Hyaluronic Acid for Mentaland Mandibular Contour

Débora T. S. Ormond and Paulo R. Pacola

ContentsIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297

Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298

Hyaluronic Acid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306

Injection Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308

Take Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310

AbstractNonsurgical dermatological procedures suchas the use of hyaluronic acid (HA) are part ofthe therapeutic and preventive armamentariumagainst facial aging. Several intrinsic andextrinsic factors interfere with facial aging,many modifying the youthful anatomy of theface. In this process, alterations of bone, mus-cles, and face and skin fat together transformthe standard face from convex to concave. Thepurpose of this chapter is to address the use ofHA for rejuvenation and correction ofimperfections.

KeywordsFiller · Hyaluronic · Mental · Mentum ·Mandibular · Contour · Rejuvenation · Facial ·Volume · Aging

Introduction

Nonsurgical dermatological procedures have beengaining increasing importance in the therapeuticarmamentarium of facial rejuvenation due to theirsafety and the reliability of the results. These lessinvasive procedures follow current trends, as well asbeing more preventive interventions for aging.

The process of facial aging is influencedby natural chronological factors (gravitationalforces, subcutaneous fat loss, bone resorption),photo damage (breakdown of collagen and elas-tin, neoplastic changes), and traumas (diseases,inflammations, surgeries). Together, dentitionalterations, bone remodeling, the SMAS (superfi-cial musculoaponeurotic system), supporting lig-aments, and dermal thickness, as well as facial fatloss and repositioning lead to loss of facial vol-ume. These alterations cause the transformation ofthe young, convex face into the aged, concaveface, forming face shadows (Fig. 1). The agedaspect is accentuated by the emergence of

D. T. S. Ormond (*) · P. R. PacolaUniversidade Federal de MatoGrosso, Cuiabá, Brazile-mail: dormond@terra.com.br; paulopacola@hotmail.com

# Springer International Publishing AG, part of Springer Nature 2019M. C. A. Issa, B. Tamura (eds.), Botulinum Toxins, Fillers and Related Substances, Clinical Approaches andProcedures in Cosmetic Dermatology 4, https://doi.org/10.1007/978-3-319-16802-9_22

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dynamic wrinkles, resulting from the kineticactivity of the facial mimetic muscles throughoutlife. Hence the importance of using fillers at thementum and mandibular level, in isolation or inassociation with other techniques (neurotoxins,peeling, laser, radiofrequency and microfocusedultrasound), to restore facial contours.

Anatomy

In-depth knowledge of the middle and lower thirdof face and neck anatomy is of fundamental impor-tance for the interpretation of the physiological andpathological alterations that resonate in the man-dibular region, as well as to identify the anatomical

structures that should be monitored during theprocedure in order to prevent complications.

The mandible, the main representative of thelower third of the face, establishes the relationshipwith the structures of the middle third and neck. It isdivided into a body (presenting as a “U” shape) andbranch, which joins perpendicularly to the mandib-ular branch, forming an angle that may vary from110� to 140�, with a mean value of 125�. Theexternal surface of the mandible in the median lineis marked by the faint ridge called the ‘mandibularsymphysis.’The space between the mentum and themandibular angle is known as the mandibular line.The alveolar part of the mandibular region containsthe teeth in the lower arch. Below the second pre-molar tooth lies the mental foramen (Fig. 2), which

Fig. 1 Merz classification: typical changes from a youthful appearance (convexity of the face) to an aged appearance(flattened and concave face)

Fig. 2 Mandible anatomic structures

298 D. T. S. Ormond and P. R. Pacola

gives passage to the nerve and the mental vessels(Tamura 2010a), and is located in an approximatelyvertical line that passes through the limbus of theeyes, a little medially to the mid pupil. Neuralblocking at mental foramen level anesthetizes thelower lip and part of the mentum.

Bone alterations as a result of resorption(Fig. 3) of the alveolar parts of the maxillary andmandibular bones, loss of the dental arch (Fig. 4),and vertical and horizontal maxillomandibulardiscrepancies are directly responsible for theimproper positioning of the soft tissues, causingthinning and narrowing of their portions, reinforcingthe impression that the face is “falling” and forming

the famous “bulldog” formation (Fig. 5) and loss offacial contour.

The muscles that insert under the mandible areimportant in the treatment of the lower third of theface. These comprise the masseter muscle,platysma, depressor muscle of the angle of themouth, depressor muscle of the lower lip, andmentalis muscle.

