Tái Tạo Thể Tích Khuôn Mặt Bằng Filler – Kyle K. Seo (2021)

186
4.10
Sunken Cheek
Augmentation
Difficulty
Level:
A,
Effectiveness:
A,
Complications: B
Deflation of cheek volume is primarily the
result of facial aging or weight loss, though it can
also be caused due to congenital volume deficit.
Depression of the cheeks creates the appearance
of sagginess and age, as the relative prominence
of the zygomatic arch, the nasolabial folds, and
the saggy jowls serve to disrupt the smooth con-
tinuity in facial contour seen in a youthful face.
Restoring volume deficiency in the cheeks not
only brings the overall face closer to the ideal
oval shape by obscuring the cheek bones but also
gives the face a more tightened and uplifted look
(Fig. 4.74).
4.10.1 Anatomical Considerations
The cheek is divided by the masseteric ligament
anterior to the masseter m. into two separate seg-
ments, namely the anterior cheek, a.k.a. the buccal
area  or submalar area, and the posterior cheek,
a.k.a. the lateral cheek, or the subzygomatic region
(Fig. 4.75) [24]. Accordingly, the depressions of
the anterior cheek (the buccal hollows) and the
posterior cheek (the subzygomatic hollows) should
also require separate consideration. While the vol-
ume depletion in anterior cheek is usually accom-
panied by a corresponding loss of volume in the
posterior cheek, patients who received  BoNT-A
treatment for masseter reduction  1–3 months
before may present with a more significant degree
of hollowing in the posterior cheek.
The anterior cheek consists of the following
soft tissue layers arranged in the order of the out-
ermost to the deepest as follows: the skin—sub-
cutaneous fat—facial expression muscles and
SMAS—buccal fat pad—buccinator m—oral
mucosa [24]. The fat compartments of the cheek
are made up of the subcutaneous fat lying beneath
the skin surface and the buccal fat pad located
deep to the facial expression muscles/SMAS. The
buccal fat pad is readily distinguishable from the
subcutaneous fat not only based on the relevant
tissue planes, but also because it is wrapped in a
distinct envelope of thin fascia. The buccal fat
pad is supported inferiorly by the risorius muscle,
and it is the loosening and ptosis of the risorius
Summary 1: The use of a cannula is advised
for cheek augmentation. The target injec-
tion plane is the superficial subcutaneous
fat layer  underlying the skin surface as
opposed to the deep buccal fat pad.
Summary 2: When creating the cannula
entry point for anterior cheek augmenta-
tion, the needle should be introduced slowly
with a downward-­facing bevel to prevent
hematoma formation from injury to the
facial artery which runs superficially
beneath the skin surface.
Summary 3: Different aspects of the cheek
can be addressed according to different aes-
thetic goals. To diminish the prominence of
the lateral zygoma on the frontal view and
achieve an oval face, volume should be
directed at the posterior cheek, that is, the
area inferior to the zygomatic arch. To off-
set the pronounced zygoma from the
oblique view or to improve the saggy jowls,
volume should be placed in the lateral
aspect of the anterior cheek also referred to
as the submalar hollow. Where improve-
ments in the nasolabial folds are desired,
the medial aspect of the anterior cheek
should be restored.
Summary 4: In patients in their mid-40s and
above presenting with pronounced buccal
fat pads or preexisting jowls, judicious
placement of HA filler in conservative
amounts is advised.
4  Regional Particulars

187
a
b
c
d
Fig. 4.74  (a) Before and (b) after sunken cheek augmentation. (c) Before and (d) after posterior cheek augmentation
4.10  Sunken Cheek Augmentation

188
due to aging which results in the descent of the
buccal fat pad, exacerbating the appearance of
jowls. While both the subcutaneous fat and the
buccal fat pad are affected by the loss of volume
in the cheek, volume restoration is to be under-
taken primarily at the subcutaneous fat compart-
ment, as direct injection of volume into the buccal
fat pad may cause the material to weigh down the
face, accentuating the saggy appearance in
patients with prominent jowls.
Caution should be exercised while puncturing
the cannula entry points for anterior cheek aug-
mentation since the facial artery runs superfi-
cially in proximity to the potential entry point,
the damage to which can cause extensive bruising
[24] (Fig. 4.76). In posterior cheek augmentation,
care should be taken not to injure the transverse
facial artery branching from the superficial tem-
poral artery emerging 1 cm inferior to the zygo-
matic arch toward the anterior cheek [25].
4.10.2 Pretreatment Assessment
As a preliminary matter, it is important to estab-
lish the location and severity of the volume defi-
ciency in the anterior and/or posterior cheek.
Consideration must also be given to the patient’s
subjective aesthetic concerns, as it determines
both the target site(s) to be addressed and injec-
tion volume. Confirm with the patient whether
the aim is to ovalize the face on the frontal view
by diminishing the prominence of the lateral
zygoma, or to deemphasize the zygoma from the
45° angle, or to improve the appearance of naso-
labial folds or saggy jowls by restoring the peri-
oral region (Fig.  4.75); notably, sunken cheek
volumization is not often practiced in Caucasians
since a moderate undulation in facial contour
from the convexity of the lateral zygoma to the
concavity of the subzygomatic region (“Ogee
curve”) is a trait considered aesthetically desir-
Fig. 4.75  The cheek is
divided by the
masseteric ligament
anterior to the masseter
m. into two separate
segments, namely, the
anterior cheek, a.k.a.
submalar area or the
buccal area, and the
posterior cheek, a.k.a.
the lateral cheek, or the
subzygomatic region
4  Regional Particulars

189
able by Caucasians (Fig. 4.13) [17]. Therefore,
when performing this indication in a Caucasian
patient, injection of discreet amounts is advised
just enough to improve the severity of submalar
depression or irregular lateral facial contour.
Likewise, when treating a male cheek, the goal
should be simply to mitigate the severely gaunt,
hollowed-out appearance of the patient instead of
achieving full correction since a mildly rugged,
angulated facial contour is considered manly and
desirable in men.
4.10.3 Injection Technique
(Table 4.12)
In sunken cheek augmentation, different com-
partments of the cheek are injected depending on
the patient’s aesthetic need. Posterior cheek
Table 4.12  Summary of cheek filler injection technique
Item
Contents
Needle vs. Cannula
23-G 5 cm Cannula
HA filler
Monophasic HA filler
Amount of HA
filler
2–5 mL per side for ant. Cheek
1–2 mL per side for post. Cheek
Depth of injection
Subcutaneous level
Entry point for
cannula
Ant. cheek: 3 cm lateral and
1 cm inferior to the mouth
corner
Post. cheek: point where vertical
line drawn 2 cm lateral to the
lateral canthus meets the
imaginary line connecting the
mouth corner and the tragus
Target area
Ant. cheek for the nasolabial
fold and the submalar
depression
Post. cheek for the
subzygomatic depression
Anesthetics
Topical anesthetics
Fig. 4.76  Danger zones
for bruising by needle
insertion
4.10  Sunken Cheek Augmentation

190
­augmentation is indicated for creating an oval
face on the frontal view by diminishing the visi-
bility of the lateral zygoma (Fig. 4.77). To offset
the pronounced zygoma from the oblique
view  or  to improve the saggy jowls, volume
should be placed in the lateral aspect of the ante-
rior cheek also referred to as the submalar depres-
sion (Fig. 4.78). Finally, to improve the appearance
of nasolabial folds, volume should be restored in
the medial aspect of the anterior cheek (Fig. 4.78).
Injection is performed with a 23-G cannula.
The relevant plane of injection is in the subcutane-
ous adipose layer. When augmenting the anterior
cheek, the ideal entry point is located 3 cm lateral
and 1 cm inferior to the oral commissure. For pos-
terior cheek volumization, the cannula entry point
is at the intersection between the vertical line
drawn 2 cm lateral to the lateral canthus and an
imaginary line connecting the oral commissure
and the tragus [25]. When treating the anterior
cheek, the relevant sequence of injection is to first
fill the lateral aspect (i.e., the submalar depression)
of the anterior cheek before proceeding to address
the medial part (i.e., nasolabial fold. For the poste-
rior cheek, start by addressing the deepest point of
the subzygomatic hollow, with subsequent grada-
tion in volume inferiorly to achieve a smooth taper
toward the jawline. Note, however, that the thick
ligamentous tissue lying behind the masseteric
ligaments may, similarly to scar tissues, hinder the
smooth and even distribution of HA filler.
Aggressive filling is to be avoided, as it can cause
unwanted bulging of the region inferior to the liga-
mentous tissue. While the subcision technique can
be employed to create space for HA filler place-
ment, bruising is to be expected.
The standard amount of HA filler injected for
anterior cheek volumization is 1 mL medially in
the nasolabial fold and 1 mL laterally in the sub-
malar depression totaling a minimum of 2 mL per
Skin
Subcutaneous fat layer
Parotid temporal fascia
Parotid gland
HA filler
Masseter m.
Periostium
a
b
Fig. 4.77  (a) The cannula entry point for posterior cheek augmentation. (b) Proper placement of HA filler in the pos-
terior cheek confirmed by sonography evaluation
Skin
Subcutaneous fat layer
HA filler
Buccal fat pad
a
b
Fig. 4.78  (a) The cannula entry point for anterior cheek augmentation. (b) Proper placement of HA filler in the anterior
cheek confirmed by sonography evaluation
4  Regional Particulars

191
side subject to individual variations. For more
severe depressions, the injection volume can be
increased to as much as 3–5  mL per side. For
posterior cheek depressions, 1–2 mL is required
depending on the severity of the condition. The
use of topical anesthetic cream is sufficient for
numbing the treatment.
4.10.4 Complications
Irregularity: The posterior cheek lies posterior to the
masseteric ligament, and as such, patients with nat-
urally large ligamentous tissue may have a slight
bulge 1–2 cm under the zygomatic arch at baseline,
which they may not have noticed previously
(Fig. 4.79). This must be brought to the patient’s
attention before treatment and documented in the
pretreatment photos. Otherwise, the patient may
attribute the bump to HA filler placement.
Bruising: The facial artery is at risk during the
puncture of the cannula entry point for anterior
cheek augmentation, while the transverse facial
artery is in danger when making the relevant
access point for filling the posterior cheek. When
creating the cannula entry point for anterior
cheek augmentation, the needle should slowly
enter the skin with the bevel facing down to avoid
injuring the facial artery running superficially
below the skin surface. In the case trauma to the
facial artery is suspected, press the area hard for
at least 3 min to prevent a hematoma.
Sagging Jowls: In patients in their mid-40s and
above with preexisting saggy jowls or bulging
buccal fat, cheek augmentation can result in the
exacerbation of jowl descent. While this is caused
mostly by placement of HA filler directly into the
deep buccal fat pad, in patients with severe jowls,
sagging can occur even from subcutaneous HA
filler placement. Accordingly, care must be taken
to place cheek filler only in the subcutaneous fatty
layer and in minimum amounts in patients with
preexisting jowls. Concominant steriod fat reduc-
ing injection for the sagging jowl and butulinum
toxin injection for the masseteric reduction should
be performed.
Bogus Face (Fig. 1.13): Occasionally, patients
seeking cheek augmentation may present with
cheek dimples formed by the action of bifid zygo-
maticus major m. Repeated contraction of the
zygomaticus major m. each time the patient
smiles can progressively push the implanted HA
filler away from its original location. This, in turn,
may cause the cheeks to stick out laterally when
the patient smiles, like the cartoon character Mr.
Bogus with characteristically bulging cheeks
(Fig. 1.13). In such patients, most of the volume
should be placed medial to the dimples with only
minimum amounts applied in the lateral aspects.
Vascular Adverse Effect: Patients previously
treated with fat graft, Sculptra, or collagen stimu-
lators in the cheek are often left with scar tissue
adhesions in the subcutaneous fat, with blood
vessels trapped inside. Vessels trapped by scar-
ring lie vulnerable to the risk of rupture, or intra-
vascular embolization even when a blunt cannula
is used for the injection. The 40-year-old female
patient in the photo developed mottled erythema
in the posterior cheek the day following posteri-
ors cheek augmentation; even though the damage
to  transverse facial artery was highly  sus-
pected, 48 hrs had already passed since the onset
of symptoms, and symptoms were mild enough
not to justify taking further interventions apart
from medication for improving blood circulation.
Fortunately, full recovery was achieved within a
week without reversing the HA (Fig. 4.80).
Pain: Patients with enlarged masseteric liga-
ments may develop bruising and pain persisting
for more than 2 weeks due to the rupture of the
ligament caused by the cannula movement.
Fig. 4.79  Irregularity due to masseteric ligament
4.10  Sunken Cheek Augmentation

