Original article

Accepted Article
Vectorial Facial Sculpting: A Novel Sub-SMAS Filler Injection Technique
to Reverse the Impact of the Attenuated Retaining Ligaments

Sarit Cohen, MDa,c,*, Ofir Artzi, MDb,c,*, Joseph N. Mehrabi, MScc, Lior Heller, MDa,c

aDepartment of Plastic and Reconstructive Surgery, Assaf Harofeh Medical Center, Zerifin,
Israel
bDepartment of Dermatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
cSackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

*Drs. Cohen and Artzi contributed equally to this work.

Corresponding author: Dr. Sarit Cohen, MD, Department of Plastic and Reconstructive
Surgery, Assaf Harofeh Medical Center, Zerifin 70300, Israel. Tel: +972-50-8804180; Fax:
+972-3-5751476; E-mail: sariti@zahav.net.il (S. Cohen)

Conflict of interest
The authors declare no potiential conflicts of interest with respect to the research,
authorship, and publication of this article.

Funding
The authors received no financial support for the research, authorship, and publication of
this article.

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1111/JOCD.13546
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 Authors’ Contributions
Accepted Article
Sarit Cohen: Developed the theoretical and computational framework, drafted the
manuscript, and revised it critically.
Ofir Artzi: Equally contributed to conception, design, drafting the article and interpretation of
the results.
Lior Heller: Revised the manuscript critically for important intellectual content.
Joseph N Mehrabi: Revised the manuscript and figures critically.

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Accepted Article
DR. O. ARTZI (Orcid ID : 0000-0003-1391-5843)
MR. JOSEPH NATHANIEL MEHRABI (Orcid ID : 0000-0002-2212-7075)

Article type : Original Contribution

Vectorial Facial Sculpting: A Novel Sub-SMAS Filler Injection

Technique to Reverse the Impact of the Attenuated Retaining
Ligaments

Summary

Background: Age-related attenuation of the orbital, zygomatic and masseteric

ligaments contribute to temporal brow ptosis, deepening nasolabial fold and jowl,
respectively. We present and assess the vectorial facial sculpting technique, a novel
nonsurgical panfacial rejuvenation method which focuses on reversal of the impact
of attenuated ligaments on the aging face.
Methods: This case series included women who underwent vectorial facial sculpting
at a private clinic from June 2018 to January 2019. Sagging tissues in the lateral
brow, nasolabial fold and jowl were repositioned in a directed manner with vectors
whose cross product counteracted the vector of the respective causative attenuated
ligament. Filler material was deposited into the supraperiosteal/sub-SMAS plane in
right angle vectors at the lateral supra-orbital rim for brow ptosis, pre-auricular and
malar region for nasolabial fold and across the jawline region for jowl. Standardized
photographs were taken before and at 3 months following treatment. Outcome was
assessed by both the patients and an independent investigator using a validated
Global Aesthetic Improvement Scale. Adverse outcomes were documented.
Results: Forty-five patients of mean age 59.8±3.9 years were included. Mean Global
Aesthetic Improvement Scale scores for patients and an independent investigator
alike at 3 months following treatment indicated "very much improved" (1.44±0.66 and
1.56±0.78, respectively). The procedure was well tolerated with no adverse events.

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 Conclusion: Vectorial facial sculpting is a comprehensive anatomical approach for
Accepted Article
nonsurgical directional tissue mobilization. Based on physical and mathematical
rules to reverse the respective causative attenuated ligament, the technique
effectively and safely restores youthful facial contours.

