Dr Ana Mansouri is an aesthetic doctor at Kat & Co in Birmingham with a background in GP training. She graduated with a Bachelor of Medicine and Bachelor of Surgery (MBBS) from Newcastle University Medical School and has completed a postgraduate diploma in Clinical Dermatology with Queen Mary University London. She is a member of the British Association of Dermatology (BAD), British Association for Dermatological Surgery (BSDS) and Aesthetics Complications Experts (ACE) Group.
Filler blending is an advanced technique of mixing a particular dermal filler with any other injectable product. It started out as a trend in the US some years ago as traditionally fillers didn’t come with any anaesthetic agents inside the syringe, and so doctors started mixing their fillers with lidocaine solution to accommodate for this.
When injecting lips, it is firstly important to establish that increasing volume isn’t our sole purpose. The aim of the treatment will often be a combination of improving the definition of the vermilion border, lifting the cupid’s bow, providing hydration, showing more of the pink lip (superficial or highdefinition volume) or increasing projection (deep or lower-definition volume). In simple terms, we deal with contour, volume and hydration. Weall know that the ageing process takes place in multiple tissues and at multiple depths such as bone, fat, muscle and skin. Therefore, we need to assess each area in its entirety and provide the support needed in all the layers where signs of ageing or an inherent deficiency are present.
In my experience, approaching lips in a three-dimensional fashion provides much more aesthetically desirable results but also lowers the risk of complications such as Tyndall effect and filler migration. The consistency of patients’ lip tissue varies significantly depending on the depth. The delicate border is significantly different to the soft fatty tissue which lies on top of the deep dense muscle layer. Depending on the depth and consistency of the tissues where the lip is lacking structure and support, I will combine different filler products accordingly. The key is to add filler in a manner which will complement and simulate the patient’s own tissues.
Different filler products have different characteristics depending on their specific blend of hyaluronic acid (cross-linking between the HA molecules). Essentially, they have different consistencies and different abilities to attract water. Working with a wider range of products with different characteristics allows us to treat each patient’s tissues in truly a bespoke manner; I think of it as providing an artist with 10 colours to paint with instead of three. One size definitely doesn’t fit all when it comes to dermal fillers and injectables as a whole.
In order to minimise the risk to the relevant anatomical structures, different filler characteristics, injection techniques and tools should be used depending on varying tissue depths. Therefore, especially when it comes to mature or ageing lips, I find there is rarely a single filler which will accommodate for all of these factors.
Most of the time, I tend to stay within each brand’s range as this is in keeping with the manufacturer recommendations and support pathways, thereby eliminating any difficulty managing complications if they were to occur. Generally speaking, my preference for treating mature lips is using a soft-density filler superficially with a needle in the vermilion border to define this delicate structure. I may also use the same soft filler superficially in the body of the lip to further define this area using a needle. This type of filler will also lend itself nicely to soft blanching the peri-oral lines. I usually combine the above with a medium-density filler in the deeper plane (cautiously, using a cannula in order to respect the critical vascular structures) to address the volume deficiency in the body of the lip as I find mature lips often have a certain looseness or emptiness of laxity to the body.
If the patient requires hydration on top of this, I’ll consider adding a super-soft filler intradermally in the body of the lip as well as across the peri-oral lines for textural improvement. An example of this kind of combination is Merz’s Belotero Balance (soft), Belotero Intense (medium) and Belotero Soft (super-soft). Alternatively, I may use Allergan’s Juvederm Volbella (soft) with Volift (medium). I find that when treating lips superficially or near the vermilion border, using a soft-density filler greatly reduces the chance of migration, Tyndall effect and lumps. Likewise, the deeper cannula approach (micro-droplets or very fine threads) with the medium-density filler while keeping well away from the vermilion border gives me a much more seamless outcome.
In complex lip cases, such as M-shaped lips or other lip types where there is a certain “tightness” to the tissues, I prefer to stay with a soft-density filler alone (usually Belotero Balance) while staging the treatment in multiple sessions at a minimum of four weeks apart. I find this reduces the risk of filler migration, allows for larger volumes to be used in total without compromising definition; and allows a more seamless integration over a prolonged period of time.
However, I will occasionally mix products between different brands (off-licence use) if I expect the outcome will be superior as a result. For instance:
• Mature lip with particularly delicate structures and very fine perioral lines: Belotero Balance for the body blended with Juvederm Volbella in the vermilion border and peri-oral lines.
• Deep or challenging perioral lines: Belotero Balance layered with Juvederm Volbella (consider a combination with toxin and laser resurfacing).
• Deep or challenging marionette lines: Juvederm Voluma layered with Belotero Intense.
Having said this, I wouldn’t recommend novice injectors to mix between filler brands, as this off-license approach is more suitable for experienced practitioners in line with their clinical judgement.
Generally speaking, I have adapted the blending approach to most of my treatments. I find that appropriately combining different density products allows more seamless integration into the different tissues and avoids the filler looking out of place. Ageing isn’t a two-dimensional process and we do need to adjust for this. In my experience, this type of layering/ blending technique looks much more natural both at rest and on animation. Filler blending also prompts me to look at each structure in its entirety, such as the lip, peri-oral and marionette area. Having said this, often a single filler will be adequate, especially for younger patients or when budget is a limiting factor.
