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How to best utilize the line of ligaments and the surface volume coefficient in
facial soft tissue filler injections

Article in Journal of Cosmetic Dermatology · December 2019

DOI: 10.1111/jocd.13245

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Received: 15 October 2019 | Accepted: 21 October 2019

DOI: 10.1111/jocd.13245

ORIGINAL CONTRIBUTION

How to best utilize the line of ligaments and the surface

volume coefficient in facial soft tissue filler injections

Gabriela Casabona MD1 | Francesco P. Bernardini MD2 | Brent Skippen MD3 |

Gianna Rosamilia BS4 | Hassan Hamade BSc4 | Konstantin Frank MD5 |
5 6 7
David L. Freytag | Jonathan Sykes MD | Emy C. Onishi MD |
Sebastian Cotofana MD, PhD, PhD4,8

1
Ocean Clinic, Marbella, Spain
2 Abstract
Oculoplastica Bernardini, Genova and
Milano, Italy Background: Recent advances in facial anatomy have increased our understanding of
3
University of New South Wales, Sydney, facial aging and where to best position facial soft tissue fillers.
NSW, Australia
4
Aim: Aim of this study was to investigate a novel injection protocol which makes use
Division of Anatomy, Department of
Medical Education, Albany Medical College, of concepts like the line of ligaments or the surface - volume coefficient.
Albany, NY, USA Materials and Methods: A total of 306 Caucasian patients (270 females, mean age
5
Department for Hand, Plastic and Aesthetic
45.1 ± 11.4 years; 36 males, mean age 45.9 ± 11.6 years) were retrospectively inves-
Surgery, Ludwig–Maximilians University
Munich, Munich, Germany tigated after the injection following a standardized protocol. This protocol comprised
6
Facial Plastic and Reconstructive Surgery, a total of six boluses and one retrograde fanning injections in the infraorbital area
UC Davis Medical Center, Sacramento, CA,
USA utilizing a 22G and a 25G blunt-tip cannula, respectively. Medial midfacial distances
7
Private Practice, Manila, Philippines were measured using skin surface landmarks and compared after the injection of the
8
Division of Plastic Surgery, Department partial and the total algorithm.
of Surgery, Albany Medical Center, Albany,
NY, USA
Results: Distances between the dermal location of the lateral SOOF and the dermal
location of the mandibular ligament increased by 0.17 ± 0.11 mm with P < .001, to
Correspondence
Sebastian Cotofana, Division of Anatomy
the corner of the mouth by 0.20 ± 0.09 mm with P < .001 and to the nasal ala by
and Surgery, Albany Medical College, 47 0.20 ± 0.11 mm with P < .001. The repositioning of the facial soft tissues resulted
New Scotland Avenue MC-135, Albany, NY
12208.
also in a decrease of the height of the lower eyelid by 0.49 ± 0.13 mm with P < .001.
Email: scotofana24@gmail.com Conclusion: The results revealed that utilizing these novel anatomic concepts, a
mean amount of 0.32 cc high G-prime soft tissue filler injected in the lateral SOOF
can change midfacial distances by an average of 0.19 mm.

KEYWORDS

infraorbital hollow, line of ligaments, soft tissue filler, sub-orbicularis oculi fat, surface volume
coefficient

1 | I NTRO D U C TI O N tissues has introduced the 3-dimensional perspective into minimally

invasive treatments as layers were identified with greater or reduced
Recent advances in facial anatomy have increased our understand- effectiveness7 and which layers inherit a greater risk for adverse vas-
1-5
ing of facial aging and where to best position facial soft tissue fill- cular events.8 The description of the facial fat compartments is guid-
6
ers. The description of the layered arrangement of the facial soft ing practitioners toward more precise injections as compartment

J Cosmet Dermatol. 2019;00:1–9. wileyonlinelibrary.com/journal/jocd© 2019 Wiley Periodicals, Inc. | 1