The masseter muscle is located in theparotideomasseteric region and is one of the mas-ticatory muscles. The portion of the masseter mus-cle that is inserted all around the lateral branch ofthe jaw has the function of lifting the jaw. Treat-ment is indicated when there is pathological and

Fig. 3 Four centimeters before the angle of the mandible(this parameter might change in the same patient and indifferent subjects – always palpate and feel the sulcus to

confirm the exact location): In the basis has the arterialsulcus through which the facial artery passes, where pal-pation is perceptible

Fig. 4 Bone alteration in the aging process: zygomatic arch with reduction of the curve and an increase in the mandibularangle

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functional hypertrophy, as well as to soften thefacial contour.

The muscles considered to be depressorsinclude the (Fig. 6):

• Depressor of the angle of the mouth• Depressor of the lower lip• Mentalis

The depressor muscle of the lower lip isinserted in the base of the mandible (over theorigin of the depressor of the angle of themouth) and in the lower lip. The mentalis muscle

originates in the mental fossa and is inserted in thementum skin; it has the function of wrinkling theskin of the mentum and everts the lower lip(Fig. 7). The depressor muscle of the angle ofthe mouth has its insertion at the base of themandible and the angle of the mouth. It is themost superficial muscle of this group.

The platysma muscle (Fig. 8) originates in thesternoclavicular joint, clavicle, and acromion ofthe scapula and is attached to the base of themandible and some of its fibers in the angle ofthe mouth. Its function is to distend the skin of theneck and pull latero-inferiorly along the angle of

Fig. 5 Tissue looseness resulting from age and repeated muscle contractions: marionette sulcus, so-called “bulldog”formation, and platysma banding

Fig. 6 Muscles in thedepressor group: lipdepressor and depressor ofthe angle of the mouth

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the mouth. This muscle has a strong anterior por-tion, which moves in the anterior region of thechin towards the lip, meeting the complex calledthe modiolus (Fig. 9). It can also stretch laterallyup to the angle of the mandible; however, not allindividuals have this presentation (Tamura2010b). With aging, its resting tonus increasesand shortening of the vertical length occurs, lead-ing to the formation of anterior bands, whicheliminate the cervicomandibular angle. Underthe jaw, contractions of the depressor muscle ofthe mouth angle stimulate the platysma muscle,discarding the deep fat anteriorly.

So-called “marionette” lines (Fig. 10) areformed because of the influence of the depressormuscle of the mouth angle and platysma, as wellas because of flabbiness of the SMAS with aging.

The set of actions/functions of the facialmimetic muscles in youth has a curvilinear con-tour, presenting an anterior surface convexity.

This reflects a curve in the underlying fat com-partment to the deep surface of these muscles,acting as an efficient mechanical sliding plane.The amplitude of muscle movement is also higherduring youth. The convex contour becomes recti-linear during the aging process and the underlyingfat is expelled from beneath the muscles (Fig. 11),causing the superficial fat to decrease (Coimbraet al. 2014).

The combined actions of several muscles thatare inserted in the mandible provide a balance offorces that keeps young faces harmonious. How-ever, when an imbalance occurs in a muscle clus-ter of antagonistic forces, either an increase ordecrease of the forces, the result is the loss offacial harmony. Hence, anatomical knowledgeand a good aesthetic sense for the “lifting of thefacial expression” is important to balance theseforces.

Sensory innervation occurs through the man-dibular branch of the facial nerve, which passesthe medial portion of the mandible anteriorly. It isusually located in the mandible angle at the man-dibular midlateral zone and its location is deepbeneath the platysma until to approximately 2 cmlateral to the corner of the mouth where it surfaces(Zoumalan 2011).

The nerves of the infratemporal area – themasseteric, deep temporal, buccal, inferior alveo-lar, lingual, auriculotemporal, chorda tympani,and optic ganglion nerves – are involved inmotor innervation.

Fig. 7 Muscles withinsertion in the mandible

Fig. 8 Platysma muscle showing its mandible insertion

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The buccal nerve (Fig. 12) is a continuation ofthe mandibular nerve, which is situated laterallybetween the bundles of the lateral pterygoid mus-cle and continues anteroinferiorly and medially tothe fibers of the deep bundle of the temporalmuscle. It runs through the buccal fat pad anddistributes its fibers to the skin and mucosa ofthe cheek and the vestibular gingiva of the lowermolars (and occasionally of the upper molars).The inferior alveolar nerve travels downwards,passing near the deep lateral pterygoid muscleregion and then between the medial and lateralpterygoid muscles. It flows inferiorly down themedial region of the mandible branch, enters the

mandibular foramen, crosses the mandibularcanal, and subdivides into dental branches to themolars and lower premolars. After passing themental foramen, it gives rise to the mental nerve(which innervates the soft tissues of the mentumand lower lip, vestibular gingiva incisors, canines,and lower premolars) and incisive nerve (whichinnervates the incisors, canines, and their respec-tive periodontium).

