Quantitative Analysis of The Lifting Effect Of.10

COSMETIC
Quantitative Analysis of the Lifting Effect of

Facial Soft-Tissue Filler Injections
Rami Haidar, B.D.S.

Background: Although injectable soft-tissue fillers are frequently used for facial
David L. Freytag, M.D. rejuvenation, there is a dearth of objective data evaluating the tissue-lifting
Konstantin Frank, M.D. effects. Current practices for efficacy evaluation include some subjectivity. This
Christina Rudolph, M.D. study seeks to evaluate the lifting effects of facial soft-tissue fillers in a quantifi-
Hassan Hamade, B.Sc. able, objective setting.
Thilo L. Schenck, M.D., Ph.D.
Downloaded from http://journals.lww.com/plasreconsurg by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 05/17/2021
Methods: Twenty fresh hemifaces obtained from 10 Caucasian body donors

Jeremy B. Green, M.D. (seven women and three men) with a mean age of 83.5 ± 6.8 years and a mean
Riccardo E. Giunta, M.D., body mass index of 25.3 ± 4.3 kg/m2 were injected with soft-tissue fillers fol-
Ph.D. lowing a predefined treatment algorithm. Three-dimensional surface scanning
Robert H. Gotkin, M.D. procedures were performed to assess postinjection effects.
Sebastian Cotofana, M.D., Results: Injections in the medial face [i.e., forehead, medial midface, and peri-
Ph.D. oral (chin and labiomandibular sulcus)] increased the local surface volume by
Riyadh, Saudi Arabia; Munich, Germany;
0.67, 0.56, and 0.87 cc and created local (but not regional) lifting effects of 1.11,
Albany, N.Y.; Coral Gables, Fla.; New 0.11, and 0.74 mm. Injections in the lateral face (temple, lateral midface, and jaw-
York, N.Y.; and Rochester, Minn. line) changed the local surface volume by 0.45, 0.02, and −0.38 cc, and created
local lifting effects of 0.57, 0.81, and 0.29 mm, respectively. Lateral face injections,
however, created additional regional lifting effects by co-influencing neighboring
lateral facial regions, which was not observed for medial face injections.
Conclusions: This cadaveric study provides evidence that soft-tissue fillers,
although typically classified as volumizers, can induce lifting effects of the face.
Whereas temporal deep supraperiosteal injections have limited lifting effects,
the combined effects of subdermal injections of the temple, lateral midface,
and mandibular angle can induce lifting effects of the total lateral face. (Plast.
Reconstr. Surg. 147: 765e, 2021.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.
F
acial aging is a multifactorial process result- have indicated that, depending on the targeted
ing in physiologic and morphologic changes layer, various aesthetic outcomes occur when soft-
in hard and soft tissues (i.e., bones, ligaments, tissue fillers are administered for volumization.11
muscles, fasciae, subcutaneous fat, and skin).1–6 Suwanchinda et al.9 demonstrated that in addi-
Soft-tissue filler injection use to address facial aging tion to volumizing, soft-tissue fillers can induce
signs has increased according to an American local and regional lifting. Using living patients
Society of Plastic Surgeons survey that demon- and human donors, the authors theorized that
strated a 312 percent rise in the number of soft- the tissue lifting induced by temple subdermal
tissue filler procedures between 2000 and 2017.7 filler injections was attributable to lateral face lay-
Injectable fillers are frequently used to restore ered anatomy.
age-related facial soft-tissue volume loss.8–10 Studies The lateral face is arranged in layers paral-
lel to the skin surface. Conversely, in the medial
From private practice; the Department for Hand, Plastic,
and Aesthetic Surgery, Ludwig Maximilian University; the
Disclosure: The authors have no commercial asso-
Division of Anatomy, Department of Medical Education,
Albany Medical College; Skin Associates of South Florida; ciations or financial disclosures that might pose or
and the Department of Clinical Anatomy, Mayo Clinic create a conflict of interest with the methods applied
College of Medicine and Science, Mayo Clinic. or the results presented in this article.
Received for publication March 31, 2019; accepted
November 10, 2020.
The first two authors contributed equally to this work. Related digital media are available in the full-text
Copyright © 2021 by the American Society of Plastic Surgeons version of the article on www.PRSJournal.com.
DOI: 10.1097/PRS.0000000000007857
www.PRSJournal.com 765e
Copyright © 2021 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • May 2021
midface, obliquely running muscles change

