Received: 12 June 2020 | Accepted: 8 July 2020

DOI: 10.1111/jocd.13621

ORIGINAL CONTRIBUTION

Clinical validation of the temporal lifting technique using soft

tissue fillers

Claudia A. Hernandez MD1 | David L. Freytag2 | Michael H. Gold MD3 |

Tajana Pavicic MD | Benjamin Ascher MD | Ada Trindade de Almeida MD6,7 |
4 5

Jeremy B. Green MD8 | Sabrina G. Fabi MD9 | Konstantin Frank MD2 |

10
Sebastian Cotofana MD, PhD
1
CH Dermatologia, Medellin, Colombia, USA
2 Abstract
Department for Hand, Plastic and Aesthetic
Surgery, Ludwig–Maximilian University Background: While the temporal lifting technique has gained increasing attention,
Munich, Munich, Germany
there is a dearth of objective and reliable evidence of its effects.
3
Gold Skin Care Center, Tennessee Clinical
Research Center, Nashville, TN, USA
Aim: The objective of the present study is to analyze the ability of the temporal lifting
4
Private Practice, Munich, Germany technique to reduce the midfacial volume by soft tissue repositioning and to achieve
5
Think in Clinic, Paris, France an improved pan-facial appearance by targeting exclusively the subdermal plane of
6
Clinica de Dermatologia do Hospital do the posterior and superior temple with soft tissue fillers.
Servidor Público Municipal de São Paulo,
São Paulo, Brazil Methods: A total of 12 patients (1 male and 11 females) with a mean age of
7
Private Practice, Sao Paulo, Brazil 36.75 ± 6.6 years and a mean body mass index of 23.04 ± 1.3 kg/m2 were included in
8
Skin Associates of South Florida and Skin this prospective clinical single-center interventional study. Injection-related outcome
Research Institute, Coral Gables, FL, USA
9
was evaluated utilizing 3D skin vector displacement and surface volume analyses and
Cosmetic Laser Dermatology, San Diego,
California, USA scoring based on five different evaluators.
10
Department of Clinical Anatomy, Mayo Results: Three months after the treatment, the global esthetic improvement scale rating
Clinic College of Medicine and Science,
showed an improved outcome (3.08) when evaluated by the independent observers, very
Rochester, MN, USA
improved outcome when evaluated by the treating physician (4.33), and exceptional im-
Correspondence
provement when rated by the patient (4.83). Temporal volume improved by 0.36 (P < .001),
Sebastian Cotofana, Department of Clinical
Anatomy, Mayo Clinic College of Medicine lower cheek fullness by 0.47 (P < .001), and jawline contouring by 0.51 (P < .001). No
and Science, Mayo Clinic, Stabile Building
major adverse events were reported during the 3-month observational period.
9-38, 200 First Street, Rochester, MN,
55905, USA. Conclusion: Objective outcome measures have provided evidence that by augment-
Email: cotofana.sebastian@mayo.edu
ing the posterior superior temple the volume of the middle face can be reduced and
the contour of the jawline can be accentuated; this is due to the underlying fascial
anatomy and the resulting soft tissue re-position.

KEYWORDS

facial anatomy, facial lifting, facial volume, soft tissue fillers, temporal hollowing

1 | I NTRO D U C TI O N
In 2019, a total of 784 185 soft tissue filler injections of hyaluronic
acid (HA) and calcium hydroxylapatite (CaHA) products were per-
formed in the United States according to the annual statistics re-
port of The Aesthetic Society.1 This represents an increase by 18.7%
when compared to the usage of the same products in 2015 and is
reflective of an increased desire for esthetic enhancement.
Soft tissue filler materials are generally considered to increase
the local volume based on their individual physico-chemical char-
acteristics and the targeted anatomic region. Recent research how-
ever has suggested that some areas of the face can influence other

J Cosmet Dermatol. 2020;19:2529–2535. wileyonlinelibrary.com/journal/jocd© 2020 Wiley Periodicals LLC | 2529

