Clinical Anatomy and Regional PDF

lww 15/9/15 10:32 4 Color Fig(s): F1-22 Art: PRSJ-D-15-00632
CLINICAL ANATOMY/REGIONAL APPROACHES
Lower Face: Clinical Anatomy and Regional

Approaches with Injectable Fillers
AQ3 André Braz, MD (Plast. Reconstr. Surg. XXX: 00, 2015.)
Shannon Humphrey, MD,
FRCPC, FAAD
Susan Weinkle, MD
G. Jackie Yee, MD
B. Kent Remington, MD,
FRCP
Z. Paul Lorenc, MD, FACS
Steve Yoelin, MD
Heidi A. Waldorf, MD
Babak Azizzadeh, MD, FACS
Kimberly J. Butterwick, MD
Mauricio de Maio, MD,
ScM, PhD
Neil Sadick, MD, FAAD,
FAACS, FACP, FACPh
Patrick Trevidic, MD
Gisella Criollo-Lamila, MD
Philippe Garcia, MD
Rio de Janeiro and São Paulo, Brazil;
Vancouver, British Columbia, and Cal-
gary, Alberta, Canada; Bradenton and
Miami, Fla.; New York, N.Y.; Newport
Beach, Beverly Hills, and San Diego,
Calif.; and Paris, France
T
he mandible (or inferior maxilla) consists Different mechanisms explain the aging
of an inferior portion that has a horseshoe- process of the mandible contour:2,3
like appearance, denominated body of the
mandible, and 2 perpendicular parts, which are Atrophy of the superior and inferior mandibu-
the mandibular ramus. The external surface is lar fat compartments, specially the subman-
marked in the median line by a faint ridge, indi- dibular compartment;
cating the symphysis or line of junction of the 2 Dehiscence of the mandibular septum causing
pieces of which the bone is composed at an early the superior and inferior compartments to
period of life. We name mandibular line the area move downward to the neck;
between the mentum and the angle of the man- Bone resorption;
F1 dible (Fig. 1).1 Skin laxity.
AQ2
From private practice; Carruthers & Humphrey Cosmetic
Medicine; Department of Dermatology & Skin Science, Uni-
versity of British Columbia; Remington Laser Dermatology
Fat Compartments and Ligaments
Centre; Laser & Cosmetic Dermatology, Mount Sinai Medi- Reece, Pessa, and Rohrich4 described 4 fat
cal Center; Clínica Médica Dr. Maurício de Maio Ltda.; compartments in the mandibular region. Two
and Expert2Expert Group. of them over the inferior mandibular border,
Received for publication June 11, 2015; accepted August 7, named superior and inferior mandibular fat
2015. compartments; a submandibular fat compart-
Copyright © 2015 by the American Society of Plastic Surgeons ment; and another covering the parotid-masse-
DOI: 10.1097/PRS.0000000000001836 teric fascia. (See Video, Supplemental Digital
www.PRSJournal.com 1
Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • November Supplement 2015
Disclosure: Dr. Braz reports financial disclosures

with Allergan, Galderma, Loreal (La Roche-PO-
SAY, Vichy, SkinCeuticals), and Palomar. Shannon
Humphrey is a consultant and investigator for Al-
lergan Pharmaceuticals, Galderma, and Kythera
Biopharma. Susan Weinkle has received honoraria
for her services as a speaker for Allergan, Bioform/
Merz, Dermik, Galderma, OrthoNeutrogena, and
Proctor & Gamble. She declares having received no
compensation for services as a consultant to Medi-
cis. She has received honoraria for her services as
an advisor for Allergan, Bioform/Merz, Dermik,
Kythera, OrthoNeutrogena, Proctor & Gamble,
and Stiefel. Dr. Weinkle is a stockholder in Derm
Advance. Dr. Yee reports that no funds were used to
support this work. Dr. Yee has associations with Al-
lergan (consultant, trainer, speaker), Merz Aesthet- Fig. 1. Anatomical features of the mandible.
ics (consultant, speaker), Galderma/Medicis (con-
sultant, trainer, speaker), Valeant Pharmaceutical
Corporation (consultant), Paradigm Medical Com- Content 1, which demonstrates lifting the fresh V1
munications, LLC (speaker), X-Medica (speaker), cadaver’s skin to show the superficial fat com-
Revance Therapeutics (consultant), Sientra (con- partments of the face, available in the “Related
sultant), and Medical Education Advocates, LLC Videos” section of the full-text article on PRS-
(speaker). Dr. Remington has no financial interest Journal.com or, for Ovid users, at http://links.
in any of the products, devices, or drugs mentioned lww.com/PRS/B468.)
in this article. He also did not receive any finan- The lower face’s fat compartments have 2 lay-
cial aid or reimbursement or honorariaum for the ers: the superficial fat compartment and the deep F3
project he submitted. Dr. Lorenc is a consultant for fat compartment (Figs. 2 and 3).5 F2
Galderma, Merz, Mentor, and La Lumiere. Dr. Mandibular septum is a membranous sep-
Yoelin has associations with Allergan (consultant, tum that separates the 2 compartments located
investigator) and Galderma (consultant). Dr. Wal-
dorf has associations with Allergan (consultant, ad-
visory board member, speaker’s bureau), Caudalie Valeant (consultant), Galderma (consultant, advi-
(advisory board member), Ferndale (consultant, sory board), and Suneva (advisory board). Dr. de
AQ16 advisory board member), Galderma (consultant, Maio has no financial interest in any of the prod-
advisory board member), Kythera (consultant, advi- ucts, devices, or drugs mentioned in this article. Dr.
sory board member, investigator, speaker’s bureau), de Maio is a consultant and speaker for Allergan.
L’Oreal (speaker’s bureau), Merz Aesthetics (con- Dr. Sadick has associations with Allergan (grants/
sultant, advisory board member, speaker’s bureau), research funding, honoraria), Galderma Laborato-
Neostrata (consultant, advisory board member, ries, L.P. (honoraria), and Valeant Pharmaceuticals
speaker’s bureau), Proctor & Gamble (speaker’s International (grants/research funding, honoraria).
bureau), Revance (consultant, advisory board Drs. Trevidic, Criollo-Lamilla, and Garcia have no
member), Sunvea (consultant, advisory board mem- financial interest in any of the products, devices, or
ber), Unilever (consultant, advisory board member, drugs mentioned in this article.
speaker’s bureau), and Valeant (consultant, advi-
sory board member, speaker’s bureau). Dr. Waldorf
reports receiving honoraria from all of the aforemen-
Supplemental digital content is available for
tioned entities, and additionally has received re-
this article. Direct URL citations appear in the
search support from Kythera. Dr. Azizzadeh reports
text; simply type the URL address into any Web
no relevant disclosures for his portion of the article.
browser to access this content. Clickable links
Dr. Butterwick has associations with Allergan (con-
to the material are provided in the HTML text
sultant, advisory board, investigator, stockholder),
of this article on the Journal’s website (www.
Merz (consultant, advisory board, speaker bureau),
PRSJournal.com).
2
Volume 136, Number 5S • Use of Fillers in the Lower Face AQ1
Video 1. Supplemental Digital Content 1, demonstrating lifting

of the fresh cadaver’s skin to show the superficial fat compart-
ments of the face, is available in the “Related Videos” section Fig. 3. The midface and lower face of a cadaver show the deep
of the full-text article on PRSJournal.com or, for Ovid users, at layer of fat compartments. The tip of the tool shows the deep
http://links.lww.com/PRS/B468. portion the buccal fat pad.
over the mandibular edge from the submandibu-

lar fat compartment. Fibers from the platysma
intermingle with the mandibular septum and are
inserted at the anterior border of the mandible.
Behind the depressor anguli oris (DAO) muscle,
inserting the skin, is the mandibular ligament
(Fig. 4).4 F4
MUSCLES
The mental area is composed of 3 muscles:
DAO muscle, depressor labii inferioris (DLI)
muscle, and mental muscle. These muscles merge
inferiorly with the platysma.6 It is important to
Fig. 2. The lower face of a cadaver shows the superficial layer of remember the relation of these muscles with the
fat compartments. orbicularis oris muscle (Fig. 5). F5
Fig. 4. The marionette fold and the jowl, in this female patient, are explained by the mandibular
ligament in the cadaver’s picture. The latter still shows the DAO muscle and the masseter muscle.
3
Fig. 5. The lower face of a cadaver shows the orbicularis oris

muscle and the DLI muscle.
Orbicularis Oris Muscle

Origin and insertion: It is not merely a sphinc-
ter muscle like the orbicularis oculi. It consists of Fig. 6. The lower face of a cadaver shows the DLI muscle and the
numerous strata of muscular fibers surrounding DAO muscle.
the mouth orifice with different directions. It con-
sists partly of fibers derived from the other facial Function: It helps to depress the lower lip.
muscles, which are inserted into the lips, and Innervation: Mandibular branch of the facial
partly of fibers proper to the lips. Of the former, nerve.
a considerable number are derived from the buc-
cinator muscle and form the deeper stratum of Depressor Anguli Oris Muscle
the orbicularis. The medial fibers decussate at the
angle of the mouth: those arising from the max- Origin and insertion: It arises from the
illa passing to the lower lip, and those from the oblique line of the jaw where its fibers converge
mandible to the upper lip. The uppermost and to be inserted into the angle of the mouth. At its
lowermost fibers of the buccinator pass across the origin, it fuses with the platysma, and at its inser-
lips from side to side without decussation. Super- tion with the orbicularis oris and risorius muscle
ficial to this stratum is a second one, formed on (Fig. 6).10,11
either side by the levator and DAO, which cross Function: This muscle depresses the corner of
each other at the angle of the mouth; those from the mouth.10
the levator passing to the lower lip, and those Innervation: The mandibular branch of the
from the depressor to the upper lip, along which facial nerve.7
they run, to be inserted into the skin near the
median line. In addition to these, fibers from the Mentalis Muscle
levator labii superioris, the zygomaticus, and the Origin and insertion: It originates from man-
DLI intermingle with the transverse fibers above dible, covers the mentum, and inserts into the
described, and have principally an oblique direc- skin below the lower lip (Fig. 7).12 F7
tion. The proper fibers of the lips are oblique and

pass from the under surface of the skin to the
mucous membrane, through the thickness of the
lip. There are also fibers that connect the muscle
with the maxilla and the septum of the nose above
and with the mandible below (Fig. 5).6,7
Function: Closes and projects the lips outward.
It is responsible for perioral rhytides formation.8
Innervation: Buccal branches from facial
nerve.6
Depressor Labii Inferioris Muscle