planes, thereby connecting layers.3 The lateral
face may potentially lift the jawline when the tem-
ple is injected with fillers (regional lifting effect).
In the medial midface, this regional lifting effect
is not possible because of eye position (which
separates the forehead from the medial midface)
and mouth position (which separates the medial
midface from the chin and the labiomandibular
sulcus). Thus, effects are limited locally but can be
used to improve the nasolabial sulcus by targeting
the infraorbital region.
The study aims are to objectively investi-
gate whether lifting effects can be induced by
volumizing soft-tissue filler application and to
determine the facial location at which this can
be best accomplished. We used the cadaveric
model described previously by Freytag and col-
leagues,12 as its position could be fixed, ensuring Fig. 1. Cadaveric image illustrating the performed injection
accurate and precise pretreatment and post- technique for the temple.
treatment three-dimensional surface scanning
imaging of surface volume and skin vector dis- Temple
placement measurements. Moreover, in each Product (1.0 cc) was placed supraperiosteally
subject, a precise injection location and volume with a 25-gauge, 38-mm, sharp-tip needle using
algorithm could be followed, which is difficult a perpendicular approach. Injection location is
in living models, where injected product volume shown in Figure 1.
and location are customized to ensure optimal
aesthetic outcomes. Forehead
Soft-tissue filler (0.5 cc) was placed supraperi-
MATERIALS AND METHODS osteally with a 21-gauge, 70-mm, blunt-tip cannula
using a retrograde fanning technique accessing
Study Sample from the temporal dermal access point (Fig. 2).
The presented cadaveric study sample was
previously described by Freytag and colleagues.12 Lateral Midface
In brief, 20 cadaveric hemifaces were obtained Soft-tissue filler (0.5 cc) was placed subdermally
from 10 Caucasian body donors (seven women with a 21-gauge, 70-mm, blunt-tip cannula using a
and three men; mean age, 83.5 ± 6.8 years; mean
body mass index, 25.3 ± 4.3 kg/m2). Facial opera-
tions, facial trauma, or any type of diseases influ-
encing normal facial anatomy were regarded as
exclusion criteria. The study conformed with
institutional guidelines for cadaveric research
studies.
Injection Procedure
Injections of the facial thirds were performed
with body donors tightly secured in an upright
position to account for the effects of gravity.
Commercially available hyaluronic acid–based
soft-tissue filler (Perfectha Subskin; Sinclair,
London, United Kingdom) was used for all injec-
tion procedures. A detailed description of the
performed injection techniques was published
previously and is termed the three-point full face Fig. 2. Cadaveric image illustrating the performed injection
fanning technique.12 technique for the forehead.
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Volume 147, Number 5 • Lifting Effect of Soft-Tissue Fillers
Fig. 3. Cadaveric image illustrating the performed injection Fig. 5. Cadaveric image illustrating the performed injection
technique for the lateral midface. technique for the nasolabial sulcus.
Fig. 4. Cadaveric image illustrating the performed injection Fig. 6. Cadaveric image illustrating the performed injection
technique for the medial midface. technique for the mandibular angle.
retrograde fanning technique advancing from the Mandibular Angle

lateral infraorbital area into the temple (Fig. 3). Soft-tissue filler (0.5 cc) was placed subdermally
with a 21-gauge, 70-mm, blunt-tip cannula using a
Medial Midface retrograde single-line technique advancing from the
Soft-tissue filler (0.5 cc) was placed supraperioste- midportion of the mandible posteriorly (Fig. 6).
ally with a 21-gauge, 70-mm, blunt-tip cannula using Labiomandibular Sulcus
a retrograde bolus technique advancing from the lat-
eral infraorbital area into the palpebromalar groove Soft-tissue filler (0.5 cc) was placed subdermally
(2 × 0.1 cc) and tear trough (3 × 0.1 cc) (Fig. 4). with a 21-gauge, 70-mm, blunt-tip cannula using a
retrograde fanning technique advancing from the
Nasolabial Sulcus midportion of the mandible anteriorly (Fig. 7).
Soft-tissue filler (0.5 cc) was placed supraperios- Chin
teally with a 25-gauge, 38-mm, sharp-tip needle using Soft-tissue filler (0.5 cc) was placed supra-
a perpendicular approach as shown in Figure 5. periosteally with a 25-gauge, 38-mm, sharp-tip
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Fig. 8. Cadaveric image illustrating the performed injection

