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Stained gelatin
Deep fat on the chin Superficial fat Stained gelatin Deep fat on the chin
3.5 Identication ofSubSMAS Spaces oftheFace forFiller Injection: Cadaver Studies Using Stained Gelatin
87
obliquely appears at the boundary between the
cheek and lips. As you get older, you can see that
the commissural line gets worse and the mouth
corner gets drooping when the lateral lower lip
fat compartment gets depressed among the fat
compartments (two lateral and one central supercial fat compartments) under the lower lips.
This line, which is the supercial anatomical
boundary between the cheek and jaw, has become
dominant as the difference in thickness of the tissue forming the layer becomes clear, which is
called melolabial fold.
In this case, lling the area under the relatively
depressed wrinkle line can alleviate the boundary
difference, and the space including the deep fat
under the depressor auguli oris muscle should be
lled (Fig.3.32).
3.5.11 Premental Space
When using a ller injection for chin augmentation, ller placement just above the bone at the
tip of the chin would require large amounts of
ller. Therefore, for volumization using smaller
amounts of ller, ller should be injected into the
premental space. The premental space, which
includes the deep fat layer, is between the mentalis muscle and bone. The presence of gelatin in
the premental space between the mentalis muscle
and the mentum was conrmed (Fig.3.33).
Depressor anguli oris muscle
Fig. 3.32 Gelatin in subdepressor anguli oris space
Fig. 3.33 Gelatin in premental space
88
3 Anatomical Considerations forFiller Procedures
3.6 SSRT (Skin andSMAS Layer
Remodeling Technique)
forVolumization andLifting
Eect oftheFace
The recent trend in minimally invasive procedures has shifted from interventions to address
wrinkles or appearance of the face when it is in
the expressionless, static state. There is greater
emphasis on practical treatments that consider
dynamic nature of the facial soft tissues and
wrinkle formations when making diverse facial
expressions involving movement of soft tissue
and wrinkle formation when smiling or making
facial expressions.
Patients seek total facial harmony and balance, including bilateral symmetry from deep to
supercial facial layers. Therefore, the goal of
ller procedures goes beyond simple volumization in the static, expressionless state. Creating a
face that looks natural with facial movement has
become a priority. Evaluating facial proportions
and harmony in terms of the positions of the skeletal landmarks and age-related changes of the
skull is important. However, it is more important
to understand anatomical positions, composition,
and age-related changes of the soft tissues covering the facial bones. In addition, accurate facial
analysis and objective and up-to-date standards
of beauty should be used to identify the individuality of each patient.
To go beyond regional volumization or treating just the sunken wrinkles to create a threedimensional, aesthetically pleasing face with a
good impression, several conditions must be met.
HA llers, which are currently the most
widely used material, can be divided into biphasic llers with good lifting capacity and monophasic llers with good cohesive properties.
Biphasic llers consist of particles but monophasic llers are often considered to be a uniform gel
with no particles. However, when viewed under a
microscope, all llers consist of gel particles, and
monophasic llers simply feel soft as though
there are no particles. Therefore, categorizing
llers according to the presence or absence of
particles is not appropriate. The author classies
llers based on their consistencies as either soft
or rm llers.
Fillers with different viscoelastic properties
when used in the right combination can not only
volumize the face but can also create a natural
v-shaped face with a smiling effect by lifting the
skin. Fillers are selected based on the site of
injection, target layer, and treatment goals.
Combination treatments with botulinum toxin
will product synergistic effects and the author
refers to this ller technique as the “oval face”
technique.
To create an oval face, it is necessary to understand the changes that occur in soft tissues when
smiling. When smiling or making facial expressions, the volume in the lower face is reduced and
is pushed upward to give the natural appearance
of a slim face. The soft tissue in the anterior malar
area moves anterosuperiorly, and the soft tissues
in the paranasal and perioral area move laterosuperiorly. By creating changes in the soft tissues in
this pattern, a natural egg-shaped face with a
smiling impression and elegant image can be created (Fig.3.34).
For successful outcomes, the right combination of llers with specic rheological properties
must be used for different parts of the face to
account for the difference in soft tissue density.