Origin and insertion: This muscle arises from
the line of the mandibule going upward to insert
Fig. 7. The lower face of a cadaver shows the mentalis muscle
F6 at the lower lip (Figs. 5 and 6).9
between the superficial and deep fat compartments of the chin.
4
Volume 136, Number 5S • Use of Fillers in the Lower Face
Function: It elevates and projects the lower lip

outward. At the same time, it causes wrinkling of
the chin skin. Hypertrophy of the mentalis mus-
cle results in the formation of a fold and creates a
“witch chin” look.10
Innervation: Mandibular branch of the facial
nerve.7
Masseter
The masseter has a square shape and comprises
a superficial and a deeper portion. (See Video, Fig. 8. The lower face of a cadaver shows the parotid, the parotid
V2 Supplemental Digital Content 2, which demon- duct, and the masseter muscle.
strates a simulation, with hyaluronic acid, on the
cadaver in the superficial fat compartment tem-
porolateral below the skin and above the masseter easily felt. A lot of vascular branches will appear
muscle, available in the “Related Videos” section after that: facial artery, inferior lip artery, superior
of the full-text article on PRSJournal.com or, for lip artery, angular artery (Fig. 9). F9
Ovid users, at http://links.lww.com/PRS/B469.) The Laterally and deeper than the facial artery and
superficial portion is the largest and arises from respective branches (inferior lip artery and superior
the zygomatic process and from the anterior two- lip artery), we can notice the facial vein (Fig. 10).14 F10
third of the inferior border of the zygomatic arch.

Its insertion is at the angle and inferior portion of Innervation
the mandibular ramus. The deeper portion arises The inferior teeth are localized in the alveo-
from the posterior third of the inferior border of lar part of the mandible. Below the second pre-
the zygomatic arch and is inserted at the superior molar tooth, on either side, midway between the
half of the mandibular ramus. The posterior rim upper and lower borders of the body, is the men-
of the masseter is covered by the parotid gland and tal foramen for the passage of the mental vessels
the anterior margin projects over the buccinators. and nerve. The mental nerve provides a sensory
The parotid gland’s duct (Stensen duct) arises innervation; because of that, the chin and prejowl
from the anterior part of the gland, crosses the sulcus area are very painful.
masseter muscle, and at its anterior border pene- On the other hand, in the motor innervation of
trates into the buccinator to enter the oral cavity at the lower face, the branches of the motor nerve are
F8 the level of the second superior molar (Fig. 8).6,13 buccal branches and marginal mandibular branch.
The latter promotes the motor innervation of the
Vascularization corresponding region and also provides the sen-
Generally, the facial artery appears 3 cm in sory innervation of the same area (Fig. 11).15 F11
front of the jaw angle and its pulsation can be
Video 2. Supplemental Digital Content 2, a simulation, with HA,

on the cadaver in the superficial fat compartment temporolat-
eral below the skin and above the masseter muscle, is available
in the “Related Videos” section of the full-text article on PRSJour- Fig. 9. The facial artery and branches: inferior lip artery, superior
nal.com or, for Ovid users, at http://links.lww.com/PRS/B469. lip artery, and angular artery.
5
Fig. 11. The buccal and the mandibular marginal branches of

the facial nerve.
the chin and the jaw angle. The sequence of the

Fig. 10. The facial artery with branches: inferior lip artery, supe- layers of this area is as follows: skin, superficial fat
rior lip artery. The facial vein is more lateral and in a deeper posi- compartment, final fibers of the platysma muscle,
tion than the artery. The facial vein can be seen inside of the deep fat compartment, and the bone (Fig. 12).4,16 F12
deep fat compartment of the midface. (See Video, Supplemental Digital Content 3, V3
which demonstrates HA, in green, in the superficial
fat compartment temporolateral above the masse-
Melomental Folds
ter muscle, available in the “Related Videos” sec-
The melomental folds are the crease formed tion of the full-text article on PRSJournal.com or,
between de commissures of the mouth and the area for Ovid users, at http://links.lww.com/PRS/B470.)
beside of the chin. We can notice the sequence of The prejowl sulcus is the area between the
the layers of this area: skin, superficial fat compart- chin and the jowl. The jowl begins after the man-
ment, final fibers of the platysma muscle, deep fat dibular ligament. The sequence of the layers of
compartment, DAO muscle, and the bone.7 this area: skin, superficial fat compartment, final
Jawline and prejowl sulcus: As we told you fibers of the platysma muscle in fusion with the
before, the mandibular line is the area between DAO muscle, deep fat compartment, and the
Fig. 12. A simulation, with a heavier HA, on the cadaver in the superficial fat compartment tempo-
rolateral above the masseter muscle. (Below) After the dissection, we can notice the HA (in green)
in the superficial fat compartment temporolateral above the masseter muscle.
6
Chin
The chin is composed for the structures above
of the mental’s symphyses. The sequence of the
layers of this area: skin, superficial fat compart-
ment, mental muscle, deep fat compartment, and
the bone (Fig. 14). (See Video, Supplemental Dig- V5
ital Content 5, which demonstrates the chin area F14
with the skin lifted to expose the superficial fat
compartment, the 2 portions of the mentalis mus-
cle, and the deep fat compartment, available in
the “Related Videos” section of the full-text article
Video 3. Supplemental Digital Content 3, showing HA (in green) on PRSJournal.com or, for Ovid users, at http://
in the superficial fat compartment temporolateral above the links.lww.com/PRS/B472.)
masseter muscle, is available in the “Related Videos” section Braz et al10 described a combined technique
of the full-text article on PRSJournal.com or, for Ovid users, at to prejowl sulcus augmentation with HA filler
http://links.lww.com/PRS/B470. and botulinum toxin injections on DAO muscle,
depressor inferioris labii muscle, and mentalis
F13 bone (Fig. 13).4,16,17 [See Video, Supplemental muscle. (See Video, Supplemental Digital Con- V6
V4 Digital Content 4, which demonstrates HA, in tent 6, which demonstrates a simulation with
green, in both layers of fat compartments (super- HA, on the cadaver in the deep fat compartment
ficial and deep), in other words, below and above of the chin with the HA in green. We can notice
the DAO and platysma muscles, available in the above the injection site the mentalis muscle and
“Related Videos” section of the full-text article on the superficial fat compartment of the chin. This
PRSJournal.com or, for Ovid users, at http://links. video is available in the “Related Videos” sec-
lww.com/PRS/B471.] tion of the full-text article on PRSJournal.com
Fig. 13. (Above) The superficial fat compartment of the prejowl area. Inside the circle are the melo-
mental folds and the prejowl sulcus area. (Below) After the dissection of the prejowl sulcus area,
we can notice the HA (in green) in both layers of fat compartments (superficial and deep), in other
words, below and above the DAO and platysma muscles.
7
lower lips, commissures, philtral column and phil-

tral groove, Cupid’s bow, tubercule, white roll,
and vermilion (Fig. 16).18 F16
The lips are formed by an outer portion
represented by the skin and its annexes, a tran-
sition zone, known as lip vermilion or semimu-
cosa, and an inner portion, called lip mucosa.
The lip mucosa is wet while the other portions
are dry. The orbicularis oris muscle inserts its
fibers at the boundary between the semimucosa
and lip mucosa and defines 2 fat compartments,
described previously by Rohrich et al19:
Video 4. Supplemental Digital Content 4, showing HA (in green)
in both layers of fat compartments (superficial and deep), in Superficial fat compartment, under the semi-
other words, below and above the DAO and platysma muscles, mucosa and above the orbicularis oris
is available in the “Related Videos” section of the full-text article muscle (Fig. 17). F17
on PRSJournal.com or, for Ovid users, at http://links.lww.com/ Deep fat compartment, below the orbicularis
PRS/B471. muscle and above the lip mucosa (Fig. 17).
or, for Ovid users, at http://links.lww.com/PRS/ -André Braz, MD

