Facial aging is a multifactorial process resulting in physiologic and morphologic changes in hard and soft tissues (i.e., bones, ligaments, muscles, fasciae, subcutaneous fat, and skin).1–6 Soft-tissue filler injection use to address facial aging signs has increased according to an American Society of Plastic Surgeons survey that demonstrated a 312 percent rise in the number of soft-tissue filler procedures between 2000 and 2017.7
Injectable fillers are frequently used to restore age-related facial soft-tissue volume loss.8–10 Studies have indicated that, depending on the targeted layer, various aesthetic outcomes occur when soft-tissue fillers are administered for volumization.11 Suwanchinda et al.9 demonstrated that in addition to volumizing, soft-tissue fillers can induce local and regional lifting. Using living patients and human donors, the authors theorized that the tissue lifting induced by temple subdermal filler injections was attributable to lateral face layered anatomy.
The lateral face is arranged in layers parallel to the skin surface. Conversely, in the medial midface, obliquely running muscles change planes, thereby connecting layers.3 The lateral face may potentially lift the jawline when the temple 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 investigate 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 colleagues,12 as its position could be fixed, ensuring accurate and precise pretreatment and posttreatment three-dimensional surface scanning imaging of surface volume and skin vector displacement measurements. Moreover, in each subject, a precise injection location and volume algorithm could be followed, which is difficult in living models, where injected product volume and location are customized to ensure optimal aesthetic outcomes.
MATERIALS AND METHODS
The presented cadaveric study sample was previously described by Freytag and colleagues.12 In brief, 20 cadaveric hemifaces were obtained from 10 Caucasian body donors (seven women and three men; mean age, 83.5 ± 6.8 years; mean body mass index, 25.3 ± 4.3 kg/m2). Facial operations, facial trauma, or any type of diseases influencing normal facial anatomy were regarded as exclusion criteria. The study conformed with institutional guidelines for cadaveric research studies.
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 injection procedures. A detailed description of the performed injection techniques was published previously and is termed the three-point full face fanning technique.12
Product (1.0 cc) was placed supraperiosteally with a 25-gauge, 38-mm, sharp-tip needle using a perpendicular approach. Injection location is shown in Figure 1.
Soft-tissue filler (0.5 cc) was placed supraperiosteally with a 21-gauge, 70-mm, blunt-tip cannula using a retrograde fanning technique accessing from the temporal dermal access point (Fig. 2).
Soft-tissue filler (0.5 cc) was placed subdermally with a 21-gauge, 70-mm, blunt-tip cannula using a retrograde fanning technique advancing from the lateral infraorbital area into the temple (Fig. 3).
Soft-tissue filler (0.5 cc) was placed supraperiosteally with a 21-gauge, 70-mm, blunt-tip cannula using a retrograde bolus technique advancing from the lateral infraorbital area into the palpebromalar groove (2 × 0.1 cc) and tear trough (3 × 0.1 cc) (Fig. 4).
Soft-tissue filler (0.5 cc) was placed supraperiosteally with a 25-gauge, 38-mm, sharp-tip needle using a perpendicular approach as shown in Figure 5.
Soft-tissue filler (0.5 cc) was placed subdermally with a 21-gauge, 70-mm, blunt-tip cannula using a retrograde single-line technique advancing from the midportion of the mandible posteriorly (Fig. 6).
Soft-tissue filler (0.5 cc) was placed subdermally with a 21-gauge, 70-mm, blunt-tip cannula using a retrograde fanning technique advancing from the midportion of the mandible anteriorly (Fig. 7).
Soft-tissue filler (0.5 cc) was placed supraperiosteally with a 25-gauge, 38-mm, sharp-tip needle using a perpendicular approach as shown in Figure 8.