Fig. 10 Marionette lines

Fig. 9 Modiolus region

Fig. 11 Fat compartments and mandibular displacement

302 D. T. S. Ormond and P. R. Pacola

The motor nerves of the parotideomassetericregion are the terminal branches of the facial nervethat arise from intraparotid plexus (temporal,zygomatic, oral branches, marginal mandibular,and cervical branch) (Fig. 12). The oral branchesare the motor nerves of the muscles in the upperlip and the marginal mandibular branch in thelower lip. They are considered to be high risk inrelation to traumas and complications in thinpatients. Therefore, like the zygomatic nerve(a facial nerve), one must be careful and delicatewhen injecting products 2 cm lateral to the angleof the mouth where the nerve is more exposed andprone to trauma (Goldberg 2008; Hirsch andStier 2008).

Facial vascularization occurs mainly via theexternal carotid artery, and its main branches arethe thyroid artery, lingual artery, facial artery(Fig. 13), occipital artery, posterior auricularartery, maxillary artery, and superficial temporalartery.

The facial artery is the most studied artery andits path follows the outer surface of the mandible,under the platysma, to the inner corner of the eye.It crosses the buccinator muscle and the maxilla,deep into the zygomatic major and elevator of theupper lip muscles. The facial artery branches offto the lip and lateral face of the nostril. The angu-lar artery is the terminal part of the facial artery

that runs along the nose to the inner corner of theeye to supply the eyelids.

In the mental region, the submental arteryoriginates from the facial artery in the subman-dibular region, passes through the base of themandible up to the mentum, and irrigates themylohyoid muscle, the anterior belly of thedigastric muscle, and the adjacent structures.The mentum is also supplied by the inferior alve-olar artery branch of the mental artery, whichemerges through the mental foramen. Venousdrainage corresponds to the arterial supply. Themandible is supplied by the facial and inferioralveolar arteries.

Procedures in the region of the facial artery atthe mandibular level performed on the skin orsubcutaneously do not usually cause arterialinjury; however, aggressive procedures carriedout without anatomical knowledge may causeserious injure to the facial artery.

Facial lymphatic drainage occurs in a posteriorand inferior direction, whereas the medial region(including the upper and lower lips) drains into thefacial lymph nodes – the submental (including thecentral region of the lower lip) and submandibularlymph nodes – the side of the face, and scalp, inaddition to the forehead on a diagonal line(infraorbital, zygomatic, and cheek region) up tothe parotid lymph node.

The superficial fat compartments (Fig. 14) areseparated by fascial septae, which are nothingmore than pillars of the fascia that retain thesecompartments (Rohrich and Pessa 2007). Theloss of this fat leads to alterations in the facialcontour, especially in its lower third. This pseudo-ptosis of the face leaves an unsupported skinexcess that contributes to a loss of submandibularcontour and accentuation of the nasolabial folds(Coleman and Sengelmann 2009).

Coleman and Sengelmann (2009) describeddifferent compartments of fat, subdivided intoregions: periorbicular, temporal, perioral, middlethird of the face, cheek, and mandibular (Rohrichand Pessa 2011).

In a study of facial tomographies with contrastin cadavers, Gierloff et al. (2012) proposed adifferent classification of fat compartments tothose already discussed. In their classification,

Fig. 12 Branch innervation of the trigeminal nerve in theface; anatomical relationship with the artery and facialvein: anatomical relationship with innervation of the mas-seter muscle

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the compartments were divided into fat of themiddle third of the face consisting of two layers(superficial and deep) and the paranasal regiondivided into three anatomically different layers.