Generally, the density in the plane below the
SMAS layer increases after injection of a rm
ller resulting in tissue expansion causing the
upward push of the SMAS layer. In response to
the tension, there is homeostatic function of the
surrounding connective tissue resulting in subsequent stretching of the skin and lifting/tightening
effect.
In addition, if the skin surface is uneven or
wrinkled, injecting soft consistent llers directly
under the skin will make the skin surface smooth
and improve wrinkles. This is possible because
the vertically oriented brous septa in the supercial fat layer between the skin and the SMAS
layer extend toward the skin and become retinacular cutis holding the skin rmly. The soft consistent ller injected between the retinacular cutis
under this skin will help stretch and harden the
skin.
or dermal layer to make smooth &flexiblestretchingsurface
3.6 SSRT (Skin andSMAS Layer Remodeling Technique) forVolumization andLifting Eect oftheFace
Fig. 3.34 Oval and
smiling face
89
Firmconsistent filler
-injectedunder theSMASorintodeepsubcutaneouslayer of lubricant fibro-adipose
tissue to make volume or compensation for depressed regions
Soft consistent filler
-injectedintosubdermal layerofsuperficial solid fibro-adiposetissue
Fig. 3.35 Dual plane injection of rm and soft consistent llers to make smooth and exible stretching surface with
volumization
The author calls this technique of targeting the
skin and SMAS layer as the SSRT (skin and
SMAS layer remodeling technique) (Fig.3.35).
Looking around the mouth, tightening of the
SMAS with ller placement and subsequent lifting effect in the adjacent region occurs in the following patterns: injection into the anterior malar
area with lifting effect in nasolabial area, into
nasolabial area with effect in the upper lip area,
into anterior cheek area with effect in the lower
lip area, into the prejowl area with effect in the
mentum, and into side cheek area with effect in
the jawline (Fig.3.36).
The reason such a phenomenon occurs is that
the entire face is covered by a SMAS layer that
has variable thickness. The anatomical structures
connected to each other and connected like a
single layer are called SMAS layers, and the
structures corresponding to the SMAS layer are
summarized as Fig.3.37 and the skin is affected
by changes in the SMAS layer as it is attached to
this layer.
As demonstrated in the cadaveric study using
gelatin, the SMAS separates the soft tissue of the
face into supercial and deep broadipose connective tissues, each with distinct characteristics
90
Orbicularis oris muscleDepressor anguli oris muscle
ascia
Galea
Frontalis muscleProcerus muscle
Fig. 3.36 Change of mid and lower face by SSRT
3 Anatomical Considerations forFiller Procedures
Nasalis
muscle
Superficial fat layer above SMAS layer
Fig. 3.37 Continuity of SMAS layer from forehead to neck—the muscles and fascia that make up SMAS layer
and shapes. Appropriate distribution of llers
with different viscoelastic properties into the two
layers will result in adequate volumization with
smiling and lifting effect (Fig.3.38).
To achieve volumizing effect with smiling and
lifting effect, it is important to understand the
broadipose layers of the face. The SMAS layer
separates the supercial fat layer from the deep
SMAS layer
fat layer. As these fat layers seemed to be connected to the naked eye, they were thought to be
a single, broad layer. However, since the 2000s, it
was recognized that the fat layer is actually composed of several compartments by facial region
(Fig.3.39).
The fat layer that is comprised of numerous
compartments differ by facial region. In the mid-
Superficial temporal f
Orbicularis oculi muscle
SMAS
3.6 SSRT (Skin andSMAS Layer Remodeling Technique) forVolumization andLifting Eect oftheFace
Fig. 3.38 Choice of
HA ller based on the
consistency and particle
size according to facial
region
91
Fig. 3.39 Compartments of supercial fat layer
face, the supercial and deep fat compartments
are distinct and distinguishable, while in the
upper and lower face, there are differences in the
thicknesses and distribution of the two fat layers.
Thus, it is necessary to perform ller injections
considering such differences in the fat layers in
the different parts of the face.