KEYWORDS: Facial sculpting; Vectorial; Filler injection; Retaining ligaments

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 Introduction
Accepted Article
Minimally invasive facial procedures have gained widespread popularity during the
last quarter of the century, with remarkable evolution. The seminal anatomic studies
by Rohrich and Pessa1,2 paved the path to a newer understanding of specific
anatomic targets in the aging face as applied to injectables: superficial and deep fat
compartments.3 This approach was attributed by the authors to augmentation alone
in selective patients. However, it most often complements face-lifting. Thus, volume
augmentation alone of site-specific compartments focus on volume loss within facial
fat compartments that are deflated preferentially and not on the overall age-
dependent volumetric changes – inferior migration (sagging) of the midfacial fat
compartments, and inferior volume shift.4 Many other studies support the notion that
facial fat deflation and inferior descent serve as key factors for determining an aged
facial shape.5,6
The sagging appearance of the aging face is partly due to the attenuation of
the retaining ligaments that tether facial tissues into the anatomic position of youth.7,8
Age-related attenuation of the orbital, zygomatic and masseteric ligaments have
been demonstrated to contribute to temporal brow ptosis, deepening nasolabial fold
(NLF) and formation of jowl, respectively.9-12
The retaining ligaments and their superficial ramifications contribute to the
formation of septa that divide the face into fat compartments.2,13 With aging, these
fibrous septa lengthen significantly, predisposing their fibers to weakening and
distension.14 This laxity promotes inferior migration and compartmental shape
change.15 These age-related changes might well elucidate their pivotal role in facial
aging, ultimately resulting in an aged facial shape.
It is well known that restoration of a youthful facial shape entails the
repositioning of the descended facial fat to the anatomic position of youth. 5 This
allows for facial fat redistribution and improved blending of the esthetic subunits.
Herein lies the significant rejuvenating and “lifting” effect attained by the surgical
mobilization of facial tissue in superolateral vectors, counteracting the overall
inferomedial tissue sagging. Cadaveric studies of lifting using filler injections into the
temple have demonstrated a general orientation of skin displacement toward the
temple, which involved the labiomandibular sulcus and the jawline.16

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 Currently, there is no systematic anatomically based non-invasive approach to
Accepted Article
reposition the descended soft tissues. We propose a novel conceptual filler injection
strategy which results in directional repositioning of tissues, counteracting the
directions of tissue descent.

Subjects and methods

Study design and population
This study took place in a private practice between June 2018 and January 2019.
Subjects with mild-moderate sagging (manifested by lateral brow ptosis, inferior
descent of the malar fat and jowling), aged 45-70 years, whose body mass index
(BMI) was less than 25 were enrolled to the study group. Each signed an informed
consent form. Subjects were excluded if they had undergone cosmetic procedures in
the face and neck in the previous 6 months, had scars or infections in the target
area, significant facial asymmetry, were receiving anticoagulants or
immunosuppressive treatment, had autoimmune diseases, history of massive weight
loss or those who were pregnant or breastfeeding. Patients with unrealistic
expectations were excluded as well.
The study was approved by the Assaf Harofeh Medical Center Institutional
Review Board (ASF-17-0156). We adhered to the STROBE guidelines.

Outcome measures
Outcome was assessed by the subjects and a blinded independent investigator at 3
months using the validated Global Aesthetic Improvement Scale (GAIS). This 5-point
scale ranges from 1 (very much improved) to 5 (worse) and rates global esthetic
improvement in appearance compared with pre-treatment levels. An evaluation of
safety and tolerability was based on spontaneous reports of adverse events by the
subjects during follow-up visit at 2 weeks following treatment. The treatment areas
were also assessed for local reactions by the investigators at the scheduled visits.
Subgroup analysis was undertaken to compare GAIS improvement following
Radiesse® (+) vs. Stylage® XL for both subjects and the independent investigator–
rated scores using the Mann-Whitney test.
Significant level was defined as α=0.05. Analyses were carried using SPSS
24.01.

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Accepted Article
The anatomic basis
The retaining ligaments were first defined by McGregor7 with the zygomatic
cutaneous ligaments (ZCL), known as McGregor’s patch, and later by Furnas, 6,8,9
Mendelson,17,18 and Stuzin et al.6,10 These ligaments play a pivotal role in stabilizing
facial tissues in a normal anatomical position, resisting gravitational change.6,8 As
the ligaments attenuate with age, they stretch, lose elasticity, and are unable to hold
the suspended tissues in the original youthful location.9,11,19 As a result, facial fat
descends in a plane between the superficial and deep facial fascia and the stigmata
of facial aging develop.
The ZCL are stout fibers that originate at or near the inferior border of the
anterior zygomatic arch and extend anteriorly to the junction of the arch and the body
of the zygoma.8,9,11 They suspend the malar soft tissue over the zygomatic
eminence. A loss of zygomatic ligaments’ support progressively influences the NLF
prominence.
The masseteric cutaneous ligaments (MCL) extend along the entire anterior
border of the masseter from the body of the zygoma above, to the inferior border of
the mandible below.9,11 This ligamentous system supports the cheek superiorly
above the mandibular border. Loss of MCL support allows for the inferior descent of
facial fat to the mandibular border, leading to the formation of jowls.
The orbital retaining ligament (ORT), coined by Muzaffar et al.,12 is a
circumferential periorbital ligament.20 It originates from the periosteum of the orbital
rim transversing the orbicularis oculi muscle and inserting into the dermis. 17 Loss of
ORT support contributes to temporal brow ptosis, lateral hooding, and an aged
periorbital appearance.18,21 These anatomical changes account for inferomedial
tissue sagging and loss of the youthful facial contour and gives the appearance of a
longer, square, aged face.