Three-dimensional surface scanning was performed within 20 minutes after each injection step using the Vectra H1 system (Canfield Scientific, Fairfield, N.J.). The facial regions scanned included the forehead, temple, medial and lateral midface, perioral region (chin and labiomandibular sulcus), and jawline. Before each injection procedure, a baseline scan of each donor’s face was performed. A follow-up scan was performed after each injection step. Three separate (two-dimensional) standardized images were taken of each subject investigated (i.e., left, center, and right). The three two-dimensional images were automatically “stitched” into one three-dimensional full-face image. The generated three-dimensional images (baseline and consecutive follow-up images) were analyzed using Mirror Software Suite (Canfield Scientific). (See Figure, Supplemental Digital Content 1, which shows a graphic representation of the volumes measured by three-dimensional surface analysis per analyzed area. Blue represents a volume increase, and orange indicates a volume decrease, http://links.lww.com/PRS/E417.) Each follow-up scan was aligned automatically to its respective baseline scan to compute surface projection and skin displacement differences (vector skin displacement) (Figs. 9 through17) for each facial region investigated. Procedure outcomes were analyzed locally (i.e., results for each facial region injected individually) and regionally (i.e., across multiple facial regions injected).
Applying the Mirror Software Suite algorithm, local volume changes (difference between follow-up and baseline scans) per injected facial region were calculated (in cubic centimeters). Relative skin displacement (skin movement between baseline and each follow-up scan) (Figs. 9 through17) was likewise computed by the Mirror Software Suite automated algorithm. Displacement in x and y directions is given in millimeters and is comparable to x and y coordinates in a two-dimensional Cartesian coordinate system (Figs. 9, 12, and 15). The x coordinates represent displacement in the posterior (i.e., occipital) direction, whereas y coordinates represent displacement in the superior (i.e., cranial) direction; the latter can be understood as a lifting effect of the performed intervention.
The surface-volume coefficient for each investigated facial region was calculated by dividing the absolute scanned surface projection change (in cubic centimeters) by the injected volume amount (in cubic centimeters). This coefficient denotes the surface effect of a defined injected volume amount, which could represent the clinical effectiveness of the injected material. A coefficient of 1.0 could be interpreted as very efficient, whereas a coefficient of 0 could be regarded as ineffective (none of the injected material had a surface effect). The effects of the performed injections were quantified per facial region analyzing local volume changes, computation of the local surface-volume coefficients, and the calculation of local skin vector displacement.
To analyze the sequential lifting effects in the lateral face, we also conducted regional skin vector displacement analyses of sequential injections starting with the temple, followed by the lateral midface, and then the mandibular angle. Calculation of the magnitude of the y vector was used to objectify the resulting lifting effect. Descriptive analyses comparing volume changes and skin vector displacement were computed using IBM SPSS Version 25.0 (IBM Corp., Armonk, N.Y.).
Local Volume Change and Surface-Volume Coefficients
In the temple, 1.0 cc was injected supraperiosteally, yielding an average surface projection volume change of 0.45 ± 0.68 cc and a surface-volume coefficient of 0.45. In the forehead, 0.5 cc was injected, yielding a mean volume change of 0.67 ± 0.37 cc and a surface-volume coefficient of 1.34 (Table 1).
Table 1. -
Injected Volume, Measured Volume,*
Surface-Volume Coefficient, and Skin Displacement for the Investigated Facial Regions
||Injected Volume (cc)
||Measured Volume (cc)
x Axis (mm)
y Axis (mm)
||−0.340 ± 1.32
||0.567 ± 1.29
||−0.235 ± 1.76
||1.109 ± 1.86
||−0.165 ± 1.87
||0.808 ± 2.14
||0.044 ± 1.23
||−0.110 ± 1.05
||−0.238 ± 2.71
||0.292 ± 2.02
||−0.074 ± 1.58
||−0.743 ± 2.03
SVC, surface-volume coefficient.
*In cubic centimeters, applying three-dimensional surface-volume scanning.
In the lateral midface, 0.5 cc was injected. The resulting volume change was 0.02 ± 0.82 cc, generating a surface-volume coefficient of 0.03. In the medial midface, 1.0 cc was injected, yielding an average volume change of 0.56 ± 0.67 cc and a surface-volume coefficient of 0.56 (Table 1).