192
4.11
Nasolabial Folds
Difficulty
Level:
A,
Effectiveness:
B,
Complications: B
Nasolabial folds are the creases that extend
obliquely from the alar groove located lateral
to the ala nasi down to the outer corners of the
lips. They are formed along the border between
the malar fat pad and the respective insertion
points of the various upper lip elevators and
zygomaticus major muscle into the skin sur-
face. Significantly, similar to how the infraor-
bital crease running horizontally below the
pretarsal roll does not constitute a facial wrin-
kle associated with aging, the nasolabial folds
represent one of the primary arcs which natu-
rally make up the three-dimensional human
face as a gradient between the tall cheeks and
the lips. Consequently, even young people in
their teens have nasolabial folds, though the
folds may deepen and elongate with age as the
skin loses elasticity and the malar fat pad
begins to droop and bulge inferiorly. As such,
complete eradication of the alar groove during
a nasolabial fold treatment with HA filler
should not be attempted, as the fusing of
injected volume with the malar fat pad located
immediately above removes three-dimension-
ality from the face, blows the malar cheeks out
of proportion, and ultimately confers an unnat-
ural simian appearance to the face. It bears not-
ing the absence of this vital structure on the
face of a monkey in this regard.
Depending on the underlying cause, nasola-
bial folds which warrant aesthetic improvement
with HA filler consist of deep static folds visible
even at rest and dynamic folds which appear only
upon facial animation such as talking and smiling
due to the activity of relevant musculature includ-
ing the upper lip elevators and the zygomaticus
major m. Loss of skin elasticity with aging can
exacerbate the appearance of the dynamic folds,
while repeated wrinkling in the nasolabial area
over time eventually causes these dynamic folds
to deepen and elongate into static folds. Treatment
of deep static nasolabial folds involves placement
of HA filler directly into the folds (Fig. 4.81). In
contrast, dynamic nasolabial folds are treated
using the fern technique aimed to enhance the
Summary 1: Inject using a thick 23-G 5-cm
cannula to minimize trauma to the facial
artery running along the nasolabial fold.
Both biphasic HA fillers with large particle
size and monophasic HA fillers with high
viscoelasticity are acceptable for use.
Summary 2: Nasolabial folds constitute one
of the three-dimensional arcs that make up
the human face. Correspondingly, correction
of the alar groove located lateral to the nasal
ala is best avoided if not provided sparingly
only in severe cases. Most of the volume
correction should instead be directed at the
lower two-thirds of the nasolabial fold.
Summary 3: Both the dynamic and the
static components of the nasolabial fold
should be considered. The appropriate
injection method should be tailored accord-
ing to the nature (i.e., static vs. dynamic) of
the nasolabial fold.
Summary 4: Concurrent volume restoration
is recommended if any marionette lines or
cheek hollowing is concomitantly present.
Fig. 4.80  The 40-year-old female patient developed mot-
tled erythema in the posterior cheek the day following
posterior cheek augmentation due to the damage to trans-
verse facial artery
4  Regional Particulars

193
overall elasticity and resilience of the surround-
ing skin (Fig. 4.82) [26].
4.11.1 Anatomical Considerations
The upper lip elevators including the LLSAN
(levator labii superioris alaeque nasi), LLS (leva-
tor labii superioris), zygomaticus minor m., and
some muscle fibers of zygomaticus major m.
attach directly into the skin overlying the nasola-
bial folds (Fig.  4.83) [27]. Insertion of these
muscles into the skin where the nasolabial folds
form gives rise to the prominence of nasolabial
folds upon smiling due to relevant muscle con-
tracture (i.e., dynamic nasolabial folds), and delin-
eates a boundary that keeps the malar fat pad lying
above the fold from descending further. The deep-
ening of this demarcation over time eventually
leads to static nasolabial folds that are obvious at
rest. Considering the origin, insertion, and vector
of each of these mimetic muscles, it can be postu-
lated that the medial one-third of the nasolabial
fold is formed by the LLSAN and LLS, the mid-
dle one-third by the zygomaticus minor m., and
the lateral one-third by the zygomaticus major m.
The use of a cannula is preferred over a needle
to avoid injuring the facial artery running parallel
if not along the nasolabial fold. Vigilance must be
exercised not to rupture the facial artery, as it may
cause extensive hematoma (Fig. 4.76).
The facial artery branches from the external
carotid artery, loops around the antegonial notch
from which it reemerges, and passes the masseter
muscle anteriorly before coursing tortuously up
to the nasion. Along the path, it is known to give
off the branches of the inferior labial a., the supe-
rior labial a. and the lateral nasal a. before termi-
nating as the angular a. Given that the superior
labial a. typically arises from the facial artery
within an area 15 mm superolateral to the mouth
corner, particular care must be practiced not to
injure the relevant vasculature when using a nee-
dle in this region [27]. Note also that while the
a
b
Fig. 4.81  (a) Before and (b) after treatment of deep static nasolabial folds
a
b
Fig. 4.82  (a) Before and (b) after treatment of dynamic nasolabial folds using the fern technique
4.11  Nasolabial Folds

194
facial artery mostly runs deep to mimetic muscles
during its course, it is afforded no such protection
in the spaces immediately above and below the
risorius m. by the overlying musculature. Hence,
caution is required when injecting this segment
with a needle as the facial artery runs superfi-
cially beneath the skin without any cover.
Likewise, when puncturing the cannula entry
point with a needle, care should be taken to insert
the needle very slowly, at an angle almost hori-
zontal to the skin with the bevel facing down so
as not to traumatize the facial artery running
superficially in this area. A sudden swelling
occurring within seconds of injection followed
by a palpable hematoma indicates that the facial
artery has been transected upon.
4.11.2 Pretreatment Assessment
Establish the type of nasolabial fold the patient
wishes to improve, that is, whether it is the deep
static nasolabial folds visible at rest or the promi-
nent dynamic nasolabial folds formed upon smil-
ing and tailor the approach accordingly. Identify
the presence of any sunken cheeks, marionette
lines, saggy jowls or prominent nasolabial fat pads
in the adjacent regions to ensure overall facial bal-
ance and harmony. Sunken cheeks should be
restored in conjunction with the nasolabial folds,
as correction to the nasolabial folds alone may
result in an unbalanced facial appearance. Where
the nasolabial folds extend into the marionette
lines, concurrent correction of the marionette lines
is advised. Meanwhile, excess volume in the naso-
labial fat pad contributes to the deepening of the
nasolabial folds as the upper cheeks sag and fold
over across the nasolabial crease. In such case,
results can be optimized with adjuvant fat-reduc-
ing injections or liposuction, which should ideally
precede the nasolabial fold correction with HA
filler.  Likewise,  saggy jowls shouild be bet-
ter  treated with concominant  fat-reducing injec-
tions, liposuction or thread lifting. 
4.11.3 Injection Method (Table 4.13)
4.11.3.1
Deep Static Nasolabial Folds
Both biphasic HA fillers with large particle size
and monophasic HA fillers with high viscoelas-
ticity are acceptable for treating deep static naso-
labial folds. A23-G 5-cm cannula is used for
injection. A25-G or 27-G cannula may also be
employed to perform double layering in the
superficial subcutaneous fatty layer.
Note that the nasolabial fold should never be
effaced completely, as it constitutes an essential
curvilinear structure of a three-dimensional
human face. This applies particularly to the alar
Fig. 4.83  The upper lip elevators including the LLSAN
(levator labii superioris alaque nasi), LLS (levator labii
superioris), zygomaticus minor m., and some muscle
fibers of zygomaticus major m. attach directly into the
skin overlying the nasolabial folds. (Photo: courtesy from
Professor Hee-Jin Kim)
4  Regional Particulars

195
groove located lateral to the ala nasi. Full leveling
of the alar groove removes dimensionality from
the face, makes the face appear doughy and pil-
lowy, and overinflates the nasolabial fat pad
hanging above the nasolabial fold. Moreover,
repeated movement of the upper lip elevators
which attach to the skin can tug and displace the
product into the nasolabial fat pad located above
the nasolabial fold, further exaggerating the
upper cheek volume. Correction of the alar
groove should, therefore, be reserved only for
severe cases and performed only to the minimum
necessary extent. Hence, it is often the case that
the alar groove is intentionally left untreated,
while enhancement is directed only at the lower
two-thirds of the nasolabial fold.
The cannula entry point is made 1–1.5 cm
lateral and 1 cm inferior to the mouth corner.
Typically, this should put the cannula entry
point along the continuum of the nasolabial
fold. Where concurrent correction of sunken
cheeks is desired, the relevant cannula entry
point can be made slightly lateral to this point
(Fig.  4.84). The desired depth of injection
depends on the relevant indication. Where cor-
Table 4.13  Summary of nasolabial fold treatment
technique
Item
Contents
Needle vs. Cannula
23-G 5-cm cannula
HA filler
Biphasic HA filer with large
particle size or monophasic
HA filler with high
viscoelasticity
Amount of HA filler
0.5–2 mL per side
Depth of injection
Deep subcutaneous layer
above the muscle layer
Superficial subcutaneous
layer if necessary
Entry point for
cannula 
1–1.5 cm lateral and 1 cm
inferior to the mouth corner
Target area
Lower 2/3 of nasolabial fold
Anesthetics
Topical anesthetics
Nondominant hand
Hold the skin inferiorly in
order to maintain skin
tension
a
c
b
Skin
Subcutaneous fat layer
HA filler
SMAS
Fig. 4.84  The cannula entry point and appropriate loca-
tion for the volume restoration of the nasolabial fold. (a)
Correction of the alar groove should, be reserved only for
severe cases, and (b) correction performed only to the
lower two-thirds of the nasolabial fold (c) Sonographic
image displaying HA filler placed in subcutaneous layer
at nasolabial fold 
4.11  Nasolabial Folds

196
Fig. 4.85  The depth of
injection for the
nasolabial fold
rection of the alar groove is required, deep
injection into the supraperiosteal plane of the
canine fossa is performed, while to address
volume in the lower two-thirds of the
­nasolabial fold, volume is placed in the
­superficial  subcutaneous fat lying superficial
to the orbicularis oris m. (Fig. 4.85). Utilizing
the double-layering technique, additional vol-
ume may be administered in the  subdermal
layer. Where necessary, HA filler may be
injected intradermally to address any surface
wrinkles.
Using the retrograde linear threading tech-
nique, place  the HA filler to fill out the deep
static groove as needed. A parallel injection of
HA is then delivered medially to the nasolabial
fold to achieve a smooth gradation in contour.
The volume range is 1–2 mL per side, depend-
ing on the depth of the fold. For anesthesia,
application of topical numbing cream should
suffice. The nondominant hand should be used
to stretch the skin taut both inferiorly and later-
ally during the injection to facilitate cannula
advancement.
4  Regional Particulars