Recently, Wan et al. (2013) analyzed 63hemiface dissections on cadavers and observedthree main alterations: (1) the adipocytes in thesuperficial fat compartments were bigger than theadipocytes of the deep fat compartments; (2) thesize of the adipocytes in compartments ofnasolabial fat (NLF) and deep medial cheek fat(DMCF) in males was significantly lower than infemales; and (3) the size of the adipocytes in thenasolabial compartment (NLF) in patients with anormal body mass index (BMI) was significantlyhigher in females than in males. This supports theclinical and anatomical observations that suggestthere are morphological differences between thecompartments of superficial and deep fat, specif-ically selective atrophy in the deep fat compart-ments in the elderly. This finding may beclinically relevant for the effects of volumetricfacial rejuvenation.

Fig. 13 Vascularization of the temporal, zygomaticus, and mandibular area

Fig. 14 Compartments of facial fat: (1) lateral temporalcheek fat; (2) deep medial cheek fat (lateral part);(3) inferior jowl fat; (4) superficial jowl fat; (5) nasolabialmalar fat; (6) medial malar fat; (7) middle malar fat; (8) lat-eral malar fat

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In the maxillary region, the angle and the bodyof the mandible, with their overlying masseter andplatysma muscles, define the inferior border of theinferior part of the face and create the mandibleline. With aging, there may be remnants of fatdeposits, which descend and deform the borderof the mandible, reducing facial supplenessTamura (2010a).

The fat on the cheek, in the nasolabial groove,and on the mandible is dense. The Bichat ball islocated anteriorly to the masseter and deeper intothe posterior fascia in the buccal region. Thelocalization of these structures and the shape ofthe face must be considered when preparing toinject fillers with the purpose of lifting the malarand middle regions. It is necessary to avoidpatients presenting with an artificial result, as if aprosthesis had been implanted.

In the parotideomasseteric area, the skin adheresclosely to the fibers of the risorius and platysmamuscles. The branches of the facial nerve (Fig. 3)and the parotid duct (Fig. 9) are located in a poste-rior position to the SMAS and anterior to the mas-seter and buccal fat.When carrying out treatment inthe parotid region, it is worth remembering andbeing aware that the duct is beneath the lineconnecting the angle of the mouth to the tragus asthere have been reports of traumatic fistulas.

The adipose tissue superficial to the SMAS(Fig. 15) in the mental region is firmly attachedto the dermis via a fibrous septum, which makesthe deep tissues very adherent to the skin at thislevel. Due to this adhesion, products injected inthis area do not move easily with massage and,

therefore, supraperiosteal injection is preferred forthe reconstruction of the mentum and mandiblewith fillers. When a greater amount needs to beinjected in the mentum region we might inject intothe subcutaneous tissue as the mental muscle istightly inserted to the bone, and the injection canbe very painful for the patient.

At skin level, the changes and impacts that takeplace are the result of multiple interactions betweenintrinsic and extrinsic factors. The intrinsic factors,which reflect our genetics, influence the characteris-tics of the dermal collagen and the elastic tissue.With aging, the collagen starts to have increasedcross-linking and its volume and elasticityreduces. The elastic fibers are more abundantin the dermis of the face than in the scalp andare therefore responsible for maintaining thestatic tension of the skin and for restoring thedeformed collagen to its original status. Long-term sun exposure subjects the elastic fibers tostructural and functional deterioration, gradu-ally losing the ability to return to their originallength, resulting in loss of skin firmness.

Extrinsic aging is caused mainly by sun expo-sure, but smoking, excess alcohol, and poor diet,among other conditions, also have an importantrole in skin damage over the years. In addition toextrinsic factors, it should be noted that the facialexpression muscles are inserted directly into theskin, meaning there is continuous tension evenwhile resting. Over time, collagen elongationoccurs in the direction of the muscle contraction.Linear wrinkles result from the union of multiplefibers of the SMAS with the dermis, stretching the

Fig. 15 Relationship of theSMAS (superficialmusculoaponeuroticsystem) with subcutaneoustissue

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skin and reducing the tension in the direction ofthe movement of the facial muscles. Reduction intension, an increase in the stretch of collagenfibers, and the progressive reduction of the elastictissue create lines that exacerbate with age and/orsolar damage (Salasche et al. 1988). Thus, thesefactors together lead to increased cutaneous flab-biness and sagging of the face and neck skin.

Combined, these changes result in vertical andhorizontal maxillo-mandibular discrepancies,which have a significant effect on facial harmony.The mentum is a prominent component of the facethat, along with the associated musculature, hasgreat importance in the perioral function and aes-thetic facial balance (Wolford and Bates 1988).