In the chin and in the labiomandibular sulcus, 1.0 cc was injected, causing a mean perioral volume change of 0.87 ± 1.1 cc and resulting in a surface-volume coefficient of 0.87. At the mandibular angle, 0.5 cc was injected, yielding a volume change of –0.38 ± 0.98 cc and a surface-volume coefficient of −0.76 (Table 1).
Local Vector Skin Displacement Analysis
The temple application of 1.0 cc resulted in an average lateral skin displacement of 0.34 ± 1.32 mm (x value) and an average cranial skin displacement of 0.57 ± 1.29 mm (y value) (Figs. 9 through11). The forehead application of 0.5 cc resulted in an average lateral skin displacement of 0.24 ± 1.76 mm (x value) and an average cranial skin displacement of 1.11 ± 1.86 mm (y value) (Table 1).
The application of 0.5 cc in the lateral midface resulted in an average lateral skin displacement of 0.17 ± 1.87 mm (x value) and an average cranial skin displacement of 0.81 ± 2.14 mm (y value) (Figs. 12 through14). The application of 1.0 cc in the medial midface resulted in an average lateral skin displacement of 0.04 ± 1.23 mm (x value) and an average caudal skin displacement of 0.11 ± 1.05 mm (y value) (Table 1).
The application of 0.5 cc at the mandibular angle resulted in an average lateral skin displacement of 0.24 ± 2.71 mm (x value) and an average cranial skin displacement of 0.29 ± 2.02 mm (y value) of the jawline (Figs. 15 through17). The perioral application of 1.0 cc resulted in an average medial skin displacement (toward the mandibular symphysis) of 0.07 ± 1.58 mm (x value) and an average caudal skin displacement of 0.74 ± 2.03 mm (y value).
Regional Skin Vector Displacement Analysis
The temple filler injections using the deep injection technique resulted in a cranial skin displacement of the temple of 0.57 mm (y value) (local effect), and in a regional lifting effect of the lateral midface of 0.55 mm (y value) and of the jawline of 0.03 mm (y value) (Figs. 9 and 10). Additional injections of soft-tissue filler into the lateral midface (temple and lateral midface injected) resulted in a cranial skin displacement of the lateral midface of 0.81 mm (y value), indicating a 47.3 percent increase in cranial skin displacement (from 0.55 mm to 0.81 mm; y value). The additional cranial skin displacement after the temple and lateral midface injections was 17 percent for the temple (from 0.57 mm to 0.67 mm; y value), and 100 percent for the jawline (from 0.03 mm to 0.06 mm; y value) (Figs. 12 and 13).
Additional injections into the mandibular angle (temple, lateral midface, and mandibular angle injected) resulted in a 0.29-mm (y value) cranial skin displacement of the jawline, representing an increase of 383.3 percent (from 0.06 mm to 0.29 mm; y value). The additional mandibular angle injection resulted in an additional 0.23 mm (y value) cranial skin displacement of the temple, indicating an increase of 34.3 percent (from 0.67 mm to 0.90 mm; y value). In the lateral midface, the skin displacement vectors were reduced by the mandibular angle injections by 42.0 percent (from 0.81 mm to 0.47 mm; y value) (Figs. 15 and 16 and Table 1).
This study sought to objectively quantify tissue lifting and volumizing effects of injectable hyaluronic acid–based fillers in a full-face cadaveric model. Applying three-dimensional surface volumetric and skin vector displacement analyses revealed that soft-tissue fillers can induce local volume effects and local and regional lifting effects, depending on the facial region injected. Injections in the medial face [i.e., forehead, medial midface, and perioral region (chin and labiomandibular sulcus)] increased the local surface volume by 0.67, 0.56, and 0.87 cc and created local (but not regional) lifting effects of 1.11, 0.11, and 0.74 mm, respectively, without co-influencing neighboring medial facial regions. Injections in the lateral face (temple, lateral midface, and jawline) 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.
