Fillers for the lower face: The cuts and the squares

In a live webinar, as part of the Aesthetic Medicine Digital Series, Dr Amit Luthra, Consultant Dermatologist, Ishira Skin Clinic, New Delhi, spoke on ‘Fillers for the lower face: The cuts and the square’.

Here’s presenting key takeaways from the insightful and communicative session:

• How do we differentiate between the female lower face and the male lower face? You should look at the different aspects of the male and female lower face and accordingly you have to treat it.

• There is a difference when you are treating the mid face and the lower face. The mid face should have soft transitions, especially in a woman, but when you come down to the lower face, especially the jawline, you should have more sharp definitions and more angular transitions to the neck.

• When you are trying to volumise the area, like you are injecting into the skin, or you are trying to inject at the angle of the jawline, you would be using a volumising filler. But my personal recommendation is that when you want to do a pre-jowl or post-jowl or for that matter the ramus of the mandible, you have to use a filler which has more of a robust quality in it so it gives you a sharp contour. If you put in a volumizing filler, sometimes what happens is, it ads bulk to the jawline and the patient may not be happy.

• Aesthetic patients often present with a loss of continuity that comes with a straight, youthful jawline, commonly associated with age-related jowling.

• Face jowling can be worsened by the attenuation of the mandibular septum leading to the descent of the superior and inferior jowl fat compartments.

How do we treat it? The accurate placement of an appropriately selected hyaluronic acid (HA) dermal filler at the mandibular angle, in the chin and the peri-jowl region can re-create an aesthetically youthful and structured jawline.

• When considering lower third treatments, the recommendation would be of revolumising the upper and middle thirds of the face first, providing superior volumetric support to the jawline. The key areas to consider are the temples, cheeks and preauricular regions.

• MDTM Codes Injection Technique Guide: This is just a kind of a suggestion. It is a landmark for where you should be injecting, in what planes, and then you can have your permutations and combinations.

MD Codes: The 5-point jawline reshape

Code: Jw1 | Injection area: Mandible angle

Code: Jw2 | Injection area: Pre-auricular area

Code: Jw3 | Injection area: Mandible body

Code: Jw4 (L6, C6) | Injection area: Pre-jowl sulcus

Code: Jw5 (C2) | Injection area: Chin apex

Mandible angle: Jw1 for men: Widens the face (for masculine-looking results).
Mandible angle: Jw1 for women: Lifts and defines the mandible angle.
Pre-auricular area: Jw2: Lifts the skin and reduces jawline sagginess. Alert: Parotid gland.
Mandible body: Jw3: Improves definition of the jawline. Be wary of the facial artery! Do not touch the bone with the needle.
Pre-jowl sulcus: Jw4 (L6, C6): Reduces the prominence of the pre-jowl sulcus.
Chin apex: Jw5 (C2): Improves vertical dimension or chin height.

The 6-point chin reshape

• Code: C1 | Injection area: Mental crease / Labial-mental angle – Reduces the protrusion of the lower lip, gives support to the oral commissure and elongates the chin.

• Code: C2 (Jw5) | Injection area: Chin apex – Improves vertical dimension / chin height.

• Code: C3 | Injection area: Anterior chin / soft tissue pogonion – Improves anterior projection of the chin. Don’t go too lateral due to the mental artery.

• Code: C4 | Injection area: submental / soft tissue menton – Enhancer of C2 and C3 – further improves vertical dimension and anterior projection; it also rotates the chin upwards.

• Code: C5 | Injection area: Lateral lower chin – Ideal for men. Widens the chin and gives lateral support, producing a more square chin.

• Code: C6 (L6, Jw4) | Injection area: Prejowl sulcus – Reduces the prominence of the pre-jowl sulcus.

All these points can be done at one go. But it is always recommended that you go in phases. Do the mid-face first, let the patient come back after a month. Then get into the upper face and give it a month. Let the patient come back, and then you work on the lower face.

The 3-point marionette reshape

The last part is the mentolabial area. It is the mentolabial fold that some patients complain of. But you must sure that the mid-face is done, specially the preauricular point, before you get in to the mantolabial fold.

In conclusion
When treating the jawline, use the toxin or the EBD.
• Fillers in the midface and upper face first.
Do the angle and the chin first followed by the perijowl area.
Inject either subdermal or supraperiosteal.