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I would like to introduce Tina now, who has just turned 50 years old, and she presents with 3 very specific concerns. Firstly, the area around her jowl, which she finds is bothering her much more than any lines she may have on her forehead. Secondly, she has a degree of hollowing under the eye, and finally, a degree of hollowness in the upper eye. We will discuss these regions in more detail, but looking at the concern of her jawline, we find that a number of patients are bothered by what they perceive to be sagginess. We can see why this would bother Tina specifically, because if we look at her face shape overall, she has an oval face shape, so she has a smoothness and a youthful convexity in the forehead and the cheek, but when we get to the lower face, this is disrupted along the jawline by the face that she has these marionette lines, a wide chin, and jowls.
Let’s look at the midface from the glabella to the subnasale. The first thing I can see is a hollowness of the upper orbit, and this gives the eyes a sunken appearance, which has the effect of making Tina look fatigued. If this was more severe, we might call it an “A-frame” deformity, and this area is amenable to filling, as we will demonstrate during her treatment. After looking at the upper orbital region, we can look at the lower orbital region, and just from the front, we can see that there is clearly some hollowing here, and again this also makes Tina look tired or fatigued. If we tilt her head down, we will see that this extends all the way from her tear trough region into the midcheek, and we can see that a gentle filling of this region would tend to improve the hollowness that we can see. However, if we are proposing to treat anybody in the infraorbital region, we should test the integrity of the skin, and you will notice that the cheek skin is nice and thick, however when I pull the skin from the eyelid we can see that the elastic recoil is slightly sluggish. When I asked Tina about her eyes, she mentioned that she frequently gets swelling of the region in the morning, so although her distraction test is relatively normal, we are just aware of a little bit of scleral show at rest, and that added to the poor elastic recoil makes me reluctant to treat her directly with dermal filler in this region. However, we will see what degree of improvement we can get with an indirect approach. From the oblique, we can see that she is volume deficient in the anterior part of her cheek, and again this is a good target for revolumisation with dermal filler. It is quite possible that filling this area will improve her infraorbital hollows indirectly.
Let’s examine Tina’s lower third. If we begin with the width of the nose, we will see that her nasal flare is wider than her intercanthal distance, and ideally we would prefer this to be slightly narrower. Moving below the nose, we can see that she has well defined philtral columns, and that the overall shape of her lip is reasonable, however, you can see a very obvious asymmetry, where her right lower lip is fuller than the left lower lip. If I see an asymmetry like this on a patient, I like to examine the dental arcade to see if there is any dental reason for this, and we can see that although her lower teeth are irregular, there is no obvious reason for a dental predisposition to the lip asymmetry. Accordingly, we will just treat the lip with dermal filler to improve this. If we now look at the chin, we can see that the chin width is also wide. In a female patient, we prefer to have a chin width in line with the intercanthal distance and nasal flare. However, Tina’s chin is almost as wide as her oral commissures, which is a male trait. Accordingly, we can improve the aspect of her lower face by narrowing her chin. This can be difficult to achieve, but we will use a product injected into the midline to achieve this. Finally, we have marionette lines on both sides, which are giving rise to the jowl formation that we can see on oblique view. Accordingly, we need to look to see how we may improve her jawline, her marionette region, her chin, and her lip to improve her lower third. We can best do this by using a lifting procedure, because these issues are clearly caused by deflation and dissent of the soft tissues in the mid and lower face.
Marking and strategy
Let’s have a look in the strategy involved in treating Tina. If I tilt her forward, you will notice that she has some significant sagging that is more obvious on her right side than on her left side. This is evident from a prominent jowl and deep marionette line formation. If I now turn Tina to the oblique view, you will see that I have marked out the jowl in red, and this is the area of heaviness and sag. This is a ‘no-go’ area, and we don’t want to inject here. We have to ask ourselves if we will get improvement if we lift superiorly, posteriorly, posteroinferiorly, and anteriorly, and we can see that we do. If we can get lift along these vectors, we can see that we get an improvement in the sagginess, and this will be the basis for Tina’s treatment.