Moreover, it is important to consider the location and role of retaining ligaments that support
and maintain the shape of soft tissues to ensure
effective treatment of sunken areas and volume
restoration in the face. Major retaining ligaments
in the face were previously categorized as the
true or false depending on where they originated.
True retaining ligaments originate from the bone
while false retaining ligaments originate from
soft tissue. This type of categorization is outdated, and currently, the morphological characteristics and tissue components of retaining
ligaments are considered to differentiate true
92
and malar eminence
3 Anatomical Considerations forFiller Procedures
retaining ligaments from tough brous structures
such as septae, adhesions, or septum.
Retaining ligaments do not provide support to
just the skin right above them. As seen in cadaveric studies, rm and tough brous tissues
extending to the face can be seen around the
retaining ligaments. These brous structures
connect the skin tissue to the deeper tissues. Just
as atrophy occurs in the fat layer deep to the
SMAS layer, the reduction of fat depots near ligamentous tissues weakens the support that holds
the retaining ligaments causing them to sag.
Typically, sagging of the skin and soft tissues
associated with aging is explained by the uniform
weakening of the facial retaining ligaments
across the face. The author however, believes that
the degree of sagging varies by the type and location of the retaining ligaments. The zygomatic
and mandibular ligaments, which are the strongest facial retaining ligaments, do not weaken to
a great extent and are better able to hold and
retain tissue over time. However, the weaker
retaining ligaments and ligamentous brous tissues in the adjacent region are more susceptible
to drooping with age. The skin and tissue supported by these weaker structures thus would sag
more. Thus, the hollows and grooves formed due
to strong retaining ligaments become more pronounced with age (Fig.3.40).
Zygomatic ligaments on zygomatic arch
Fig. 3.40 Zygomatic ligaments on temporal and zygo-
matic region
Consequently, when establishing a treatment
plan, strength of retaining ligaments and consequent clinical manifestation must be taken into
account. In areas with a severe groove or hollow
due to surface tissue being pinched in by strong
retaining ligaments, it is difcult to project the
SMAS layer by merely injecting ller into sunken
area. In case of strong retaining ligaments, a lifting effect by tightening of the SMAS layer can be
achieved after rst obtaining space by tunneling
to release the areas held by these strong ligamentous tissues, followed by injecting a ller that is
strong enough to lift and tighten the SMAS layer.
This will ensure projection of the sunken area.
However, if the retaining ligaments are not
retracting the skin and the soft tissues are actually
maintained by these ligamentous structures, then
tunneling with a cannula and placing a strong
ller is unnecessary. In fact, such ligamentous
structures recede into the deep fat layer with age
and their strength in supporting the adjacent tissue decreases. Further weakening by aggressive
tunneling is actually contraindicated. In areas
where slight resistance is felt when inserting the
cannula, space just enough for smooth administration of the ller is needed. Tunneling may not
be needed, and in these cases, procedures may be
performed with a needle (Fig.3.41).
The SMAS is a composition of the broadipose layer and separates this layer into the supercial and deep layers. It is also the structure that
relays the movement of the deep facial muscles to
the skin to where it attaches to allow formation of
facial expressions. Therefore, for total facial contouring and creation of an oval face with a smiling and lifting effect, a procedure that effectively
tightens the SMAS layer is needed. In addition, it
is important to understand the role of retaining
ligaments. As structures that connect the skin to
the deeper tissues, they provide support to the
soft tissues to prevent facial skin and soft tissues
from sagging. Depending on the part of the face
and strength of the retaining ligaments, tunneling
for partial release of retaining ligaments and rm
brous tissue layer may be required to ensure
effective ller placement into the desired areas
and depths. Conversely, for areas in which sagging is due to weakened ligamentous tissues,
Further Reading
Fig. 3.41 Partial
tunneling or supporting
according to the
tightness of ligaments
93
ligamentous tissues should be lifted and reinforced by increasing tissue density using ller
injections into nearby ligamentous tissues.
Aggressive tunneling, which may actually
weaken the tissues, should be avoided.