2 |
boundaries need to be respected to achieve the best aesthetic and
safest outcomes.
A recent cadaveric study by Cotofana et al introduced the
surface volume coefficient (SVC), a novel parameter to describe
the effectiveness of each facial fat compartment when applying
7
volumizing treatments. The authors identified the sub-orbicularis
oculi fat (SOOF) compartment to be the most effective facial fat
compartment as 95% of an injected product are being translated
into surface projection. For comparisons, the deep medial cheek
fat compartment was observed to have a SVC of 26% which in-
dicates that 74% of the injected product does not translate into
surface projection.
Previously, the concept of the line of ligaments was intro-
9,10
duced. This imaginary line is the connecting trajectory between
the 4 major facial ligaments, that is, true osteo-cutaneous connec-
tions: temporal ligamentous adhesion (temple, upper face), lateral
orbital thickening (peri-orbital, upper/middle face), zygomatic lig-
ament (zygomatic arch, middle face), and the mandibular ligament
(jawline, lower face). The line of ligaments separates the face into a
medial and a lateral face. Volumizing treatments of the lateral face
result majorly in lifting effects, whereas these treatments in the me-
10
dial face result majorly in volumizing effects.
A recent study by Casabona et al10 utilized the concept of the
line of ligaments in a prospective clinical study and reported that the
volume needed in the medial midface to achieve a symmetric out-
come was significantly reduced if injections points lateral to the line
of ligaments were targeted first (lateral injections point performed
before medial injection points). The authors concluded that volumiz-
ing treatment of the lateral face repositions the medially located soft
tissues which in turn need less volume to achieve a symmetric volu-
mizing effect.
CASABONA et al.
To date, few injection algorithms are presented which respect
the underlying anatomy and make use of concepts like the line of
ligaments or the surface volume coefficient. In the present study, we
describe the results of a new injection algorithm which respects the
aforementioned novel anatomic concepts. The data comprise the
retrospective analysis of n = 306 patients who underwent minimally
invasive soft tissue filler injections for infraorbital and medial mid-
face volume loss treatment between 2014 and 2018.
2 | M ATE R I A L A N D M E TH O DS
2.1 | Study sample
A total of 306 electronic medical records of Caucasian patients who
underwent minimally invasive soft tissue filler injections for infraor-
bital and medial midface volume loss treatment between 2014 and
2018 were retrospectively investigated. The retrospectively inves-
tigated records originated from consecutive patients treated with
the same injection technique. Patient records were retrospectively
analyzed and anonymized for further statistical processing. Written
information and verbal explanations about the scope and goals of
this retrospective analysis were given to participants before inclu-
sion into this study. Patient records were not analyzed if willingness
to participate was declined. Written informed consent and signed
picture and photograph release agreement were obtained from
every patient included. This investigation was performed in adher-
ence to the Declaration of Helsinki (1996), and in accordance with
regional laws and good clinical practice for studies in human sub-
jects.11 The total sample consisted of n = 270 females (mean age
45.1 ± 11.4 years) and n = 36 males (mean age 45.9 ± 11.6 years).
F I G U R E 1 Photographs showing the
injection scheme. The connecting line
between inferior aspect of the nasal ala
and the tragus, connecting line between
the lateral canthus and the corner of the
mouth, and connecting line between
the intersection of the two lines and
a perpendicular line connecting to the
lateral canthus form the G-point (left
face). The position of the boluses given
off into the medial SOOF is marked with
purple and blue dots (middle face), while
the contouring between the cheek and
the lower eyelid is shown in the right face
CASABONA et al.
2.2 | Injection technique
The same injection technique was applied independent of the center
where the patients were treated. The location for product applica-
tion was marked on the skin surface according to the following pro-
