The “Smile-and-Fill” Injection Technique: A Dynamic Approach to Midface Volumization

Injectable poly-L-lactic acid (PLLA) is a biodegradable, biocompatible, synthetic polymer that acts as a scaffold to promote collagen formation.¹ It is FDA-approved for the correction of facial lipoatrophy in patients with human immunodeficiency virus (HIV) infection.¹ The safety and efficacy of injectable PLLA for the treatment of HIV-associated facial lipoatrophy has been demonstrated in clinical studies and is accompanied by improvement in patient quality of life.^2-3 There are currently three injection techniques for PLLA administration into the face: the tunneling, depot, and fanning techniques.^4-5 The importance of respecting patient mid-face differences at rest and in motion was highlighted in a study that demonstrated effectiveness of silicone microdroplets (0.01 mL) in a depot manner to treat HIV patients with facial lipoatrophy.⁶ One of the challenges of facial volume rejuvenation with these techniques is preserving and enhancing dynamic facial movements after treatment. To address this challenge, we propose an injection technique termed “smile-and-fill.”

In the smile-and-fill technique, 2 vials of injectable PLLA are reconstituted with 5 mL sterile water for at least 2 hours prior to use. Immediately before injection, 3 mL of 1% lidocaine with epinephrine is added for local anesthesia during injection to create a total volume of 8 mL of PLLA in solution. The reconstituted mixture is drawn up into 3 mL syringes attached to 22-gauge, 1.5 inch needles. The patient is instructed to smile to accentuate the malar cheeks. While the patient is smiling, the needle is then inserted into the subcutaneous tissue of the accentuated malar cheek, superficial to the zygomatic arch and parallel to the skin surface of the cheek (Figures 1 A and B). A reflux maneuver is performed to avoid intravascular injection. If no blood is pulled back into the syringe, then approximately 3 mL of PLLA is injected into each cheek in a retrograde fashion. Following injection, the PLLA material is manually redistributed using firm pressure to ensure an even global texture and to minimize the development of aggregates of the filler material. The patient is asked to massage the injected sites for 5 minutes, 5 times a day, for 5 days after the treatment to reduce the risk of granuloma nodule formation and to ensure even distribution of the product across the globe of the cheeks.

In this case series, we describe three patients with HIV-associated facial lipoatrophy on antiretroviral therapy who underwent PLLA injection with the smile-and-fill technique, for a total of three treatments per patient between February 2013 and July 2013 (Table 1). All three patients benefited from visible augmentation of their cheek contours with no adverse effects. This filling technique accentuated dynamic cheek fullness and movement associated with smiling, without an artificial "overfilled" appearance at rest.

A 49-year-old man with a 28-year history of HIV presented to our clinic with facial lipoatrophy, most prominently in the cheeks bilaterally. His malar cheeks were treated with injectable