197
4.11.3.2
Dynamic Nasolabial Folds
For improving the prominence of dynamic naso-
labial folds upon smiling (Fig. 4.82), HA filler is
placed perpendicularly in a fern pattern technique
by depositing numerous aliquots of HA filler
perpendicular to the direction of the nasolabial
fold in the dermal plane (Fig. 3.11a). A mono-
phasic HA filler with medium viscoelasticity is
typically selected for treating dynamic nasolabial
folds. Injection is performed with a 30-G needle
and 0.25–0.5 mL of HA filler is dispensed per
side in the dermal plane. Application of topical
numbing cream for more than 30 min is advised
to minimize pain.
4.11.3.3
Combination Treatment
Concurrent correction of the labio mandibular
folds or marionette lines is recommended where
applicable, as the presence of these lines contrib-
utes to an elongated appearance of the nasolabial
folds. Meanwhile, depressions in the cheeks
should preferably be addressed concomitantly for
a more fluid transition to the nasolabial folds. In
patients with prominent nasolabial fat pads, it is
advisable to undertake 2–3 rounds of corticoste-
roid fat-reducing injections to achieve a more
natural and toned appearance.
4.11.4 Complications
Bruising: Care should be taken to avoid the facial
a. running along the nasolabial fold, the damage
to which can cause severe bruising such as hema-
toma when a needle is used for the nasolabial
fold correction instead of a cannula or when
puncturing the cannula entry point with a
needle.
Vascular Insufficiency: Compression of the
lateral nasal a. caused by injection of too much
filler at the canine fossa may bring about vascular
insufficiency in the nasal region in patients whose
vascular circulation has already  been compro-
mised by a previous nose surgery involving
injury to the columella a., etc. Meanwhile, filler
embolization from inadvertent injection of filler
into the facial artery may bring about vascular
complications including necrosis of the nose,
glabella, and forehead due to the broad anasto-
mosis present at the nasal dorsum between the
lateral nasal artery as a branch of facial artery and
the dorsal nasal artery, a branch of supratrochlear
artery (see Sect. 5.1).
Irregularity: Injection of too much filler too
superficially in the superficial dermis may result
in surface irregularities. Meanwhile, treating
only the nasolabial folds in isolation without con-
sidering the balance with the rest of the face may
also bring about contour irregularities. For exam-
ple, correcting the nasolabial folds only without
concomitant treatment of the hollow cheeks may
accentuate the prominence of the cheek hollow-
ness. Likewise, in patients with prominent naso-
labial fat pads, filling  out the alar groove may
contribute to a more pronounced appearance of
the nasolabial fat.
Sagging Jowls: In patients in their mid-40s
and above with preexisting saggy jowls or bulg-
ing buccal fat, cheek augmentation can result in
the exacerbation of jowl descent (Fig.  4.86).
Accordingly, care must be taken to augment
nasolabial fold  only  in minimum amounts in
patients with preexisting jowls. Concominant
steriod fat reducing injection, liposuction or
thread lifting for the sagging jowl should be
considered.
4.11  Nasolabial Folds

198
4.12
Lip Filler
Difficulty
Level:
B,
Effectiveness:
A,
Complications: B
Lips represent an essential focal point in the
face, as it constitutes the only part of the face that
appears red in color. In Asia, the expression “red
lips and white teeth” has been used traditionally
to capture the ideals of female facial beauty.
Summary 4: It is important to assess the lips
from the lateral view before the injection, to
check for any over-projection of the upper
lip. Patients with a  protruded upper lip
require HA placement in the lower lips
only. Inject no more than 2 mL per session
to avoid an overdone appearance.
Summary 1: Inject using a 27-G 3-cm can-
nula  or 30-G needle. The target plane of
injection is either the subdermal or the sub-
mucosal layer of dry mucosa. The cannula
insertion point is created 0.3 cm lateral to
the oral commissure. Use only monophasic
HA fillers.
Summary 2: The lips consist not of a sin-
gle long unit but of a sum of different ana-
tomical subunits, including the central
tubercle and lateral tubercles, which must
be respected during the augmentation with
HA filler.
Summary 3: Age-related changes in the lips
include the thinning of the lips, elongation of
the philtrum, and loss of prominence in the
vermillion border. With age, the  lower lip
progressively rolls inward, the mouth cor-
ners invert downwards, and multiple fine
lines develop in the perioral area.
a
b
Fig. 4.86  (a) Before and (b) after anterior sunken cheek
augmentation  for the nasolabial fold improvement in
68-year-old-patient with preexisting sagging jowls or
bulging buccal fat. She also received concominant steriod
fat reducing injection and butulinum toxin injection for
the masseteric reduction
4  Regional Particulars

199
Adequately full voluptuous lips are associated
with youth and beauty in both men and women.
By contrast, thinning of the lips is considered an
aging feature which also creates the perception of
coldness and apathy. Lip augmentation is instru-
mental not only to adding fullness to the lip but
also to creating balance between the upper and
lower lips or between the left and right lips. In
brief, lip enhancement serves not only as a beau-
tification tool for plumping and refining lips in a
young patient but also as a rejuvenation tool in
older patients for addressing lip thinning as well
as counteracting other morphological changes
that occur in the lips with age (Fig. 4.87).
4.12.1 Anthropometry of the Lips
Anatomically speaking, the lips are not confined
only to the red mucosal region, but instead con-
sist of the red portion, or the vermillion body, and
the white part, or areas of cutaneous skin
surrounding the circumference of the red lip.
Underlying the white lips is the musculature that
enables the mouth to perform such functional
aspects as the puckering and closure of the lips.
In reference to the relevant facial landmarks, the
lips extend from the subnasale superiorly down
to the pogonion inferiorly and to the nasolabial
folds laterally. The boundary between the red and
a
b
c
d
e
f
Fig. 4.87  (a, c, e) Before and (b, d, f) after volumization of the lips
4.12  Lip Filler

200
white lips is demarcated by the vermillion border.
The red lip is further divided into the dry mucosa
on the outside and the wet mucosa on the inside
(Fig. 4.88).
Knowledge of aesthetic facial proportions is a
prerequisite to defining the ideal shape and size
of the lips and their balance with the rest of the
face. The ideal proportion between the upper,
middle, and the lower face, extending respec-
tively from hairline to glabella, from glabella to
subnasale, and from subnasale to gnathion is
described as 1:1:1 [28] (Fig. 4.89). It should be
noted, however, that in aesthetic Asians, the
lower third of the face is known to be smaller
with the ideal facial ratio approaching 1:1:0.8
[29]. The lower face is further divided into equal
thirds, with the ideal ratio between the distance
from subnasale to stomion relative to the dis-
tance from stomion to gnathion described as 1:2.
In aesthetic lips, the lower lip should also be
slightly thicker than the upper lip, with the ideal
vertical height ratio between the upper and lower
lip described as 2:3 or 1:1.6 (π). The ideal lip
width is where each oral commissure is aligned
precisely with a line dropped vertically from the
medial pupil. On profile, a number of facial anal-
ysis have been described, which aid in the evalu-
ation of the relative prominence of the upper an
lower lips to the facial profile, especially to the
nose and chin. The upper lip should ideally proj-
ect slightly over the lower lip from the provile
view. Accordingly, based on a straight line con-
necting the subnasale (Sn) and the pogonion, the
upper lip should protrude 3.5 mm and the lower
lip 2 mm anterior to this line (Sn-Pog’ line by
Burston)  (Fig. 4.90). Based on the different
anthropometric analyses which exclude  the
influence of the chin protrusion, the upper lip
should be 1–2 mm anterior to the true vertical
line from the Sn (SnV) while the lower lip should
be on or 1 mm in front of this SnV (to exclude
the influence of the chin protrusion). The Pog’
should be on a line drawn tangent to the upper
and lower lips (Riedel line). The lips should also
fall behind the line connecting Pog’ and nasal tip
(Pronasale, Prn) (Ricketts line). In Caucasians,
the upper lip should be 4–6 mm behind the
Ricketts line with the lower lip 2–4 mm behind;
while this should be to a lesser degree in Asians.
However, in Black individuals, the lips tend to
protrude beyond this line due to the greater soft
tissue thickness of the lips and a greater tendency
Fig. 4.88  Anatomic landmarks of lips
4  Regional Particulars

201
for bimaxillary dentoalveolar protrusion as well
as the reduced prominence of the nose and the
chin compared with Caucasians. Intermediate
and Southern type Asians also show a tendency
for the lips to protrude beyond the Ricketts line
due to the reduced prominence of the nose and
the chin. Meanwhile, the philtrum lies immedi-
ately superior to the upper lip and is flanked by
two raised vertical philtral columns extending
respectively from the bilateral peaks of the
cupid’s bow. The lowest point of the cupid’s bow
on the midline of the philtrum is referred to as
the GK point.
The lip anatomy is highly detailed as the lips
consist not of a single long uniform entity, but as
a sum of various different anatomical subcompo-
nents, which should be appraised and volumized
as such (Fig. 4.91). On the upper lip, there is one
central tubercle below the cupid’s bow with two
lateral tubercles sitting on either side. Meanwhile,
the lower lip features a central depression with
two lateral tubercles formed on either side. The
two tubercles on the lower lip should fit neatly
into the relative recesses of the upper lip, while
the three upper lip tubercles should rest comfort-
ably on the corresponding flatter regions of the
lower lip. Accordingly, in beautiful lips, the pres-
ence of these structures should create a smooth
waveform along the oral fissure when the mouth
is closed with alternating convexities and con-
vexities undulating from one end of the mouth
corner to the other (Fig. 4.91).
Fig. 4.89  Facial
proportions relevant
to the lips
4.12  Lip Filler

202
4.12.2 Anatomical Considerations
4.12.2.1
Sagittal View of the Lips
In the sagittal view, the anatomical layers of
the lips from the outer to the innermost layers
are comprised as follows: the skin or the dry
mocosa of lips—subdermal or submuco-
sal  layer—orbicularis oris m.—submucosa—
wet mucosa in oral cavity. The lip mucosa can
be divided into the dry mucosa on the outside
a
b
Fig. 4.90  Lateral view of ideally proportioned lips (Sn:
subnasale, Pog’: soft tissue pogoniion). (a) The upper lip
should protrude slightly beyond the lower lip from porfile
view. (b) Pog’ is on a line tangent to the upper and lower
lips (Riedel line). Lips should be behind the line connect-
ing Pog’ and Pronasale (Prn) (Ricketts line)
Fig. 4.91  Subunits of the lip anatomy
4  Regional Particulars

203
and the wet mucosa in the oral cavity. The sub-
mucosa on the oral cavity side lies deep to the
orbicularis oris m. and is supplied by the labial
artery, the labial glands, and the branches of
the mental nerve (Fig. 4.92).
4.12.2.2
The Labial Artery
The superior labial artery branches from the facial
artery within the perimeters of a square drawn
15  mm lateral and 15  mm superior to the oral
commissure and courses along the vermillion bor-
der of the upper lip within the substance of the
orbicularis oris m., if not at the depth between the
orbicularis oris m. and mucosa [29]. Before
reaching the peak of the cupid’s bow, it descends
from the vermillion border into the red lip and
runs medially toward the midline of the upper lip,
where it either terminates as the columellar artery
superiorly or anastomoses with the contralateral
superior labial artery approaching from the oppo-
site side. Unlike the superior labial artery, the
inferior labial artery seldom traverses along the
vermillion border and shows individual variations
in its distribution pattern. Branching from the
facial artery, it often traverses between the lower
lip and the chin within the substance of the depres-
sor angulioris (DAO) and the depressor labii infe-
rioris (DLI) before ascending superiorly and
terminating at the lower lip mucosa (Fig. 4.93).
Both the superior and inferior labial arteries
lie close to the wet mucosa of the inner lip, with
the superior labial artery located at a depth of
5.3 mm from the vermillion border and the infe-
rior labial artery at a distance of 4.2 mm [30].
Since both labial arteries routinely run deep to
the orbicularis oris m., injection of HA superfi-
Fig. 4.92  Depth of
injection for lip
augmentation is
submucosal (body) or
subdermal (vermillion
bordore) layer
4.12  Lip Filler