Rationale
Newton’s third law of motion of classical mechanics states that every action is
accompanied by a reaction of an equal magnitude but opposite direction. 22 A
simplified description, in terms of motion, is that if a force acts upon an object, then a
force of equal magnitude and opposite direction will negate the movement. In the
aging face, the force is the gravitational descent of facial tissues. When the age-
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 induced laxity of the ligaments exerts a vector downward and medially, a force that
Accepted Article
counteracts this (an upward and lateral vector) will reposition the descended soft
tissues. Vectors are used to represent any quantity that has magnitude and direction
(e.g. force). The magnitude (or length) is the distance between 2 points (A and B),
and the direction refers to the direction of displacement from A to B.
One of the basic properties of vectors is the rule of vector addition. The sum
of vectors A (blue color) and B (green color) equals vector C (red color) (Figure 1).
Vector addition can be illustrated by application of the triangular rule (Figure 1, upper
row) or by the parallelogram rule (Figure 1, lower row), since A and B form the sides
of a parallelogram (or a triangle) and A and B is one of the diagonals. The cross-
product is equivalent when either rule is applied.
Filler injections along specific vectors, whose cross-product counteracts the
direction of tissue descent, will mobilize the overlying tissues and reverse sagging in
a predicted direction.

Technique
Nasolabial folds
As mentioned, attenuation of the ZCL results in anterior, downward and medial
migration of the malar fat pad with subsequent deepening of the NLF. The
counteracting vector should be pointed posteriorly, upward, and laterally –towards
the root of the helix. As this counteracting corrective vector is, in fact, a force, it can
be injected outside the target area into the lateral face, pulling the facial tissues in
that direction. This vector is actually the cross-product of the injected areas: the
preauricular region and the lateral cheek malar region (Figure 2A), in accordance
with the parallelogram rule of vector addition. By injecting these areas, one can truly
mobilize mid-facial tissues in a superolateral direction, thereby effacing the NLF
prominence.

Jowls
Attenuation of the MCL results in downward and medial migration of the cheek below
the mandibular border, with subsequent formation of a jowl. The counteracting vector
points upwards and laterally towards the root of the helix. This vector is the cross-
product of the injected areas: across the jawline and along the preauricular region, in

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 accordance with the triangular rule of vector addition. By injecting these areas, lower
Accepted Article
facial tissues are mobilized in a superolateral vector, counteracting the inferomedial
sagging. This improves jawline definition and facial jowl (Figure 2B).

Brow
Loss of the ORL support results in a droopy temporal brow. The counteracting vector
points towards the glabella. This vector is the cross-product of the injected area:
along the tail of the eyebrow and in a perpendicular line to the previously injected
line along the tail of the brow. By injecting these areas, one can rejuvenate the
lateral periorbital region, and accomplish vertical brow lifting and horizontal brow
projection (Figure 2C).
All patients were treated with a standardized protocol in terms of volume
injected, location and depth. Each hemi-face was injected with a total volume of
3.5cc: the preauricular region, lateral cheek and the jawline were injected with 1cc
each and the lateral brow with 0.5cc. All injections were performed into the sub-
SMAS/supraperiosteal plane using a 25-gauge 2-inch cannula (except for the brow,
27-gauge ½-inch cannula) in a retrograde linear threading technique using high G'
fillers using either Radiesse®(+) (Merz Aesthetics, Lausanne, Switzerland) or
Stylage® XL (Vivacy Laboratories, Paris, France) in a consecutive fashion.

Results
Forty-five women (mean age 59.8±3.9 years) were enrolled. Twenty-two subjects
(n=22) were injected with Radiesse® (+) (Merz Aesthetics). Twenty-three (n=23)
were injected with Stylage® XL (Vivacy Laboratories).
All subjects attended follow-up visits at 2 weeks and 3 months following
treatment. GAIS scores and tolerability diaries were available for all subjects. Both
patients and investigators alike rated their satisfaction with treatment at the 3-month
visit. Mean subject-rated GAIS scores at that time were 1.44±0.66 (range 1-3),
indicating a “very much improved” appearance compared with baseline. Similar
values were reported by the investigator [1.56±0.78 (range 1-4)]. No statistically
significant differences in GAIS improvement scores were documented when
analyzed for filler type injected (Radiesse® (+) vs. Stylage® XL) neither in the
subjected-rated (1.35±0.65, vs. 1.55±0.67, respectively, p=0.226) nor in the