Fig. 7. Cadaveric image illustrating the performed injection technique for the chin.
technique for the labiomandibular sulcus.
needle using a perpendicular approach as shown injected individually) and regionally (i.e., across
in Figure 8. multiple facial regions injected).
Applying the Mirror Software Suite algorithm,
Imaging local volume changes (difference between follow-
Three-dimensional surface scanning was up and baseline scans) per injected facial region
performed within 20 minutes after each injec- were calculated (in cubic centimeters). Relative
tion step using the Vectra H1 system (Canfield skin displacement (skin movement between base-
Scientific, Fairfield, N.J.). The facial regions line and each follow-up scan) (Figs. 9 through 17)
scanned included the forehead, temple, medial was likewise computed by the Mirror Software
and lateral midface, perioral region (chin and Suite automated algorithm. Displacement in x and
labiomandibular sulcus), and jawline. Before y directions is given in millimeters and is compa-
each injection procedure, a baseline scan of each rable to x and y coordinates in a two-dimensional
donor’s face was performed. A follow-up scan Cartesian coordinate system (Figs. 9, 12, and 15).
was performed after each injection step. Three The x coordinates represent displacement in the
separate (two-dimensional) standardized images posterior (i.e., occipital) direction, whereas y
were taken of each subject investigated (i.e., left, coordinates represent displacement in the supe-
center, and right). The three two-dimensional rior (i.e., cranial) direction; the latter can be
images were automatically “stitched” into one understood as a lifting effect of the performed
three-dimensional full-face image. The gener- intervention.
ated three-dimensional images (baseline and con-
secutive follow-up images) were analyzed using Statistical Analysis
Mirror Software Suite (Canfield Scientific). (See The surface-volume coefficient for each inves-
Figure, Supplemental Digital Content 1, which tigated facial region was calculated by dividing
shows a graphic representation of the volumes the absolute scanned surface projection change
measured by three-dimensional surface analy- (in cubic centimeters) by the injected volume
sis per analyzed area. Blue represents a volume amount (in cubic centimeters). This coefficient
increase, and orange indicates a volume decrease, denotes the surface effect of a defined injected
http://links.lww.com/PRS/E417.) Each follow-up volume amount, which could represent the clini-
scan was aligned automatically to its respective cal effectiveness of the injected material. A coeffi-
baseline scan to compute surface projection and cient of 1.0 could be interpreted as very efficient,
skin displacement differences (vector skin dis- whereas a coefficient of 0 could be regarded as
placement) (Figs. 9 through 17) for each facial ineffective (none of the injected material had a
region investigated. Procedure outcomes were surface effect). The effects of the performed injec-
analyzed locally (i.e., results for each facial region tions were quantified per facial region analyzing
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Fig. 9. Scatter diagram of the skin displacement in x and y values in the temple. Points within the coordinate
system correspond to the direction in the x and y axes and the amount corresponds to the length of the
respective skin displacement after injection; negative x axis values correspond
to a medial skin displacement
(toward the midline); positive x axis values correspond to a lateral skin displacement; negative y axis values
correspond to a caudal skin displacement; positive y-axis values correspond
to a cranial skin displacement.
local volume changes, computation of the local by the lateral midface, and then the mandibu-
surface-volume coefficients, and the calculation lar angle. Calculation of the magnitude of the y
of local skin vector displacement. vector was used to objectify the resulting lifting
To analyze the sequential lifting effects in effect. Descriptive analyses comparing volume
the lateral face, we also conducted regional changes and skin vector displacement were com-
skin vector displacement analyses of sequen- puted using IBM SPSS Version 25.0 (IBM Corp.,
tial injections starting with the temple, followed Armonk, N.Y.).
Fig. 10. (Left) Three-dimensional photograph showing the skin displacement vectors of the right half of
the face after injection in the temple. The length of the vectors corresponds to the amount of the skin
displacement that has taken place in the direction of two-dimensional x and y axes; the color of the
vectors corresponds to the local volume increase (red) or decrease in volume (blue). (Right) Bar graph
showing the mean values o f the skin displacement vectors in the y-axis direction of the lateral half of the
face after injection of the temple indicated by the black arrow. Positive values indicate an average skin
displacement in the cranial direction, which can be interpreted clinically as a lifting effect.
769e
Fig. 11. Graphic illustration of the lateral face anatomy. The soft-tissue filler injection was placed
in the supraperiosteal plane of the temple. Note the angle of the facial ligaments and adhesions
throughout the lateral face.
Fig. 12. Scatter diagram of the skin displacement in x and y values i nto the lateral midface. Points within
the coordinate system correspond to the direction in the x and y axes, and the amount corresponds
to the length of the respective skin displacement after injection; negative x-axis values correspond to
a medial skin displacement; positive x-axis values correspond
to a lateral skin displacement; negative
y-axis values correspond to a caudal skin displacement; positive y-axis values correspond to a cranial
skin displacement.
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Fig. 13. (Left) Three-dimensional photograph showing the skin displacement vectors of the right half
of the face after previous injection in the temple and subsequent injection into the lateral midface. The
length of the vectors corresponds to the amount of the skin displacement that has taken place in the
direction of a two-dimensional x and y axes; the color of the vectors corresponds to the local volume
increase (red) or decrease in volume (blue). (Right) Bar graph showing the mean values of the skin dis-
placement vectors in the y-axis direction of the lateral half of the face after injection of the midface indi-
cated by the black arrow. Positive values indicate
an average skin displacement in the cranial direction,
which can be interpreted clinically as a lifting effect.
in the subdermal plane. Note the angle of the facial ligaments and adhesions throughout the
lateral face.
RESULTS 0.67 ± 0.37 cc and a surface-volume coefficient of