Cytologically, injection of an HA ller comprised of small particles into the dermal layer
improves skin elasticity and enhances skin suppleness by inducing the following effects:
increases volume of the skin, moisturizes the skin
through hydration, facilitates collagen production by increasing the number of brocytes, and
provides antioxidant activity for removal of reactive oxygen species. However, there are claims
that stimulation of soft tissue by ller injection
causes immediate cell contraction due to changes
in the cytoskeleton of broblasts, tissue remodeling from adapting to such changes, as well as
activation and proliferation of broblasts.
Moreover, there are theories that the soft tissue
HA volume llers do not induce skin neocollagenesis but instead modies subcutaneous white
adipose tissue (sWAT). Changes in sWAT promote activation and proliferation of adiposederived stem cells (ADSCs) and expansion of
mature adipocytes. In the long run, these changes
lead to volumization and tissue tightening by
hyperplasia and hypertrophy of ADSCs and
mature adipocytes. However, more in-depth studies are needed regarding these mechanisms.
Further Reading
1. Cong L-Y, Phothong W, Lee SH, Wanitphakdeedecha
R, Koh I, Tansatit T, Kim HJ.Topographic analysis of
the supratrochlear artery and the supraorbital artery.
Plast Reconstr Surg. 2017;139(3):620e–7e.
2. Lee JG, Yang HM, Choi YJ, Favero V, Kim YS, Hu
KS, Kim HJ. Facial arterial depth and relationship
with the facial musculature layer. Plast Reconstr Surg.
2015;135(2):437–44.
3. Hwang K, Lee GI, Park HJ.Branches of the facial
artery. J Craniofac Surg. 2015;26(4):1399–402.
4. Sykes JM, Trevidic P, Suárez GA, Criollo- Lamilla
G. Newer understanding of specic anatomic targets in the aging face as applied to injectables. Plast
Reconstr Surg. 2015;136:56S–61S.
5. Lefkowitz T, Hazani R, Chowdhry S, Elston J,
Yaremchuk MJ, Wilhelmi BJ.Anatomical landmarks
to avoid injury to the great auricular nerve during
rhytidectomy. Aesthet Surg J. 2013;33(1):19–23.
6. Dorafshar AH, Borsuk DE, Bojovic B, Brown EN,
Manktelow RT, Zuker RM, etal. Surface anatomy of
the middle division of the facial nerve. Plast Reconstr
Surg. 2013;131(2):253–7.
7. Trussler AP, Stephan P, Hatef D, Schaverien M,
Meade R, Barton FE.The frontal branch of the facial
nerve across the Zygomatic Arch: anatomical relevance of the high-SMAS technique. Plast Reconstr
Surg. 2010;125(4):1221–9.
8. CosmeticSurgical anatomy of the ligamentous
attachments in the temple and periorbital regions.
2000;1–16.
9. Sullivan PK, Hoy EA, Mehan V, Singer DP.An anatomical evaluation and surgical approach to the perioral mound in facial rejuvenation. Plast Reconstr
Surg. 2010;126(4):1333–40.
94
3 Anatomical Considerations forFiller Procedures
10. Surek CK, Vargo J, Lamb J. Deep pyriform space.
Plast Reconstr Surg. 2016;138(1):59–64.
11. Wan D, Amirlak B, Rohrich R, Davis K.The clinical importance of the fat compartments in midfacial
aging. Plast Reconstr Surg. 2013;1(9):e92–8.
12. Rohrich RJ, Pessa JE.The anatomy and clinical implications of perioral submuscular fat. Plast Reconstr
Surg. 2009;124(1):266–71.
13. Rohrich RJ, Pessa JE.The fat compartments of the
face: anatomy and clinical implications for cosmetic
surgery. Plast Reconstr Surg. 2007;119(7):2219–27.
14. Gierloff M, Stöhring C, Buder T, Wiltfang J. The
subcutaneous fat compartments in relation to aesthetically important facial folds and rhytides. Br J Plast
Surg. 2012;65(10):1292–7.
15. Rohrich RJ, Pessa JE.The retaining system of the
face: histologic evaluation of the septal boundaries
of the subcutaneous fat compartments. Plast Reconstr
Surg. 2008;121(5):1804–9.
