When a physician is placing a dermal filler, how is s/he able to tell which layer of the skin the filler is actually being deposited? For example, is it readily obvious if the needle or cannula is in the deep dermis vs underneath the dermis and sitting atop the muscle? Or if the needle is in the deep dermis vs the mid dermis?
How Does a Physician Know Exactly What Layer S/he is Injecting a Filler Into?
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Doctor Answers 14
Experienced Restylane or Juvederm filler injectors know which layer because they know surgical anatomy.
You ask a smart question: How does the injector know how deep she is injecting dermal fillers like Restylane, Juvederm, or Perlane? The answer is that it is NOT "readily obvious" as you ask. There are accidentally decent injectors, who can do all right on the more straightforward areas (which can still lead to permanently damaging defects in the face if done wrong), and there are trained, experienced injectors who can visualize what's going on under the skin because they've SEEN IT with their own two eyes doing surgery. There is a big difference between these two groups. Go for an experienced dermatologic surgeon, plastic surgeon, ENT surgeon, or oculoplastic surgeon when picking your injector. Good luck!
Injector experience and training are important for filler treatments
There really is no substitute for injector experience and training when discussing filler treatments. It really is a "feel" that the injector has for the level of the injection. The dermis (the layer most superficial) is more firm, the subcutaneous layer, which is mostly fat, is more "loose", the injector can get an idea of the level by the resistance on the needle. When injecting in the superficial dermis, the needle is almost visible in the skin, the deeper dermis is just above where the needle resistance lessens. Experience and training are necessary to “feel” the difference.
Dermal and deep fillers
It is difficult to tell the exact location of the layers but here is a general guideline.
Superficial (epidermis): you can see the needle
Mid skin depth ( dermis): you cannot see the needle and the tissue is thick and needs force to push the needle through.
Deep skin (Sub-dermis): Needle can move through easily in all directions.
To be accurate in placement takes practice and experience.
Disclaimer: This answer is not intended to give a medical opinion and does not substitute for medical advice. The information presented in this posting is for patients’ education only. As always, I encourage you to see your personal physician for further evaluation of your individual case.
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Physician or injector experience
A well-trained and experineced injector knows by feel which "layer" he or she is injecting to, when placing dermal fillers. Be sure you're consulting and meeting with someone reputable and experienced for best results!
What Layer for Fillers?
An experienced plastic surgeon, particularly one who performs many facelifts, eyelid surgeries, rhinoplasties, chin surgeries, brow lifts, fat grafting, etc., can place the filler in virtually every millimeter possible.
Injection and tissue layer
I think that experience performing these procedures is the key to treatment. Most injection of fillers have been placed in the subcutaneous space and not so much in the dermis. Dermal filling with HA's may lead to the Tindal effect.
How does a physician know which level of skin is being injected?
Well-trained physicians, particularly those who go through board-certifications for derm and plastic surgery, have an advanced level of understanding of the skin and depths. I get this question a lot when I have to do procedures on the eyelid: how is if you're not going to stab into my eye?? answer: well, a well-trained physician doesn't inject blindly and will know there are varying layers of skin and depths in every area, so I can inject your eyelid safely, I promise! Good injectors know where fillers need to be injected - all at varying depths, and sometimes they do go under the muscle intentionally! So, pick a good, board-certified injection and they will know what depth to put your injectable, because that's what we are skilled to do!
Experienced injectors of dermal fillers should have a good feel for depth. The way the skin tents with the needle inserted is helpful as well as needle resisitance.Depending on the filler and type of wrinkle or skin fold, the injector will decide what depth to inject. For instance, for superficial lines and wrinkles, a very shallow depth is needed, in this case the needle may even be visible under the skin. For deeper folds, like around the nasolabial area, mid to deep dermal depth is required. For larger volume replacement, filler is sometimes injected on or just above bone, so the injector may tap on the bone for orientation. Injectors with poor training or less experience may not be as good at determining depth.
Yes, if the injector is experienced, they can feel what layer they are in. If your injector is a board certified plastic surgeon, they know the layers very well as see them during their surgical dissections and also have studied them in anatomy. If your injector is not a plastic surgeon or doctor or does not have a lot of experience, you need to be very careful having them inject you.
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.