Vertical harmony of the inferior third of the faceis characterized by equal division into thirds, as thedistances between the subnasal craniometric(Sn) and the stomion (St) points, the St pointsand the labiomental groove, and the labiomentalgroove and the lowest point of the soft mentaltissue (Me) must be compatible. There shouldalso be similar measurements between the Snpoints and the mucocutaneous junction of thelower lip and between this and the most inferiorpoint of the soft tissue of thementum. The distancefrom the Sn to the St corresponds to half of thedistance between the lower St and Me (Fig. 16).

In turn, cephalometric analysis plays a key rolein evaluating the relationship between the men-tum and other bone structures and with the softtissue, enabling a tri-dimensional analysis of thementum region and more accurate aesthetic orsurgical planning of the correction. Various ana-lyses, such as those described by González-Ulloa(1987), Ricketts and Langlade (1978), and Steiner(2015) can be used to relate the pogonion (the mostanterior point of the soft tissue of the mentum in themidline) with other facial structures. According toGonzález-Ulloa and (1987), the soft tissue of thenasion must be perpendicular to the soft tissue ofthe pogonion. Ricketts andLanglade (1978) believethat the upper lip must be 4 mm and the lower lipshould be 2 mm posterior to the line that goes fromthe tip of the nose to the soft tissue of the pogonion.Steiner (2015) recommends that the upper andlower lips should border a line through the centralregion of the columella and the soft tissue of the

pogonion (Fig. 17). It is important to observe thatthe various analyses do not allow a complete eval-uation in isolation, since each one gives a relation-ship considered to be ideal between the bone andthe soft tissue of the mentum.

As described previously, cephalometry is avery important diagnostic tool in planningmentoplasty; however, it is important to remem-ber that for the evaluation of the soft tissues,tri-dimensional clinical examination of the patientis of more value in informative terms than con-ventional cephalometric analyses, which arebi-dimensional in nature (Freitas 1999; Pachecoet al. 2010).

Hyaluronic Acid

Hyaluronic acid (HA) is an absorbable substancethat has been used in Europe since 1996 andreceived US FDA approval for cosmetic treat-ments in 2003 (Restylane®).

HA is produced using two techniques:

– Extraction from rooster combs– Nonpathogenic bacterial fermentation (Strep-

tococcus equi or S. zooepidermis)– Biotechnology.

Fig. 16 Harmony of the inferior third and between thethirds of the face. Me the lowest point of the soft mentaltissue, Sn subnasal, St union point between the upper andlower lip

306 D. T. S. Ormond and P. R. Pacola

The most commonly used type of HA on themarket is that obtained using biotechnology dueto its lower risk of hypersensitivity. The differentversions of HA available differ in their concentra-tion, ability to provide volume, cross-linking, andresistance to degradation (free radicals andenzymes), allowing correction from surface wrin-kles to volumization. Treatment for the lower thirdregion is through fillers that promote volumi-zation and redefine facial contours.

Considering the anatomical location in whichthe filler should be placed (subdermal and supra-periosteal) as well as the noble structures that canbe injured, the use of microcannulae is crucial dueto the safety that they provide. The cannulaerecommended for this procedure are as thin aspossible, with 21G and 22G being the preferredchoices. Longer cannulae (40 mm and 50 mm) arealso advantageous as they produce fewer

punctures and therefore less pain and swellingfor the patient. Being blunt, the cannulae doesnot progress into the dermis, contributing indi-rectly to reaching the ideal level of HA injection.

According to Tamura (2013), we need to con-sider topographical areas to be potentially riskyzones, e.g., the mental foramen in the mentalregion, through which nerves and vessels pass,and the risk of hematomas and ecchymoses atthe labiomental sulcus (arterial branch of thelower lip and the venous system). At the posteriormandible region, near the anterior border of themasseter, there is a depression in the mandiblebone where the facial artery is located, which is

Fig. 18 Facial topography: emphasis on the lower face ofthe injection zone: (1) malar area; (2) posterior mandibleregion (between the anterior border of the masseter and themandible angle); (3) anterior mandible region (between themental lip sulcus and anterior border of the masseter);(4) buccal area; (5) mental lip sulcus; (6) inferior lip; and(7) mental region (Tamura 2013)

Fig. 17 Cephalometric tracing of a 20-year-old woman:(1) nasion; (2) nasal tip; (3) central region columella; and(4) pogonion (most anterior point of the mentum soft tissuemidline). Analysis through the methods of González-Ulloa(1987) (line A), Ricketts and Langlade (1978) (line B), andSteiner (2015) (line C). In the tracing in question, the appli-cation of all analyses shows that this a retrognathic patientwith a poorly positioned anterior to posterior mentum

Fig. 19 Blue arrow indicates the ptosis area in the man-dibular line, which should not be filled Lenza et al. (2015)

Hyaluronic Acid for Mental and Mandibular Contour 307

the result of blood pressure on the bone through-out life. There is a risk of worsening the localsagging at the anterior mandible region due to anexcess of the injected product (Fig. 18).