16. Nakajima, etal. Anatomical study of subcutaneous
adipofascial tissue: a concept of the protective adipofascial system(PAFS) and lubricant adipofascial
system(LAFS). Scand J Plast Reconstr Surg Hand
Surg. 2004;38(3):261–6.
17. Castro CC, Boehm KA, Codner MA.Midface surgery. Elsevier Saunders; 2009.
18. Mendelson BC, etal. Age-related changes of the orbit
and midcheek and the implications for facial rejuvenation. Aesth Plast Surg. 2007;31:419–23.
19. Kim YS, etal. The anatomical origin and course of
the angular artery regarding its clinical implications.
Dermatologic Surg. 2014;40:1070–6.
20. Yang HM, et al. New anatomical insights on the
course and branching patterns of the facial artery:
clinical implications of injectable treatments to the
nasolabial fold and nasojugal groove. Plast Reconstr
Surg. 2014;133:107782.
21. Koh KS, et al. Branching patterns and symmetry of
the course of the facial artery in Koreans. Int J Oral
Maxillofac Surg. 2003;32:414–8.
22. Wong CH, etal. Facial soft-tissue spaces and retaining ligaments of the Midcheek: dening the premaxillary space. Plast Reconstr Surg. 2013;132:49–56.
23. Mendelson BC, etal. Surgical anatomy of the middle
premasseter space and its application in sub-SMAS
face lift surgery. Plast Reconstr Surg. 2013;132:57–64.
24. Gierloff M, etal. Aging changes of the midfacial fat
compartments: a computed tomographic study. Plast
Reconstr Surg. 2012;129:263–73.
25. Chang H.Arterial anatomy of subdermal plexus of the
face. Keio J Med. 2001;50(1):31–4.
26. Lee JG, etal. Facial arterial depth and relationship
with the facial musculature layer. Plast Reconstr Surg.
2015;135:437.
27. Brandt MG, etal. Biomechanical properties of the
facial retaining ligaments. Arch Facial Plast Surg.
2012;14(4):289.
28. Scheuer JF, etal. Anatomy of the facial danger zones:
maximizing safety during soft-tissue ller injections.
Plast Reconstr Surg. 2017;139:50e.
29. Ghassemi A, etal. Anatomy of the SMAS revisited.
Aesth Plast Surg. 2003;27:258–64.
30. Furnas DW, et al. The retaining ligaments of the
cheek. Plast Reconstr Surg. 1989;83:11–6.
31. Haddock NT, et al. The tear trough and lid/cheek
junction: anatomy and implications for surgical correction. Plast Reconstr Surg. 2009;123:1332–40. discussion 1341.
32. Sundine, etal. Analysis of the effects of subcutaneous musculoaponeurotic system facial support on the
nasolabial crease. Can J Plast Surg. 2010;18(1):11–4.
33. Lee HJ, etal. Description of a novel anatomic venous
structure in the nasoglabellar area. J Craniofac Surg.
2014;25:633–5.
34. Marur T, et al. Facial anatomy. Clin Dermatol.
2014;32:14–23.
35. Loukas M, etal. Gross anatomical, CT and MRI analysis of the buccal fat pad with special emphasis on
volumetric variations. Surg Radiol Anat. 2006;28:254.
36. El-Garem YF.Estimation of bony orbit depth for optimal selection of the injection technique to correct the
tear trough and palpebromalar groove. Dermatologic
Surg. 2015;41:94–101.
37. Mendelson BC, etal. Changes in the facial skeleton
with aging: implications and clinical applications in
facial rejuvenation. Aesth Plast Surg. 2012;36:753–60.
38. Liew S.Ethnic and gender considerations in the use of
facial injectables: Asian patients. Plast Reconstr Surg.
2015;136(5):22S–7S.
39. Cotofana S, etal. The anatomy of the aging face: a
review. Facial Plast Surg. 2016;32:253–60.
40. Bartlett SP, etal. Age-related changes of the craniofacial skeleton: an anthropometric and histologic analysis. Plast Reconstr Surg. 1992;90:592–600.