B473.) The author believes that the combined
technique provides a much better result to the
cosmetic treatment of the chin and the prejowl REGIONAL APPROACHES
F15 sulcus (Fig. 15). Lips
Shannon Humphrey, MD, FRCPC, FAAD,
Lips Vancouver, BC
The landmarks to the perfect lips are some In the lip, individual anatomical assessment
structures very well defined: convex upper and and specific treatment goals dictate the choice
Fig. 14. (Above) The chin area before and after the skin is lifted to expose the superficial fat com-
partment of this area. (Below) The superficial and deep fat compartments of the chin and the 2
portions of the mentalis muscle.
8
Video 5. Supplemental Digital Content 5, showing the chin area Video 6. Supplemental Digital Content 6 shows a simulation
with the skin lifted to expose the superficial fat compartment, with HA on the cadaver in the deep fat compartment of the chin,
the 2 portions of the mentalis muscle, and the deep fat com- with the HA in green. We can notice the mentalis muscle and the
partment, is available in the “Related Videos” section of the full- superficial fat compartment of the chin above the injection site,
text article on PRSJournal.com or, for Ovid users, at http://links. available in the “Related Videos” section of the full-text article
lww.com/PRS/B472. on PRSJournal.com or, for Ovid users, at http://links.lww.com/
PRS/B473.
of filler. To improve lip texture without signifi-
cant augmentation or alteration in size or shape, vertical rhytides in the vermilion lip and imparts
the injection of a soft HA filler with high flow a hydrated and more radiant appearance. In the
capacity (low G' and viscosity) in the immedi- video, I am using Juvéderm Volbella (15-mg/mL AQ4
ate submucosal plane reduces the likelihood of HA). (See Video, Supplemental Digital Content V7
lumping and facilitates tissue integration for a 7, which demonstrates Dr. Shannon Humphrey’s
smoother and softer look. Using a lighter product personal approach to lip treatment, available in
allows for very superficial injection, which softens the “Related Videos” section of the full-text article
Fig. 15. (Above) The superficial fat compartments of the chin, the 2 portions of the mentalis mus-
cle, and the deep fat compartments of the chin with the HA in green. (Below) The HA, in green,
inside both layers of the fat compartments (superficial and deep). Between those layers of fat
compartments we can notice the mentalis muscle.
9
deeper lip while retaining a soft, natural look and

feel. In the videos, I am injecting Juvéderm Volift
(17-mg/mL HA).
I use a combination of needles and cannulas in
the lip. In my experience, cannulas reduce the risk
of bruising and may mitigate swelling, although
they can be technically more difficult to use in the
highly mobile free lip. I prefer a 30-gauge 1-inch
microcannula (TSK Laboratory, Vancouver, BC or
Dermasculpt) when using a cannula, particularly
for immediate submucosal injection. For muscu-
lar or deep fat pad injections, or to augment the
angle of the mouth, I use a 28-gauge 3/4-inch
hypodermic Excel needle.
When it comes to the lips, less truly is more.
Conservative treatments will often provide the
Fig. 16. We can notice on the upper and lower lips the vermilion-
best combination of subtle aesthetic enhance-
cutaneous junction (V-C junction), semimucosa (or dry mucosa),
ment and patient satisfaction (Figs. 18 and 19). F18, F19
and mucosa (or wet mucosa).
Moreover, our deeper understanding of facial
aging and anatomy—the complex anatomical
on PRSJournal.com or, for Ovid users, at http:// relationships of various tissues (bone, muscle,
links.lww.com/PRS/B474.) For injection in orbicu- fat, and skin)—means we no longer treat certain
laris oris or the deep fat pad, an HA filler with areas in isolation but take a more global approach
intermediate flow and lift capacity (intermediate to rejuvenation.
G' and viscosity) augments the size and shape of Overzealous augmentation of the lip without
the lip, depending on the injection technique, regard to proper lip proportions in the context
and offers some substance and support in the of the face as a whole is a common pitfall. Big
Fig. 17. On the fresh-frozen cadaver after a sagittal cut on the upper lip, we can notice semi-
mucosa (S.M), superficial fat compartment (S.C), orbicularis muscle (O.M), deep fat compartment
(D.C), and lip mucosa (L.M).
10
white lip that is—in my experience—difficult to

achieve by injection of the lip itself.
When treating the lips, I almost always com-
bine HA with low-dose onabotulinumtoxinA (typi-
cally 4 U, with a dilution of 2.5 mL/100 U) divided
circumferentially into 8 evenly spaced injection
points in the orbicularis oris muscle. Neuromodu-
lators alone offer subtle eversion of the lips and
softening of vertical rhytides, whereas combina-
tion therapy in the perioral region prolongs the
duration of effect compared with either treatment
alone.21
Video 7. Supplemental Digital Content 7, showing Dr. Shannon The aesthetic endpoint is highly individual-
Humphrey’s personal approach to lip treatment, is available in ized and can only be determined after a careful
the “Related Videos” section of the full-text article on PRSJour- facial assessment. A “cookie cutter” approach
nal.com or, for Ovid users, at http://links.lww.com/PRS/B474. rarely works in the lip and is the root cause of the
“trout-pout” phenomenon.
AQ5 does not necessarily mean beautiful. The PHI The labial artery can be affected, leading to
approach20 provides an excellent framework for hematoma and—less commonly—vascular occlu-
beautification in contrast to rudimentary size aug- sion. A thorough grasp of anatomy is required
mentation (the infamous duck lip), which is out before injecting in all anatomic areas.
of date and greatly feared by patients themselves. Susan Weinkle, MD, Bradenton, Fla.
Isolated lip treatment in a patient with other sig- Successful lip rejuvenation begins with careful
nificant signs of facial aging will also lead to less assessment of each patient’s unique perioral and
satisfactory results; a youthful lip without an inte- lip anatomy. While identifying aesthetic strengths
grated, combination approach will always look and weaknesses and balancing the patient’s goals
unnatural on the aging face. with realistic clinical outcomes, I create a reju-
Although it is tempting to augment the white venation plan. In general, most patients desire a
roll alone in aging patients who have lost defini- natural, age-appropriate look.
tion of the vermilion border, doing so often leads Throughout my experience with a multitude
to rigid and unnatural results. Since most of these of injectable aesthetic treatment modalities, I
individuals suffer from loss of perioral volume have found specific products that target some
and bony support, revolumizing the surrounding of the aging symptoms my patients find trouble-
structures produces a lip that is better supported, some. For perioral lip barcode treatment as well as
slightly everted, and more natural looking in general lip enhancement, Restylane Silk HA is my AQ6
appearance than augmenting the white roll alone. first choice, for its ability to evenly spread within
Lengthening of the white lip occurs with aging the submucosal plane. For the patient requiring
and results in decreased projection and eversion primarily lip volume and contour augmentation,
of the vermillion lip. Poly-l-lactic acid injected I prefer the more soft and malleable Juvéderm
in the piriform fossa produces a natural looking Ultra. Regardless of the HA product chosen, I find
eversion of the upper lip and shortening of the it advantageous to blend in 0.2 mL of lidocaine
Fig. 18. Before (left) and after treatment (right) with 4 U of onabotulinum toxin A, 1 mL of 15 mg/mL cohesive HA filler, and 0.5 mL
of 20mg/mL cohesive HA filler.
11
Fig. 19. Before (left) and after treatment (right) with 4 U of onabotulinum toxin A, 1 mL of 15 mg/mL cohesive HA filler, and 0.5 mL
of 20mg/mL cohesive HA filler.
with epinephrine. This causes slight vasoconstric- The anatomy of the lips is very complex. It
tion, thereby reducing the incidence and severity is important to address each area. Aesthetically
of ecchymosis. Controlled injection speed is also notable features include the oral commissure,
extremely important. white roll, ergotrid and barcode, Cupid’s bow,
Beyond choosing the best product, I find the Cupid’s peak, Glogau-Klein (G-K) point, philtral
instrument of delivery critical for achieving ideal columns, tubercles, and wet dry line in addition to
results. Generally, I use 30-gauge ½-inch needles, the overall balance of upper and lower lip volume.
30-gauge 1-inch needles, and a variety of 27- and It is also necessary to understand the surrounding
30-gauge cannulas. However, I continue to return vascular anatomy and the depth of vessels to avoid
to the 30-gauge ½-inch needle, which provides the an inadvertent and potentially serious vascular
most precise injection control. I frequently use occlusive event.
cannulas on the upper lip barcode for the hori- Many patients find aging perioral anatomy a
zontal injection and then, if needed, efface fine hindrance to their self-confidence and personal
lines with a 31-gauge needle. (See Video, Supple- interactions. Most commonly, turned down oral
V8 mental Digital Content 8, which demonstrates Dr. commissures can communicate sadness, even in
Susan Weinkle’s technique to lip rejuvenation, an adynamic face. Treating this area with the sup-
available in the “Related Videos” section of the port of HAs, while relaxing the depressor angula-
full-text article on PRSJournal.com or, for Ovid ris oris muscle with a neuromodulator, can make
users, at http://links.lww.com/PRS/B475.) To avoid a significant difference in a patient’s appearance
lip distortion during injection, I prefer to use top- and quality of life.
ical anesthesia and “talk” anesthesia rather than As we mature, the upper lip elongates and flat-
local blocks. tens. By adding volume to the piriform aperture
and enhancing the philtral columns, the perioral
area can be significantly enhanced. It is important
to note that the philtral columns in the mature
patient are narrow at the base of the nose and
widen as they meet the G-K point. It is desirable to
add slight accentuation at the G-K point, thereby
enhancing Cupid’s peak. When adding volume to
the lip, I start at the lateral wet dry line and inject
slowly anterograde. Once the overall desired vol-
ume has been achieved, it may be necessary to
accentuate the upper and lower lip tubercles to
avoid a “sausage lip” look. Classically, the maxi-
mum volume should be in the middle two-thirds
Video 8. Supplemental Digital Content 8, showing Dr. Susan of the lips tapering off laterally to the corners.
Weinkle’s personal technique to lip rejuvenation, is available in Before injecting the entire volume of HA, it is
the “Related Videos” section of the full-text article on PRSJour- recommended that you pause and show the patient
nal.com or, for Ovid users, at http://links.lww.com/PRS/B475. his or her progress. If an area is not adequately
12
filled, you can still have enough remaining filler