The deep temporal injection lifted the lateral midface by 0.55 mm and the jawline by 0.03 mm. The additional lateral midface injection lifted the lateral midface by an additional 0.26 mm and the jawline by an additional 0.03 mm but also lifted the temple by an additional 0.10 mm. The mandibular angle injection lifted the jawline by an additional 0.23 mm and the temple by an additional 0.23 mm but reduced the lifting effect of the lateral midface by 0.34 mm. These results indicate that lateral face injections co-influence adjacent lateral facial regions and can thus induce regional lifting effects.
Study strengths included the standardization of the soft-tissue filler injections and that outcomes were objectively assessed using three-dimensional surface scanning, which identifies surface-volume changes and skin movement between two three-dimensional images.13,14 These measurements were based on a mathematical algorithm that is independent of observer subjectivity. Calculations yielded changes in surface volume (in cubic centimeters) and the skin displacement in a two-dimensional Cartesian coordinate system (x and y values). The y values represent the lifting effect induced by soft-tissue filler injection. Another study strength is the upright donor positioning to account for gravity. Supine positioning would result in laterally oriented gravitational effects, thereby reducing generalizability to real-life clinical scenarios. This study used a commercially available soft-tissue filler with rheologic properties identical to those used in living patients.
A limitation includes the use of cadavers instead of living patients. The cadaveric model was chosen to facilitate more accurate image analysis, as the subjects were secured in an upright, fixed position during image acquisition. In living individuals, facial expressions and posture changes influence skin position and skin light/shadow relationships, even when using a manual matching algorithm for image alignment. Every patient has different needs when addressing facial aging signs, so patient recruitment using a standardized protocol is challenging; a standardized treatment algorithm using the same volume amount for prescribed facial regions may yield aesthetically unappealing results. In a cadaveric model, one protocol can be used to obtain objective and standardized results. A drawback inherent in cadaveric studies is that cadavers lack blood pressure, muscle tone, and regular tissue pressure and have a different temperature than living individuals. Furthermore, cadaveric subjects were older (83.5 ± 6.8 years) than most aesthetic patients.
The investigation results are consistent with previous facial anatomy reports.15–19 The concept of “line of ligaments” was introduced, where the facial ligaments (true osteocutaneous connections) are located in an imaginary line from the temple (temporal ligamentous adhesion),20 to the orbit (lateral orbital thickening),21 the zygomatic arch (zygomatic ligament, or McGregor patch),22 and the mandible (mandibular ligament).8 This line of ligaments is posterior to the lateral orbital rim and separates the face into medial and lateral regions. Whereas deep fat compartments in the medial facial regions can be identified,6 the lateral facial regions are arranged in layers parallel to the skin surface.19 These parallel fascial layers are connected with each other by means of those aforementioned ligaments and by means of a variable amount of short subdermal fibrous septae. These are especially located along the zygomatic arch and in the parotid region and form compartment boundaries of the superficial facial fat compartments.3 The biomechanical basis for the observed lifting effects is the interaction between dermis, subdermal fatty layer, short subdermal fibrous septae, and the superficial fascia.23–25 Together, this unit is termed the superficial fascial system26 and has been shown to play an important role during surgical and nonsurgical procedures.23–29 The biomechanics of the superficial fascial system can be influenced by volume deposition into the subdermal fatty layer, thus changing the tension within that functional unit.30 This change in tension results in a repositioning of the facial soft tissue and can be summarized as a lifting effect, which was quantified in the present study.
Using a cohort of living patients and human donors, Suwanchinda et al.9 demonstrated that temple subdermal soft-tissue filler injections treat temporal volume loss and reduce middle and lower face signs of age-related changes by using the temporal biomechanical properties of the subdermal fatty layer and the fascial layered arrangement. The present investigation confirms those findings and broadens the applicability to the total lateral face, as the results reveal that soft-tissue filler can be used to achieve local and regional lifting effects.
