Practical application of the facial fat compartments and the line of ligaments concept in achieving the lifting effect in the lower face region in female patients.

Abstract

Dear Editors, The rhytidectomy has always been the gold standard in treating facial sagging and loss of facial contour, however recent years brought better understanding of the facial anatomy and facial aging processes, especially those affecting fat pads and ligaments. Understanding the fact that face is not a static structure but a 3D dynamic one allows for applying new injection techniques to achieve natural results. The concept of subcutaneous facial fat compartments1 suggests that the face does not age as a composite mass. The shearing forces between neighboring compartments may be the reason behind soft tissues malposition. This knowledge, together with the concept of the line of ligaments (Fig. 1A) and the preconditioning effect of the lateral injection2,3 allows to gain an aesthetic lifting effect in the lower face area. The technique reported here is based on the filling of the superficial lateral temporal cheek fat compartment (Fig. 1B). Specific targeting of this region with the moderate amount of hyaluronic acid (HA) can lift the position of soft tissues of the lower face and accentuate the jawline contour. Novelty of this technique is based on the fact that this region of the face is usually not a target area for the injection procedures using HA fillers. In recent years, however, there was a number of publications on non-surgical temporal lifting techniques proving their efficacy in the correction of facial shape.2–5 In author’s personal experience, combining temporal lifting with the presented here technique of the lateral non-surgical lifting is more beneficial toward improving facial contours. To assess the aesthetic improvement of the treated area, the Global Aesthetic Improvement Scale (GAIS) was used. The GAIS is a scale where 0 = worse, 1 = no change, 2 = improved, 3 = much improved, and 4 = very much improved. The patient was also asked to report her level of personal satisfaction with the treatment (very satisfied, satisfied, not satisfied) and whether she would recommend the treatment to her friends (yes or no). The patient presented here is a 56-year-old woman. She had no previous soft tissue filler treatments of the face, reported absence of previous thread treatment, and had no previous face or neck surgery. Medical history revealed an absence of allergies, contraindications, or chronic diseases that would exclude the application of soft tissue fillers in the face (Fig. 2). After topical skin disinfection (Skinsept Pur; Ecolab Deutschland GmbH, Düsseldorf, Germany), it was punctured 1.5 cm to the Porion with a 23 G needle and a 25 G 50 mm blunt cannula (TSK, Japan) was inserted in the downward direction. The entire length of the cannula was advanced in the superficial subdermal plane until reaching the mandibula angle. Using the fanning technique, a total volume of 0.7 mL of the product (TEOSYAL RHA 4; Teoxane, Geneva, Switzerland) was injected in a triangular shape starting from the mandibular angle all the way to the anterior border of the superficial lateral temporal cheek fat compartment. The cannula was then withdrawn to the point where direction change was possible and it was redirected