for augmentation without having to utilize a sec-
ond syringe.
One must remember that the aesthetic end-
point in lip rejuvenation is extremely variable.
The patient’s age, initial volume, and facial shape
are important variables. Many patients require
gradual lip augmentation over a number of treat-
ments. I have also noted that over time with repeat
injections, most patients require far less product
to maintain their desired goal.
Fortunately, lip injections are overall safe, with
Video 9. Supplemental Digital Content 9, showing Dr. G. Jackie
only a few potential adverse side effects. Excessive
Yee’s personal approach to lip injections with HA for augmenta-
or unbalanced injections are of course undesir-
tion using Juvéderm Voluma, is available in the “Related Videos”
able. Occasionally, small nodules may result from
section of the full-text article on PRSJournal.com or, for Ovid
too much product injected in a small space. This
users, at http://links.lww.com/PRS/B476.
can either be expressed or dissolved with hyal-
uronidase. Frostbite can result from prolonged
exposure to ice post injection, especially if anes- wrinkles, available in the “Related Videos” section
thesia is used. The most concerning adverse event of the full-text article on PRSJournal.com or, for
of course is vascular occlusion. Fortunately, due to Ovid users, at http://links.lww.com/PRS/B477.) I
the depth of the arteries and the collateral circu- like the very precise correction and fine tuning
lation in this area of the face, this complication is accomplished with Restylane Silk.
uncommon. I use the needles that come with the products
Following these basic guidelines, I have been (not cannulas). I blend the 1-cm3 syringe of Juvé-
able to achieve beautiful lip rejuvenation that is derm Voluma with 0.15 cc of 1% lidocaine with
extremely gratifying for both the patient and epinephrine (1:100,000) for increased anesthetic
physician. effect and smoother, softer results.
It is important to inject products slowly and
G. Jackie Yee, MD, Miami, Fla. precisely into lips. I believe that fast injections lead
When considering lip injections, I determine to more irregularities, less precise placement, and
whether a patient needs volumization and/or def- more immediate swelling. I use very minimal mas-
inition and accentuation. sage or manipulation after placing the product.
A patient with a well-defined lip border may I inject using both anterograde and retrograde
need pure volumization and augmentation. The techniques, changing my needle frequently.
product of choice is Juvéderm Voluma. It gives the
lushness and softness that is desirable in lips. It
has a long duration and it causes very little imme-
diate edema after injection. (See Video, Supple-
V9 mental Digital Content 9, which demonstrates
Dr. G. Jackie Yee’s personal approach to lip injec-
tions with HA for augmentation using Juvéderm
Voluma injections to the lips for augmentation,
available in the “Related Videos” section of the
full-text article on PRSJournal.com or, for Ovid
users, at http://links.lww.com/PRS/B476.)
I use Restylane Silk in patients with perioral
rhytides, patients who need more definition to
their lip border, and patients with shape asym- Video 10. Supplemental Digital Content 10, showing Dr. G.
V10 metries. (See Video, Supplemental Digital Con- Jackie Yee’s personal approach to lip injections with HA for defi-
tent 10, which demonstrates Dr. G. Jackie Yee’s nition, accentuation, and wrinkle correction using Restylane Silk
personal approach to lip injections with HA for injections to define and accentuate lip shape and correct peri-
definition, accentuation, and wrinkle correction oral wrinkles, is available in the “Related Videos” section of the
using Restylane Silk injections to the lips to define full-text article on PRSJournal.com or, for Ovid users, at http://
and accentuate the shape and correct perioral links.lww.com/PRS/B477.
13
The amount of product injected should be

for full correction or full augmentation. No over-
correction should ever be performed on lips.
Proper anatomical proportions of the lips in rela-
tion to the patient’s face and anatomy should be
respected.
Intraarterial injection and subsequent tis-
sue necrosis and compromise can be avoided by
knowledge of the location and depth of the labial
artery.
B. Kent Remington, MD, FRCP, Calgary, AB
“Lip Blueprint.” the aim of this short video Video 11. Supplemental Digital Content 11, showing Dr. B. Kent
and the blueprint discussion below is to assist in Remington’s unique technique to lip injections using his formu-
creating the beautiful lip in Caucasian patients lated lip blueprint approach, is available in the “Related Videos”
and patients with skin of color. There is a differ- section of the full-text article on PRSJournal.com or, for Ovid
ence between inflation, reflation, enhancement, users, at http://links.lww.com/PRS/B478.
augmentation, and restoration. Most patients
just want the lips they once had. Evaluation of work and youthful lift of the corner of the mouth
good-resolution, nonanimated youthful photo- are important to understand. In this patient, I
graphs usually in the early 20s is very instructive used Juvéderm Voluma, making sure to get above
in this regard and can help with evaluating what the lateral “red” of the lip and lip when I inject
the philtral columns were like, the presence or anterograde.
absence of a vermilion tubercle, and what the bal- Subvermilion sheeting—the effect of
ance of the upper and lower lips were like. In lip Restylane Silk as well as Juvéderm Volbella in the
restoration, we are really trying to create a form subvermilion sheeting concept to erase the reticu-
of biomimicry—mimic what the lips looked like, lated lines and creases of the vermilion zone of
say 10 years ago. both the upper and lower lips. The injection tech-
Lip and perioral animation. Evaluation of the nique is both retrograde and anterograde. The
perioral animation and how this affects the appear- positive youthful results are almost like lipstick in
ance of the lips is an important consideration. a syringe. In this patient’s video, you can see the
Evaluate for lip pursing, gummy smiles (2 main shallow subvermilion technique and at the end of
types—“roll-up blind” and “Venetian blind”— video how the reticulated lines have dissipated.
require a different neuromodulator approach), These products also work well when contour-
and strong pull of the DAO giving the patient a ing and reflating the ergotrid zone above the ver-
pouty, grumpy look. Exaggerated chin dimpling milion right and left sides and the equivalent zone
when talking, chewing, and other animation can on the lower lip. Injecting a less viscous HA filler,
detract from the youthful appearance of the lip injecting anterograde and retrograde in a fan pat-
and perioral area. Neuromodulators can erase tern, using very small amounts of product. Use the
these undesirable features. same technique indicated on the left and right
The patient in this video did not require any side of the deflated zone on the lower lip below
neuromodulator in the upper lip zone, but I the vermilion. Both upper and lower lips have sep-
AQ7 injected 4 U of Botox in both DAOs. (See Video, tae adjacent to the vermilion border. There are
V11 Supplemental Digital Content 11, which demon- usually 2–4 septae in both upper and lower lips
strates Dr. B. Kent Remington’s unique technique and are like speed bumps noticed with cannulas,
to lip injections using his formulated lip blue print but rarely felt with needles.
approach, available in the “Related Videos” sec- Inject Restylane Silk and Juvéderm Volbella
tion of the full-text article on PRSJournal.com or, as with most HA fillers only subdermal—submu-
for Ovid users, at http://links.lww.com/PRS/B478.) cosal—and subvermilion. Avoid injecting into the
Lateral oral commissure management is key orbicularis oris muscle and the mucous glands of
to the youthful look of the lips—this zone is so the lip. Lip swelling is related to technique and
easily treated poorly. Products like Restylane Silk speed as well as product choice. One of the many
(fine lines) or Juvéderm Volbella do not have positive personalities of both products (Juvéderm
enough viscosity and lifting ability to lift the down- Volbella and Restylane Silk) is the patients tell us
turned LOC. The techniques to recreate the strut they feel, look, and behave like lips.
14
The “White Roll” of the upper lip—what is it has a high lifting capacity and a robust viscosity,
and how important is it and how do we restore which makes it ideally suited for correction of
it for the nice youthful looking lip; advantages of volume depletion of the prejowl sulcus and for
cannulas versus needles. Is there an equivalent building the support of the oral commissure.
“white roll” on the lower lip? On a routine basis, filler injection of the melo-
Philtral columns: with the aging process and mental fold is contemporaneously treated with a
genetics, the philtral columns may “splay” at the neuromodulator such as Xeomin (Merz Aesthet-
base giving an older aged appearance to the ics, Franksville, Wis.). The neuromodulator is
upper lip. To reestablish the narrower youthful directed at the midportion of the DAO muscle to
look, inject just to the medial side of each phil- decrease the mimetic muscle forces in the area of
tral columns in a retrograde pattern. This unique treatment, thereby increasing the persistence of
technique is a combination of feel proprioception the filler agent.23
and sight. This is best done with needles rather Method of delivery of an agent is dependent
than a cannula. In this patient, I used Juvéderm on the anatomical area treated. In the area of the
Voluma for the lateral oral commissure lifting melomental fold, I use 2 different techniques. For
and contouring and for recreating the philtral revolumization of the PJS, a subperiosteal place- AQ8
columns. ment of Perlane-L (Galderma Laboratories LP) is
Ultrasound gel helps to softly blend the filler made using a 29G 12-mm needle (Terumo Corp.,
so that there are no detectable transition zones. Tokyo, Japan) at 90 degrees to the skin surface in a
It also tells you the areas that need more atten- depot fashion. The oral commissure and the fold
tion. Be aware that there is a difference between itself are revolumized with Perlane-L (Galderma
blending, molding, and the most aggressive form, Laboratories LP) using a 27G 25-mm cannula
which is massaging with cool ultrasound gel. (TSK Laboratory) delivered by a needle punc-
Longevity is dependent upon degree of ini- ture in the deep dermal/submucosal plane. Each
tial correction, age group, smokers versus non- injection area is corrected to 100%; no overcor-
smokers, lip animation such as lip pursing habit rection is performed. Gentle massage is employed
and playing a musical instrument. We teach our to assure an even distribution of the filler mate-
patients that life is about maintenance; your hair, rial. Total volume injected varies from patient to
teeth, house, car, dog, and your face including lips. patient depending on the volume loss, average
My many years of experience show some patients being 1.5 cc per session. Xeomin (Merz Aesthet-
will go up to 1 year before a “top-up” is necessary. ics) is prepared at a 100 U/4-cc NaCl dilution
Their choice of timing of top-ups will depend and 2.5 U is injected into the midportion of each
on their goals—special upcoming events and how DAO, which has been previously marked with the
focused they are in having a youthful look. patient in a sitting position.24
Other than the routine aesthetic concerns
Melomental Folds taken into account during the consultation and
Z. Paul Lorenc, MD, New York, N.Y. delivery of the products, rejuvenation of the
Rejuvenation of any anatomical area, utiliz- melomental fold has an area-specific safety con-
ing injectable agents, is based on 3 critical factors. sideration pertaining to potential inadvertent
The first being a thorough aesthetic clinical assess- weakening of the DLI muscle. As demonstrated
ment of the patient with particular attention paid in the accompanying video, my preference is to
to each distinct anatomical area. Second is a thor- inject 2.5 U of incobotulinum toxin A per each
ough understanding of the functional anatomy DAO at the midportion of a vertical line drawn
of the particular anatomical area and the under- between the oral commissure and the angle of
standing of the complex interaction between vol- the jaw. (See Video, Supplemental Digital Con- V12
ume loss and mimetic muscle activity. Finally, an tent 12, which demonstrates Dr. Z. Paul Lorenc’s
in-depth knowledge of the physiochemical prop- personal technique to treating the melomental
erties of agents is necessary to be able to make the folds, available in the “Related Videos” section
correct agent selection for each anatomical area of the full-text article on PRSJournal.com or, for
to be treated. 22 Ovid users, at http://links.lww.com/PRS/B479.)
In my practice, based on the above factors, The injection point is located 1.0 cm lateral to
treatment of the melomental area may be per- the line in its midportion. Delivering the neuro-
formed using Perlane-L (Galderma Laboratories modulator at this specific point prevents an inad-
LP, Fort Worth, Tex.) with high G' (541 Pa) and vertent injection into the muscle fibers of the
high viscosity (124,950 cPa).6 This particular HA DLI, which may cause oral incompetence and/or
15
melomental folds by using dermal fillers to aug-