Despite injections administered at the mandibular angle, a negative jawline coefficient resulted because of aggregate lifting effects of injections into the temple, lateral midface, and mandibular angle, which reduced local volume and thus surface projection. This soft-tissue behavior can be used clinically to change the facial shape, as upper face lifting induces middle and lower face volume reduction.
The sequential lateral face injections revealed that the deep temporal injection has a limited lower face-lifting capacity but a good temporal and lateral midface-lifting capacity. An additional filler application into the temple subdermal plane using a subdermal fanning technique cranial to the zygomatic arch with an access point in the infraorbital region (temple and lateral midface injected) increased the temple-lifting effect by 17.5 percent and the jawline-lifting effect by 100 percent.
Injections at the mandibular angle resulted in jawline lifting (383.3 percent) and increased temple lifting (34.3 percent). This observation (lower face injections can result in upper face-lifting effects) can be explained by reduced lateral face downward pull, caused by positioning of soft-tissue filler subdermally. This reduction resulted in an increased overall temporal lifting effect. Because of mandibular angle product positioning, the lateral midface skin was compressed because of the jawline-lifting effect and the resulting skin vectors were reduced compared to skin position before mandibular angle injection (−42.0 percent; from 0.81 mm to 0.47 mm).
Because of the characteristics of the lateral facial anatomy and the biomechanical properties of the superficial fascial system, injections lateral to the line of ligaments can be used clinically. Subdermal soft-tissue filler placement in the temple and in the lateral midface can achieve volume reduction in the lower face. Because of the resulting lifting effect, the lower face soft tissues are repositioned more cranially, which results in a volume reduction in the lower face. This can be used to change the facial shape from square to oval or heart-shaped and to treat patients with sufficient volume in the lower face.
The methods applied in the present study can be of great potential for future investigations. Current practices for assessing soft-tissue filler efficacy include blinded investigators using validated scales, two-dimensional photographs, and/or live subjects. Future research directions include objective tissue displacement measurements following filler injections as presented in this study, thus eliminating the subjectivity inherent in even the most expert observer assessment.
Although aesthetic injectable fillers are traditionally classified as fillers or volumizers, this cadaveric study provides evidence that these products can be used to induce face-lifting effects. In the medial midface, soft-tissue fillers have a greater potential to volumize and locally lift. In the lateral face, the fascial layers are contiguous; thus, co-influencing the temple, lateral midface, and jawline is possible. 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.
This study received funding by Sinclair Pharmaceuticals Ltd., London, United Kingdom (grant no. 12112018).
1. Gierloff M, Stöhring C, Buder T, Gassling V, Açil Y, Wiltfang J. Aging changes of the midfacial fat compartments: A computed tomographic study. Plast Reconstr Surg. 2012;129:263–273.
2. Cotofana S, Fratila AA, Schenck TL, Redka-Swoboda W, Zilinsky I, Pavicic T. The anatomy of the aging face: A review. Facial Plast Surg. 2016;32:253–260.
3. 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;141:1351–1359.
4. Schenck TL, Koban KC, Schlattau A, et al. Updated anatomy of the buccal space and its implications for plastic, reconstructive and aesthetic procedures. J Plast Reconstr Aesthet Surg. 2018;71:162–170.
5. Cotofana S, Mian A, Sykes JM, et al. An update on the anatomy of the forehead compartments. Plast Reconstr Surg. 2017;139:864e–872e.
6. Cotofana S, Gotkin RH, Frank K, et al. The functional anatomy of the deep facial fat compartments: A detailed imaging-based investigation. Plast Reconstr Surg. 2019;143:53–63.
7. American Society of Plastic Surgeons. 2017 plastic surgery statistics report. Available at: https://www.plasticsurgery.org/documents/News/Statistics/2017/plastic-surgery-statistics-full-report-2017.pdf
. Accessed March 1, 2019.