41. Dumont T, etal. Anatomy and imaging of the deep fat
of the face. Clin Anat. 2000;13:373–82.
42. Coleman SR, etal. The anatomy of the aging face:
volume loss and changes in 3-dimensional topography. Aesthet Surg J. 2006;26 Suppl:4S–9S.
43. Raskin E, etal. Why do we age in our cheeks? Aesthet
Surg J. 2007;27:19–28.
44. Donofrio LM.Fat distribution: a morphologic study of
the aging face. Dermatologic Surg. 2000;26:1107–12.
45. Wan D, etal. The clinical importance of the fat compartments in midfacial aging. Plast Reconstr Surg
Glob Open. 2104;1:e92.
46. Pessa JE, etal. Double or bid zygomaticus major
muscle: anatomy, incidence, and clinical correlation.
Clin Anat. 1998;11:310–3.
47. Macchi V, etal. Histotopographic study of the broadipose connective cheek system. Cells Tissues
Organs. 2010;191(1):47–56.
48. Pessa JE, etal. Relative maxillary retrusion as a natural consequence of aging: combining skeletal and
soft-tissue changes into an integrated model of midfacial aging. Plast Reconstr Surg. 1998;102(1):205–12.
49. Wulc AE, et al. The anatomic basis of midfacial
aging. In: Hartstein ME, etal., editors. Midfacial rejuvenation, vol. 2. Springer Science+Business Media,
LLC; 2012. p.15–28.
Further Reading
95
50. Richard MJ, etal. Analysis of the anatomic changes
of the aging facial skeleton using computer-assisted
tomography. Ophthalmic Plast Reconstr Surg.
2009;25(5):382–6.
51. Khan DM, etal. Aging of the bony orbit: a threedimensional computed tomography study. Aesthet
Surg J. 2008;28:258–64.
52. Spiegel JH, etal. The anatomic relationship between
the orbicularis oculi muscle and the levator labii
superioris and zygomaticus muscles complexes. Plast
Reconstr Surg. 2005;116:1937–42.
53. Morris DE, etal. Aesthetic facial skeletal contouring
in the Asian patients. Clin Plast Surg. 2007;34:547–56.
54. Gu Y, etal. Comparison of craniofacial characteristics
of typical Chinese and Caucasian young adults. Eur J
Orthod. 2011;33:205–11.
55. Arlette JP, etal. Anatomic location of hyaluronic acid
ller material injected into nasolabial fold: a histologic study. Dermatologic Surg. 2008;34:56S–63S.
56. Niamtu J 3rd. Filler injection with microcannula instead of needles. Dermatologic Surg.
2009;35(12):2005–8.
57. Rohrich RJ, Pessa JE.The fat compartments of the
face: anatomy and clinical implications for cosmetic
surgery. Plast Reconstr Surg. 2007;119:2219–27. discussion 2228–31.
58. Wu W, et al. Novel administration technique for
large-particle stabilized hyaluronic acid-based gel of
nonanimal origin in facial tissue augmentation. Aesth
Plast Surg. 2010;34:88–95.
59. Guyuron B, etal. Factors contributing to the facial
aging of identical twins. Plast Reconstr Surg.
2009;123:1321–31.
60. Langevin HM, et al. Subcutaneous tissue broblast
cytoskeletal remodeling induced by acupuncture: evidence for a mechanotransduction-based mechanism. J
Cell Physiol. 2006;207:767–74.
61. Thaller SR, etal. The submuscular aponeurotic system (SMAS): a histologic and comparative anatomy
evaluation. Plast Reconstr Surg. 1990;86:690–6.
62. Sundaram H, et al. Biophysical characteristics of
hyaluronic acid soft-tissue llers and their rele-
vance to aesthetic applications. Plast Reconstr Surg.
2013;132:5S–21S.
63. Berros P, etal. Hyalurostructure treatment: superior
clinical outcome through a new protocol-a 4-year
comparative study of two methods for tear trough
treatment. Plast Reconstr Surg. 2013;132:924e–31e.