ment the regions noted above before addressing
the marionette lines themselves. Initially, address-
ing the problem of volumetric loss, rather than
the symptom of volumetric loss, can be a more
effective, more efficient, and more aesthetically
pleasing way to rejuvenate the aging face in gen-
eral and the melomental folds in particular.
Once the issue of peripheral volume loss
has been addressed, it has been my experience
that the marionette lines may still be noticeable
and problematic. If this is the case, I will con-
Video 12. Supplemental Digital Content 12, showing Dr. Z. Paul sider treating the DAO muscles with neurotoxins
Lorenc’s personal technique to treating the melomental folds, as well as treating the marionette lines directly
is available in the “Related Videos” section of the full-text article with dermal fillers. I feel that, if a patient has an
on PRSJournal.com or, for Ovid users, at http://links.lww.com/ active DAO, it is important to consider treating
PRS/B479. this muscle with an appropriate amount of neu-
rotoxin. Given the fact that many dermal fillers
asymmetry of the lower lip. Placing the injection are now formulated with lidocaine, an ingredi-
point significantly higher than the routinely advo- ent that may complicate the evaluation and treat-
cated injection at the level of the angle of the jaw ment of DAOs, it may be advantageous to treat
allows for a very efficient use of the neuromod- the DAOs before using dermal fillers.
ulator. Because the DAO is a pyramidal muscle, I find it challenging to attain consistently
injection at this point has a longer duration due good results when treating the melomental folds
AQ9 to the BNT unit/muscle mass ratio being higher. with dermal fillers. This may be because there is a
Immediately after the injection, gentle massage lack of boney support beneath the folds. This lack
in a medial to lateral direction is applied to assure of boney support makes it more difficult to create
avoidance of injecting the DLI. a lifting effect with dermal fillers.
Patients are routinely seen 1 week post injec- I use both needles and cannulas to treat this
tion to evaluate symmetry and the possible need area of the face. (See Video, Supplemental Digital
of further treatment to achieve the appropri- Content 13, which demonstrates Dr. Steve Yoelin’s V13
ate aesthetic endpoint. Utilizing the multimodal personal approach to treating the melomental
approach for the correction of the aging melo- folds, available in the “Related Videos” section
mental fold allows the practitioner to address both of the full-text article on PRSJournal.com or, for
causative factors, volume loss, and hyperactivity Ovid users, at http://links.lww.com/PRS/B480.)
of the mimetic musculature of the area. Not only I think that it is important to note that needles
both factors are addressed, but the persistence of may allow a greater level of precision relative to
the aesthetic effect is prolonged.
Steve Yoelin, MD, Newport Beach, Calif.
Melomental folds, also known as marionette
lines or “puppet lines,” commonly occur during
the aging process. It has been my experience
that people often consider melomental folds to
be the most bothersome feature of their faces. A
downward-turning mouth can indicate sadness or
unhappiness. This is very unfortunate since the
individual in question is typically neither sad nor
unhappy at all.
Marionette lines may be a symptom of pre-
vious or current volumetric changes in regions
Video 13. Supplemental Digital Content 13, showing Dr. Steve
peripheral to the area inferior to the oral com-
Yoelin’s personal approach to treating the melomental folds, is
missure. These peripheral areas include, but are
available in the “Related Videos” section of the Full-Text article
not limited to, the lateral portions of both the
on PRSJournal.com or, for Ovid users, at http://links.lww.com/
midface and lower face. It is reasonable to address
PRS/B480.
16
cannulas; however, some feel that cannulas may more viscous or stiff filler like calcium hydroxyl-
be safer than needles. In my experience, cannulas apatite (Radiesse or Radiesse Plus) or a lifting HA
tend to cause less bruising relative to needles. like Juvéderm Voluma or Perlane-L for injections
During the treatment process, I typically fill directly along the boney margin.
AQ10
the folds themselves with robust HA-based filler. Injection of the prejowl sulcus can be done
This can be done with a needle or cannula. from a lateral entry or, my preferred method,
When using a needle, the HA filler can be injected perpendicularly directly on bone with a
administered in layers in the deep dermis and needle where possible. (See Video, Supplemen-
in the subdermis. When using a cannula, the HA tal Digital Content 14, which demonstrates Dr. V14
dermal filler can be administered in the subder- Heidi A. Waldorf’s personal approach to treating
mal regions of the face. Once the folds have been the jawline and prejowl sulcus, available in the
addressed, I will typically administer a series of HA “Related Videos” section of the full-text article
threads just below the lateral portion of the lower on PRSJournal.com or, for Ovid users, at http://
lip. This can be done using a needle or cannula. links.lww.com/PRS/B481.) Because many patients
After the area just below that lateral lower lip has requiring lower face definition have had prior
been treated, I turn my attention to the area lat- facial surgery or are men with dense terminal hair
eral to the oral commissure. I will place a series of follicles, threading a cannula may be difficult. I
small aliquots in the subdermis, with one aliquot choose a 27- or 28-gauge 5/8- or 1.5-inch needle. I
lateral to another just below and a third aliquot use a combination of retrograde linear injections
just above the commissure. These final injections and bolus.
are administered using a needle. The order of improvement is important to
It is important to understand the anatomy of allow the patient to see improvement and maxi-
this region of the face. The mental nerve, artery, mize the effect of the filler used. Because volume
and vein may be found close to the inferior aspect loss in the midface and upper face causes ptosis
of the melomental fold. A clear understanding of of skin below, I begin by adding support to pull
these vital structures will help to reduce the risk of the upward vectors. That means revolumizing the
vascular compromise and will help to reduce the cheeks to reduce the pseudoptosis that aggravates
incidence of both bruising and patient discomfort the nasolabial folds and marionette lines. Adding
during the injection procedure. support in the prejowel sulcus reduces the mari-
My goal is to create an improvement in the onette lines, lifts the corners of the mouth, and
depth of the melomental fold and to elevate the develops the anterior portion of the forward pull-
downward-turning mouth. If I am able to accom- ing vector of the jawline. Finally, I develop the pos-
plish these 2 goals, I feel that the treatments are terior jawline from the edge of the jowl to the ear.
successful. It is vital not to overtreat melomental All areas can be treated in 1 treatment ses-
folds to avoid an unnatural end result. sion or over 1 year depending upon how conser-
Once the treatment is completed, I typi- vative the patient is medically, cosmetically, and
cally massage the region to make sure that that financially and the degree of volume loss and
the product is evenly distributed throughout the
treatment area. It may be helpful to schedule a
follow-up visit with your patient 10 to 14 days after
his/her initial treatment session so that you can
evaluate the treated area.
Jawline and Prejowl Sulcus