tocol (Figure 1): connecting line between inferior aspect of the nasal
ala and the tragus, connecting line between the lateral canthus and
the corner of the mouth, and connecting line between the intersec-
tion of the two lines and a perpendicular line connecting to the lateral
canthus. This dermal location was termed G-point, as it combines the
G-prime effect maximized in a specific starting point (Figures 1,2).
A dermal access puncture was performed with a 21G needle (TSK
Laboratory) 1 cm supero-lateral to the midportion of the nasolabial
sulcus. A 22G 50 mm blunt-tip cannula (Dermasculpt) was introduced
into the superficial nasolabial fat compartment and advanced in di-
rection of the G-point. After the level of the infraorbital foramen
was passed, the cannula was introduced deeper into the supraperi-
osteal plane. This “first-superficial-then-deep” cannula advancement
technique assured that the infraorbital neurovascular structures and
the angular vein were crossed superficially. The correct positioning
of the tip of the cannula was digitally controlled and assured that
it corresponds to the lateral aspect of the sub-orbicularis oculi fat
(SOOF)12 and that it is located lateral to the line of ligaments.7,9,10
In the next step contouring, the cannula was retracted (with-
out exiting the facial soft tissues) and re-advanced cranially in the
mid-pupillary line. Again, a “first-superficial-then-deep” cannula
advancement was performed to assure that the infraorbital neu-
rovascular structures were crossed superficially. Three serial bolus
injections were applied in the supraperiosteal plane targeting the
upper/middle/lower aspects of the medial SOOF.
In a next step, the cannula was retracted and re-advanced crani-
ally following the “first-superficial-then-deep” approach positioning
another supraperiosteal bolus in the palpebromalar groove, inferior
to the orbicularis retaining ligament at the level of the lateral canthus
and another bolus in the supraperiosteal plane in the tear trough.
Thus, a total of 6 boluses of soft tissue filler of high visco-elastic
characteristics were positioned in the supraperiosteal plane utilizing
one single dermal access puncture (Figures 1,3).
F I G U R E 2 Figure showing the volume
changes (middle face) and vectorial skin
changes (right face) after injection in
the G-point. An increase in volume is
represented by dark blue, as a decrease is
represented by dark red. Note the laterally
oriented skin vectors, indicating a lifting
effect after injection into the G-point
| 3
In a next step, the contour between the cheek and the lower
eyelid was addressed. Dermal access was made by a 23G needle
(TSK Laboratory) in the dermal location of the G-point. A 25G
38 mm blunt-tip cannula (Dermasculpt) was introduced into the
SOOF without establishing bone contact. The cannula was ad-
vance medially deep to orbicularis oculi muscle and superior to the
orbicularis retaining ligament. During retrograde movement, small
amounts of soft tissue filler (low visco-elastic characteristics) were
injected (Figures 1,4). Detailed information on the amount and type
of product injected for each of the seven locations can be found in
Table 1.
2.3 | Clinical assessment and measurements
After the injection of the G-point (but before the injection of the re-
maining six locations), the distances (measured in mm) between the
dermal location of the G-point and the inferior aspect of the nasal
ala, the corner of the mouth, and the dermal location of the mandib-
ular ligament were assessed and recorded. Additionally, the height
of the lower eyelid, that is, distance between the lower eyelid-cheek
junction and the eyelashes was measured.
After the completion of the treatment, that is, injections of the
seven locations, the improvement of the infraorbital hollowness
and the medial midface volume was scored according to the global
aesthetic improvement scale: 1 = little or no improvement (0%-
25% change) 2 = fair improvement (26%-50% change); 3 = good
improvement (51%-75% change); 4 = Excellent improvement (>75%
change). The scoring was conducted 6 months after the last injec-
tion and was scored by the patient and by the treating physician
separately.
2.4 | Statistical analyses
Descriptive and comparative analyses were performed using
SPSS Statistics 23 (IBM), and results were considered significant at
a probability level of ≤.05.
4 | CASABONA et al.