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 independent investigator–rated group (1.48 ± 0.79 vs. 1.64±0.79 respectively,
Accepted Article
p=0.358).
The procedure was well tolerated by all subjects. Injection-related side effects
(bruising and localized swelling) resolved spontaneously within one week of
treatment. No other adverse events were reported

Case examples

Case 1 (Figure 3)
A 62-year-old woman presented with prominent inferomedial tissue sagging (i.e.,
inferior descent of the malar fat pad, prominent NLFs, MLFs and facial jowling) and
an aged facial shape. Figures 3A, B demonstrate pre-treatment left oblique and left
lateral views, respectively. The subject underwent VFS with 7cc of Radiesse® (+)
(Merz Aesthetics) using superolateral vectors to both the mid- and lower face in
accordance with the above-mentioned protocol. No injections were performed
directly to NLF, prejowl depression, or tear trough. Post-injection photographs
(Figures 3C, D left oblique and left lateral, respectively) at 3 months demonstrate
restoration of the malar highlight, softening of the NLF and MLF and marked
improvement of jawline definition. Note the overall improvement in facial shape.

Case 2 (Figure 4)
A 61-year-old woman presented with tissue sagging, flattening of the malar area,
undulating convexities and concavities on the profile view, and an overall aged facial
contour (Figure 4a, c, e). The subject underwent VFS with 7cc of hyaluronic acid
(Stylage® XL, Vivacy Laboratories) using the superolateral vectors in accordance
with the above-mentioned protocol. No injections were performed directly into the
NLF, prejowl depression or tear trough. Post-injection right oblique view (Figure 6d,
f) at 3 months portrays a younger curvilinear profile with smooth graceful curves that
form an architectural ogee.

Discussion
Facial aging refers to complex additive and subtractive changes acting on an
intricate three-dimensional geometric solid. These changes are the result of volume
deflation, gravitational descent, repetitive shearing forces, and the loss of the
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 intrinsic support of the retaining ligament system. Attenuation of the retaining
Accepted Article
ligaments with aging results in laxity and descent of the soft tissue they support.
Current dermal filler injection techniques highlight the third dimension in
rejuvenation – volume. These volumetric approaches target compartment-specific3
or esthetic subunits-specific23 midfacial volume loss. Although this paradigm shift is a
significant milestone in facial rejuvenation, volume augmentation alone does not
address the inferior descent of midfacial fat compartments and the inferior volume
shift within the compartments.
Considering the impact of the attenuated ligaments on the aging face and the
esthetic results attained by surgical correction of the retaining ligaments, 11 our aim
was to propose a filler injection strategy that focuses on the reversal of the direction
of sagging tissues (i.e., inferomedially) by application of supero-lateral vectors to the
lateral face. The lateral part of the face is a relatively immobile, fixed zone compared
to the highly mobile anterior part. The highly dense septa in the platysma-auricular
fascia,14 in the retro-orbicularis oculi fat,24 and along McGregor's patch25 significantly
influence fixation, provide stronger anchorage, and potentially better counteract the
inferomedial tissue sagging of the aging face. Application of posterior, superolateral
vectors stimulates the vectors in which facial tissues are mobilized surgically.
Suwanchinda et al. implemented this technique on the temple injections supraSMAS
of cadavers for vectorial measurements, noting significant skin displacement and
lifting.16
One important caveat is that no direct shortening of the retaining ligaments is
proposed by or attributed to the technique since such manipulation is only surgically
feasible. Our results verify that both subjects' and the independent investigator's
assessment of esthetic outcome of the technique was high with mean GAIS scores
of 1 ('very much improved') compared with baseline. Prior work has suggested this
technique involving temple injections is very effective where 80% cosmetic
improvement was appreciated at 1-month follow-up.16
Fillers with high G’ (elastic modulus) and high viscous properties are preferentially
suitable for directional tissue repositioning due to their abilities to resist deformational
forces and precisely stay where injected. Deep filler deposition of high G' material is
better suited to the relatively fixed, more compacted, lateral part of the face.
One may argue that the technique presented herein is similar to augmentation
of facial fat compartments. However, both the anatomic targets and the location of
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 the injections differ significantly. Augmentation of facial fat compartments is targeted
Accepted Article
to restore volume of the deflated deep medial cheek, nasolabial, superficial medial
and lateral cheek compartments.3 VFS is targeted to reverse the direction of tissue
descent affected by the attenuated retaining ligaments. To this end, volume is
inserted into the supero-lateral part of the face. In VFS, it is not only volume
augmentation, but the directional movement and tissue displacement which
constitute the treatment approach. But careful attention must be sought in this
technique as fanning and increased injection volume can compromise its
effectiveness.16 One could also dispute that the retaining ligaments remain relatively
strong and fixed throughout life. This premise is not substantiated when considering
NLF and jowling. Both these aging manifestations are at least partially attributed to
attrition of the zygomatic and masseteric causative ligaments. 11,26 Another potential
argument is the feasibility of counteracting sagging by injections in an area remote
from the sagging tissues. It is a well-known tenet that facial tissues interrelate
through juxtaposition. Rohrich et al. showed that by injecting into the deep medial
cheek fat compartment, they were able to efface the NLF, diminish the nasojugal
fold, and improve the malar regions.2
VFS properly addresses the four-dimensional topographic changes of aging
(where the fourth dimension refers to the direction) via directed vectorial movement.
The technique could be considered as an alternative to surgery for younger patients
presenting with mild sagging or for patients who refuse to undergo surgery or are
otherwise nonsurgical candidates. Yet, for patients presenting with moderate to
severe sagging, face lift is the ultimate solution.
In appropriately selected patients, this technique effectively and safely
restores youthful facial contours.