Heidi A. Waldorf, MD, New York, N.Y.
The jawline and prejowl sulcus are an impor-
tant unit to create a naturally youthful 360-degree
appearance. The jawline and prejowl sulcus will
improve as outlined below with replenishment of
the remainder of the face. Although almost any of
the USFDA approved filling agent can be used, I Video 14. Supplemental Digital Content 14, showing Dr. Heidi
like poly-l-lactic acid for generalized volumization A. Waldorf’s personal approach to treating the jawline and prej-
or more focal lifting with almost any of the HAs or owl sulcus, is available in the “Related Videos” section of the full-
with calcium hydroxylapatite. Because an attrac- text article on PRSJournal.com or, for Ovid users, at http://links.
tive jawline is well defined or “sharp,” I prefer a lww.com/PRS/B481.
17
photodamage. Patients with fat loss along the using poly-l-lactic acid or HA gel, and/or using a
boney jawline but a slim neck will see results fast- cannula of 25G or higher.
est, particularly in combination with other nonin-
Babak Azizzadeh, MD, FACS, Beverly Hills,
vasive tightening and resurfacing techniques. This
Calif.
technique is not for those with excess fat of the
The prejowl sulcus is an area that has been
neck and submental area until that fat is reduced
traditionally undertreated. Alloplastic implants,
with other methods. Otherwise, filler will be “lost”
autologous fat grafting, and fillers have been
and invisible.
described.25–27
Women’s jawlines should be a continuous line
Fillers are used for all patients not undergo-
ending at the ear. However, the masculine jawline
ing rhytidectomy and/or chin augmentation.
is more angular. Adjusting injection technique
A variety of different products are available that
from 1 retrograde injection to 2 perpendicularly
can adequately treat the area. HA gels, calcium
placed injections makes the difference.
hydroxylapatite, and poly-l-lactic acid can be uti-
Patients need to be prepared that even the
lized. The author does not like utilizing perma-
most expert injector cannot create a jawline in the
nent fillers.
patient who really requires a surgical face or neck
For most patients, the author recommends
lift. For those with significant laxity who refuse sur-
HA gels due to their reversibility. Restylane Silk
gical intervention to improve the lower face, the
and Perlane-L have a fairly high G' that allows
noninvasive therapeutic plan must include a com-
maximal lifting, whereas Juvéderm Voluma pro-
bination of lifting and volumizing from the inside
vides a potentially longer duration.
with filling agents and improving the tone of the
A single access point is typically utilized at the
skin with tightening devices like radiofrequency,
anterior portion of the jowls. (See Video, Supple-
ultrasound, and fractionated lasers. Although
mental Digital Content 15, which demonstrates V15
multiple procedures can be done simultaneously,
Dr. Babak Azizzadeh’s personal technique to
I generally prefer to separate them with a long-
treating the jawline and prejowl sulcus with der-
enough interval that any posttreatment edema or
mal fillers, available in the “Related Videos” sec-
skin barrier disruption has cleared.
tion of the full-text article on PRSJournal.com or,
For very thin patients, the jawline and prejowl
for Ovid users, at http://links.lww.com/PRS/B482.)
sulcus will not camouflage fillers that have been
The entry point and the mental foramen are infil-
injected too superficially. In these same patients,
trated with 1–2 cc of 1% lidocaine with 1:100,000
there is a small risk of fillers in the prejowel sulcus
epinephrine. Small aliquots are injected in retro-
being visible from within the mouth through the
grade and fanning fashion. Special attention is
buccal mucosa. I have had 3 patients with either a
made to the area just below the mandible as there
small asymptomatic nodule from poly-l-lactic acid
is often a significant depression.
or what appeared to be a white plaque after cal-
The aesthetic endpoint is full correction to
cium hydroxylapatite biopsied by an oral surgeon
restore a straight jawline and create a smooth
concerned about malignancy. In all 3 patients,
pathology revealed only a mild foreign body
reaction.
In an attempt to reduce the risk of infection
after soft tissue augmentation, including biofilm
reaction, it is important to cleanse the face well
with antiseptics extending preparation under the
jawline and onto the lips and ears. Patients are
asked to avoid dental procedures or cleansing 2
weeks before and after treatment and aggressive
flossing for a week after to reduce the risk of bac-
teremia. Patients with any history of oral or facial
herpes virus infection are given 2 g of Valacyclovir
before treatment and 2 g approximately 12 hours
later. The most serious concern when treating Video 15. Supplemental Digital Content 15, showing Dr. Babak
the lower face is the risk of vascular occlusion. Azizzadeh’s personal technique to treating the jawline and prej-
Avoidance of intravascular injection by injecting owl sulcus with dermal fillers, is available in the “Related Videos”
directly on bone where possible, pulling back on section of the full-text article on PRSJournal.com or, for Ovid
the syringe plunger to check for blood flow when users, at http://links.lww.com/PRS/B482.
18
transition between the jowls and chin. Sometimes, with CaHA and supraperiosteal depot injections
the area posterior to the jowl region needs also to with HA, available in the “Related Videos” sec-
be filled to accomplish this task. tion of the full-text article on PRSJournal.com
Pain and blanching along facial artery distribu- or, for Ovid users, at http://links.lww.com/PRS/
tion are warning signs of potential vascular occlu- B483.) For depot injections, I transfer higher G'
sion or embolism. The physician must immediately HA fillers into 31-gauge insulin syringes for safe
intervene to avoid serious complications. Hyal- low pressure injections on bone that are com-
uronidase should be infiltrated. Warm compresses, fortable for the patient. For retrograde fanning,
topical nitroglycerin, aspirin, hyperbaric oxygen, I prefer longer needles: 28G ¾ inch (27ID) and
and low-molecular-weight heparin could also be 25G 1–1.5 inch.
considered depending on patient’s condition. Technical pearls: start with supraperiosteal
depot injections at the chin—if recessed, pre- and
Kimberly J. Butterwick, MD, San Diego,
postjowl concavities, mandibular angle, and some-
Calif.
times zygoma for lifting the jowl. Then inject with
I prefer needles in this area. Although I joined
retrograde threads along the preauricular, man-
the cannula bandwagon a few years ago, I have
dibular, and zygomatic areas to create a smooth
now returned to needles for faster treatments and
mandibular border and balance facial shape. Aes-
more tactile feel. I do like cannulas in the medial
thetic caveats in females include overfilling the
cheek, periorbital area, and hands to minimize
chin and prejowl area causing an overly square
bruising and reduce the risk of intravascular injec-
jawline rather than a tapered feminine one.
tion in key areas. In the preauricular and mandib-
The aesthetic goal is to elongate and smooth
ular angle areas, the tissue is often fibrous as many
the mandibular border, erasing the concavity of
patients who need filler here are older and have
the pre- and postjowl sulci, and to lift and pull
had rhytidectomy or other tightening procedures.
back the jowl (Fig. 20). F20
Needles pass through this tissue more readily.
Safety considerations include avoiding the
My preferred fillers for the jawline and prej-
facial artery as it crosses the mandibular border
owl sulcus are CaHA28 and higher G' HA fillers29
at the anterior border of the masseter. Deeper
for maximum lift. If volumizing the entire face,
structures in the preauricular area (superficial
AQ11 I may choose monthly poly-l-lactic injections. I
temporal vessels and parotid gland) are avoided
prefer needles due to ease of passage and tactile
by staying in the immediate subdermal plane.30
feel and use a combination of supraperiosteal
Inject slowly while constantly moving retrograde
depot and retrograde fanning techniques. (See
to avoid intravascular injection. Aspirate near ves-
V16 Video, Supplemental Digital Content 16, which
sels before injection.
demonstrates Dr. Kimberly J. Butterwick’s per-
sonal technique to treating the jawline and prej- Chin
owl sulcus using 2 methods, retrograde threading
Mauricio de Maio, MD, ScM, PhD, São Paulo,
Brazil
Chin reshape is important to bring balance,
harmony, and proportion to the face. It is usually
neglected by most injectors. Juvéderm Voluma is
versatile to compensate bone, muscle and, chin
fat pad. Its rheological properties enable natural
result at rest and on animation.
The art of Chin architecture is demonstrated
by the MD Codes. Each chin subunit is coded as
follows: The 6-point chin reshape—C1 (mental
crease—labiomental sulcus); C2 (chin apex); C3
(anterior chin—soft tissue pogonion; C4 (submen-
tal—soft tissue menton); C5 (lateral lower chin),
Video 16. Supplemental Digital Content 16, showing Dr. Kim- and C6 (prejowl sulcus) (Fig. 21).31 Volumizing F21
berly J. Butterwick’s personal technique to treating the jawline the chin with a single big bolus or injecting at ran-
and prejowl sulcus using 2 methods, retrograde threading with dom will not provide optimal and natural contour.
CaHA and supraperiosteal depot injections with HA, is available The aesthetic endpoint should be assessed
in the “Related Videos” section of the full-text article on PRSJour- with the patient on animation (full smile, kiss-
nal.com or, for Ovid users, at http://links.lww.com/PRS/B483. ing, and pouting), in different positions (oblique,
19
Fig. 20. A 55-year-old woman before (left) and after (right) receiving 2 cc total volume of highly cross-linked HA filler along the
mandibular border, prejowl sulcus, mandibular angle, and preauricular region. Note the smoother, more defined mandibular bor-
der and chin and tighter lower third of face with pullback of jowl.
profile, and tilting down). On animation, total reshaping using Juvéderm Voluma, available in
absence of creasing or lines is desirable. How- the “Related Videos” section of the full-text article
ever, the skin cannot be too tight and circulation on PRSJournal.com or, for Ovid users, at http://
and venous return on digital pressure should be links.lww.com/PRS/B484.) Proper aspiration is
at normal speed. The soft tissue at the chin level mandatory especially close to mental foramen.
should be slightly movable and not paralyzed.
The chin area is quite forgiving. Needles Blunt cannulas (25G) are advisable if the skin is
(27G) are preferably used when deep injections adhered to the bone. Expanding the subcutane-
onto the bone are required. (See Video, Supple- ous and muscle fibers with blunt cannulas may be
V17 mental Digital Content 17, which demonstrates required in severe cases. Needles may be needed
Dr. Mauricio de Maio’s personal approach to chin back for final retouch.
Fig. 21. The MD codes: the 6-point chin reshape.
20
face rejuvenation in a 53-year-old neuromodula-

