Practical Application of the Facial Fat Compartments and the Line of Ligaments Concept in Achieving the Lifting Effect in the Lower Face Region
Published on: 2021-12-31
HA fillers can be used to restore the youthful appearance of aging faces however quite often the treatment leads to achieving unnatural or “done” result. What are the anatomical determinants of facial identity and how to achieve a natural result? According to the author’s opinion, respecting the line of the retaining ligaments together with the position and volume of facial fat compartments is crucial to preserve the natural phenotype without losing the patient’s identity. The technique reported here is based on the filling of the superficial lateral temporal cheek fat compartment, which lies behind the line of retaining ligaments. It demonstrates that lateral midface injection repositions the midfacial soft tissues and provides an efficient injection related lifting in the lower face area.
KeywordsLine of Ligaments; Facial Fat Compartments; Lifting Effect; Soft Tissue HA Filler; Lower Face Region
Respecting the line of ligaments and the anatomical location of the fat compartments, using moderate amounts of the soft tissue HA fillers placed in certain fat compartments allows to achieve an aesthetic outcome of the treatment.
Filling of the superficial lateral temporal cheek fat compartment provides lifting effect in the lower face: accentuates the jawline contour and repositions the soft tissues of the lower face.
The concept of the subcutaneous facial fat compartments [1,2] suggests that the face does not age as a composite mass. The shearing forces between neighboring compartments may be the reason behind soft tissues malposition. This knowledge, together with the concept of the line of ligaments and the preconditioning effect of the lateral injection [3-5] resulting in a tensioning of the midfacial fascial layers, applied into the minimally invasive augmentation techniques allows to gain an aesthetic lifting effect in the lower face area.
The technique reported here is based on the filling of the superficial lateral temporal cheek fat compartment. The author has found that specific targeting of this region can lift the position of soft tissues of the lower face and accentuate the jawline contour. What is also important – the amount of HA used in this procedure is moderate and does not create an excess volume. This is in line with the observations of Casabona et al  who reported that lateral midface injection repositions the midfacial soft tissues and brings an efficient injection - related outcome.
The patient presented here is a 56 years old woman, with no previous soft tissue filler treatments of the face, absence of previous thread treatment, and no previous facial or neck surgery. Medical history shows an absence of allergies, contraindications, or chronic diseases that exclude the application of soft tissue fillers in the face.
After topical skin disinfection of the face with alcohol (Skinsept Pur, Ecolab, USA) the skin was punctured 1.5 cm to the Porion with a 23 G needle and a 25 G 50 mm blunt cannula (STERiGLIDE™, TSK, Japan) was inserted in the downward direction. The entire length of the cannula was advanced in the superficial subdermal plane until reaching the mandibula angle. To check the plane position of the cannula it was lifted against the skin so that its contour was visible under the skin. Using the fanning technique, a total volume of 0.7 mL of the product (TEOSYAL RHA® 4, Teoxane, Switzerland) was injected slowly in a triangular shape starting from the mandibular angle all the way to the anterior border of the superficial lateral temporal cheek fat compartment.The cannula was then withdrawn to the point where direction change was possible and it was redirected towards the temporal region. It was still located in the subdermal plane and one bolus (0.5 mL) of the HA filler (TEOSYAL RHA® 4, Teoxane, Switzerland) was injected slowly, with an extreme caution  to avoid any blood vessels in a region of the posterior temple. The index finger of the nondominant hand was placed at the projection of the cannula’s tip on the skin, to compress the injected area in order to prevent a retrograde injection flow.The immediate effect of the treatment in terms of improving contour of the jaw, accentuation of the mandibular angle and decreasing of the marionette lines was observed by the patient, the treating physician and an independent observer. To further improve the effect and the appearance of the lower face, slight augmentation of the lips was performed using 1 mL of the HA filler (TEOSYAL RHA® 2, Teoxane, Switzerland) with 0.4 mL of the product being placed along the contour of the lips with a 30 G 13 mm needle and 0.6 mL of the product placed subdermally in the vermillion using a 25 G 38 mm blunt cannula (STERiGLIDE™, TSK, Japan). The two points of insertion were placed over the oral commissures.
Following the procedure, no major adverse events were reported during the two weeks observation period. The patient reported slight tension and sensitivity in the treated area, which resolved without medical intervention within <48 hours. The images presented here relied on the frontal and direct lateral view. The same position of the patient was captured on the images before the treatment, immediately after the treatment and 2 weeks post treatment. The images were evaluated retrospectively by the treating physician and by an independent observer with experience in aesthetic medicine.
The Global Aesthetic Improvement Scale (GAIS) was assessed 2 weeks after the treatment. The evaluation of the GAIS relied on the assessment by the patient, by the treating physician and one independent observer. The patient rated her overall facial improvement as exceptional. The treating physician and independent observer rated the effect as very much improved. The results of the retrospective image analysis and GAIS assessment confirmed the positive outcome and the role of the temporal lateral cheek fat compartment in soft tissue filler injections for aesthetic facial treatments. The subdermal product placement  in the described area had its effect in the lower face by visibly improving the contour of the jawline and the mandibular angle. The described technique preserves the facial identity  and can be recommended to achieve a lifting effect in the lower face with the usage of moderate amount of the soft tissue HA fillers. Fot. 5. 48 h after second dose of vaccine
This study (retrospective analysis) was conducted in accordance with regional laws (Poland) and good clinical practice. The patients provided written informed consent for the use of both their data and associated images prior to the treatment.
Conflict Of Interest
The author declares no potential conflicts of interest with respect to the research, authorship, and publication of this article.
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