204
cial to the orbicularis oris m. and close to the sub-
dermal or submucosal layers is more favorable to
avoid the risk of arterial injury.
4.12.2.3
Age-Related Changes
in the Lips
Aging lips demonstrate a loss of volume as well
as the loss of definition in the vermillion border.
With increased age, the lips tend to thin out
while the vermillion border loses definition due
to volume deflation. Aging upper lips demon-
strate a loss of volume, elongation of the phil-
trum, and loss of definition in the philtral
columns, the cupid’s bow, and the vermilion bor-
der. The lower lip also becomes progressively
thinner and starts to rotate inwards. Multiple
perioral lines begin developing around the
periphery of the lips while the mouth corners
start to invert downwards (Fig. 4.94).
4.12.3 Pretreatment Assessment
Assessments should be made of the proportion
between the upper and lower lips as well as the
presence of any asymmetry between the left and
right lips on the frontal view prior to treatment.
While no consensus has been reached on what
constitutes the ideal lip volume, thin lips are gen-
erally considered aesthetically unfavorable, as
they tend to impart a lack of warmth and callous-
ness and are typically associated with an aging
face. It is important to consult with the patient
regarding the desired lip volume, since the ade-
quacy of injected volume hinges significantly on
the specific aesthetic preferences and desires of
the individual.
Generally speaking, younger patients tend to
favor augmenting their natural lip size and full-
ness while the main aesthetic goal in older
patients is the restoration of age-related lip vol-
ume loss. The patient’s ethnicity must also be
considered since ethnic differences exist with
Fig. 4.93  Vascular supply of the lip
Fig. 4.94  Aging of the lips
4  Regional Particulars

205
respect to desired lip volume. Asians tend to pre-
fer relatively smaller lips compared to Caucasians
[31]. Blacks prefer the biggest lip size, followed
by Caucasians and Asians. Arabs whose facial
bone structure bears a close resemblance to
Caucasians also tend to show a preference for
fuller and more voluptuous lips as wearing a
hijab serves to draw more attention to the aesthet-
ics of individual facial features. It is also essential
to examine the lips from the profile view to deter-
mine the presence of any bimaxillary protrusion
or over-projection of the upper or the lower lip.
Note that lip augmentation with HA is not recom-
mended in patients presenting with a protruded
mouth, or bimaxillary protrusion, while an over
projected upper lip can be balanced out with the
placement of HA filler in the lower lips only. In
case the patient has a visibly prominent central
tubercle on the upper lip, the volume should pref-
erably be added only in the lateral tubercles with-
out further augmenting the central tubercle.
In older patients in their fifth decade and
beyond seeking lip rejuvenation with HA fillers,
it may be worthwhile to also identify opportuni-
ties for rejuvenation in other parts of the perioral
complex which manifest signs of aging. For
instance, the appearance of deep perioral rhytids
is an indication for the combined use of BoNT-A
and HA filler for the treatment of fine lines.
Placement of HA filler additionally in the mari-
onette lines can produce a more synergistic out-
come in everting the  downturned mouth
corners.
4.12.4 Injection Technique
(Table 4.14)
Inject using only soft monophasic HA fillers. The
injection tool is  primarily a 27-G  ×  3-cm can-
nula. However, a 30-G needle can be used (see
Sect. 4.12.4.3). The target depth of injection var-
ies depending on the specific indication. Inject
subdermally to enhance  the vermillion border
and into the submucosal layer of the dry mocosa
to plump the body of the lips. The entry point of
cannula insertion is created 0.3 cm lateral to the
oral commissure (Fig. 4.95). When creating the
lateral tubercles of the upper and lower lips
respectively, the nondominant hand should
be used to press the medial one-third of the upper
lip or the midline of the lower lip as the case may
be to prevent the spread of HA filler into areas of
relative concavity.
Regarding the injection volume, first place
1–1.5 mL of HA across the lips for overall vol-
ume and assess the interim result with the patient
using a mirror before deciding if additional HA
filler may be appropriate. Note, however, that lips
can
appear
larger
immediately
following
the  injection due to the surplus volume of the
anesthetics mixed with the HA filler as well as
the immediate postprocedure swelling of tissue.
Where practicable, make sure to inject no more
than 2 mL per session to avoid the appearance of
“duck lips” due to overfilling.
For anesthesia, application of topical numbing
cream and local anesthetic injection at the can-
nula entry point should suffice. The use of infra-
orbital and mental nerve blocks may be
considered in patients highly sensitive to pain,
but generally not advised since the temporary
drooping of the lips from the  nerve block
Table 4.14  Summary of lip filler injection technique
Item
Contents
Needle vs. Cannula
27-G 3-cm, or 30-G needle
can be used
HA filler
Monophasic HA filler
Amount of HA filler
1–2 mL per session
Depth of injection
Subdermal layer for the
vermilion border
Submucosal layer of the dry
mucosa for the body
of the red lip
Entry point for cannula 0.3 cm lateral to the oral
commissure
Target area
Vermilion border
Central tubercle and lateral
tubercles
Philtral columns if necessary
Anesthetics
Topical anesthetics and local
anesthetics at entry point
Infraorbital and mental
nerve block may be required
in patients sensitive to pain
Nondominant hand
Used to press the midline of
the lower lip and medial
one-third of the upper lip
4.12  Lip Filler

206
may  hinder proper postinjection assessment of
the lip volume.
4.12.4.1
The Upper Lip
Advance the cannula subdermally along the
vermillion border toward the peak of the cupid’s
bow. Place HA filler using the retrograde linear
thread technique to enhance the vermillion bor-
der. Next, proceed to augment the lateral
tubercles of the upper lip by redirecting the
cannula toward the red lip lying below the ver-
milion border and placing HA filler in the sub-
mucosal layer. This gives a slightly upturned
appearance to the oral commissures when the
mouth is closed as the inferior border of the
upper lip curls up into a relative concavity at
the mouth corners. Note, however, that no more
than 0.2–0.3 mL should be injected into each
upper lateral tubercle as overfilling the tuber-
cles to achieve this perceived eversion  might
lead to the appearance of unnatural lumps.
Where accentuation of the central tubercle is
desired, introduce a 30-G sharp needle through
the midpoint of the cupid’s bow, a.k.a. the GK
point, and advance inferiorly toward the central
tubercle. 0.1  mL of HA is appropriate for
enhancing the central tubercle. The use of the
30-G needle is also employed to define and
enhance the cupid’s bow and the philtral col-
umns in case they are either congenitally weak
or have flattened with age. To enhance the phil-
tral columns, insert the 30-G needle at the peak
of the cupid’s bow and advance superiorly to
deliver 0.1 mL of HA at the dermal and subder-
mal layer.
4.12.4.2
The Lower Lip
The same method can be applied for lower lip
augmentation. First, HA filler is injected along
the vermillion border to define and enhance the
lower lip contour. Once the outline has been
treated, volumize the body of the lips by aug-
menting the lateral tubercles. The nondominant
hand should be used to press down the midline of
the lower lip to prevent the spreading of HA filler
into the midline. The presence of two distinct
bumps resembling “cherries” formed on either
side of the midline culminates in the appearance
of aesthetically pleasing cherry lips. It is also
worth pointing out that lower lip volumization is
usually performed only at the medial two-thirds
of the lip, and that the lateral edges are rarely
addressed, as the  flattening of the lip volume
toward the lateral edges provides a more natural
Fig. 4.95  Injection technique for lip augmentation using cannula
4  Regional Particulars

207
appearance. However, when treating patients pre-
senting a horizontally short lower lip, volume can
also be placed in the lateral one-third of the lower
lip  to elongate the lip width. Typically, 0.3–
0.4 mL of HA is placed into each lateral tubercle.
To fill out the remaining lateral edges of the bot-
tom lip, however, more than  0.5  mL of HA is
required per side of the lower lip.
4.12.4.3
The Needle Technique
A 30-G needle can be used instead of a cannula
by placing several short retrograde linear threads
of HA filler  sequentially along the border
(Fig. 4.96). Alternatively, merely pushing in the
product at the mouth corner into the subdermal
layer of the vermillion border allows the product
to track along the ridges, even without advancing
the needle, toward the medial aspect of the lips.
From this, it can be inferred that a particular path
of least resistance exists within the anatomy of
the vermillion border. When augmenting the body
of the lips with a needle, the injection should be
made at the submucosal level superficial to the
muscular layer as the labial arteries run deep to
the orbicularis oris m. As with all needle injec-
tions, aspiration before each injection is critical to
prevent inadvertent intravascular filler injection.
4.12.4.4
Combination Treatments
Lip enhancement can include the use of BoNT-A
for the treatment of perioral rhytids. For severe
perioral rhytids, intradermal or subdermal place-
ment of HA filler into the cutaneous part of the
lips following the restoration of the vermillion
border can provide direct wrinkle improvement
as well as overall enhancement in skin elasticity
in the perioral region. Meanwhile, downturned
mouth corners can be addressed by placing 0.2–
0.5 mL of HA filler immediately below the oral
commissure, either intradermally or subdermally,
to  provide upward structural support. Volume
restoration in the marionette lines may also pro-
duce more synergistic results (Fig.  4.96).
The adjunctive use of BoNT-A injections in the
depressor angulioris (DAO) is also commonly
performed to relax its downward pull on the
mouth corners (Fig. 4.97).
4.12.5 Complications
Duck Lips: Overcorrection of lip volume should
be avoided as it may result in the so-called “duck
lip” appearance (Fig. 4.98).
Fig. 4.96  Injection technique for the lip augmentation using needle (left lip) and mouth corner elevation (right mouth
corner)
4.12  Lip Filler

208
Embolization: Intra-arterial injection of HA
filler in the labial arteries may occur in the
event the injection was performed with a needle.
Violaceous discoloration of lips following HA
filler injection is highly indicative of an embolic
event which requires immediate dissolution of
the HA filler. While tissue necrosis hardly occurs
in the lips owing to its extensive vascularity, care
is advised nonetheless.
Bumps and Lumps: On occasion, the injection
pressure may cause the HA filler to shift within
the soft and loose matrix of the wet mucosa and
a
b
Fig. 4.97  (a) Before and (b) after Botulinum toxin injections 3U per side in the depressor angularis oris (DAO) for
mouth corner elevation
a
b
c
d
Fig. 4.98  (a, c) Before and (b, d) after hyaluronidase injection at upper lip for the treatment of “duck-lip” from overfilling
4  Regional Particulars

209
protrude like frog eggs from inside of the lips.
This appearance can be disfiguring and requires
dissolution (Fig. 4.99).
Bruising: Rupture of the superior labial artery
must be avoided as it may result in a significant
hematoma (Fig. 4.99). 
Asymmetry: Asymmetric volume change may
occur after lip filler.
Herpes Simplex: Outbreak of herpes simplex
following HA filler injection has been reported, if
only rarely.
Fig. 4.99  (a) Frog egg-lke protrusion at wet mucosa, (b) Bruising due to rupture of the superior labial artery, (c)
Asymmetry of lower lip after lip filler
a
c
b
Episode: Beautiful Red Lips, the Eternal
Symbol of Beauty.
Traditionally, a wide variety of idiomatic
­expressions have been used in Asia to refer
to exceptionally beautiful women. Women
with unrivaled beauty have been exalted as
possessing “out of this world beauty,”
“beauty that only exists at the edge of the
world,” or “beauty to match the heaven.”
Indeed, history is replete with examples of
ancient kings and emperors who have led
their kingdoms to doom due to their blind
infatuation with lethally beautiful women.
Examples include King Zhou of Shang and
his consort Daji, King You of West Zhou
dynasty and Baosi, King Fuchai of Wu
kingdom and Xi Shi, Emperor Xuan Zibg of
Tang and Yang Guifei. Hence, expressions
such as “beauty capable of overthrowing a
dynasty” or “beauty that could precipitate
the downfall of a kingdom” have been used
to glamorize women possessing an almost
dangerously stunning charm. Other tradi-
tional descriptors used to praise exquisite
female beauty include “face like a flower
and posture resembling the moon,” “lucent
irises and lustrous teeth” (from the poem
Lament by the River by renowned poet Du
4.12  Lip Filler