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 References:
Accepted Article
1. Rohrich RJ, Pessa JE, Ristow B. The Youthful Cheek and the Deep Medial
Fat Compartment. Plastic and Reconstructive Surgery. 2008;121(6):2107-
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 12. Muzaffar AR, Mendelson BC, Adams WP. Surgical Anatomy of the
Accepted Article Ligamentous Attachments of the Lower Lid and Lateral Canthus. Plastic and
Reconstructive Surgery. 2002;110(3):873-884.
13. Rohrich RJ, Pessa JE. The Retaining System of the Face: Histologic
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Attenuation. Plastic and Reconstructive Surgery. 2012;130(1):180e-181e.
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supraSMAS minimally invasive lifting technique using soft-tissue fillers. J
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Principles of Release, Vectors, and Fixation. Plastic and Reconstructive
Surgery. 2001;107(6):1545-1552.
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Observations of the Jowls in Aging—Implications for Facial Rejuvenation.
Plastic and Reconstructive Surgery. 2008;121(4):1414-1420.
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 24. Griepentrog GJ, Lucarelli MJ. Anatomical Position of Hyaluronic Acid Gel
Accepted Article Following Injection to the Eyebrow. Ophthalmic Plastic and Reconstructive
Surgery. 2013;29(5):364-366.
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 Legends to Figures
Accepted Article
Figure 1. Illustration of vector addition rule. The sum of vectors A (blue color) and
B (green color) may be represented graphically by placing the tail of the
arrow B at the head of the arrow A, and then drawing an arrow from the
tail of A to the head of B. The new arrow drawn (C, red color)
represents the cross-product of vectors A and B. This can be
represented by the triangular rule (upper row) or by the parallelogram
rule (lower row).
Figure 2. A) The NLF. Attenuation of the ZCL (illustrated as whitish bars along
the malar eminence) results in infero-medial descent of the malar fat
pad, affecting the nasolabial prominence (red arrow). The counteracting
vector points upward and laterally towards the root of the helix (blue
arrow). This vector is the cross-product of the injected areas: along the
preauricular region and the lateral cheek-malar area, in accordance
with the parallelogram rule of vector addition. (grey arrows). B) The
Jowl. Attenuation of the MCL (illustrated as whitish bars along the
anterior border of the masseter muscle) results in infero-medial descent
of the cheek below the mandibular border, leading to the formation of
facial jowling (red arrow). The counteracting vector points upward and
laterally towards the root of the helix (blue arrow). This vector is the
cross-product of the injected areas: across the jawline and along the
preauricular region (grey arrows), in accordance with the triangular rule
of vector addition. C) The temporal brow. Loss of the ORL support
results in a droopy eyebrow. The counteracting-corrective vector points
towards the glabella (blue arrow). This vector is the cross-product of
the injected areas and the tail of the brow, and in a perpendicular line to
the previously injected line along the tail of the row (grey arrows).
Figure 3. Case Example 1. A 62-year-old female before and 3 months following
VFS with Radiesse® (+). Pre- (A, B) and postinjection (C, D) left oblique
and left lateral views, respectively. Note the overall improvement in
facial shape, blurring of the NLFs, MLFs marked improvement of
jawline definition and the younger appearing facial profile.

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 Figure 4. Case Example 2. A representative patient before (a,c,e) following
Accepted Article (b,d,f) the VFS technique

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