Right cheekbone treatment
We are going to treat Tina in her right lateral cheek area. We have marked out the zygoma in terms of the upper and lower border. I will use a 25 gauge, 38 mm cannula, and my product of choice here is Juvederm Voluma. Because I am injecting her over the hairline, I am using a sterile drape to keep the field clean. After pinching the skin, I introduce the cannula at a deep level, and ideally I want to inject the product along the periosteum. Remember, the cheekbone has a comet or meteor shape, and therefore I want to inject more product anteriorly and less along the zygomatic arch. I will use the finger of my non-injecting hand to guide me so that I know that the product I’m injecting is regular and I am not missing out any areas. It is important to inject slowly and to watch the tissue as you inject so that you can see how much fill is being created. From this view, we are aware that slowly we are getting a projection and definition of the cheekbone. We will use 0.5 mls in this region, and as I mentioned, there will be more product injected anteriorly and less along the arch. This will form the comet shape, with the head at the front and the tail over the arch. It is vital to be deep in this region – if you inject in the superficial fat, you will find that when the patient animates, such as during a smile movement, product will move and give a very unaesthetic appearance, so our target is along the periosteum and the suborbicularis oculi fat, also known as the SOOF. After removing the cannula I will often give a very gentle mould and I am very keen not to over massage because we want to keep the projection that we have created, because this is what will give us the lift that we are looking for in the lower face.
Right pre-auricular cheek lift treatment
Let’s have a look at Tina after the treatment of her right cheekbone. We can see that on the treated side she actually appears slimmer due to the fact that she has projection with some contouring below it. If we look at the non-treated side, you will see that she remains flat in the region of the cheekbone. In the treated side she now has a pleasing OG curve, which is due to the filler in the cheekbone region. Again, if we look at her from the front, we will notice that she has an improved canthal tilt and the infraorbital hollow seems to have lifted compared to the non-treated side due to lateral support gained by the treatment.
We now move on to treatment of the pre-auricular area to get more lift. We need to be superficial here, so we introduce our entry at a very flat or shallow angle, and when we remove the needle, I hold the cannula like a dart to get easy entry into the skin, remaining superficial. I can then adjust the grip on my cannula and I am looking to lay a series of linear threads of product in a fan-like distribution, so I will start by bringing the cannula forward. If I meet any resistance, I can inject a little bit of product to open up the tissue planes. We will often get some resistance in this region due to the masseteric cutaneous retaining ligaments. I will often tell my patients that they may hear a popping sound and not to be alarmed by this. You can see that Tina, who has never had any cosmetic treatment prior to today, is very comfortable, despite the fact that she has not had any anaesthetic or numbing. I believe that one of the reasons for this is that we spent a lot of time preparing her for this treatment so that she would know exactly what to expect. I also make use of the fact that the product contains Lidocaine, so if I see that the patient has any discomfort, I will inject some product and let it exert its anaesthetic effect before continuing. You may be surprised by the level of volumes which are required in this region, and it is not unusual to require up to 1 ml of product per side. In Tina’s case, I am injecting 0.8 mls of Voluma in total. After treating in this region, unlike the cheekbone area where we don’t massage, moulding the product and massaging it with a little bit of cream is vital, because we want the product to disperse to give us our lifting effect.
Right anterior cheek treatment
We now see Tina after treatment of her cheekbone and the pre-auricular area for the lift, and we can see that she continues to look slimmer and more lifted on the treated side compared to the non-treated side. We can see that we started on the more severe side, but now we can see if we compare her left to her right, which is the treated side, that the two look almost identical now. We can see that we have got the maximum lift from our superior vectors, so we now need to move on to the posterior and anterior vectors. Before doing that, we will move on to treatment of the anterior cheek, and you can see that she’s got a lovely projection laterally, but she’s very concave in the anterior part of her cheek. I have divided this area into two – the area lateral to the mid pupillary line and the area medial to the mid pupillary line. The red mark denotes the presence of the infraorbital foramen.
