techniques that prioritize patient safety and enhance treatment efficacy.”

Study Limitations and Call for Additional Research

The authors acknowledged that including only seven studies in the final analysis may restrict the generalizability of findings and highlight the need for further research to corroborate and expand upon current evidence. They advocated for additional high-quality studies to strengthen the evidence base and support the development of standardized guidelines.

Both authors are affiliated with the Allergan Medical Institute. This study was supported by internal funding from the authors.

Source: PRS Global Open