F I G U R E 3 Figure showing the volume

changes (middle face) and vectorial skin
changes (right face) after injection in the
G-point and giving off six infraorbital
boluses. An increase in volume is
represented by dark blue, as a decrease is
represented by dark red

F I G U R E 4 Figure showing the volume

changes (middle face) and vectorial skin
changes (right face) after injection in the
G-point and giving off six infraorbital
boluses and infraorbital contouring. An
increase in volume is represented by dark
blue, as a decrease is represented by dark
red

TA B L E 1 Overview of the amount (in cc), location, and type of product injected in the total sample (n = 306). Values are presented as
mean value ± standard deviation

Juvederm Voluma, Belotero Volume, Juvederm Volbella, Belotero Balance,

Allergan Merz Allergan Merz

G-point 0.32 ± 0.092 0.34 ± 0.085

Upper Medial SOOF 0.02 ± 0.005 0.02 ± 0.005
Middle Medial SOOF 0.05 ± 0.005 0.05 ± 0.000
Lower Medial SOOF 0.14 ± 0.048 0.17 ± 0.046
palpebromalar groove 0.07 ± 0.024 0.07 ± 0.025
Tear Trough 0.01 ± 0.009 0.01 ± 0.007
Lower Eyelid 0.05 ± 0.040 0.07 ± 0.060
Count (n) 259 47 260 46

3 | R E S U LT S 3.2 | Averse events

3.1 | General description
The total sample consisting of n = 306 study participants was suc-
cessfully injected according to the technique described above and
followed up until 6-month after the last injection was performed.
The detailed amount per location and product type injected is pre-
sented in Table 1.
The overall rate of adverse events after the described injection pro-
cedure was 11.4% (n = 35) independent of the injected location or
product type. All adverse events were minimal and resolved in 99.7%
(n = 305) within the first 15 days by itself without requiring treat-
ment. One single case 0.3% (n = 1) resulted in the increase of palpe-
bral bags after the lower eyelid injection step. 250 IU hyaluronidase
was injected locally to dissolve the surplus of volume.
CASABONA et al.
The most frequent adverse event was reported to local edema
with 5.9% (n = 18), followed by bruising 4.9% (n = 15), surface ir-
regularities 0.3% (n = 1), and increase of lower eyelid bags 0.3%
(n = 1).
3.3 | Postinjection outcome
When rated by the treating physician, the improvement 6 months
after the procedure was excellent (>75% change) in 88.2% (n = 270)
and good (51%-75% change) in 11.8% (n = 36) cases. However, when
rated by the patient, the 6-month follow-up was in 81.4% (n = 249)
excellent, in 6.5% (n = 20) good, in 11.8% (n = 36) fair, and in one case
little to no improvement was reported.
Concordance in the 6-month follow-up was noted in 79.1%
(n = 242) of the cases with P < .001. Positive discordance (patient-rated
outcome better than the treating physician) was observed in 2.6%
(n = 8), whereas negative discordance (patient-rated outcome worse
than the treating physician) was noted in 18.3% (n = 56) cases.
3.4 | Change in surface position
The distances (in mm) between the dermal location of the G-point
and the dermal location of the mandibular ligament, the corner of
the mouth and the base of the nasal ala were measured right before
and after the injection of the G-point to determine its effectiveness
in facial soft tissue repositioning. The distances significantly in-
creased to the mandibular ligament by 0.17 ± 0.11 mm with P < .001,
to the corner of the mouth by 0.20 ± 0.09 mm with P < .001 and to
the nasal ala by 0.20 ± 0.11 mm with P < .001 (Figure 5).
p < 0.001
F I G U R E 5 Bar graph showing the
distance between G-point and nasal ala,
corner of the mouth, and mandibular
ligament. Note how the mean of all three
distances increased significantly in the
6-month follow-up, compared to the
baseline measurements
| 5
A greater effect in change in surface measurements was observed
to results from the application of Juvederm Voluma for the distance to
the dermal location of the mandibular ligament with P = .060, to the
corner of the mouth P = .014 and to the nasal ala with P = .508.
The height of the lower eyelid was measured after the injection