8. Suwanchinda A, Rudolph C, Hladik C, et al. The layered anatomy of the jawline. J Cosmet Dermatol. 2018;17:625–631.
9. Suwanchinda A, Webb KL, Rudolph C, et al. The posterior temporal supraSMAS minimally invasive lifting technique using soft-tissue fillers. J Cosmet Dermatol. 2018;17:617–624.
10. Pilsl U, Rosmarin W, Anderhuber F. The premaxillary space: A location for filler injection? Dermatol Surg. 2014;40:301–304.
11. Cotofana S, Koban CK, Frank K, et al. The surface-volume-coefficient of the superficial and deep facial fat compartments: A cadaveric 3D volumetric analysis. Plast Reconstr Surg. 2019;143:1605–1613.
12. Freytag DL, Frank K, Haidar R, et al. Facial safe zones for soft tissue filler injections: A practical guide. J Drugs Dermatol. 2019;18:896–902.
13. Koban K, Schenck T, Metz P, et al. En route for objective evaluation of form, volume, and symmetry in plastic surgery using 3-D intraoperative scans (in German). Handchir Mikrochir Plast Chir. 2016;48:78–84.
14. Koban KC, Cotofana S, Frank K, et al. Precision in 3-dimensional surface imaging of the face: A handheld scanner comparison performed in a cadaveric model. Aesthet Surg J. 2019;39:NP36–NP44.
15. Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg. 1989;83:11–16.
16. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: Relevance to rhytidectomy and aging. Plast Reconstr Surg. 1992;89:441–449; discussion 450–451.
17. Mendelson BC, Wong CH. Surgical anatomy of the middle premasseter space and its application in sub-SMAS face lift surgery. Plast Reconstr Surg. 2013;132:57–64.
18. Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg. 1989;83:11–16.
19. Cotofana S, Lachman N. Anatomy of the facial fat compartments and their relevance in aesthetic surgery. J Dtsch Dermatol Ges. 2019;17:399–413.
20. Alghoul M, Codner MA. Retaining ligaments of the face: Review of anatomy and clinical applications. Aesthet Surg J. 2013;33:769–782.
21. Muzaffar AR, Mendelson BC, Adams WP Jr. Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus. Plast Reconstr Surg. 2002;110:873–884; discussion 897–901.
22. Seo YS, Song JK, Oh TS, Kwon SI, Tansatit T, Lee JH. Review of the nomenclature of the retaining ligaments of the cheek: Frequently confused terminology. Arch Plast Surg. 2017;44:266–275.
23. Lockwood TE. Fascial anchoring technique in medial thigh lifts. Plast Reconstr Surg. 1988;82:299–304.
24. Lockwood T. Brachioplasty with superficial fascial system suspension. Plast Reconstr Surg. 1995;96:912–920.
25. Lockwood T. High-lateral-tension abdominoplasty with superficial fascial system suspension. Plast Reconstr Surg. 1995;96:603–615.
26. Lockwood TE. Superficial fascial system (SFS) of the trunk and extremities: A new concept. Plast Reconstr Surg. 1991;87:1009–1018.
27. Frank K, Hamade H, Casabona G, et al. Influences of age, gender, and body mass index on the thickness of the abdominal fatty layers and its relevance for abdominal liposuction and abdominoplasty. Aesthet Surg J. 2019;39:1085–1093.
28. Frank K, Casabona G, Gotkin RH, et al. Influence of age, gender and body mass index on the thickness of the gluteal subcutaneous fat: Implications for safe buttock augmentation procedures. Plast Reconstr Surg. 2019;144:83–92.
29. Casabona G, Frank K, Koban KC, et al. Influence of age, sex, and body mass index on the depth of the superficial fascia in the face and neck. Dermatol Surg. 2019;45:1365–1373.
30. Song AY, Askari M, Azemi E, et al. Biomechanical properties of the superficial fascial system. Aesthet Surg J. 2006;26:395–403.