64. Lee SK, etal. Recent trend in the choice of llers
and injection techniques in Asia: a questionnaire
study based on expert opinion. J Drugs Dermatol.
2014;13(1):611.
65. Kim HJ, etal. Clinical anatomy of the face for ller
and botulinum toxin injection. Springer; 2016.
66. Shaw RB, etal. Aging of the facial skeleton: aesthetic implications and rejuvenation strategies. Plast
Reconstr Surg. 2011;127:374–83.
67. Shaw RB, etal. Aging of the midface bony elements:
a three-dimensional computed tomographic study.
Plast Reconstr Surg. 2007;119(2):675–81.
68. Edsman KL, etal. Is there a method that can measure
cohesivity? Cohesion by sensory evaluation compared with other test methods. Dermatologic Surg.
2015;41:S365–72.
69. Rohrich RJ, etal. The retaining system of the face:
histologic evaluation of the septal boundaries of the
subcutaneous fat compartments. Plast Reconstr Surg.
2008;121:1804–9.
70. Kruglikov IL, etal. Soft tissue llers as non-specic
modulators of adipogenesis: change of the paradigm?
Exp Dermatol. 2015;24:912–5.
71. Landau, etal. Science of hyaluronic acid beyond lling: broblasts and their response to the extracellular
matrix. Plast Reconstr Surg. 2015;136(5S):188–95.
72. Stefano, et al. Hyaluronate increases polynucleotides effects on human cultured broblasts. J Cosmet
Dermatol Sci Appl. 2013;3:124–8.
73. Shirakabe Y, etal. A new paradigm for the aging asian
face. Aesth Plast Surg. 2003;27(5):397–402.
74. Stuzin JM, etal. The relationship of the supercial
and deep facial fascias: relevance to rhytidectomy and
aging. Plast Reconstr Surg. 1992;89(3):441–9.
Basic Techniques forFiller
Procedures
4
4.1 Design Guidelines
In the clinic, we encounter many patients who
desire ller treatments. Some patients want llers
in specic areas, while others seek a complete
facial correction using llers. In such cases, we
analyze the patient’s face and identify the areas
that need step-by-step correction. The preferred
process is as follows:
(a) First, check the ratio of the face’s length and
width from the front. Evaluate the length of
the forehead/nose/chin, and then decide
which areas need correction.
(b) Second, check the balance of the areas
around the cheeks from the front. Evaluate
the front cheek/side cheek/forehead/nasolabial area. Design the midface in the shape of
a heart.
(c) Third, from the side, check the silhouette line
of the forehead-nasal bridge-chin. The line
from the forehead to the nasal bridge and
from the lips to the chin should be a natural
curve. The curvature of the side cheek can
vary according to personal preference.
(d) Fourth, from the side, check the Ricketts
line. Evaluate the height of the nose, the volume of the lips, and the protrusion of the
chin, and ensure they do not deviate signicantly from the Ricketts line.
We will now discuss these four stages in
detail. Detailed design techniques for each area
are covered in the procedural considerations of
each chapter (Chap. 5). This section addresses
the design of the entire face and tips for naturally
connecting adjacent areas.
4.1.1 Frontal View: Horizontal/
Vertical Proportions
oftheFace
The rst step is to check the horizontal and vertical proportions of the face from the front view.
If the vertical length of the face is relatively
short, the face may appear wider or disproportionately large. In such cases, designing a longer
vertical length can balance the horizontal/vertical
proportions and make the face appear smaller. As
mentioned in Sect. 1.3, the ideal forehead/nose/
chin ratio for Westerners is 1:1:1, while for
Asians, a lower facial ratio of 0.8–0.9 is considered most desirable. Regardless, the length of the
forehead should match the length of the midface
(Fig.4.1).
After checking the lengths of the forehead/
nose/chin from the front, evaluate whether the
proportions are balanced or if any part is shorter.
Proportions can be measured using measuring
tools. Some tools are specically designed for
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2025
G. Hong et al., The Art and Science of Filler Injection,
https://doi.org/10.1007/978-981-96-9215-6_4
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