2530 | HERNANDEZ et al.
facial regions when specifically targeted, that is, an increase in local
volume can influence soft tissue position of adjacent facial regions.
Examples for these interesting biomechanical effects were provided
by Casabona and colleagues. 2,3 In one of their studies, the authors
injected soft tissue fillers to volumize the midface, on one side in-
3
jecting lateral to the line of ligaments before injecting medial, and
on the contralateral side injecting medial prior to lateral. They found
that the injected volume required medial to the line of ligaments
was statistically significantly reduced when the lateral midface was
injected first, compared to the contralateral side where the medial
midface was injected prior to the lateral. They argued that the lat-
eral face injection preconditioned the ipsilateral midface for a more
efficient injection-related outcome. Another example was provided
when injecting the midface lateral to the line of ligaments and tar-
geting the infraorbital region in a second step.3 Here, the authors
reported a statistically significant repositioning of the midfacial soft
tissues though they were not a priori targeted.
4
Another study by Suwanchinda and colleagues provided
evidence that by injecting the subdermal plane of the posterior
superior temple, a repositioning of the soft tissues of the mid-
dle and of the lower face can be achieved. The authors argued
that the fascial layered arrangement and the retinacula cutis are
able to transmit the local (= temporal) volumizing effect into a
pan-facial lifting effect. While the authors utilized skin vector dis-
placement analyses to support their theory, the study had several
weaknesses.
To date, this temporal lifting technique 4,5 has gained increasing
attention despite objective and reliable evidence for supporting the
proposed underlying pathophysiologic mechanism still remains elu-
sive. The objective of the present study is to analyze the ability of
the temporal lifting technique to reduce the midfacial volume by soft
tissue repositioning and to achieve an improved pan-facial appear-
ance by exclusively targeting the subdermal plane of the posterior
and superior temple with soft tissue fillers.
2 | M ATE R I A L S A N D M E TH O DS
2.1 | Study participants
This prospective clinical single-center interventional study inves-
tigated the esthetic effects of the temporal lifting technique in a
total of n = 12 patients (1 male and 11 females) with a mean age of
36.75 ± 6.6 years [range: 25 - 46] and a mean body mass index (BMI)
of 23.04 ± 1.3 kg/m2 [range: 20.1-25]. Study participants were re-
cruited from consecutive patients of the private practice of the first
author of this study (CAH).
Inclusion criteria were age below 60 years, BMI below 30 kg/
m2 , absence of previous soft tissue filler or biostimulator treat-
ments of the face, absence of previous facial suspension thread
treatment, absence of previous facial or neck surgery and absence
of allergies, contraindications, comorbidities, or chronic diseases
that exclude the application of soft tissue fillers in the temple.
Patients were not included in this analysis if they were unwilling
to complete a follow-up period of 3 months or if they not agreed to
the aims and scopes of the study including the publication of their
personal data and facial images for research purposes.
Each patient provided written informed consent for the use of
both their data and associated images prior to their inclusion into
the study. The study was approved by the Institutional Review
Board of Universidad CES Medellin, Colombia (IRB protocol num-
ber: 866). This study was conducted in accordance with regional
laws (Colombia) and good clinical practice. Soft tissue filler injec-
tions were conducted between January 2019 and January 2020,
and analyses were conducted between April and May 2020.
2.2 | Injection technique
The temporal lifting technique was described previously.4,5 In brief,
after topical disinfection with alcohol of the pre-auricular area, cu-
taneous access was achieved 1 cm anterior to the apex of the tragus
with a 21G needle, and a 22G 50 mm blunt-tip cannula (Feeltech CO
Ltd) was inserted. The entire length of the cannula was advanced in
the subdermal plane in the superior direction until reaching the su-
perior posterior temporal region. During the advancement process,