210
Episode: Origin of the Term
“Vermillion”
Vermilion (otherwise spelled vermillion)
refers to a bright red, almost scarlet-colored
pigment (Fig. 4.100), obtained from a red
mineral called cinnabar. The name vermil-
ion is originally derived from the term ver-
meillon, meaning worm, as in Ancient
times, red dye was extracted from scale
insects or cochineal insects. That said, the
production of vermillion today bears no
­relation to insects and is extracted instead
from minerals.
Fu during the Tang dynasty) and “red lips
and white teeth.” Among these, the origins
of “red lips and white teeth” can be traced
to the Chinese historical text “Records of
the
Three
Kingdoms”
(Sanguozhi).
According to the narrative, Cao Cao, one
of the key figures of the book and portrayed
as a master strategist, defeats Yuan Shao in
the battle of Ye (present-day Handan,
Heibei) in 204. Upon conquering Ye, Cao
Cao’s son Cao Pi (187–226) kills Yuan
Shao’s second son Yuan Xi and claims
Yuan Xi’s wife, lady Zen (182–221) as his
own. Lady Zen was a woman of sublime
beauty. Indeed, her gorgeousness was such
that Cao Cao lamented that the battle of Ye
might have been fought ultimately to
acquire lady Zen. Even Cao Pi’s 13-year-
old baby brother Cao Zhi secretly kept
amorous feelings for his sister-in-­law. In
220, Cao Pi succeeded Cao Cao as the king
of Wei and took in the two daughters of the
dethroned emperor Xian of the Han dynasty
as his concubines. Cao Pi was a king of
violent and ruthless temperament, and
when he suspected lady Zen of being jeal-
ous of the young concubines, he merci-
lessly ordered his first wife of many years
to be executed. While many stifled their
grief of lady Zen’s death for fear of inviting
Cao Pi’s wrath, only his younger brother
Cao Zhi dared to dedicate a poem in mem-
ory of his once beloved sister-in-law, enti-
tled “Ode to the goddess of the Luo River.”
A passage from the poem reads, “your red
lips luminesce outwards while your white
teeth gleam from within” from which the
expression “red lips and white teeth” origi-
nates and has been used almost as a byword
for female beauty.
In my general perception, the expression
“red lips and white teeth” applies not only
to describing beautiful Asian women.
“Tess” (1979) directed by Roman Polanski
based on Thomas Hardy’s classic novel, is a
film I saw as a young boy and one that
introduced me to the irresistible allure of
Nastassja Kinski. As is the case with many
old movies, the film is only remembered in
odd snippets of scenes. One scene, how-
ever, remains engraved into my mind like a
still image; the one where Alec d’ Urberville
with a penchant for beautiful women tries
to seduce Tess with strawberries. The tight
close-up shot of Nastassja Kinski’s luscious
red lips and brilliantly white teeth as she
bites into the freshly picked strawberry was
mesmerizing to the point of being intoxi-
cating. Spellbound by the pure, pristine,
almost wild beauty of Nastassja Kinski
captured in the scene at her innocent age of
18, my tender teenage heart longed to be
the strawberry she was devouring. Without
doubt, it can be said that the allure of full
red lips transcends both time and space as
the eternal hallmark of youthful beauty.
Having said that, it should come as no sur-
prise that Nastassja Kinski was the goddess
whose picture adorned the plastic writing
board that I kept between the notebooks in
my school bag.
4  Regional Particulars

211
Fig. 4.100  The color of Vermillion
4.13
Marionette Lines
Difficulty
Level:
B,
Effectiveness:
B,
Complications: B
Summary 1: Injection is performed using
23-G  ×  5-cm/27-G  ×  3-cm cannulas and
monophasic
HA
fillers
with
high
viscoelasticity.
Summary 2: The marionette fold is not sim-
ply an indented line or wrinkle but repre-
sents
a
three-­dimensional
curvilinear
structure produced by the sagging of the
jowls. While the fold itself may be filled in
with HA filler, the inferior descent and pro-
trusion of the cheek fat giving rise to the
fold must be addressed using the appropri-
ate adjunct treatment modality.
Summary 3: HA filler is deposited along the
depressed area under the mouth corner along
the marionette line. Considering that the
depression is the deepest at the area immedi-
ately under the mouth corner as well as along
the  depth of the fold itself, augmentation
should be directed primarily at these areas,
with a gradual decrease in injection volume
toward the medial and inferior aspects of the
marionette line. The relevant plane of injec-
tion lies above (superficial to) the DAO
(depressor anguli oris m.).
Summary 4: Concurrent volume restoration
is recommended if any volume deficiency is
present in the cheeks, nasolabial folds, pre-
jowl sulcus, or the labiomandibular folds.
Marionette lines are the oblique creases that
extend from the oral commissures to the mandibular
border. They take their name from the marionette
string puppets featured in European puppet shows
with visible crevices running down the mouth cor-
ners to allow animation of the jaws. Similar to the
nasolabial fold, the marionette fold is not simply an
indented crease or line but represents a three-dimen-
sional structure produced by the sagging of the
jowls precipitated by the laxity of cheek skin and
the clumping and descent of the jowl fat pad. The
repeated contraction of the DAO (depressor anguli
oris m.) and the platysma m. which pull the mouth
corners downwards also cements the static mario-
nette lines in place. In sum, marionette lines result
from several contributing causes; hence, each cause
should be approached individually to achieve the
most effective outcome (Fig. 4.101).
4.13.1 Anatomical Considerations
The marionette line is caused by the suspension
of the superficial jowl fat and the deep buccal fat
pad over the boundary against the modiolus, the
risorius m. and the mandibular ligament, which
anchors and restricts these overhanging structures
from further descent. The downward displace-
ment of the redundant cheek skin and underlying
4.13  Marionette Lines

212
fat pads with age leads to the elongation and
deepening of the marionette lines as well as the
formation of jowls and the pre-jowl sulcus, a dip
in the jawline appearing anterior to the jowl.
Another cause of the marionette lines is the
repeated contraction of the DAO and the platysma
m. which continuously pulls the mouth corners
downwards and outwards, causing the static mar-
ionette lines to deepen with time. When treating
the marionette lines, the use of a cannula is
preferred over a needle as the facial artery advanc-
ing superomedially toward the nasolabial fold
gives off the inferior labial artery under the lower
lip medial to the marionette line (Fig. 4.92) [32].
Modiolus and Marionette Lines
The term modiolus is derived from Latin
and means the “hub of a wheel.”
Histologically, the modiolus is a small,
thick, and dense structure. As the name aptly
suggests, it represents a point of conver-
gence for various facial expression muscles
which insert near the angle of the mouth
[33] (Fig. 4.102). The insertion of the zygo-
maticus major m., depressor anguli oris m.,
levator anguli oris m., depressor labii inferi-
oris m., orbicular oris m., risorius m., and
the buccinator m into the modiolus plays a
pivotal role not only in the development of
nasolabial folds and marionette lines but
also in the animation of facial expressions in
the perioral region for communicating vari-
ous emotions such as joy and sorrow.
Whereas the modiolus is more commonly
located above the intercheilion horizontal
line in Caucasians (66%), the modiolus in
Asians is more commonly located below
this line (58.4%) and is visible to the naked
eye in up to 21.4% of the population [34]
(Fig. 4.103). Presumably, this explains why
a  semblance of marionette lines can be
seen in Asians even as early as their teens
and twenties. Loss of volume in the cheek
contributes to the increased prominence of
the modiolus. As a tendinous nodule with
dense collagen fibers, the visibility of the
a
b
c
d
Fig. 4.101  (a, c) Before and (b, d) after the treatment of marionette line
4  Regional Particulars

213
4.13.2 Pretreatment Assessment
Presence of any cheek depressions, nasolabial folds,
or prominent buccal fat pad in the adjacent regions
must be identified to ensure overall facial balance
and harmony. Sunken cheeks should preferably be
restored in conjunction with the marionette lines, as
Fig. 4.102  The modiolus. The structure in the blue circle
represents the tendinous nodule located in the center of
the modiolus. To clearly demonstrate the tendinous nod-
ule, the LAO and the risorius were folded open to the
medial side. (OOr orbicularis oris, Zmj zygomaticus
major, Buc buccinators, R risorius, LAO levator anguli
oris, DAO depressor anguli oris, DLI depressor labii infe-
rioris) (photo: courtesy of Professor Hee-Jin Kim)
Zmi
Zmj
DAO
OOr
DAO
a
b
c
Fig. 4.103  Position of the modiolus by reference to the
intercheilion horizontal line. Type  A—Modiolus is
located lateral to the cheilion on the intercheilion horizon-
tal line. Type B —Modiolus is located above the interchei-
lion horizontal line. Type C —Modiolus is located below
the intercheilion horizontal line (OOr orbicularis oculi,
DAO depressor anguli oris, R risorius, Zmj zygomaticus
major, Zmi zygomaticus minor, LAO levator anguli oris)
(Modified from Ref. [32])
modiolus can overage the face in patients
exhibiting even the slightest degree of jowl
fullness  by giving the appearance of age-­
related jowl descent and accentuating the
marionette lines.
4.13  Marionette Lines

214
correction to the marionette lines alone can serve to
highlight the cheek hollows. Concurrent correction
of the nasolabial folds is recommended where the
marionette lines merge with the said folds. In
patients with a severe pre-­jowl sulcus, it is advisable
to also place HA filler along the mandibular line on
either side of the chin to mask the pre-jowl concav-
ity and straighten the jawline.
Concurrent correction  of  the sagging  jowl fat
using other treatment modalities such as  fat-­
reducing injections or liposculpture should also be
considered as well as energy devices such as high-
intensity-focused ultrasound (HIFU) or thread lift-
ing to provide contraction and suspension to a
sagging face.
4.13.3 Injection Technique
(Table 4.15)
4.13.3.1
Deep Static Marionette Lines
Correction is performed using monophasic HA
filler with high viscoelasticity and a 23-G 5-cm
cannula. A25-G or 27-G cannula may also be
employed to perform double layering in the
superficial subcutaneous fat layer. The 30-G nee-
dle can also be used for subdermal or intradermal
injection of HA filler just inferior to the oral com-
missures to concurrently lift the downturned
mouth corners (Fig. 4.96). It is useful to envisage
a three-dimensional space in the shape of a trian-
gular pyramid with the base at the marionette line
and with the lower vertex at the point where the
marionette line meets the inferior mandibular
border (Fig. 4.104).
The cannula entry point is created at the vertex
of the pyramid (Fig.  4.104). The HA filler is
deposited in the depressed area under the mouth
corner along the marionette line using linear
threading and fanning in the deep subcutaneous
plane above the DAO (Fig.  4.105). Since the
depression is the severest at the top end of the
marionette line just below the mouth corner and
along the length of the line itself, volume aug-
mentation should be directed primarily in these
areas with a gradual tapering off toward the
medial and inferior aspects of the marionette line.
In patients with severe jowls, the goal should be
to soften the appearance of the deep-set mario-
nette line rather than its obliteration as full level-
ing of the depression can exacerbate the
appearance of jowl ptosis and reinforce the per-
ception of a perpetual frown in these individuals.
The deep-set part of the marionette line should
be filled to 80–90% using a 23-G cannula.
Superficial refinements can then be made in the
subdermal layer with a 27-G cannula to complete
the correction.  A 30G needle can be used for
mouth corner elevation.
The standard amount of HA filler injected is
0.5–1.5 mL per side, depending on the depth of
the marionette line. The use of topical anesthetic
cream is sufficient for numbing the treatment
area. The nondominant hand should be used to
stretch the skin both inferiorly and laterally dur-
ing the injection to maintain tension on the skin
and facilitate cannula advancement.
4.13.3.2
Combination Treatment
Concurrent correction is recommended where vol-
ume deficiency exists in adjacent regions, includ-
ing the labiomandibular folds, pre-jowl sulcus, or
the nasolabial folds. Note, however, that in patients
with extremely heavy jowls, treatment of the pre-
Table 4.15  Summary of marionette line injection
technique
Item
Contents
Needle vs. Cannula
23-G 5-cm cannula
27-G 3-cm cannula for
superficial correction
30-G needle for correction of
the oral commissure
HA filler
Monophasic HA filler with
high viscoelasticity
Monophasic HA filler with
moderate viscoelasticity for
superficial correction and oral
commissure correction
Amount of HA filler
0.5–2 mL per side
Depth of injection
Deep subcutaneous layer above
the DAO muscle
Superficial subcutaneous layer
if necessary
Entry point for
cannula
Point where the marionette line
meets the mandibular border
Target area
The depressed area under
mouth corner along the
marionette line
Anesthetics
Topical anesthetics
Nondominant hand
Hold the skin inferiorly and
posteriorly in order to maintain
tension on the skin
4  Regional Particulars