Because I need to treat this entire area, I will use a cannula. It is vital not to over inject this area, because this is the region of the lip elevator muscles, and if we inject too much product in this region we can cause smile asymmetries, so I will pinch the skin and introduce my entry needle. Remember, the depth here must be deep as the target is the medial part of the suborbicularis oculi fat and the deep medial cheek fat pad. A common mistake in this region is to inject the superficial fat pads, which will give a poor aesthetic result. You will notice that I have introduced my cannula deep, and I am using Juvederm Volift for this treatment. I use the finger of my non-injecting hand to protect the infraorbital foramen and also the orbital rim. I am also using my finger to guide the product that I want to inject, and what I’m aiming to do is get a better concavity of the anterior cheek. The other important caveat of this treatment is to ensure that we get a more harmonious transition from the anterior to the lateral aspect. We will often come against resistance, either from the fibrous septae or retaining ligaments. At this point, it is vital not to force the cannula, as you may end up creating too much pressure and passing the cannula too far forward in the delicate structures. If you do encounter resistance, simply inject a little bit of product to open up the tissue plane. You can now see that as I am injecting from the anterior to the lateral, we are already creating a better convexity and smoothness in this region. I will inject a total of 0.5 mls in this entire region.
Left cheek treatments
We can now see Tina after the treatment of her anterior cheek, her cheekbone, and the pre-auricular area. Notice how the lid cheek junction line has risen and improved on the treated side – her entire right eye area looks more open and more youthful. If we look at the transition of convexity from the cheekbone to the anterior cheek on the treated, we can see that on the other side we have a groove and a very obvious hollowing. The other important observation to make is that the untreated side looks heavier and saggier, whereas on the treated side we have a very clear lift, with an obvious definition and projection, and a very obvious contour below, making her look slimmer and younger on the treated side. As I check Tina’s animation, you will notice that she has a very natural smile with no obvious display of product. The left side is treated in an identical way, and we have edited the footage for speed. We begin with the cheekbone, where we treat the pre-auricular area to create lift. I always tend to inject patients with exactly the same quantity on both sides, even if there is pre-existing asymmetry, and make corrections at the end. Finally, we will treat the anterior cheek as per the other side to improve the front convexity and blend in with the lateral cheek. After massage, let’s review the treatment of Tina’s upper face.
Chin and prejowl treatment
When we look at Tina now, we can see that she looks symmetrical, we can see good and defined projection of the cheekbone on both sides, and we can also see the same degree of contouring below the cheek. We can see that the jawline has improved on both sides merely by treating her midface. This is an important lesson in treating the lower face – we must ensure that we have adequate midface support before commencing any lower face treatment. If I tilt her down, you will notice that she has also got some improvement in the infraorbital hollows from the lateral support, and finally, you can see that the marionette lines have already started to lift.
We now move onto treatment of the chin. We are treating Tina in the labiomental region, and I will use a cannula for this purpose. The important consideration here is depth – we want to be mid level, ideally subcutaneous or in the muscle layer. We cannot be superficial as we may see visible strands of product, and we cannot be deep or else we will be inside the oral cavity. This can be a sensitive area for patients, so it is important to inject slowly and introduce the product anterograde so the product can start giving the patient a numbing effect. We are giving slow anterograde threads of product, concentrating mainly in the midline, and injecting a little bit less towards the sides. If there is any resistance, it’s important not to force the cannula, but inject a small amount of product as it will have the effect of opening up the tissue plane. Use the finger of the non-injecting hand to guide your product placement.
After treating the labiomental crease, we can swing the syringe up and direct the cannula down towards the midline and tip of the chin. When we inject in this region, we can give an elongation or an increased inferior projection, and it is important to stay in the midline and not venture too far laterally, because we want to get a narrower chin as long as a longer chin. In the MD Codes, this area is known as C2. I have injected 0.3 mls of the Voluma in her labiomental crease, and a further 0.2 mls at the tip of the chin to get the lengthening. Although you can use a needle in this region, I prefer a cannula because it is very vascular and prone to bleeding. We will treat her left side in exactly the same way as her right side, using the same volume of product in the labiomental crease and also the chin. Therefore, in total, we will have used 1 ml of voluma to treat her chin. After treatment, it is important to check the oral cavity to make sure you haven’t inadvertently injected any product inside the gingival sulcus. At the end of treatment, I like to give her a little bit of massage and mould the product, and if we look at her chin now from this angle, we can see that the chin width appears to be narrower.