the cannula was lifted against the skin in a direction perpendicular to
the long axis of the cannula to verify that it was located in the sub-
dermal plane and did not change position toward deeper planes. The
cannula contour was readily visible in the skin as it was contacting
the undersurface of the skin during advancement, helping to ensure
a subdermal position (Figure 1).
A single bolus (no fanning) was injected at slow speed while
communicating with the patient and informing about the sensation
of increasing pressure of the temple. The index finger of the non-
dominant hand was placed on the skin superficial to the cannula to
compress the created injection canal and thereby reduce retrograde
product flow.6
A single bolus of 1.0 cc HA-based soft tissue filler material
(Belotero Volume, Merz Pharma GmbH, Frankfurt, Germany) or
a single bolus of 0.75 cc CaHA material (Radiesse, Merz Pharma
North America, Raleigh, NC, USA) was administered. No massag-
ing or manual manipulation was performed or recommended to the
patient after the procedure. However, the patient was informed
about a potential foreign-body sensation and the perception of the
increased local surface volume which could last up to 7 days after
the procedure.
2.3 | Outcome assessment
2.3.1 | Image analyses
3D images of the patient's faces were taken before the treatment,
immediately after treatment, and three months after the treatment
using a Vectra H2 camera system (Canfield Scientific Inc). 3D images
HERNANDEZ et al.
were aligned to their respective baseline image in each patient, and
difference between baseline and immediately after the treatment
and three months after the treatment was calculated. In this way,
inter-individual morphometric variations were eliminated as each
patient served as its own control. Differences in skin position and
surface volume were computed by the automated algorithm of the
Vectra Software Suite® (Figure 2).
F I G U R E 1 Clinical image of the injection procedure of a male
patient. Please note the sharp contour of the cannula when lifted
against the dermis, indicating that the cannula is in the subdermal
plane
F I G U R E 2 Image capture during
the 3D image analysis process. Image A
shows the area (1) where the horizontal
and vertical skin displacement measures
were conducted, whereas Image B shows
the areas where the volume increase
(2) and the volume decrease (3) were
calculated
| 2531
Skin vector displacement and surface volume analyses were
conducted to objectively quantify treatment-related outcomes.
Analyses included horizontal lifting (=movement of skin toward the
ear), vertical lifting (=movement of skin toward the temple), and in-
crease or decrease in surface volume when compared to baseline.
All surface analytic procedures were conducted by the same inves-
tigator (DLF).
2.4 | Subjective outcome scoring
The global esthetic improvement scale (GAIS) was assessed three
months after the treatment with values ranging from 1 (=worsened
patient) to 5 (=exceptional improvement). This evaluation was per-
formed by the treating physician and by the patient during the last
consultation.
2.5 | Objective outcome scoring
Based on the 3D images taken, the following scores were
assessed by three additional independent observers who were
blinded to the sequence of image capture:
Temple hollowing scale ranging from 0 (= convex, rounded tem-
ple) to 4 (= severe, deeply recessed temple) 7
Brow position grading scale ranging from 0 (= youthful, refreshed
look) to 4 (= flat eyebrow with barely any arch) 8
Crow's feet grading scale ranging from 0 (= no wrinkles) to 4 (=
very severe wrinkles)9
Lower cheek fullness scale ranging from 0 (= full lower cheek) to
4 (= very severely sunken lower cheek)10
Jawline contouring scale ranging from 0 (= no sagging) to 4 (=
very severe sagging)10
GAIS11
(A) (B)
2532 | HERNANDEZ et al.
2.6 | Statistical analysis
Differences between time points were calculated as paired analy-
ses using paired Student's t test for continuous variables and using
Wilcoxon signed rank test for ordinal variables. To relate the consist-
ency (=reliability) in the assessment of two observers on the same
outcome, the interclass correlation coefficient (ICC) was calculated
based on a two-way mixed effect model with absolute agreement
for k = 2 and 3 raters, respectively. Analyses were performed using