tor and filler-naïve female patient using Dysport,
Juvéderm Voluma XC, and Juvéderm XC, avail-
able in the “Related Videos” section of the full-
text article on PRSJournal.com or, for Ovid users,
at http://links.lww.com/PRS/B485.)
It is often necessary to employ a neuromodu-
lator before filler implantation to relax an overac-
tive mentalis muscles, elevate the nasolabial angle
by targeted DAO injections, treat fine rhytides, or
reduce masseter hypertrophy in this region.
A bimodal approach yields optimal results in
Video 17. Supplemental Digital Content 17, showing Dr. Mau-
this area with deep depot injections, carried out
ricio de Maio’s personal approach to chin reshaping using Juvé-
from an inferior site in a vertical deep dermal
derm Voluma, is available in the “Related Videos” section of the
fashion utilizing a fanning technique, to achieve
full-text article on PRSJournal.com or, for Ovid users, at http://
mandibular fat pad support followed by custom-
links.lww.com/PRS/B484.
ized dermal subcutaneous level injections for con-
touring as outlined by the physician and patient
Neil Sadick, MD, FAAD, FAACS, FACP, during the initial consultation.
FACPh, New York, N.Y. The aesthetic endpoint is correction and sym-
The lower face and chin represent the final metrical contouring of the chin, nasolabial folds,
artistic sculpturing touches in panfacial struc- and mandible (Fig. 22). F22
tural rejuvenation employing fillers and neuro-
modulators to achieve structural scaffolding and Patrick Trevidic, MD, Gisella Criollo-Lamila,
facial balance. I commonly employ poly-l-lactic MD, and Philippe Garcia, MD, Paris, France
acid, calcium hydroxylapatite, and larger molecu- For us, “chin” is not just the anatomical chin,
lar weight HA derivatives in the chin, mandible, but it is also all the area from one mandibular
underlying mentalis muscle, nasolabial folds, and ligament depression to the other and up to the
lateral lower face. commissure.
I prefer a 25G 1–1.5-inch needle for poly-l-lac- Because we want to project the chin and fill
tic acid and a 27G cannula for other products. the depression of the mandibular line in front of
I suggest HA products for younger individuals the jowl, we use the needle for a deep bolus or fan
and poly-l-lactic acid or calcium hydroxylapatite injection to project the anatomical chin and we
products for the middle-aged patient. (See Video, use the cannula for the depression from the man-
V18 Supplemental Digital Content 18, which demon- dibular line to the commissure with a fan tech-
strates a bimodal structural approach to lower nique above the muscle in the subcutaneous layer
For this procedure, we always use HA with high
cohesivity for its lifting capacity in this area. (See
Video, Supplemental Digital Content 19, which V19
demonstrates Dr. Trevidic, Criollo-Lamila, and Gar-
cia’s technique for chin reshaping using a highly
cohesive HA, available in the “Related Videos” sec-
tion of the full-text article on PRSJournal.com or,
for Ovid users, at http://links.lww.com/PRS/B486.)
(1) To project the chin, the product needs to
be injected in all the layers of the chin to increase
the lifting effect. Only if you inject deep, the lift-
ing effect will be less visible.
We perform, 15 days earlier, a botulinum
Video 18. Supplemental Digital Content 18, demonstrating toxin injection in the mentalis to reduce the tight-
a bimodal structural approach to lower face rejuvenation in a ness of the skin induced by this muscle.
53-year-old neuromodulator and filler-naïve female patient using (2) For the filling of the area of the depres-
Dysport, Juvéderm Voluma XC, and Juvéderm XC, is available in sion, we are not too deep to tighten the skin and
the “Related Videos” section of the full-text article on PRSJournal. to maintain the mandibular line using a high
com or, for Ovid users, at http://links.lww.com/PRS/B485. cohesivity product.
21
Fig. 22. (Left) A 53-year-old filler and neuromodulator-naïve female patient before lower face rejuvenation. (Right) The patient is
shown after lower face rejuvenation utilizing Dysport, Juvéderm Ultra Plus XC, and Juvéderm Voluma XC.
Andre Vieira Braz, MD