Prejowl and marionette treatment
Let’s have a look at Tina following treatment of her cheeks and chin. We can immediately spot that she has better support of her lower lip due to effacement of the labiomental crease. We can also see that the chin looks more refined, and it also appears to be narrower. Before treatment, it was in line with her oral commissures, and now we have managed to get it narrower so that it lies in line with her nasal flare. This is ideal for a female chin. If we look at Tina from the profile view, we can see that following treatment to the chin, we can move on to treating her in the prejowl sulcus. Finally, when I look at her from the front, I am aware that she has a little deficiency in her right side of the chin compared to the left side. Accordingly, I will treat this at the same time and I will address the deep component of her right marionette line.
I would like to discuss the markings and strategy for the treatment of Tina’s prejowl sulcus and marionette line. You will see that when I put pressure on the jowl that she has a little deficiency just anterior, so I will fill this area up with the product, and she will require more in the crease of the fold and less as we go closer to the tip of the chin. I will treat her prejowl sulcus with a needle. I will then move on to treating the deep component of her marionette line with a cannula, and I will start at the prejowl sulcus. Following this, I will treat the marionette line in the superficial plane. At the same time, I will address the deficiency in her right anterior chin with a needle. On her left you can see that the marionette line is much less deep, accordingly, I will just treat the prejowl sulcus and address the marionette in the superficial plane only.
We begin by treating the prejowl sulcus. I have marked off the deficiency and I am using Juvederm Voluma for this purpose. The important thing is to inject the product in a very precise location, so I use my finger and thumb to trap the product between my fingers because I don’t want it to go posterior into the fold or inferior below the line of the jaw. Having injected my needle through the skin, I aspirate and then inject a bolus of Voluma onto the mandible itself. In the first injection point, I will inject a total of 0.2 mls of Voluma. The aspiration is important because this injection point is very close to the mental foramen, from which the mental artery will emerge. After injecting in the first region, I will just give a gentle mould, and you can already see that there is a better transition from the posterior jaw to the anterior. I will then palpate the area and as I do so I notice that there is a deficiency just anterior to the area I injected, so I will inject here additionally. I take a wipe to re-sterilise the area then use my fingers to compartmentalise the product again. I insert deep onto bone, aspirate again, and this time I inject less product, 0.1 ml. In doing so, I will already have treated the prejowl sulcus, which forms the inferior part of her marionette line.
We will now address the deep part of her marionette line. For this purpose, we will be using a cannula, and I will insert this from the region of the prejowl sulcus in the deep plane. I make a pre hole with my 23 gauge needle, ensuring that I am in a deep location, and after withdrawing my needle I will insert my cannula vertically, ensuring that I stay medial to the fold. You will notice that after I insert the full length of the cannula that you will be able to see the tip just below the oral commissure of the lip. In doing so, the idea is to lay pillars of support in this region. The vital thing is to make sure that you stay medial to the marionette line otherwise you can add a heaviness to this region. I will add approximately 3 pillars of 0.1 ml each, and each time I do so I will get increasingly superficial. This technique allows me to address the deep component of the marionette line. Having treated the deep portion of the marionette, I then move on to treating the superficial part, but before doing so, I will address the small deficit in the anterior part of the chin. To do this, I simply inject a bolus of Voluma subcutaneously into the bottom of the deficiency, and I will inject a total of 0.1 ml here. After treating the prejowl sulcus on the right side, you can see that there has been a substantial improvement, and now we can no longer see any anterior marionette line or fold. There is still, however, a small amount of jowling visible, but the two sides now are more or less symmetrical in terms of the level of sagginess. Accordingly, we can now move to treating the marionette lines in the superficial plane.
To treat the marionette line in its superficial component, we will use a series of linear horizontal threads of Volift. I start just medial to the fold and inject retrograde linear threads of product, approximately 0.05 mls of product per thread. These are set like the horizontal rungs of a ladder. As I ascend vertically, I ensure that my needle placement becomes more superficial. The very last rung will be just below oral commissure, almost in line with the lower vermillion border of the lip. I repeat the technique for her right side, but because we already addressed the deep plane, she has less volume requirement here, and accordingly I will only need to inject one rung. I then give her face a massage.