Local Volume Change and Surface-Volume 1.34 (Table 1).
Coefficients Middle Face
Upper Face In the lateral midface, 0.5 cc was injected. The
In the temple, 1.0 cc was injected supraperi- resulting volume change was 0.02 ± 0.82 cc, gen-
osteally, yielding an average surface projection erating a surface-volume coefficient of 0.03. In
volume change of 0.45 ± 0.68 cc and a surface- the medial midface, 1.0 cc was injected, yielding
volume coefficient of 0.45. In the forehead, 0.5 cc an average volume change of 0.56 ± 0.67 cc and a
was injected, yielding a mean volume change of surface-volume coefficient of 0.56 (Table 1).
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Fig. 15. Scatter diagram of the skin displacement in x and y values of the mandibular angle. Points within
the coordinate system correspond to the direction in the x and y axes, and the amount corresponds to the
length of the respective skin displacement after injection; negative x-axis values correspond to a medial
skin displacement; positive x-axis values correspond to a lateral skin displacement; negative y-axis values
correspond to a caudal skin displacement; positive y-axis values correspond to a cranial skin displacement.
Fig. 16. (Left) Three-dimensional photograph showing the skin displacement vectors of the right half
of the face after previous injection in the temple and lateral midface and subsequent injection into the
mandibular angle (left). The length of the vectors corresponds to the amount of the skin displacement
that has taken place in the direction of two-dimensional x and y axes; the color of the vectors corre-
sponds to the local volume increase (red) or decrease in volume (blue). (Right) Bar graph showing the
mean values of the skin displacement vectors in the y-axis direction of the lateral half of the face after
injection of the mandibular angle indicated by the black arrow. Positive values indicate
an average skin
displacement in the cranial direction, which can be interpreted clinically as a lifting effect.
Lower Face Local Vector Skin Displacement Analysis