Apart from the lip, I often tend to layer and blend different types of fillers in the cheek and jawline areas, such as Belotero Volume Deep (small periosteal boluses) using a needle for the lateral and medial cheek combined with Belotero Intense in the fat pads of the medial cheek using liner threads with a cannula. This can further be combined with deep fine threads of Merz Aesthetics’ Radiesse (calcium hydroxyapatite, non-HA) across the lateral zygoma for further definition and collagen stimulation. I find this a very effective combination for the multi-factorial signs of ageing in the midface as the hyaluronic acid fillers volumise according to tissue structure, (allowing for natural mobility on animation) giving an instant visible improvement during which Radiesse’s collagen stimulation is setting in with a delayed lifting effect. In addition, I may combine Belotero Volume with Radiesse across the jawline in a similar manner.
Combining different products and techniques will certainly bring many benefits in terms of safety and minimising side effects as well as give favourable visible results. While filler blending is fully worthwhile in my opinion, it is however bound to be more costly and time-consuming. Using more than one product will naturally become more costly due to the cost of multiple syringes rather than one. Manufacturers have created a solution for this where some fillers come in 0.55-0.6ml syringes, making the cost of two different products similar to one standard-size (1ml) syringe of filler, for example Belotero Lips Shape and Belotero Lips Contour, Juvederm Volift Retouch and Juvederm Ultra Smile.
The procedure itself tends to be more laboursome and time consuming with the use of the blending technique. Sometimes the procedure can be performed in one sitting, however in most cases, dividing the treatment into a few sessions and subsequently allowing the lip to recover in between sessions will be favourable. This may on the other hand also increase the cost and time commitment required from both parties. Personally, I don’t charge more for a blended filler treatment as my fee structure is based on number of syringes of filler used.
However, as we end up using multiple syringes, the total treatment will end up more costly. I do plan my treatments accordingly and often find that any excess product can be used for separate or surrounding areas during the same sitting. For instance, by using part of a medium-thickness filler in the body of the lip and the rest in the medial cheek or marionette area. Alternatively, if the patient is better suited to be treated over multiple sessions, I may recommend opting for half syringes to make the treatment more costeffective for the patient overall (for example, Belotero Lips Shape or Contour 0.6ml or Juvederm Volift Retouch 0.55ml).
“Appropriately combining different density products allows more seamless integration into the different tissues and avoids the filler looking out of place”
Not all dermal fillers are designed to be used in the lips and therefore product choice is crucial, and ensuring appropriate training on the injection technique, depth and area of each product is imperative. Practitioners are actually discouraged from mixing between brands unless enough time has passed between the treatments (six months). The concern about using different brands of filler together is that if there is a reaction, it can become difficult to establish which filler is responsible for the unwanted effect. This can cause obstructions in the support a practitioner may be able to receive if a complication was to occur and it may also have indemnity implications.
However, as the occurrence of such complications are relatively uncommon and there is a lack of conclusive evidence to show that different HA fillers are incompatible when used together, many experienced medical practitioners do apply the blending technique across different HA fillers on an off-licence basis based on their experience and clinical judgement. Most importantly, practising within one’s competencies, training and comfort zone should always be the first priority.
All of the usual contraindications and dangers for dermal fillers will apply when blending products, and therefore respecting injection technique, depths and anatomy remain as equally important factors to consider. In the event of a complication, staying within the indication area of each product and within one manufacturer is advisable in having access to further support.
With HA fillers, the hyaluronidase protocol will remain the same although the estimated dose will need to be adjusted for the total amount of product used. I refer to the ACE Group protocol for these. As we are becoming more aware, different filler characteristics tend to be more or less resistant to hyaluronidase. Therefore, choose your products wisely.
Calcium hydroxyapatite needs to be approached with extra caution as it is not dissolvable with hyaluronidase. When blending these with HA, I prefer to separate the treatments with each product a few weeks apart to avoid adding further complications to a theoretical vascular occlusion. I take care to stay within the safest structures when using non-HA fillers, avoiding high-risk zones and using a largebore cannula with extreme caution. Productspecific practical training and complications management awareness is even more crucial for these types of fillers.
Over the last few years, I have noticed more colleagues and clinics taking on a wider selection of filler brands and ranges to accommodate individual practitioner preferences as well as allowing for truly tailored treatments. I think the increased adoption of the filler blending technique is definitely an indication that as advanced medical practitioners we feel the need to move away from the “one-size fits all” mentality, and I am sure most of us would agree that bespoke and tailored treatments are the favourable approach. I feel that the more tailored the plan, the more I am able to integrate the artistic aspect of my job which can otherwise be easily overlooked when following set protocols and routines.
Personally, I don’t like to limit myself in the tools at my disposal for treating each patient individually to achieve their best result. Having said this, safety considerations must naturally always take priority to the artistic process, which is why the implementation of more diverse filler rheologies within each manufacturer portfolio has allowed us to achieve so much more now while remaining safe and responsible practitioners.