215
a
b
Fig. 4.104  (a) The cannula entry point for the treatment
of marionette line (b) Schematic diagram of the volume
augmentation for marionette line conceptualized as filling
the three-dimensional space in the shape of a triangular
pyramid 
Fig. 4.105  The depth of injection for the treatment of marionette line
4.13  Marionette Lines

216
jowl sulcus should aim for a slight under-correc-
tion, as excessive plumping of the pre-jowl sulcus
in these individuals can distort the contour of the
jawline, making it appear bottom-heavy and
U-shaped. In patients with prominent cheek fat, it
is advisable to undertake 2–3 rounds of corticoste-
roid fat-reducing injections to achieve a more opti-
mal and toned appearance. In those with severe
jowl descent, the combined use of lifting treat-
ments such as HIFU or thread-lifting may be con-
sidered to tighten the heavy-looking lower face.
The combined use of BoNT-A injection in the
DAO may also be considered for elevating the
downturned mouth corners.
4.13.4 Complications
Irregularities: Disfiguring bumps in the form of
round buttons may occur over time  under the
mouth corners where  perioral muscle move-
ments are active, in case too much volume had
been  initially placed or where the injected HA
filler subsequently expanded  in volume due to
water absorption.
Note that the area under the modiolus is char-
acterized by significant perioral muscle activity.
The rigorous contraction of the perioral muscula-
ture and the occasional presence of cheek ­dimples
in the region may affect the injected HA filler in
such a way to clump it together or split it apart.
Meanwhile, full correction of the marionette
folds in those with pronounced jowl fat may
exacerbate the heaviness of the jowls.
4.14
Chin Augmentation
Difficulty
Level:
A,
Effectiveness:
A,
Complications: B
Reshaping a small or receded chin with HA
filler can significantly contribute to a more
refined and sculpted appearance by enhancing
the overall balance and proportionality of the
entire face, as is the case with filler rhinoplasty.
Indications for chin augmentation include the
elongation of a short chin, widening of a narrow
chin, projecting a retruded chin, and balancing
chin asymmetry (Fig. 4.106). Notably, improving
the chin projection with HA can help diminish
the appearance of an  over-projected mouth in
patients who have  normal chin size and dental
occlusion but present with bimaxillary protrusion
due to other orthodontal factors.
4.14.1 Anthropometry of the Chin
Anatomically, the chin is delineated superiorly by
the sublabiale, the deepest point of the labiomental
sulcus and inferiorly by the gnathion. While the
left and right lateral borders of the chin have not
been described in the literature, it would be rea-
sonable to assume that they lie at the marionette
lines. Significantly, the vertical length of the chin
Summary 4: HA filler is injected below the
soft tissue gnathion (Gn’) as opposed to the
Pog’ for elongation of the chin, while aug-
menting the left and right lateral aspects of
the chin results in widening of the chin.
Summary 1: Four key factors to consider
before augmenting the chin include the
height and width of the chin relative to the
entire face, the presence of chin retrusion
and chin asymmetry.
Summary 2: Treat using a 23-G 5-cm can-
nula. The target plane of injection is either
the supraperiosteal or the mentalis layer and
additionally in the superficial subcutaneous
adipose layer where necessary. Monophasic
HA fillers with high viscoelasticity is gen-
erally used for augmenting the chin.
Summary 3: For  improvement of anterior
projection, HA filler should be placed at the
central protuberance (soft tissue pogonion,
Pog’) of the chin conceptualized as an
‘ellipsoidal dome’.
4  Regional Particulars

217
tends to be shorter in Asians than in Caucasians.
Accordingly, while the ideal facial proportion
from hairline to glabella, glabella to subnasale,
and subnasale to gnathion is generally described
as 1:1:1, the preferred ratio approaches 1:1:0.8 in
Asians on account of their smaller [35]. Likewise,
while a 1:2 ratio should exist ideally between the
distance from subnasale to stomion and the dis-
a
b
c
d
Fig. 4.106  (a, c) Before and (b, d) after chin augmentation
4.14  Chin Augmentation

218
tance from stomion to soft tissue gnathion (Gn’),
the latter distance is also shorter in Asians.
Assessment should be made not only of the
height of the chin but also of its width. A congeni-
tally weak chin tends to lack not only vertical
height but also horizontal width. Males tend to
have wider chins, while females have characteris-
tically narrower chins. According to a study of the
gender difference in chin morphology, men typi-
cally presented with bi-lobed (33%) or square
(58%) chins, while the shape of the chin in women
was more pointed (55%) than square (45%) [36].
An aesthetic chin features a central protuberance
shaped like an ellipsoidal dome, with the horizon-
tal width of the said dome being similar to or
shorter than the width of the lips. Ideally, the most
prominent point of the chin, or the soft tissue
pogonion (Pog’), should lie adjacent to the inferior
one-third point of the stomion-­to-­gnathion line.
On profile, the Pog’ should be located approxi-
mately 3  mm posterior to a perpendicular line
(SnV) drawn from the Frankfort horizontal
through the subnasale (Sn) (Fig.  4.107) [37].
Generally Pog’ should never protrude beyond the
lower lip on the profile view. If Pog’ lies anterior to
the SnV, the chin is protrusive and is described as
showing prognathia or progenia or the bulging of
the lower jaw vis-a-vis the upper jaw. Conversely,
where the Pog’ falls more than 10mm behind the
SnV, the chin is retrusive otherwise described as
retorgnathia or retrogenia, where the lower jaw is
set back behind the upper jaw. It is also suggested
that, ideally, the angle formed between the line
from the radix to the subnasale and the line con-
necting the subnasale to the Pog’ should corre-
spond to 12 ± 4° [37]. An angle greater than 12° is
indicative of a retrognathic or receded chin.
Conversely, where this angle is narrower than 12°,
it suggests prognathia.
For reference, the notions of retrognathia and
prognathia were defined and classified by Angle
in 1899 [37]. According to Angle’s classification,
normal occlusion is where the teeth are aligned
properly with the first molar of the maxilla
aligned with the mandibular first molar. Class 2
malocclusion represents retrognathia where the
mandibular first molar lies posterior to the
maxillary first molar, while Class 3 malocclusion
constitutes prognathia where the mandibular first
molar lies anterior to the maxillary first molar. By
comparison, a Class 1 malocclusion occurs where
a normal relationship between the molars exists,
but there is a protrusion of the mouth due to an
overbite or bucked teeth, etc.
a
b
Fig. 4.107  Lateral view of an ideally proportioned chin.
(a) the Pog’ (soft tissue pogonion) should be located
approximately 3  mm posterior to a perpendicular line
(SnV) drawn from the Frankfort horizontal through the
subnasale (Sn). (b)  the angle formed between the line
from the radix to the Sn and the line connecting the Sn to
the Pog’ should correspond to 12 ± 41°
4  Regional Particulars

219
Retrognathia or a receded chin manifests as a
lack of anterior projection of the chin. A deficient
chin projection gives rise to the appearance of an
over-projected mouth, making the face appear
dull, goofy, and washed-out on profile. According
to established guidelines, the lower lip vermilion
in Caucasians should ideally fall behind a line
from the nose tip to the pogonion, defined as the
Ricketts’ esthetic line. In Asians, the lower lip
vermillion should preferably touch this line.
(Fig. 4.107).
4.14.2 Anatomical Considerations
In the sagittal view, the anatomical layers of the
chin from the outer to the innermost layers are
comprised as follows; the skin-subcutaneous fat-­
mentalis m.-mandible. The mentalis originates
from the mandible and inserts to the skin of the
chin. Its medial fibers intersect and overlap each
other as they insert to the skin at the median
plane, resulting in a dome-shaped prominence at
the center of the anterior chin (Fig. 4.108).
The vessels of the chin include the mental a.,
inferior labial a., and submental a. The mental a.
originates from the maxillary artery and exits the
mental foramen. The inferior labial artery
extends from the facial artery and courses
between the lower lip and the chin within the
substance of the depressor angulioris (DAO) and
the depressor labii inferioris (DLI) before
ascending superiorly and terminating at the
lower lip mucosa. The submental artery may also
provide branches that rise superiorly from under
the chin (Fig. 4.92).
4.14.3 Pretreatment Assessment
Four key factors to consider before augmenting
the chin include the height and width of the chin
relative to the entire face, as well as the presence
of chin retrusion or asymmetry. The chin should
be examined frontally for the adequacy of its ver-
tical height and horizontal width, as well as sym-
metry. A blunt U-shaped chin with adequate
width but lacking sufficient height should be dis-
tinguished from a congenitally weak chin which
manifests both the lack of width and height.
Asymmetry of the chin may appear from a dis-
parity in the size of the left and right chin or due
to the deviation of the underlying maxilla or
mandible. Chin asymmetry can be improved to
an extent by enhancing the smaller side of the
chin with HA filler.
From the lateral view, the chin should be
assessed for the presence of any retrusion (retrog-
nathia), protrusion (prognathia), or a protrusive
mouth. Consideration must also be given to the
patient’s gender as the ideal chin shape varies
between males and females. Ethnic differences
should also be taken into account as the presence
of a small receded chin is more prevalent in Asians
than in Caucasians. In particular, a round face with
a relatively small chin is a defining characteristic
of the intermediate type Asian face, found typi-
cally in those from Hong Kong, Taiwan, and
Fig. 4.108  Sagittal section of the chin (photo: cour-
tesy of Professor Hee-Jin Kim)
4.14  Chin Augmentation

220
Southern China [18]. The use of HA filler to elon-
gate the chin in these populations serves not only
to visually narrow their round faces by increasing
the overall facial length but also to add definition
and dimensionality to their undefined chin.
4.14.4 Injection Technique
(Table 4.16)
While biphasic HA filler is generally used for
augmenting the chin, monophasic HA fillers with
high elasticity can also be applied. A 23-G × 5-cm
cannula is used to deposit HA filler first into the
supraperiosteum and the mentalis layer and addi-
tionally in the superficial subcutaneous adipose
layer where necessary (Fig. 4.109).
While the use of topical anesthetic cream is
sufficient for local numbing, a mental nerve
block may be administered in patients with a low
pain threshold. Note, however, that in this case,
the procedure should begin at least 20 mins after
administering the nerve block following  suffi-
cient massage to avoid superfluous creation of
volume by the local anesthetic agent.
4.14.5 Improvement of Anterior
Projection
This technique is indicated in patients presenting
a retrusive chin (retrognathia) on profile
(Fig. 4.110). The labiomental sulcus on the chin
should be preserved to create a horizontally long
ellipsoidal dome when viewed from the front.
Care should be taken to ensure symmetry during
the procedure as even the slightest asymmetry in
the chin can become patently obvious due to its
central location along the facial midline.
Accordingly, the injection volume should be con-
trolled so that most of the HA filler is located at
the very center of the ellipsoidal dome. Further,
the nondominant hand should be used to press the
area opposite the cannula entry point during the
injection to prevent excess HA filler from diffus-
Fig. 4.109  (a) The depth of injection for chin augmentation. (b) Proper placement of HA filler in the chin con-
firmed by sonography evaluation
Skin
Subcutaneous fat layers
HA filler
Periostium
a
b
Table 4.16  Summary of chin filler injection technique
Item
Contents
Needle vs. Cannula
23-G 5-cm
HA filler
Monophasic HA fillers with
high viscoelasticity
Amount of HA filler
1–2 mL for chin projection
0.5–1 mL for chin elongation
1 mL per side for chin
widening
Depth of injection
Intramuscular and
supraperiosteal layer
Subcutaneous layer if
necessary
Entry point for
cannula
The intersection between a
vertical line from the oral
commissure and the horizontal
line which would pass through
the repositioned Pog
posttreatment
Target area
Pog’ for chin projection
Gn’ for chin elongation
Left and right sides of the chin
Anesthetics
Topical anesthetics
Mental nerve block if
necessary
Nondominant hand
Press the opposite side of the
dome and Gn’
Press the chin from under the Gn’
4  Regional Particulars