In the chin and in the labiomandibular sul- Upper Face
cus, 1.0 cc was injected, causing a mean perioral The temple application of 1.0 cc resulted in
volume change of 0.87 ± 1.1 cc and resulting in a an average lateral skin displacement of 0.34 ±
surface-volume coefficient of 0.87. At the mandib- 1.32 mm (x value) and an average cranial skin
ular angle, 0.5 cc was injected, yielding a volume displacement of 0.57 ± 1.29 mm (y value) (Figs. 9
change of –0.38 ± 0.98 cc and a surface-volume through 11). The forehead application of 0.5 cc
coefficient of −0.76 (Table 1). resulted in an average lateral skin displacement
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in the subdermal plane. Note the angle of the facial ligaments and adhesions throughout the
lateral face.
of 0.24 ± 1.76 mm (x value) and an average cra- an average medial skin displacement (toward
nial skin displacement of 1.11 ± 1.86 mm (y value) the mandibular symphysis) of 0.07 ± 1.58 mm
(Table 1). (x value) and an average caudal skin displacement
of 0.74 ± 2.03 mm (y value).
Middle Face
The application of 0.5 cc in the lateral mid-
Regional Skin Vector Displacement Analysis
face resulted in an average lateral skin displace-
The temple filler injections using the deep
ment of 0.17 ± 1.87 mm (x value) and an average
injection technique resulted in a cranial skin dis-
cranial skin displacement of 0.81 ± 2.14 mm (y
placement of the temple of 0.57 mm (y value)
value) (Figs. 12 through 14). The application of
(local effect), and in a regional lifting effect of
1.0 cc in the medial midface resulted in an aver-
the lateral midface of 0.55 mm (y value) and of
age lateral skin displacement of 0.04 ± 1.23 mm (x
the jawline of 0.03 mm (y value) (Figs. 9 and 10).
value) and an average caudal skin displacement of
Additional injections of soft-tissue filler into the lat-
0.11 ± 1.05 mm (y value) (Table 1).
eral midface (temple and lateral midface injected)
Lower Face resulted in a cranial skin displacement of the lat-
The application of 0.5 cc at the mandibular eral midface of 0.81 mm (y value), indicating a
angle resulted in an average lateral skin displace- 47.3 percent increase in cranial skin displacement
ment of 0.24 ± 2.71 mm (x value) and an aver- (from 0.55 mm to 0.81 mm; y value). The addi-
age cranial skin displacement of 0.29 ± 2.02 mm tional cranial skin displacement after the temple
(y value) of the jawline (Figs. 15 through 17). and lateral midface injections was 17 percent for
The perioral application of 1.0 cc resulted in the temple (from 0.57 mm to 0.67 mm; y value),
Table 1. Injected Volume, Measured Volume,* Surface-Volume Coefficient, and Skin Displacement for the
Investigated Facial Regions
Skin Displacement
Injected Measured
Area Volume (cc) Volume (cc) SVC x Axis (mm) y Axis (mm)
Temple 1 0.449 0.449 −0.340 ± 1.32 0.567 ± 1.29
Forehead 0.5 0.671 1.342 −0.235 ± 1.76 1.109 ± 1.86
Lateral midface 0.5 0.017 0.034 −0.165 ± 1.87 0.808 ± 2.14
Medial midface 1 0.559 0.559 0.044 ± 1.23 −0.110 ± 1.05
Mandibular angle 0.5 −0.375 −0.750 −0.238 ± 2.71 0.292 ± 2.02
Perioral 1 0.872 0.872 −0.074 ± 1.58 −0.743 ± 2.03
SVC, surface-volume coefficient.
*In cubic centimeters, applying three-dimensional surface-volume scanning.
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and 100 percent for the jawline (from 0.03 mm to Study strengths included the standardization
0.06 mm; y value) (Figs. 12 and 13). of the soft-tissue filler injections and that outcomes
Additional injections into the mandibular were objectively assessed using three-dimensional
angle (temple, lateral midface, and mandibular surface scanning, which identifies surface-volume
angle injected) resulted in a 0.29-mm (y value) cra- changes and skin movement between two three-
nial skin displacement of the jawline, represent- dimensional images.13,14 These measurements
ing an increase of 383.3 percent (from 0.06 mm were based on a mathematical algorithm that is
to 0.29 mm; y value). The additional mandibular independent of observer subjectivity. Calculations
angle injection resulted in an additional 0.23 mm yielded changes in surface volume (in cubic cen-
(y value) cranial skin displacement of the tem- timeters) and the skin displacement in a two-
ple, indicating an increase of 34.3 percent (from dimensional Cartesian coordinate system (x and
0.67 mm to 0.90 mm; y value). In the lateral mid- y values). The y values represent the lifting effect
face, the skin displacement vectors were reduced induced by soft-tissue filler injection. Another
by the mandibular angle injections by 42.0 per- study strength is the upright donor positioning
cent (from 0.81 mm to 0.47 mm; y value) (Figs. 15 to account for gravity. Supine positioning would
and 16 and Table 1). result in laterally oriented gravitational effects,
thereby reducing generalizability to real-life clini-
cal scenarios. This study used a commercially