SPSS Statistics 23 (IBM), and differences were considered statisti-
cally significant at a probability level of ≤.05 to guide conclusions.
3 | R E S U LT S
3.1 | General description
A total of 24 temples were treated in 12 patients. 10 (out of 24) were
treated with HA and 14 were treated with a CaHA product.
3.2 | Adverse events
No major adverse events were reported during the three months ob-
servational period. However, in 10 out of 24 treated temples (41.7%)
the patients reported a headache which resolved within <24 hours
without medical intervention. In one case (4.2%), nonscarring alope-
cia was observed in the CaHA-treated group at an additional interim
visit at two month. The condition resolved itself four months after
the initial product application without medical intervention.
3.3 | 3D Lifting effects
The mean horizontal lifting was 0.13 ± 1.0 mm three months after
the treatment whereas the mean vertical lifting was 0.02 ± 0.5 mm.
No statistically significant differences were observed between the
products administered (Figure 3).
3.4 | Volume effects
Three months after the treatment, an increase in volume in the total
temple of 0.26 ± 1.1 cc was observed whereas in the middle and
lower face a decrease in volume of 0.22 ± 3.5 cc was observed.
No statistically significant differences were observed between the
products administered (Figure 4).
3.5 | Subjective outcome scoring
Patient rated their overall facial improvement in 20 (83.3%) cases
as exceptional improvement and in 4 (16.7%) cases as very much
improved. The treating physician rated 8 (33.3%) as exceptional im-
provement and 16 (66.7%) as very much improved with no differ-
ence between products administered (P = .439). The difference in
the rating was reflected by a poor ICC with 0.317.
3.6 | Objective outcome scoring
The mean value across the three independent observers for the
GAIS was 3.08 ± 0.6 indicating an improved facial appearance
three months after treatment; this was evaluated based on an ICC
of 0.848 (= good reliability). No statically significant change in the
GAIS was detected between immediate and three months after the
treatment with P = .366. Temples treated with CaHA were statisti-
cally significantly better rated than those treated with HA-based
filler material.
No changes in the brow position grading scale or in the crow's
feet grading scale were detected between baseline and the three
months follow-up assessment.
The assessment of the temporal shape according to the tempo-
ral hollowing scale (0 - 4, best to worst) was rated to be at baseline
2.69 ± 0.7 (ICC 0.843) and was 2.36 ± 0.7 immediately after the
treatment (ICC 0.873) representing a statistically significant change
with P < .001. This change improved slightly at the three months
visit with 2.33 ± 0.8 (ICC 0.904) but was not statistically significantly
different to the previous visit with P = .539.
Lower cheek fullness score was at baseline 0.97 ± 0.7 (ICC 0.831)
and decreased by 0.30 (ICC 0.863) immediately after the treatment
with P < .001 and decreased further at three months by 0.47 (ICC
0.758) with P < .001 indicating a statistically significant loss of vol-
ume when compared to baseline.
Jawline contouring scale was at baseline 1.61 ± 0.7 (ICC 0.792)
and was immediately after treatment 1.15 ± 0.7 (ICC 0.838) with
P < .001. The observed effect improved at the three months visit
to 1.10 ± 0.6 (ICC 0.818) with P < .001 (compared to baseline) and
with P = .043 (compared to immediate after the treatment).
Whereas the scoring of the temporal volume did not statis-
tically significantly differ between the two groups treated with
different products, the lower cheek fullness score and the jawline
contouring scale received statistically significantly better rating
by the three independent observers when the treatment was con-
ducted with the calcium hydroxyl apatite product.
4 | D I S CU S S I O N
The results of this clinical interventional study provide objective
evidence for the effectiveness of the temporal lifting technique. 3D
imaging revealed that despite very small changes in skin position,
and a volume loss of 0.22 cc was detected in the lower face after the
temporal bolus injection. Three months after treatment, the GAIS
rating showed an improved outcome (3.08) according to independ-
ent observers, a very improved outcome per the evaluation of the
HERNANDEZ et al. | 2533