221
ing into the opposite side of the said dome. Note
that projecting the chin forward has the incidental
effect of elongating the chin downward as the
injected HA filler tends to push not only anteri-
orly but also inferiorly due to gravity and pres-
sure. This implies that the relevant cannula
insertion point in a patient with a short, receded
chin should be made at the junction where a verti-
cal line from the oral commissure meets the hori-
zontal line passing through the anticipated
location of the Pog’ after treatment, which should
be closer to the patient’s Gn’ at  baseline
(Fig. 4.111). This is because elongating the chin
causes the soft tissue Gn’ to drop more inferiorly,
Fig. 4.110  (a, c) Before and (b, d) after improvement of anterior projection
a
b
c
d
4.14  Chin Augmentation

222
and given that the ideal position of the Pog’ is at
a point marking the inferior one-third of the sto-
mion-to-­Gn’ line, it logically follows that the
repositioned Pog’ should also shift more inferi-
orly, sitting more closer to the patient’s existing
Gn’. On the other hand, where anterior projection
of the chin is desired without the accompanying
increase in the chin length, injection should be
made instead at the patient’s current Pog’. Here,
the nondominant hand should be engaged to
compress the Gn’ from the base of the chin to
prevent the HA filler from migrating inferiorly
down the platysma due to the injection pressure.
Meanwhile, the width of the ellipsoidal dome at
the chin should be shorter than the width of the
lip, corresponding preferably to two-thirds of the
lip width. In general, 1–2  mL of HA filler is
required to achieve anterior projection of the
chin.
4.14.6 Lengthening of Chin Height
(Elongation of the Chin)
In patients who have decent chin width and pro-
jection but present a blunt U-shaped chin due to
the lack of chin height, simply extending the chin
vertically along the midline can create the per-
ception of a narrower, more oval face with a sharp
v-shaped jawline (Fig. 4.112). Here, the HA filler
is injected below the Gn’ as opposed to the Pog.
The entry point is created 1 cm superior to the
intersection between a vertical line dropped from
the oral commissure and the inferior margin of
the mandible (Fig. 4.113). To create the appear-
ance of a distinctly sharp pointy chin, inject first
into the deep supraperiosteal layer for primary
volumization before  adding a small top-up
amount of HA at the superficial subcutaneous fat
level. When injecting the Gn’, the nondominant
hand should be used to press the base of the chin
to prevent the HA filler from migrating inferiorly
down the platysma due to the injection pressure.
A minimum of 0.5–1 mL of HA filler is needed
for chin elongation.
4.14.7 Widening of the Chin Width
In patients with a congenitally weak chin
(micrognathia), the chin lacks not only vertical
length but also horizontal width, both of which
must be addressed (Fig. 4.114). Extending the
chin inferiorly without addressing the horizon-
tal dimension in patients with a congenitally
narrow chin can result in the appearance of a
Fig. 4.111  The cannula entry point for the improvement of anterior projection
4  Regional Particulars

223
a
b
Fig. 4.112  (a) Before and (b) after chin elongation combined with widening of chin width
Fig. 4.113  The cannula entry point for chin elongation
4.14  Chin Augmentation

224
c
d
a
b
Fig. 4.114  (a) Before and (b) after widening of chin width. (c) A  bizarre droopy chin resembling the mask of
Tutankhamun and (d) after the hyaluronidase injection for this bizarre droopy condition
bizarre droopy chin resembling the mask of
Tutankhamun
(Fig. 
4.114).
The
proper
sequence of augmenting a deficient chin is to
first extend the chin anteriorly as well as infe-
riorly using the aforementioned approaches for
increasing chin projection and height, before
proceeding to widen the chin. The entry points
for augmenting the left and right lateral aspects
of the chin are to be created at points 1 cm lat-
eral to each marionette line and 1 cm superior
to the inferior border of the mandible
(Fig. 4.115). The cannula is inserted deep into
the supraperiosteal level and approached
toward the border of the central protuberance
of the chin, where HA filler (at least 1 mL) is
delivered per side using the retrograde thread-
ing ­technique. At least 4  mL of HA filler is
required in total to augment a congenitally
small chin, including a minimum of 2  mL
injected centrally and at least 1 mL placed on
each lateral aspect of the chin.
4.14.8 Correction of Chin Asymmetry
Where asymmetry exists between the left and right
sides of the chin on the frontal view, balance can
be restored by augmenting the lateral aspect of the
smaller side of the chin (see Sect. 4.18). Note,
however, that in cases where one side of the chin is
overly large, overcorrecting the smaller side with
the intention of matching the larger side  can
instead result in an excessively bulky, oversized
chin that serves to throw the balance of the entire
face. In this case, to the extent the patient presents
an innately short chin or a blunt U-shaped chin, it
helps to also elongate the chin along its midline to
create a V-shaped jawline on the whole. Also,
where the overall face appears slanted due to a
deviated mandible or maxilla (Fig. 4.116), extend-
ing the length of the chin with HA filler to realign
it with the midline of the upper face before enhanc-
ing the lateral aspect of the chin on the smaller side
can provide moderate improvement (Fig. 4.117).
4  Regional Particulars

225
Fig. 4.115  Cannula entry point for widening of chin width
Fig. 4.116  Deviated maxilla (a) smile asymmetry, (b) tongue depressor bite test
a
b
4.14.9 Combination Treatment
The appearance of cobblestone chin or chin
dimpling is not uncommon in Asians, as the
bimaxillary protrusion prevalent in these popu-
lations often requires over-contraction of the
mentalis to achieve a lip seal. Accordingly, syn-
ergistic use of BoNT-A to relax  the  mentalis
strain can be beneficial when augmenting the
Asian chin with HA. Also, where chin augmen-
tation is performed to camouflage a bimaxillary
protrusion, concurrent volume restoration in the
buccal hollows and nasolabial folds can further
help blend the prominence of the  protrusive
mouth by restoring and restructuring the peri-
oral complex as a whole. In patients with an
innately deficient chin or deep marionette lines
from aging, filling the marionette lines can help
optimize results.
4.14  Chin Augmentation

226
4.14.10 Complications
Tutankhamun’s Chin: Augmenting a weak chin
only in its central aspect without addressing the
lateral dimensions can create the appearance of a
ptotic chin similar to that of Tutankhamun.
(Fig. 4.114c) Make sure to also treat the left and
right lateral aspects of the chin.
Asymmetry: Note that even the slightest
asymmetry in the chin becomes immediately
noticeable due to its central position along the
facial midline. Envisioning the chin as an ellip-
soidal dome, make sure to locate most of the vol-
ume at the center of the said dome. The
nondominant hand should be used to press the
opposite end of the dome to prevent the spread of
excess HA filler into the area.
Irregularities: When injecting the soft tis-
sue Gn, the injection pressure may send HA filler
traveling down the platysma band, causing it to
collect under the chin. Pressing the base of the
chin with the nondominant hand during the injec-
tion can prevent this from occurring.
Bruising: Be mindful of the inferior labial
artery or the mental artery, as injury to these ves-
sels may lead to significant bruising. Use of a
cannula is advised in this regard together with
gentle maneuvering.
4.15
Jawline Filler
Difficulty
Level:
A,
Effectiveness:
A,
Complications: A
Summary 1: Inject using a 23-G 5-cm can-
nula and biphasic HA filler with large par-
ticle size.
Fig. 4.117  (a) Before and (b) After correction of chin asymmetry
a
b
4  Regional Particulars

227
Jawline augmentation is a procedure best
suited for patients presenting a thin narrow face
on the frontal view or aspiring to have a more
angulated, square or pentagonal jawline. This
makes the procedure particularly popular among
Caucasians endowed with a dolichocephalic head
that is long in the anteroposterior direction and
narrow in the  horizontal direction. Augmenting
the jawline and mandibular angle with HA filler in
this population can add definition and structure to
an overly narrow or weak lower face. The pres-
ence of a robust, chiseled jawline is also consid-
ered a desirable feature in men which enhances
male charisma and attractiveness. By extending
the jawline laterally, jawline augmentation also
creates the optical illusion of reducing the facial
height in individuals with a long face. Conversely,
jawline filler is seldom requested by Asian patients
who already have a wide brachycephalic head,
apart, perhaps, from when seeking to address the
asymmetry between the left and right mandible.
The procedure may be attempted in Asian patients
with an overly narrow pointy jaw that visually
elongates the face or in males who wish to
enhance their charisma based on a stronger jaw-
line. That said, there is a unique demand for jaw-
line fillers within a subset of Asians to address the
suboptimum result of a previous mandibular angle
reduction surgery. Here, HA filler can be used to
restore the angle of the mandible aggressively
removed during the surgery, and thereby address
the unnaturally steep linear jawline extending
from under the ear down to the chin when
observed from the lateral view (Fig. 4.118).
4.15.1 Anatomical Considerations
When seen from the profile view, the mandible
is an L-shaped bony structure consisting of the
body of the mandible on the inferior aspect and
the ramus on its posterior aspect. The junction at
which the body of the mandible meets the ramus
is defined as the angle of the mandible. The
masseter m. inserts into the mandible. The facial
a. passes the anterior border of the antegonial
notch located just in front of the masseter m.
before running upwards and forwards to the
nose. The use of a cannula is therefore preferred
over a needle during jawline augmentation to
avoid hitting the facial artery. Meanwhile, the
male lower face is generally wider and more
angulated than that of a female. Indeed, a com-
parison study of the differences between the
male and female mandibles has found that both
the bigonial width and lateral flaring of the man-
dibular angle were greater in men compared
with women.
Summary 2: The cannula entry point is cre-
ated at the anterior one-third point of the
mandible when viewed in profile, 0.5  cm
superior to the mandibular lower border. The
desired depth of injection is in the supraperi-
osteal and supramuscular layers (i.e., super-
Summary 3: Gender-based differences
should be taken into consideration, as men
generally have wider jaws and more promi-
nent mandibular angles than females. HA
filler placement in the jawline and angle of
the mandible is not recommended for
brachycephalic northern facial type Asians
with a relatively wide face and angulated
jaws, as accentuating the mandible only
serves to broaden their wide faces.
Summary 4: In Asians, jawline fillers can be
used to recreate the bone volume lost at the
angle of the mandible due to an overly aggres-
sive mandibular angle reduction surgery.
ficial to the masseter m). Augmentation of
the jawline should start at the angle of the
mandible and proceed along the jawline.
4.15  Jawline Filler

228
a
b
c
d
Fig. 4.118  (a, c) Before and (b, d) After jawline fillers. Jawline fillers can help to restore the angle of the mandible
aggressively removed during a previous mandibular angle reduction surgery
4  Regional Particulars