DISCUSSION available soft-tissue filler with rheologic properties
This study sought to objectively quantify tis- identical to those used in living patients.
sue lifting and volumizing effects of injectable A limitation includes the use of cadavers
hyaluronic acid–based fillers in a full-face cadav- instead of living patients. The cadaveric model was
eric model. Applying three-dimensional surface chosen to facilitate more accurate image analysis,
volumetric and skin vector displacement analyses as the subjects were secured in an upright, fixed
revealed that soft-tissue fillers can induce local vol- position during image acquisition. In living indi-
ume effects and local and regional lifting effects, viduals, facial expressions and posture changes
depending on the facial region injected. Injections influence skin position and skin light/shadow
in the medial face [i.e., forehead, medial midface, relationships, even when using a manual match-
and perioral region (chin and labiomandibular ing algorithm for image alignment. Every patient
sulcus)] increased the local surface volume by has different needs when addressing facial aging
0.67, 0.56, and 0.87 cc and created local (but not signs, so patient recruitment using a standardized
regional) lifting effects of 1.11, 0.11, and 0.74 mm, protocol is challenging; a standardized treatment
respectively, without co-influencing neighboring algorithm using the same volume amount for
medial facial regions. Injections in the lateral face prescribed facial regions may yield aesthetically
(temple, lateral midface, and jawline) changed unappealing results. In a cadaveric model, one
the local surface volume by 0.45, 0.02, and −0.38 protocol can be used to obtain objective and stan-
cc, and created local lifting effects of 0.57, 0.81, dardized results. A drawback inherent in cadav-
and 0.29 mm, respectively. Lateral face injec- eric studies is that cadavers lack blood pressure,
tions, however, created additional regional lift- muscle tone, and regular tissue pressure and have
ing effects by co-influencing neighboring lateral a different temperature than living individuals.
facial regions, which was not observed for medial Furthermore, cadaveric subjects were older (83.5
face injections. ± 6.8 years) than most aesthetic patients.
The deep temporal injection lifted the lateral The investigation results are consistent with
midface by 0.55 mm and the jawline by 0.03 mm. previous facial anatomy reports.15–19 The concept
The additional lateral midface injection lifted the of “line of ligaments” was introduced, where the
lateral midface by an additional 0.26 mm and the facial ligaments (true osteocutaneous connec-
jawline by an additional 0.03 mm but also lifted tions) are located in an imaginary line from the
the temple by an additional 0.10 mm. The man- temple (temporal ligamentous adhesion),20 to the
dibular angle injection lifted the jawline by an orbit (lateral orbital thickening),21 the zygomatic
additional 0.23 mm and the temple by an addi- arch (zygomatic ligament, or McGregor patch),22
tional 0.23 mm but reduced the lifting effect of and the mandible (mandibular ligament).8 This
the lateral midface by 0.34 mm. These results line of ligaments is posterior to the lateral orbital
indicate that lateral face injections co-influence rim and separates the face into medial and lat-
adjacent lateral facial regions and can thus induce eral regions. Whereas deep fat compartments in
regional lifting effects. the medial facial regions can be identified,6 the
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lateral facial regions are arranged in layers par- Injections at the mandibular angle resulted in
allel to the skin surface.19 These parallel fascial jawline lifting (383.3 percent) and increased tem-
layers are connected with each other by means ple lifting (34.3 percent). This observation (lower
of those aforementioned ligaments and by means face injections can result in upper face-lifting
of a variable amount of short subdermal fibrous effects) can be explained by reduced lateral face
septae. These are especially located along the downward pull, caused by positioning of soft-tissue
zygomatic arch and in the parotid region and filler subdermally. This reduction resulted in an
form compartment boundaries of the superfi- increased overall temporal lifting effect. Because
cial facial fat compartments.3 The biomechanical of mandibular angle product positioning, the lat-
basis for the observed lifting effects is the inter- eral midface skin was compressed because of the
action between dermis, subdermal fatty layer, jawline-lifting effect and the resulting skin vectors
short subdermal fibrous septae, and the super- were reduced compared to skin position before
ficial fascia.23–25 Together, this unit is termed the mandibular angle injection (−42.0 percent; from