(A) (B) (C)

F I G U R E 3 Image series showing a female patient before the treatment with the temporal lifting technique (left image), three months
after the treatment (center image) and the respective skin vector displacement analyses conducted (right image). Note the direction
of the skin vectors, indicating a repositioning of the facial soft tissues toward posterior and superior

(A) (B) (C)

F I G U R E 4 Image series showing a female patient before the treatment with the temporal lifting technique (left image), three months
after the treatment (center image) and the respective surface volume analyses conducted (right image). Note the increase in volume of the
temple and the decrease in volume of the midface

treating physician (4.33) and exceptional improvement when rated
by the patient (4.83). Temporal volume improved by 0.36 (P < .001),
lower cheek fullness by 0.47 (P < .001), and jawline contouring by
0.51 (P < .001) while no changes were observed in brow position or
in the severity of the lateral canthal lines.
A strength of this study is the objective outcome assessment
which was conducted via 3D imaging and by the additional image
analyses of three independent observers. The three independent
observers were not experienced raters in the field of esthetic med-
icine. It was the intention of the investigators to have untrained
eyes evaluating the outcome of the temporal lifting injection tech-
nique to provide objectivity. Despite the fact that these raters did
not have an esthetic medicine background, the ICC values were >0.8
12
indicating a good consistency and reliability in their rating. For
comparison purposes, the ICC of the three-month outcome rating
performed by the patient and treating physician was 0.317 indicating
2534 | HERNANDEZ et al.
poor consistency. Results from 3D imaging might provide valuable
insight into theoretical basic tissue biomechanics; this imaging tech-
4,13-15
nique was utilized previously in a plethora of cadaveric studies.
However, the major drawback is the clinical relevance of the changes
measured, as the calculated changes might be statistically significant
in a theoretical (=cadaveric) model but it is unclear whether one can
extrapolate these results to the in vivo clinical setting; this was the
primary reason to expand the evaluation to objective nonesthetic
raters. Another strength of the study is that the treatment effects
were assessed across the total face which included the evaluation of
the eyebrow position and of the contour of the jawline. The temporal
region was identified to have a great potential to influence the fore-
head, the middle face, and the lower face. This was attributed to the
16
fascial anatomy of the face and its layered arrangement. This fascial
continuity can transmit treatment effects beyond the local bound-
aries of the temporal region. This effect is important to characterize
in order to develop pan-facial treatment algorithms tailored to the
needs of each individual patient. These needs are in the very minority
of the cases restricted. In very few cases, solely local improvement is
desired; therefore, understanding the pan-facial effects of the tem-
poral lifting technique demonstrated in this study can help injectors
optimize outcomes.
The major limitation of this study is the small sample size n = 12
which allowed the analysis of 24 temples only. A larger sample size
would permit a more robust analysis. However, the present study
was planned, enrolled, and conducted independently and received
no funding from industry partners. This was intentional to evaluate
the effectiveness of the temporal lifting technique while mitigating
potential bias. Although both products utilized are from the same
company, the product with the higher G-prime (CaHA) was shown
to be rated statistically significantly better when compared to the
lower G-prime HA product. It can be assumed that other products
with high G-prime properties favoring greater lifting effects might
result in better clinical outcomes. Future studies with larger cohorts
and additional products will need to expand on the results presented
herein.
The safety profile of the temporal lifting technique is based on
the layered anatomy of the temporal region. The product is admin-
istered into the superficial fat compartments (= Layer 2) utilizing
a 22G cannula. The posterior (parietal) branch and the anterior
(frontal) branch of the superficial temporal artery are located inside
the superficial temporal fascia (= Layer 3); this indicates that the
product is injected superficial to the arteries (and the accompany-
ing veins). To ensure subdermal (= Layer 2) product placement, the
cannula is lifted against the underside of the skin as it is advanced to
prevent the tip from diving into deeper planes when performing this
technique. In unpublished reports communicated to the authors,
novice injectors utilizing this technique have introduced product to
the superficial temporal artery resulting in livedo and partial tissue
loss of large areas of the ipsilateral scalp and the ipsilateral oral mu-
cosa without injection-related visual compromise. Utilizing a 22G
cannula additionally decreases the risk for intra-arterial product
as a previous study showed that the force needed to penetrate an
artery is statistically significantly reduced compared to a 25G or