We now see Tina at the end of the treatment of her prejowl sulcus and marionette lines. We can immediately see that the area looks soft, smooth, and without any obvious shadow. As I turn her to the oblique side, we can see that there is excellent effacement of the nasolabial fold and marionette line, and we can also see that this result is symmetrical. Furthermore, if I get Tina to animate, we can see that both during a smile and also pursing her lips, she has excellent support and smoothness of the perioral structures. We will move on to the treatment of Tina’s lip, and you will recall that she had a degree of asymmetry, whereby she had less fill of her left lower lip. Accordingly, I will treat this with a cutaneous approach. My needle enters through the skin and I am filling the red vermillion directly with Juvederm Volift. I add a 0.05 ml bolus in one location and then I move laterally and add another 0.05 ml bolus. Following this, I will treat her at the oral commissure for more support. My needle will enter in the very superficial plane as I want to give her a little bit of support in the submucosal region. Having treated her left oral commissure, I move to treat her right. The idea here is to just give the most gentle support in this region so that we go from a downturned commissure to a neutral standing commissure. Let’s have a look at her result – we can see Tina now after a full treatment of her lower face, including the lip. Immediately, we can see that there is better symmetry than pre-treatment and her commissures are also better supported.
Upper orbital treatment
We are now moving on to treatment of Tina’s upper orbital hollows. To do this, I am using a cannula, and I will use my product of choice, which is Juvederm Volbella. My device here is a 25 gauge, 38 mm cannula. I have to stress that this is a technique for advanced injectors only. The ideal plane is behind the orbicularis oculi muscle and in front of the orbital septum. I guide my cannula so that it travels along the inferior aspect of the orbital rim, and I will inject very small amounts of product mainly in the medial most portion of the deformity. It is imperative not to over inject in this region, otherwise the patient can get unsightly swelling and edema. After injecting the product, I apply a gentle massage. After treatment of Tina’s upper orbital sulcus, we can see that she is less hollow in this area, and we can see more eyelid show. This gives her a more open and younger looking eye, which also looks less tired. We will now proceed to treat her left eye. My cannula entry point is just below the tail of her left eyebrow. I proceed to enter and remain under the orbital rim, maintaining a superficial placement, and after depositing the product I give the area a gentle mould and massage with a cotton swab.
We will now treat Tina’s jawline, and as you can see, we have marked out lines to lay the product down. We pinch the skin and enter the pre-treatment needle at a very shallow angle. This is because we want to run in a very subcutaneous, superficial plane with the cannula. The main reason for this is that this is the region of the facial artery. We also have the masseter and the parotid gland in this region. We lay linear threads of product in this region to add definition and sculpting of the jawline. I am compartmentalising the product with the thumb and finger of my non-injecting hand, and I inject right up to the angle of jaw. Once we have finished with the left side, we will move over to the right side. You may notice that following the procedure, the patient appears a little lumpy and there may be some visible product. This is nothing to be concerned about, and you can simply massage this out.
We now see Tina following her full face treatment, and I think she has had a remarkable result from baseline. We can see substantial improvement in many aspects of her face, so let’s review her treatment. We can see that we started off by giving her more cheekbone definition, and this in turn not only gave her projection, but also improved her lift. We treated her in the pre-auricular area to enhance that lift, and in doing so started effacing her nasolabial fold and marionette lines. We proceeded to treat her chin to give her some narrowing and also some anterior support and anterior projection. We treated her then in the prejowl sulcus and in the deep and superficial aspects of her marionette lines. We proceeded to treat the asymmetry in her lip and also her oral commissures, then moving up to treat the upper orbital hollows. Finally, we treated her in the jawline.
If we look at her from the side, we notice now that she has a very youthful profile and the jawline, marionette, and nasolabial fold have all been lifted substantially from baseline. We can see that she has a very pleasing and youthful OG curve when viewed from the oblique profile, and this is mirrored by the very smooth jaw from chin to the angle of the jaw. Furthermore, we can see that her eyes appear less hooded, and this gives her a more refreshed appearance. The result appears to be symmetrical, and we can see the same degree of projection and definition on both sides. The other observation to make is that despite treating Tina in multiple areas, she looks relaxed and doesn’t appear to have any major swelling. We can see that on the angle of the jaw there is still some prominent product visible, but this is something we can massage down. I like to lay a bit of product so that it is more visible, because it gives a better definition as it subsides. In summary, Tina’s result is an example of a harmonious and natural outcome.