superficial fascial system26 and has been shown to 0.81 mm to 0.47 mm).
play an important role during surgical and non- Because of the characteristics of the lateral
surgical procedures.23–29 The biomechanics of the facial anatomy and the biomechanical proper-
superficial fascial system can be influenced by ties of the superficial fascial system, injections
volume deposition into the subdermal fatty layer, lateral to the line of ligaments can be used
thus changing the tension within that functional clinically. Subdermal soft-tissue filler place-
unit.30 This change in tension results in a reposi- ment in the temple and in the lateral midface
tioning of the facial soft tissue and can be sum- can achieve volume reduction in the lower face.
marized as a lifting effect, which was quantified Because of the resulting lifting effect, the lower
in the present study. face soft tissues are repositioned more crani-
Using a cohort of living patients and human ally, which results in a volume reduction in the
donors, Suwanchinda et al.9 demonstrated that lower face. This can be used to change the facial
temple subdermal soft-tissue filler injections shape from square to oval or heart-shaped and
treat temporal volume loss and reduce middle to treat patients with sufficient volume in the
and lower face signs of age-related changes by lower face.
using the temporal biomechanical properties of The methods applied in the present study
the subdermal fatty layer and the fascial layered can be of great potential for future investigations.
arrangement. The present investigation confirms Current practices for assessing soft-tissue filler effi-
those findings and broadens the applicability to cacy include blinded investigators using validated
the total lateral face, as the results reveal that scales, two-dimensional photographs, and/or live
soft-tissue filler can be used to achieve local and subjects. Future research directions include objec-
regional lifting effects. tive tissue displacement measurements following
Despite injections administered at the mandib- filler injections as presented in this study, thus
ular angle, a negative jawline coefficient resulted eliminating the subjectivity inherent in even the
because of aggregate lifting effects of injections most expert observer assessment.
into the temple, lateral midface, and mandibular
angle, which reduced local volume and thus sur-
face projection. This soft-tissue behavior can be CONCLUSIONS
used clinically to change the facial shape, as upper Although aesthetic injectable fillers are tra-
face lifting induces middle and lower face volume ditionally classified as fillers or volumizers, this
reduction. cadaveric study provides evidence that these prod-
The sequential lateral face injections revealed ucts can be used to induce face-lifting effects.
that the deep temporal injection has a limited In the medial midface, soft-tissue fillers have a
lower face-lifting capacity but a good temporal greater potential to volumize and locally lift. In
and lateral midface-lifting capacity. An additional the lateral face, the fascial layers are contiguous;
filler application into the temple subdermal plane thus, co-influencing the temple, lateral midface,
using a subdermal fanning technique cranial to and jawline is possible. Whereas temporal deep
the zygomatic arch with an access point in the supraperiosteal injections have limited lifting
infraorbital region (temple and lateral midface effects, the combined effects of subdermal injec-
injected) increased the temple-lifting effect by tions of the temple, lateral midface, and mandib-
17.5 percent and the jawline-lifting effect by 100 ular angle can induce lifting effects of the total
percent. lateral face.
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Sebastian Cotofana, M.D., Ph.D. 13. Koban K, Schenck T, Metz P, et al. En route for objective
Department of Clinical Anatomy evaluation of form, volume, and symmetry in plastic sur-
Mayo Clinic College of Medicine and Science gery using 3-D intraoperative scans (in German). Handchir
Mayo Clinic Mikrochir Plast Chir. 2016;48:78–84.
Stabile Building 9-38 14. Koban KC, Cotofana S, Frank K, et al. Precision in 3-dimen-
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Quantitative Analysis of The Lifting Effect Of.10

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Quantitative Analysis of The Lifting Effect Of.10

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COSMETIC

Quantitative Analysis of the Lifting Effect of

Methods: Twenty fresh hemifaces obtained from 10 Caucasian body donors

midface, obliquely running muscles change

retrograde fanning technique advancing from the Mandibular Angle

Fig. 8. Cadaveric image illustrating the performed injection

RESULTS 0.67 ± 0.37 cc and a surface-volume coefficient of

Lower Face Local Vector Skin Displacement Analysis

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