of all injection steps and compared to its pre-injection status. The
height of the lower eyelid reduced by 0.49 ± 0.13 mm with P < .001.
No statistically significant influence of the type of product injected
was observed P = .209 (Figure 6).
4 | D I S CU S S I O N
This clinical study retrospectively analyzed a total of 306 patients
treated for infraorbital and medial midface volume loss between 2014
and 2018. The treatment was conducted according to a standardized
injection algorithm based on the novel anatomic concepts: line of liga-
ments and surface volume coefficient. The results revealed that the
applied injection algorithm can significantly alter facial soft tissue po-
sition (Figures 7,8,9). This was reflected by the increase in distances
between the dermal location of the G-point to the mandibular liga-
ment by 0.17 ± 0.11 mm with P < .001, to the corner of the mouth by
0.20 ± 0.09 mm with P < .001 and to the nasal ala by 0.20 ± 0.11 mm
with P < .001. The repositioning of the facial soft tissues resulted also
in a decrease of the height of the lower eyelid by 0.49 ± 0.13 mm with
P < .001. The applied injection algorithm had an overall adverse event
rate of 11.4% with local edema being the most frequently observed
adverse event with 5.9% (n = 18), followed by bruising 4.9% (n = 15),
surface irregularities 0.3% (n = 1), and increase of lower eyelid bags
0.3% (n = 1). After a follow-up period of 6 months, the improvement
was excellent (>75% change) in 88.2% (n = 270) and good (51%-75%
p < 0.001
p < 0.001
6 |
p < 0.001
F I G U R E 7 Photograph of a female patient showing the right
side treated with the G-point algorithm, while her left side of the
face remained untreated. The right side shows the impact of the
treatment algorithm in terms of midface elevation, shortening of
the lower eyelid and correction of the tear trough
CASABONA et al.
F I G U R E 6 Bar graph showing the
significant decrease of mean height of the
lower eyelid in mm between baseline and
6-month follow-up
change) in 11.8% (n = 36) cases when rated by the treating physician
and was in 81.4% (n = 249) excellent, in 6.5% (n = 20) good, in 11.8%
(n = 36) fair, and in one case little to no improvement when rated by
the patient.
A strength of the present study is the large sample size of n = 306
retrospectively investigated patients and the standardized injection
algorithm which was applied independent of the clinical center. One
limitation of the study is that the measurements were conducted
using a ruler and dermal skin markers. This could result in less pre-
cise measurements. Using 3-dimensional skin vector displacement
analyses (Figures 2,3,4) could have increased the accuracy of the
presented results. Due to the 4-years retrospective observational
period, 3-dimensional surface analyses were not available in the
early phase of patient data collection and were as consequence not
utilized throughout the study for consistency reasons. Another lim-
itation is the relatively short (6 months) follow-up period. Longer pe-
riods could have provided valuable data on product longevity. This
will need to be assessed in future prospective clinical trials.
The utilized injection technique comprised a total of 6 bolus
injections (22G) and 1 retrograde fanning injection (25G) using
blunt-tip cannulas for all 7 targeted locations. The cannula ad-
vancement of this technique is nonlinear and requires a certain
degree of anatomic knowledge. The cannula is first introduced
into the superficial fatty layer and after the passage of the infra-
orbital neurovascular bundle and the angular vein, the cannula is
redirected deeper toward the supraperiosteal plane. This “first-su-
perficial-then-deep” cannula advancement assures that structures
at risk for intra-vascular product placement like the infraorbital
artery, the zygomatico-facial artery, the transverse facial artery
or the angular vein are respected. These structures are crossed by
the cannula superficially whereas product placement is performed
in the supraperiosteal plane.
CASABONA et al. | 7

