What are the recommended injection sites for fillers, such as hyaluronic acid (Restylane, Juvederm) or calcium hydroxylapatite (Radiesse), in a healthy adult, likely in their 40s or older, experiencing typical signs of natural aging?

Recommended Filler Injection Sites for Natural Aging

For natural aging in adults 40+, inject fillers into the tear troughs, nasolabial folds, jawline, lips, and perioral wrinkles using intradermal placement with 30-gauge needles at shallow angles to target volume loss and fine lines while avoiding deep vascular structures. 1, 2

Primary Injection Sites Based on Aging Patterns

Tear Trough Area

• The tear trough is a validated injection site for addressing hollowing and aging appearance, with significant clinical improvement demonstrated on the Tear Trough Rating Scale at 3-month follow-up 1
• Inject using intradermal technique to avoid the deep hypodermis where major vessels like the transverse facial artery reside 2
• Both hyaluronic acid and calcium hydroxylapatite show efficacy, with mean duration of 10.1 months for HA and 12.8 months for calcium hydroxylapatite 3

Nasolabial Folds

• Nasolabial folds are among the most common injection sites for facial aging, particularly for patients scoring 1-2 on the Merz 5-point scale 4, 5
• A mixture of 1.5 mL calcium hydroxylapatite with 1.0 mL hyaluronic acid maintains constant volume with high satisfaction scores, as the HA compensates for early volume loss of calcium hydroxylapatite 4
• Consider intraoral approach for deep nasolabial folds to minimize risk of intravascular injection and associated complications like skin necrosis 6

Jawline and Lower Face

• The jawline is an established injection site for addressing age-related volume loss and contour deficiency 4
• Use 3.0 mL total volume of mixed fillers for combined nasolabial fold and jawline treatment 4

Perioral Region and Lips

• Facial wrinkles and fine lines around the mouth respond well to filler injection, with Wrinkle Severity Rating Scale scores decreasing from baseline 3.18 to 1.65 at 3 months 1
• Crow's feet and perioral rhytides show significant improvement post-injection (p<0.001) 1
• Lip injections using 0.5 mL per quadrant (2 mL total) demonstrate significant rejuvenation at 3-month follow-up 1

Additional Sites for Comprehensive Rejuvenation

• Face, neck, and hands are all appropriate sites for volumizing and contouring fillers 1
• These areas benefit from both traditional fillers and autologous platelet concentrate bio-fillers 1

Critical Safety Protocol for All Injection Sites

Injection Depth and Technique

• Use intradermal placement exclusively with 30-gauge, 4mm needles inserted at shallow angles with bevel facing upward 2
• Create visible papules or wheals with blanching during injection to confirm proper intradermal placement and avoid deep vasculature 2
• Aspirate the needle prior to each injection to detect intravascular placement before filler administration 2

Volume and Distribution

• Use incremental injections rather than large boluses to minimize vascular compression and allow early detection of complications 2
• For nasolabial folds and jawline: 3.0 mL total volume is appropriate 4
• For tear troughs: individualized volume based on severity, typically 0.5-1.0 mL per side 1

Filler Selection by Site

Hyaluronic Acid (Restylane, Juvederm)

• HA fillers are appropriate for all facial sites with duration of approximately 10.1 months for tear troughs 3
• Can be mixed 1:1 with calcium hydroxylapatite for enhanced longevity and reduced early volume loss 4

Calcium Hydroxylapatite (Radiesse)

• Provides longer-lasting results with mean duration of 12.8 months for tear troughs 3
• Best used in mixture with HA (1.5 mL calcium hydroxylapatite + 1.0 mL HA + 0.5 mL lidocaine) to prevent unexpected early volume loss before neocollagenesis occurs 4

Autologous Platelet Concentrates (Bio-Filler)

• Consider APCs as a safer alternative when volumization is not the primary goal, particularly for fine lines and overall rejuvenation rather than structural volumization 2
• Appropriate for tear troughs, crow's feet, facial wrinkles, and perioral areas with effects lasting 4-6 months 1
• Lower risk of vascular occlusion complications compared to traditional fillers 1

Common Pitfalls to Avoid

• Never inject deep into the hypodermis where major vessels like the facial and transverse facial arteries reside 2
• Avoid areas with scars, bony prominences, or previous complications 2
• Do not use permanent fillers except in reconstructive procedures due to high complication rates requiring surgical correction 7
• Ensure adequate training in facial anatomy and injection techniques before performing procedures 5
• Document all treatments and obtain detailed informed consent including filler type, expected longevity, and possible complications 5