27G cannula.17
Of note, 42% of study participants treated with this technique
reported headache of variable intensity which resolved within
24 hours after injection without medical intervention. This can be
explained by the local pressure exerted by the applied volume. A
previous cadaveric study revealed that the effectiveness is superior
if the product is administered via bolus technique versus fanning
technique.18 The authors discussed that the integrity of the local
septae might be disrupted by the fanning technique which includes
subdermal subcision of the retinacula cutis and zygomatic adhesions,
which are structures integral to the ability to transmit the lifting
forces from the temple to distal facial areas.
Utilizing the CaHA product resulted in one case (=one temple
treated) of nonscarring alopecia which resolved spontaneously four
months after injection. This adverse event could be explained by the
local compression of the subdermal arterial vascular plexus by the
product which could have induced a local disturbance of the perfu-
sion of the respective hair follicles.19 With time, presumably there
was a decrease in pressure due to the product-tissue integration, and
the arterial perfusion was restored permitting resolution without
identifiable sequelae.
Another technique described by Coimbra and colleagues5 ad-
ministers soft tissue fillers via multiple smaller boluses around the
anterior and superior aspect of the auricle purported to yield similar
results. Despite the retrospective analysis of a large sample of 165
participants, the authors did not provide objective and reliable evi-
dence for their claims, leaving the study unfortunately in the realm
of subjective anecdotal outcome reports. The first study however
to report on the temporal lifting technique (as presented here) by
4,5
Suwanchinda and colleagues investigated the injection-related
outcome of 15 Asian patients and combined their results with skin
vector displacement analyses of three Caucasian body donors. Their
study reported convincing objective outcome measures for their
(clinical) injection-related outcome, but their 3D analyses were per-
formed in a different sample. It remains to be proven whether the
connection truly exists between the cadaveric study component
(conducted in Caucasians) and the clinical study component (con-
ducted in Thai-Asians).
In contrast, the present study is the first to provide objective
outcome measures originating from treated (Caucasian) patients
and 3D surface volume analyses from the same sample. The results
presented are consistent with previous reports and reveal that vo-
lumizing the posterior superior temple can reduce the midfacial vol-
ume and can accentuate the contour of the jawline. These effects
are possible due to the repositioning of the lateral facial soft tissues
which are shifted toward a more cranial location. While the values of
the skin vector displacement analyses are not great in magnitude, the
injection-related clinical outcomes were characterized as an excep-
tional improvement according to 20 (83.3%) of the treated patients.
It can be speculated that the clinical results could be improved
by additional treatments of the face depending on the esthetic re-
gion of interest favoring multi-area treatments utilizing their additive
HERNANDEZ et al.
biomechanical characteristics. If the injection-related outcome is
more focused on lateral facial lifting, soft tissue filler around the
zygomatic arch and/or the mandibular angle could be injected. 20
Another possibility to potentiate the lateral midfacial lifting effects
of soft tissue fillers could be to reducing the inferior pull of the fa-
cial depressor muscles like the platysma or the depressor anguli oris
muscles by injecting neuromodulators. If the medial midface or the
infraorbital area is the esthetic region of interest, previous studies
have shown that soft tissue filler application lateral to the line of
ligaments can precondition the medial midface resulting a reduced
amount of soft tissue filler volume needed to achieve esthetically
pleasing results. 2
5 | CO N C LU S I O N
The results of this clinical interventional study reveal the effective-
ness of the temporal lifting technique. Objective outcome measures
described herein provided evidence that by augmenting the poste-
rior superior temple, the volume of the middle face can be reduced
and the contour of the jawline can be accentuated; this is due to
the underlying fascial anatomy and the resulting soft tissue reposi-
tioning. The combination of the temporal lifting technique with ad-
ditional filler injections targeting various esthetic regions of interest
could potentially prove synergistic and yield superior outcomes.
C O N FL I C T O F I N T E R E S T
The authors declared no potential conflicts of interest with respect
to the research, authorship, and publication of this article.
ORCID
Michael H. Gold https://orcid.org/0000-0002-5183-5433
Konstantin Frank https://orcid.org/0000-0001-6994-8877
Sebastian Cotofana https://orcid.org/0000-0001-7210-6566
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How to cite this article: Hernandez CA, Freytag DL, Gold
MH, et al. Clinical validation of the temporal lifting technique
using soft tissue fillers. J Cosmet Dermatol. 2020;19:2529–
2535. https://doi.org/10.1111/jocd.13621