F I G U R E 8 Photographs of a female
patient taken before treated according
to the G-point algorithm (left) and after
6 months (right). Significant improvement
of the infraorbital region and upper cheek,
including the infraorbital hollowing and
skin tightening can be observed

The selected locations for product placement are in line with
current anatomic concepts: the line of ligaments and the sur-
face volume coefficient. The location of the first bolus injection
was termed the G-point. This location corresponds to the lateral
boundary of the lateral SOOF which is located at or lateral to
the line of ligaments. To control for proper product placement,
digital control of the noninjecting hand is performed during
cannula advancement. Once the tip of the cannula reaches the
desired location the first (of the 6) bolus injections can be per-
formed. The retrospective data analyses revealed that a mean of
0.32 cc ± 0.091 were injected. This amount was in the investi-
gated patient population sufficient to reposition the midfacial soft
tissues cranially. In detail, the distance to the dermal location of
the mandibular ligament was increased in mean by 0.17 mm, to the
corner of the mouth by 0.20 mm and to the nasal ala by 0.20 mm.
This soft tissue effect is in line with the concept of the line of
ligaments7,10 which has been reported to lift the lateral facial soft
tissues. In the present study, product was injected lateral to the
line of ligaments (G-point), but close enough to not lose efficacy
which resulted in an increase in midfacial distances between the
dermal location of the G-point and the jawline, the corner of the
mouth, and the nasal ala in a statistically significant magnitude.
These results of the present study are in line with a previous pub-
lication by Casabona et al10 where this lateral lifting effect was
utilized to reduce the midfacial volume needed during needle in-
jections for symmetric infraorbital volume restoration. Despite
needle injections were used,10 a similar effect on the medial mid-
facial structures (=repositioning) was observed providing clinical
validity for this novel anatomic concept.
The magnitude of facial soft tissue repositioning was majorly de-
termined by the high effectiveness of the SOOF, when evaluated by
the surface volume coefficient (SVC). The SVC is a measure of effec-
tiveness as it is calculated by the ratio between the change in surface
volume projection and the injected volume.7 For the SOOF the SVC