229
4.15.2 Pretreatment Assessment
Prior to treatment, assessments should be made
of the overall facial shape, width of the mandible
relative to the entire face, position and promi-
nence of the mandibular angle, and the presence
of any asymmetry between the left and right
mandible. Specifically, from the frontal view, it
should be determined whether the face is hori-
zontally wide or vertically long, whether the
bigonial width is in adequate proportion with the
overall face, and whether symmetry exists
between the left and right mandible. On the lat-
eral view, the position of the mandibular angle as
well as any visible loss of mandibular angle due
to a previous mandible resection surgery should
be identified. Gender-based differences should
also be taken into consideration, as men gener-
ally have wider mandibles and more prominent
mandibular angles than females. Jawline filler is
popularly requested by Caucasians demonstrat-
ing a thin narrow face but rarely sought by
Asians, particularly Northern Facial Type Asians,
with a relatively wide face and angulated jaws.
4.15.3 Injection Technique
(Table 4.17)
Injection is performed primarily using biphasic
HA filler with large particle size and a 23-G 5-cm
cannula, Regarding the desired depth of injec-
tion, injection is made first into the supraperios-
teal layer and the supramuscular layer superficial
to the masseter, before any further volume is
added into the deep subcutaneous fat layer, where
necessary. The use of local numbing cream
should provide sufficient anesthesia.
4.15.3.1
Jawline Augmentation
The cannula entry point is made at the anterior one-
third of the mandible in the profile view, 0.5 cm
superior to the inferior border of the mandible
(Fig. 4.119). Using the retrograde thread technique,
deposit HA filler starting at the angle of the mandi-
ble and along the jawline. Where concavities are
concurrently present in the adjacent cheeks, volume
should also be restored in the cheek to allow a
smooth transition down to the jawline. A minimum
of 1–2 mL of HA is required per side.
4.15.3.2
Mandibular Angle
Augmentation
Where too much bone has been resected at the
mandibular angle during a angle  reduction
surgery, measures must be taken to recreate the
lost bone volume. According to the study of
mandibular shape by Hu et al., in a vast majority
of cases, the mandibular ramus consist of
“slanted types” (74.5%) when viewed in profile.
As such, the angle of the mandible should be
recreated such that the gonion (the outermost
point of the ­mandibular angle at which body of
the mandible angles upward and becomes the
ramus) lies 1 cm inferior to the lower margin of
the current jawline on a vertical line dropped
from a point 1–2 cm anterior to the ear canal
(Fig. 4.120). Using the same cannula entry point
created for jawline augmentation, dispense a
bolus of HA filler at the angle of the mandible.
Connect the reshaped mandibular angle to the
jawline  by delivering  HA filler  in the  retro-
grade linear thread technique along the jawline.
When viewed in profile, the angle of the man-
dible should  reside anywhere between a hori-
zontal line extending from the mouth corner
(i.e., the intercheilion horizontal line) and the
Table 4.17  Summary of jawline filler injection
technique
Item
Contents
Needle vs. Cannula
23-G 5-cm
HA filler
Biphasic HA filler with large
particle size
Amount of HA filler
1–2 mL per side for jaw line
augmentation
>2 mL per side for mandibular
angle augmentation
Depth of injection
Supramuscular and
supraperiosteal layer
Deep subcutaneous layer if
necessary
Entry point for
cannula
0.5 cm above the mandibular
lower border at the anterior one
third of mandible. (jaw line)
Target area
Jawline and mandibular angle
Anesthetics
Topical anesthetics
Nondominant hand
Hold the chin skin anteriorly
4.15  Jawline Filler

230
soft tissue Gn. The closer the mandibular angle
sits to the intercheilion horizontal line, the slim-
mer to face appears when viewed from the front.
Consequently, where a slim, tapered jawline is
desired on the frontal view, the practitioner
should ensure  the mandibular angle, as it
appears on profile, does not descend below
intercheilion horizontal line (Fig.  4.118). In
contrast, the mandibular angle in a male patient
should ideally fall below this line (on the profile
view) for the jawline to appear more angulated
and masculine on the frontal view. It is prefera-
ble to also add volume to any concurrent cheek
hollows to ensure a smooth transition toward the
mandibular angle. A minimum 2 mL of HA is
required per side.
Fig. 4.120  The
appropriate location
for the mandibular
angle augmentation
Fig. 4.119  (a) The cannula entry point for jawline augmentation (b) Sonographic image displaying HA filler properly
placed in the supramuscular layer superficial to the masseter m
Skin
a
b
Subcutaneous fat layers
HA filler
Periostium
Masseter m.
4  Regional Particulars

231
4.15.3.3
Correction of Asymmetry
Where asymmetry exists in the size of the left and
right mandible, augmentation should be made to
the jawline, mandibular angle, and the cheek of the
smaller side in a way that best suits each individual
face. Concurrent HA filler placement is advised in
the sunken cheeks, where applicable, to ensure a
natural tapering of volume toward the jawline.
4.15.4 Complications
Irregularity: Care must be taken to distribute vol-
ume evenly across the treatment area to avoid
irregularities. Concurrent restoration is required
in the deflated cheeks to ensure a smooth transi-
tion to the jawline.
4.16
Earlobe Filler
Difficulty
Level:
A,
Effectiveness:
A,
Complications: A
The earlobe represents the most inferior part
of the ear consisting entirely of soft tissue and
skin without containing any cartilage. To many,
large ears with long stretched earlobes is one of
the first images that come to mind on hearing the
word “Buddha.” In Korea, where Buddhism has
held strong cultural influence, a large ear is posi-
tively associated with wealth, good societal
standing, familial bliss, health, and overall good
fortune according to the traditional physiognomy.
To this extent, patients may, on occasion, request
augmentation of the earlobe to increase their ear
size (Fig. 4.121).
4.16.1 Anatomy of the Outer Ear
The outer ear is an intricate structure consisting
of delicate elastic cartilage covered by thin skin.
Elements of the outer ears include, the helix, root
(or limb) of helix, antihelix, scapha or scaphoid
fossa, tragus, antitragus, inter-tragic notch, ear
meatus, and earlobe (Fig.  4.122). The earlobe
represents the noncartilaginous portion of the ear
consisting only of fibrofatty tissue. At birth, the
earlobe represents 66% of the ear length and 73%
of the  ear width. The ear reaches 80% of its
mature size at age six, 90% at age 9, 95% at age
14, and continues its gradual growth into adult-
hood [38]. The ear is believed to continue increas-
ing in size beyond the third and fourth decade,
and to  undergo a marked elongation after the
sixth decade. Some scholars attribute this elonga-
tion of the ears with aging to the gravity-induced
descent of tissue.
4.16.2 Injection Technique
Augmentation is performed using a 27-G cannula
inserted through an entry point created 0.5  cm
superior to the earlobe at the helix (Fig. 4.123).
Using a soft monophasic HA filler with medium
viscoelasticity, a bolus of 0.3–0.6 mL is injected
per side at the center of the lateral half of earlobe.
The desired depth of injection is the subcutane-
ous layer interposed between the skin of the ear-
lobe. Care must be taken not to inject more than
1  mL of HA filler per each earlobe as it may
impede the vascular circulation of the ear, possi-
bly leading to severe pain and even necrosis of
the skin. Postinjection molding is advised to pre-
vent any irregularities. Should there be any hard-
ness or blanching  due to impaired blood
circulation following an  over-injection of HA
filler, the patient should preferably be monitored
Summary 1: Treatment is performed using a
23-G cannula and a monophasic HA filler
with moderate viscoelasticity.
Summary 2: A bolus of 0.3–0.6  mL is
injected per side at the center of the lateral
half of the earlobe.
Summary 3: Where the patient desires
extra-­large-­sized earlobes, it is advisable to
repeat the treatment over 2–3 sessions at
2–3 month intervals.
4.16  Earlobe Filler

232
Fig. 4.121  (a, c) Before and (b, d) after earlobe augmentation
a
b
c
d
4  Regional Particulars

233
in-clinic for 20–30 min. In this regard, where the
patient desires extra-large-sized earlobes, it is
advisable to repeat the treatment over 2–3 ses-
sions at 2–3 month intervals rather than attempt-
ing to inject an overly large amount in a single
session. Injection of too much HA filler in the
earlobe may also result in the complication of the
Tyndall effect.
Crux of helix
Tragus
Intertragic notch
Earlobe
Antitragus
Antihelix
Crura of antihelix
Scaphoid fossa
Helix
Fig. 4.122  Anatomy of the outer ear
Episode: Where Are the Other Nine?
In Luke 17:17 of the Holy Bible, Jesus
crosses the border between Galilee and
Samaria en route to Jerusalem. Along the
way, he enters a village where he is met by
ten lepers who cry, “Jesus, Master, have
pity on us!” Upon this, Jesus responds, “Go
and show yourselves to the priests. You
would have been cleansed.” As the lepers
set forth to meet the priests, they find
they are miraculously cured of their leprosy
Fig. 4.123  The cannula entry point for earlobe
augmentation
4.16  Earlobe Filler

234
just as Jesus had foretold. One of them
turns back upon realizing he has been
healed and falls on his face at Jesus’ feet
exclaiming, “Praise God!” As it happened,
he was a Samaritan, not a Jew. To this, Jesus
lamented, “Were not ten cleansed? Where
are the other nine? How come nobody
returned to give glory to God except for this
foreigner?”
Leprosy is an infectious disease caused
by the bacteria Mycobacterium leprae,
which spreads throughout the body, primar-
ily affecting the skin, the respiratory organs,
and the peripheral nerves. It causes disfig-
uring rashes or nodules on the skin and
undermines the person’s ability to feel pain,
leading to the necrosis of the skin or the
loss of extremities, including the fingers
and toes due to unnoticed wounds.
Unsightly to the eyes and deemed highly
infectious, those afflicted with leprosy dur-
ing the ancient times were treated as sinners
and shunned from the rest of the society as
outcasts. With no effective cure at the time,
leprosy patients were condemned to live
with hideous deformities for the rest of
their lives until their eventual death. So it
was, in fact, a pretty big deal when Jesus
gratuitously cured those ten lepers of their
terrifying disease with his words alone. Yet,
none of them even bothered to thank Jesus
except for one, a foreigner from Samaria
despised by the Jewish community at large
at the time. It is not difficult then to appreci-
ate Jesus’ amazement when he asks where
the other nine were.
According to the Roman philosopher
Cicero, “Gratitude is the greatest of all vir-
tues.” Yet all too often, we find cases where
an act of kindness instead  backfires on
those who bestowed it. “Save a drowning
man only to be accused of missing his
bag” as we say in Korean, I am reminded
of a case 2  years ago where a young
woman died due to an anaphylactic shock
after receiving bee venom acupuncture
from
an
oriental
medicine
clinic.
Amazingly, the bereaved family  pro-
ceeded to sue for damages not only against
the oriental medicine doctor who per-
formed the acupuncture but also the fam-
ily medicine doctor practicing out of the
same building who undertook the emer-
gency treatment. The basis of their claim
was that patient had passed away due in
part to the inadequacy of the emergency
treatment
undertaken,
throwing
a
major  curveball at the family medicine
doctor who simply acted in good faith to
resuscitate the patient. Mercifully enough,
the court ultimately found the family med-
icine doctor not liable for the patient’s
death.
I also had a similar experience once
when I was visited by a female patient
who complained of irregular contours in
the forehead from a HA filler treatment
received elsewhere, which she wanted dis-
solving. The HA filler was succes-
fully  removed as per her request, and
smoothness was restored to the forehead
within a week. This time, however, the
patient took issue with “the descent of the
cheeks” and “the thinning of the skin” she
purportedly experienced following the
removal of HA filler in the forehead even
though the cheeks were never even treated
with hyaluronidase in the first place. Of
course, no difference could be noted in the
cheeks between the pre- and posttreatment
photos. Yet, the patient was adamant,
insisting that she knew best when it came
to her face and that I was somehow respon-
sible for these problems. The situation
escalated to the point where, following a
prolonged attempt to reason with the
unreasonable, the police had to be called
in to deal with the patient’s temper
tantrums.
4  Regional Particulars