The reported general adverse reactions are lessthan 2% and are similar to those of other productsthat can be injected, characterized by erythema,edema, ecchymosis, acneiform eruptions, andreactivation of herpes simplex.

Injection Technique

Corrections can be performed with fillers for lipaugmentation, attenuation of the labiomentalgroove, mentum volumization, redefinition ofthe lateral line to the mentum and the mandibularline, as well as mandibular contouring (mandibu-lar angle reduction) (Fig. 19).

The technical approach is to use 22G or 25Gneedles and cannulae of 38 mm or more in length,depending on the corrections to be made andextension. The use of needles allows the injectionof HA using the bolus or fan technique, as they aresmall in length. However, because they have acutting edge, the risk of neural and vascular injury,hematoma, and ischemia and thrombosis/embo-lism may occur. Thus, special attention should begiven to the mental foramen region, labiomentalgroove, and facial artery path (premasseteric,

Fig. 20 (1) 1.0 ml of hyaluronic acid was injected viaanterior access to the mentus using a 21G needle. Betterresults can be achieved when associated with botulinumtoxin in this region. Places to insert the 21G needle toovercome the fibrotic adherences of dermis for the intro-duction of the microcannula are as follows: In the para-mental point of insertion, the microcannula was introducedto fill the region and the marionette sulcus. (2) 0.5 ml of

hyaluronic acid with lidocaine was applied per marionnetesulcus; (3) 0.3 ml of hyaluronic acid injection; (4) mandib-ular lines were treated using hyaluronic acid 0.5 ml eachside; (5) mandible angle treated with 0.5 ml of hyaluronicacid each side in the subcutaneous plane via retroinjection.0.3 ml in total was used in the region of the inferior lip(above the mentus)

Fig. 21 (1) 1.0 ml applied in the mandibular angle regionto each hemiface using 22G 50 mm microcannulas in thesubdermal space. (2) 1 ml applied in each side of themandibular branch. (3) Ptosis area. (4) 1 ml applied in themental region. (5) 0.5 ml of hyaluronic acid with lidocaineapplied in the inferior lip region and to acne scars next tothe marionnete line with a 30G ½00 needle

308 D. T. S. Ormond and P. R. Pacola

identified on palpation as mandibular bodydepression).

The use of cannulae enables, in lower thirdvolumizing situations, larger areas to be filledusing a single access. With a blunt end, the can-nula is positioned into a safe layer, it is easier to fillthe subcutaneous area, and there is a slightlylower chance of vascular or nerve injuries.

In the posterior and anterior mandibularregion, access may be made via the mandibularangle to treat the branch of the mandibular, themandibular angle, and the mandibular body usingthe fan technique. Medial access to the

mandibular body has been shown to address theentire mandibular line.

The mental region can be filled with sideaccess into the center of the mentum directionusing a cannula or bolus injection centrally usinga cannula or needle.

When the groove of the marionette line and thesupramental wrinkle is filled at the dermis,needles are normally used; however, but if it isfilled under the skin it is better to use a cannula forthe procedure.

For the lips, the use of cannula or needles ispossible, and the choice will depend on whetherthe aim is to volumize or contour (Fig. 20).

Fig. 23 Before and after

Fig. 22 Before and after

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We usually inject high-viscosity HA developedfor subdermal or supraperiosteal application usinga 21G 40 mm cannula in the subdermal space aftertopical anesthesia with anesthetic cream (lido-caine + tetracaine); however, anesthetic injection(lidocaine 2%) could be used for the cannulainsertion point and create the hole. Alcohol 70%or chlorhexidine should be used for asepsis inareas to be corrected and the anesthetic point ismarked with the patient sitting at 45� under ade-quate lighting to gain a better idea of the saggingand contour of the face (Figs. 21, 22, and 23).

Take Home Messages

• Typical changes to the face during the agingprocess require therapeutic care such as the useof hyaluronic acid to restore youthfulness.

• Evaluation of changes in the mandibular andfacial contours is important for selecting thefiller and application sites.

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