F I G U R E 9 Photographs of a female
patient taken before treated according
to the G-point algorithm (left) and after
6 months (right). Significant improvement
of the infraorbital region and upper cheek,
including the infraorbital hollowing and
skin tightening can be observed
8 |
is 93% at 0.5 cc and 95% at 1.0 cc; which is the highest SVC of all
7
measured facial fat compartments (superficial and deep). This could
potentially explain why a mean amount 0.32 ± 0.091 cc injected in
the lateral SOOF can change midfacial distances by an average of
0.19 mm (Figure 3).
The rate of adverse events of 11.4%, was majorly determined
by the occurrence of edema and bruising. The pathogenesis of
edema can be explained by the exceptional lymphatic drainage of
the SOOF.13 The lymphatic outflow is directed laterally and does
not follow the angular vein. Injecting a high G-prime product might
impair the lymphatic outflow which could result in the observed rate
of edema. Bruising can be majorly attributed to the presence of the
plethora of arteries and veins located in the infraorbital area. 8 99.7%
of all observed adverse events cleared without medical intervention
within 15 days after the injection procedure. In one case, an increase
in the palpebral volume was observed which required the chemical
removal of the injected material. It seems plausible that in this case,
the cannula penetrated the orbital septum during advancement of
the lower eyelid and the product was positioned retro-septal and
increased the intra-orbital volume.
The described injection algorithm resulted in the repositioning
of the midfacial soft tissues which was additionally confirmed by
the reduction of the measured lower eyelid height. The height of
the lower eyelid was determined as the distance between the lower
eyelid-cheek junction and the eyelashes. After the follow-up period
of 6 months the distance was reduced by 0.49 mm which could be
potentially explained by the cranial repositioning of the midfacial
soft tissues. This repositioning resulted in the cranial shift of the
eyelid-cheek junction and in turn in a reduction of the distance to
the eyelashes.
After a follow-up period of 6 months, the improvement was ex-
cellent (>75% change) in 88.2% (n = 270) and good (51%-75% change)
in 11.8% (n = 36) cases when rated by the treating physician and was
in 81.4% (n = 249) excellent, in 6.5% (n = 20) good, in 11.8% (n = 36)
fair, and in one case little to no improvement when rated by the pa-
tient. Interestingly, concordance between the rating of the treating
physician and the patient was noted in 79.1% of the cases, whereas
positive discordance (patient-rated outcome better than the treat-
ing physician) was observed in 2.6% and negative discordance (pa-
tient-rated outcome worse than the treating physician) was noted
in 18.3% of the cases. The observed discordant effects could be
potentially explained by the bias toward the outcome effect of the
treating physician and/or by the unmet expectations of the patients.
Exploratory analyses revealed a statistically significant distribution
of the data toward patients with a high post-treatment rating and
the absence of adverse events. This is understandable and is a good
reflection of daily clinical work.
5 | CO N C LU S I O N
This clinical study retrospectively analyzed a total of 306 patients
treated for infraorbital and medial midface volume loss according
CASABONA et al.
to a standardized injection algorithm. This cannula injection-based
algorithm utilizes novel anatomic concepts (line of ligaments and
surface volume coefficient) and positions the product in the supra-
periosteal plane following a “first-superficial-then-deep” cannula
advancement technique. The results revealed that utilizing these
novel anatomic concepts, a mean amount of 0.32 cc high G-prime
soft tissue filler injected in the lateral SOOF (G-point) can change
midfacial distances by an average of 0.19 mm. This repositioning of
medial midfacial soft tissues resulted additionally in a reposition of
the lower eyelid-cheek junction by an average amount of 0.49 mm.
C O N FL I C T O F I N T E R E S T
None of the other authors listed have any commercial associations
or financial disclosures that might pose or create a conflict of in-
terest with the methods applied or the results presented in this
article.
E T H I C A L A P P R OVA L
WMA Declaration of Helsinki—Ethical Principles for Medical
Research Involving Human Subjects—WMA—The World Medical
Association.
ORCID
Konstantin Frank https://orcid.org/0000-0001-6994-8877
REFERENCES
1. Schenck TL, Koban KC, Schlattau A, et al. The functional anatomy
of the superficial fat compartments of the face: a detailed imaging
study. Plast Reconstr Surg. 2018;141(6):1351-1359.
2. Cotofana S, Gotkin RH, Ascher B, et al. Calvarial volume loss and
facial aging: a computed tomographic (CT)-based study. Aesthetic
Surg J. 2018;38(10):1043-1051.
3. Cotofana S, Gotkin RH, Morozov SP, et al. The relationship between
bone remodeling and the clockwise rotation of the facial skeleton:
a computed tomographic imaging-based evaluation. Plast Reconstr
Surg. 2018;142(6):1447-1454.
4. Frank K, Gotkin RH, Pavicic T, et al. Age and gender differences
of the frontal bone: a computed tomographic (CT)-based study.
Aesthetic Surg J. 2019;39(7):699-710.
5. Cotofana S, Fratila AAM, Schenck TL, Redka-Swoboda W, Zilinsky I,
Pavicic T. The anatomy of the aging face: a review. Facial Plast Surg.
2016;32:253-260.
6. Freytag DL, Frank K, Haidar R, et al. Facial safe zones for soft
tissue filler injections: a practical guide. J Drugs Dermatol.
2019;18(9):896-902.
7. Cotofana S, Koban KC, Konstantin F, et al. The surface-vol-
ume-coefficient of the superficial and deep facial fat compart-
ments – a cadaveric 3D volumetric analysis. Plast Reconstr Surg.
2019;143(6):1605-1613.
8. Cotofana S, Lachman N. Arteries of the face and their relevance
for minimally invasive facial procedures: an anatomical review. Plast
Reconstr Surg. 2019;143(2):416-426.
9. Cotofana S, Lachman N. Anatomie der Fettkompartimente des
Gesichts und ihre Bedeutung für die ästhetische Chirurgie. J Dtsch
Dermatol Ges. 2019;17(4):399-415.
10. Casabona G, Frank K, Koban KC, et al. Lifting vs volumizing-The
difference in facial minimally invasive procedures when re-
specting the line of ligaments. J Cosmet Dermatol. 2019;18(5):
1237-1243.
CASABONA et al. | 9

11. Cotofana S, Gotkin RH, Frank K, et al. The functional anatomy of

the deep facial fat compartments – a detailed imaging based inves-
tigation. Plast Reconstr Surg. 2019;143(1):53-63.
12. Mojallal A, Cotofana S. Anatomy of lower eyelid and eyelid–cheek
junction. Ann Chir Plast Esthétique. 2017;62(5):365-374.
13. Cotofana S, Steinke H, Schlattau A, et al. The anatomy of the facial
vein: implications for plastic, reconstructive, and aesthetic proce-
dures. Plast Reconstr Surg. 2017;139(6):1346-1353.
How to cite this article: Casabona G, Bernardini FP, Skippen
B, et al. How to best utilize the line of ligaments and the
surface volume coefficient in facial soft tissue filler
injections. J Cosmet Dermatol. 2019;00:1–9. https​://doi.
org/10.1111/jocd.13245​

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