Clínica Dr. André Braz AQ12
Ipanema, Rio de Janeiro, Brazil
andre@drandrebraz.com.br
and avbraz@globo.com; or
Plastic and Reconstructive Surgery
8150 Brookriver Drive, Suite s-415
Dallas, TX 75247
PRS@plasticsurgery.org
PATIENT CONSENT
Patients provided written consent for the use of their
Video 19. Supplemental Digital Content 19, showing Drs. Tre- images.
vidic, Criollo-Lamila, and Garcia’s technique for chin reshaping
using a highly cohesive HA, is available in the “Related Videos”
ACKNOWLEDGMENTS
section of the full-text article on PRSJournal.com or, for Ovid
users, at http://links.lww.com/PRS/B486.
The “Lower Face Anatomy” portion of this article was
written by André Braz, MD. The “Regional Approaches”
sections were written by Shannon Humphrey, MD,
We do not reach the jowl and do not put too FRCPC, FAAD; Susan Weinkle, MD; G. Jackie Yee, MD;
much product as it can increase the drooping of B. Kent Remington, MD, FRCP; Z. Paul Lorenc, MD,
the tissue FACS; Steve Yoelin, MD; Heidi A. Waldorf, MD; Babak
First point: indications. This technique is for Azizzadeh, MD, FACS; Kimberly J. Butterwick, MD;
patients around 40–45 years old with a beginning Mauricio de Maio, MD, ScM, PhD; Neil Sadick, MD,
of sagging of the lower face (small jowl and visibil- FAAD, FAACS, FACP, FACPh; Patrick Trevidic, MD;
ity of the fixed point of the mandibular ligament Gisella Criollo-Lamila, MD; and Philippe Garcia, MD.
and a little retrogenia) or young patient with ret-
rogenia who do not want to undergo surgery.
Second point: contraindications. This tech- REFERENCES AQ13
nique is not for patients with a middle or huge 1. Radlanski RJ, Wesker KH. The facial skeleton. In: Radlanski
RJ, Wesker KH, eds. The Face, Pictorial Atlas of Clinical Anatomy.
sagging of the lower face because it will increase United Kingdom: 2012:148–161. AQ14
the square aspect of the chin when you add too 2. Braz AV, Pirmez R. Preenchimento Global (“Volumização”).
much filler and increase the weight within the In: Steiner D, Addor F, eds. Tratado de Envelhecimento Cutâneo. AQ15
drooping tissues. These patients are candidates 3. Braz AV, Aquino BO. Reabsorção Óssea. In: Sandoval MHL,
for surgery Ayres EL, eds. Preenchedores: guia prático de técnica e produtos.
1st ed. São Paulo: AC Farmacêutica; 2013:39–44.
There is no anatomical danger in this area, 4. Reece EM, Pessa JE, Rohrich RJ. The mandibular septum:
only frequent hematoma and bruising in the area anatomical observations of the jowls in aging-implications for
of the mandibular ligament.32–37 facial rejuvenation. Plast Reconstr Surg. 2008;121:1414–1420.
22
5. Braz AV, Sakuma TH. Compartimentos de gordura. In: 22. Sundaram H, Voigts B, Beer K, et al. Comparison of the rhe-
Sandoval MHL, Ayres EL, eds. Preenchedores: guia prático ological properties of viscosity and elasticity in two categories
de técnica e produtos. 1st ed. São Paulo: AC Farmacêutica; of soft tissue fillers: calcium hydroxylapatite and hyaluronic
2013:35–38. acid. Dermatol Surg. 2010;36:1859–1865.
6. Marur T, Tuna Y, Demirci S. Facial anatomy. Clin Dermatol. 23. Carruthers J, Carruthers A. A prospective, randomized, par-
2014;32:14–23. allel group study analyzing the effect of BTX-A (Botox) and
7. Pessa JE, Rohrich RJ. The lips and chin. In: Pessa JE, Rohrich nonanimal sourced hyaluronic acid (NASHA, Restylane) in
RJ, eds. Facial Topography, Clinical Anatomy of the Face. Missouri: combination compared with NASHA (Restylane) alone in
Quality Medical Publishing; 2012:251–291. severe glabellar rhytides in adult female subjects: treatment
8. Braz AV, Mukamal LV, Costa DLM. Manejo cosmético del of severe glabellar rhytides with a hyaluronic acid deriva-
tercio médio e inferior de la cara. In: Atamoros FP, Merino tive compared with the derivative and BTX-A. Dermatol Surg.
JE, eds. Dermatologia Cosmética. Cidade do México: Elsevier 2003;29:802–809.
Masson Doyma; 2011:31–50. 24. Lorenc ZP, Kenkel JM, Fagien S, et al. IncobotulinumtoxinA
9. Hussain G, Manktelow RT, Tomat LR. Depressor labii inferi- (Xeomin): background, mechanism of action, and manufac-
oris resection: an effective treatment for marginal mandibu- turing. Aesthetic Surg J. 2013;33:18S–22S.
lar nerve paralysis. Br J Plast Surg. 2004;57:502–510. 25. Romo T, Yalamanchili H, Sclafani AP. Chin and prejowl aug-
10. Braz AV, Louvain D, Mukamal LV. Combined treatment mentation in the management of the aging jawline. Facial
with botulinum toxin and hyaluronic acid to correct Plast Surg. 2005;21:38–46.
unsightly lateral-chin depression. An Bras Dermatol. 2013;88: 26. Shire JR. The importance of the prejowl notch in face lift-
138–140. ing: the prejowl implant. Facial Plastic Surgery Clin North Am.
11. Choi YJ, Kim JS, Gil YC, et al. Anatomical considerations 2008;16:87–97,vi.
regarding the location and boundary of the depressor anguli 27. Metzinger S, Parrish J, Guerra A, et al. Autologous fat graft-
oris muscle with reference to botulinum toxin injection. ing to the lower one-third of the face. Facial Plast Surg.
Plast Reconstr Surg. 2014;134:917–921. 2012;28:21–33.
12. Hur MS, Kim HJ, Choi BY, et al. Morphology of the mentalis 28. Dallara JM, Baspeyras M, Bui P, et al. Calcium hydroxylapa-
muscle and its relationship with the orbicularis oris and incisi- tite for jawline rejuvenation: consensus recommendations.
vus labii inferioris muscles. J Craniofac Surg. 2013;24:602–604. J Cosmet Dermatol. 2014;13:3–14.
13. Lee JY, Kim JN, Yoo JY, et al. Topographic anatomy of the 29. Sundaram H, Voigts B, Beer K, Meland M. Comparison
masseter muscle focusing on the tendinous digitation. Clin of the rheological properties of viscosity and elasticity
Anat. 2012;25:889–892. in two categories of soft tissue fillers: calcium hydroxyl-
14. Pessa JE, Rohrich RJ. The cheek. In: Pessa JE, Rohrich RJ, apatite and hyaluronic acid. Dermatol Surg. 2010;36(Suppl
eds. Facial Topography, Clinical Anatomy of the Face. Missouri: 3):1859–1865.
Quality Medical Publishing; 2012:47–93. 30. Pilsl U, Anderhuber F, Rzany B. Anatomy of the cheek: impli-
15. Kaya B, Apaydin N, Loukas M, et al. The topographic anatomy cations for soft tissue augmentation. Dermatol Surg. 2012;38
of the masseteric nerve: A cadaveric study with an emphasis (7 Pt 2):1254–1262.
on the effective zone of botulinum toxin A injections in mas- 31. De Maio M, Rzany B. Jawline and chin reshaping. In: De
seter. J Plast Reconstr Aesthet Surg. 2014;67:1663–1668. Maio M, Rzany B, eds. Injectable Fillers in Aesthetic Medicine.
16. Reece EM, Rohrich RJ. The aesthetic jaw line: management 2nd ed. Berling Heidelberg: Springer-Verlag;2014:125–129.
of the aging jowl. Aesthet Surg J. 2008;28:668–674. 32. Carruthers J, Narurkar V. Management of the Lips and
17. Hazani R, Chowdhry S, Mowlavi A, et al. Bony anatomic Corners of the Mouth. Soft Tissue Augmentation. 2008;50–61.
landmarks to avoid injury to the marginal mandibular nerve. 33. Klein AW. In search of the perfect lip: 2005. Dermatol Surg.
Aesthet Surg J. 2011;31:286–289. 2005;31(11 Pt 2):1599–1603.
18. Braz AV, Mukamal LV. Lip filling with microcannulas. Surg 34. Klein AW. The efficacy of hyaluronic acid in the restoration
Cosmet Dermatol. 2011;3:257–260. of soft tissue volume of the lips and lower 1/3 of the face: The
19. Rohrich RJ, Pessa JE. The anatomy and clinical impli- Evolution of the Injection Technique. Journal of Cosmetics,
cations of perioral submuscular fat. Plast Reconstr Surg. Dermatological Sciences and Applications. 2011;1:147–152.
2009;124:266–271. 35. Dayan SH, Arkins JP. The subliminal difference: treat-
20. Swift A, Remington K. BeautiPHIcation™: a global approach ing from an evolutionary perspective. Plast Reconstr Surg.
to facial beauty. Clin Plast Surg. 2011;38:347–377, v. 2012;129:189e–190e.
21. Carruthers A, Carruthers J, Monheit GD, et al. Multicenter, 36. Narins RS, Carruthers J, Flynn TC, et al. Validated assess-
randomized, parallel-group study of the safety and effective- ment scales for the lower face. Dermatol Surg. 2012;38
ness of onabotulinumtoxinA and hyaluronic acid dermal (2 Spec No.):333–342.
fillers (24-mg/ml smooth, cohesive gel) alone and in com- 37. Narurkar V, Shamban A, Sissins P, et al. Facial treatment
bination for lower facial rejuvenation. Dermatol Surg. 2010;36 preferences in aesthetically aware women. Dermatol Surg.
(Suppl 4):2121–2134. 2015;41(Suppl 1):S153–S160.
23
Author Queries
AUTHOR PLEASE ANSWER ALL QUERIES
AQ1—Please confirm whether the short title added here is appropriate.

AQ2—Please confirm affiliations.
AQ3—Please provide an abstract for the article.
AQ4—Please provide the name and city/state location of the manufacturer of the Juvéderm
products.
AQ5—Please spell out PHI. If this is the name of a company, please supply the full company name
and city/state location.
AQ6—Please provide the name and city/state location of the manufacturer of "Restylane Silk."
AQ7—Please provide the name and city/state location of the manufacturer of Botox.
AQ8—Please spell out PJS.
AQ9—Please spell out BNT.
AQ10—Please provide the name and city/state location of the manufacturer of Radiesse/Radiesse Plus.
AQ11—Correct as edited? “PLLA” was edited to read “poly-l-lactic injections.” If not correct, please
revise as needed.
AQ12—Please confirm correspondence details and provide a street address and postal code for
Dr. Braz.
AQ13—References 22–24 and 28–30 are not cited in text (in original manuscript). Please provide
citation or confirm whether these reference should be deleted and the subsequent refer-
ences be reordered in the citation as well as in the reference list.
AQ14—Please provide the publisher details (name, location) in reference 1.
AQ15—Please provide the publisher name and location, published year, and page range in reference 2.
AQ16—Please double-check the financial disclosure statement to confirm that it is correct. If it is
incorrect, please revise as needed.

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What are the different fat compartments in the mandibular region?

What are the different fat compartments in the mandibular region?

What are some of the mechanisms that explain the aging process of the mandible contour?

What are some of the mechanisms that explain the aging process of the mandible contour?

lww 15/9/15 10:32 4 Color Fig(s): F1-22 Art: PRSJ-D-15-00632

CLINICAL ANATOMY/REGIONAL APPROACHES

Lower Face: Clinical Anatomy and Regional

Plastic and Reconstructive Surgery • November Supplement 2015

Disclosure: Dr. Braz reports financial disclosures

Volume 136, Number 5S • Use of Fillers in the Lower Face AQ1

Video 1. Supplemental Digital Content 1, demonstrating lifting

over the mandibular edge from the submandibu-

Plastic and Reconstructive Surgery • November Supplement 2015

Fig. 5. The lower face of a cadaver shows the orbicularis oris

Orbicularis Oris Muscle

tion. The proper fibers of the lips are oblique and

Depressor Labii Inferioris Muscle

Volume 136, Number 5S • Use of Fillers in the Lower Face

Function: It elevates and projects the lower lip

third of the inferior border of the zygomatic arch.

front of the jaw angle and its pulsation can be

Video 2. Supplemental Digital Content 2, a simulation, with HA,

Plastic and Reconstructive Surgery • November Supplement 2015

Fig. 11. The buccal and the mandibular marginal branches of

the chin and the jaw angle. The sequence of the

Volume 136, Number 5S • Use of Fillers in the Lower Face

Plastic and Reconstructive Surgery • November Supplement 2015

lower lips, commissures, philtral column and phil-

or, for Ovid users, at http://links.lww.com/PRS/ -André Braz, MD

Volume 136, Number 5S • Use of Fillers in the Lower Face

Plastic and Reconstructive Surgery • November Supplement 2015

deeper lip while retaining a soft, natural look and

Volume 136, Number 5S • Use of Fillers in the Lower Face

white lip that is—in my experience—difficult to

Plastic and Reconstructive Surgery • November Supplement 2015

Volume 136, Number 5S • Use of Fillers in the Lower Face

filled, you can still have enough remaining filler

Plastic and Reconstructive Surgery • November Supplement 2015

The amount of product injected should be

Volume 136, Number 5S • Use of Fillers in the Lower Face

Plastic and Reconstructive Surgery • November Supplement 2015

melomental folds by using dermal fillers to aug-

Volume 136, Number 5S • Use of Fillers in the Lower Face

Jawline and Prejowl Sulcus

Plastic and Reconstructive Surgery • November Supplement 2015

Volume 136, Number 5S • Use of Fillers in the Lower Face

Plastic and Reconstructive Surgery • November Supplement 2015

Fig. 21. The MD codes: the 6-point chin reshape.

Volume 136, Number 5S • Use of Fillers in the Lower Face

face rejuvenation in a 53-year-old neuromodula-

Plastic and Reconstructive Surgery • November Supplement 2015

Andre Vieira Braz, MD

Volume 136, Number 5S • Use of Fillers in the Lower Face

AUTHOR PLEASE ANSWER ALL QUERIES

AQ1—Please confirm whether the short title added here is appropriate.

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