10.5826/dpc.1203a95
Introduction: Non-surgical aesthetic treatments of the lower face are increasingly in demand, particularly aimed to restore facial youth following the changes secondary to a progressive resorption of facial skeleton and atrophy of facial fat compartments, which give the perception of a descent face.
Objective: The aim of this research is to describe non-surgical reshaping of aged lower jaw by means of hyaluronic acid fillers.
Methods: A retrospective analysis of data from adult female patients undergoing treatment of the lower third of the face with hyaluronic acid injections was performed. Injection techniques, relevant anatomy of the anatomical area and rheological properties of the fillers to be used are highlighted.
Results: Thirty-six consecutive patients were enrolled (100% female; mean age, 45.7 years). A minimum of 4 vials, up to 7, of hyaluronic acid filler, were injected in order to achieve the desired results. Visual analog scale (VAS) was used to assess patient satisfaction. Thirty-two patients (88.8%) rated their appearance post-treatment with a satisfaction score ranging between 85 and 100%. Total absence of ecchymosis and/or swelling in the early post-operative days has been highlighted. There were no cases of infection, paresthesia, hematoma or necrosis.
Conclusions: Jaw line remodeling with hyaluronic acid fillers, in patients not willing to undergo surgery, seems to be a viable option for ameliorating the definition of the lower third of the face, although it is mandatory to perform multi-layer injections using fillers with different rheological properties.
text/xml
2160-9381
2076
en
Giorgio Lo Giudice
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
nonsurgical
Nonsurgical Reshaping of the Lower Jaw With Hyaluronic Acid Fillers: A Retrospective Case Series
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2022-07-28
2021-09-27
2022-07-28
2022-09-14
e2022095
Dermatol Pract Concept
Introduction: Non-surgical aesthetic treatments of the lower face are increasingly in demand, particularly aimed to restore facial youth following the changes secondary to a progressive resorption of facial skeleton and atrophy of facial fat compartments, which give the perception of a descent face.
Objective: The aim of this research is to describe non-surgical reshaping of aged lower jaw by means of hyaluronic acid fillers.
Methods: A retrospective analysis of data from adult female patients undergoing treatment of the lower third of the face with hyaluronic acid injections was performed. Injection techniques, relevant anatomy of the anatomical area and rheological properties of the fillers to be used are highlighted.
Results: Thirty-six consecutive patients were enrolled (100% female; mean age, 45.7 years). A minimum of 4 vials, up to 7, of hyaluronic acid filler, were injected in order to achieve the desired results. Visual analog scale (VAS) was used to assess patient satisfaction. Thirty-two patients (88.8%) rated their appearance post-treatment with a satisfaction score ranging between 85 and 100%. Total absence of ecchymosis and/or swelling in the early post-operative days has been highlighted. There were no cases of infection, paresthesia, hematoma or necrosis.
Conclusions: Jaw line remodeling with hyaluronic acid fillers, in patients not willing to undergo surgery, seems to be a viable option for ameliorating the definition of the lower third of the face, although it is mandatory to perform multi-layer injections using fillers with different rheological properties.
Giorgio Lo Giudice
2022/07/28
10.5826/dpc.1203a95
e2022095
Department of Neurosciences, Reproductive and Odontostomatological Sciences, Maxillofacial Surgery Unit, University of Naples “Federico II”
2160-9381
nonsurgical
en
e2022095
Nonsurgical Reshaping of the Lower Jaw With Hyaluronic Acid Fillers: A Retrospective Case Series
https://dpcj.org/index.php/dpc/article/download/2076/1686
                    Dermatology Practical & Conceptual


   Nonsurgical Reshaping of the Lower Jaw With
 Hyaluronic Acid Fillers: A Retrospective Case Series
          Raffaele Rauso1, Luigi Rugge2, Fabrizio Chirico2, Giovanni Francesco Nicoletti3,
           Romolo Fragola1, Pierfrancesco Bove4, Nicola Zerbinati5, Giorgio Lo Giudice6


1 Multidisciplinary Department of Medical-Surgical and Dental Specialties, Oral and Maxillofacial Surgery Unit, University of Campania
  “Luigi Vanvitelli”, Naples, Italy;
2 Private Practice, Naples, Italy;
3 Multidisciplinary Department of Medical-Surgical and Dental Specialties, Plastic Surgery Unit, University of Campania “Luigi Vanvitelli”,
  Naples, Italy;
4 Private Practice, Milan, Italy;
5 Dermatology Department, University of Insubria, Varese, Italy;
6 Department of Neurosciences, Reproductive and Odontostomatological Sciences, Maxillofacial Surgery Unit, University of Naples “Federico II”,
  Naples, Italy;



Key words: filler injection, lower jaw, nonsurgical, multilayer injection, hyaluronic acid
Citation: Rauso R, Rugge L, Chirico F, et al. Nonsurgical Reshaping of the Lower Jaw With Hyaluronic Acid Fillers: A Retrospective Case
Series. Dermatol Pract Concept. 2022;12(3):e2022095. DOI: https://doi.org/10.5826/dpc.1203a95
Accepted: October 30, 2021; Published: July 2022
Copyright: ©2022 Rauso et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding author: Giorgio Lo Giudice, MD, Department of Neurosciences, Reproductive and Odontostomatological Sciences,
Maxillofacial Surgery Unit, University of Naples “Federico II”, Via Pansini, 5, 80131 Naples, Italy E-mail: giorgio.logiudice@unina.it




  ABSTRACT              Introduction: Nonsurgical aesthetic treatments of the lower face are increasing in demand. In par-
                        ticular, they aim to restore facial youth following the changes due to progressive resorption of facial
                        skeleton and atrophy of facial fat compartments which give the perception of a descent face.
                        Objectives: The aim of this research is to describe the nonsurgical reshaping of the aged lower jaw by
                        means of hyaluronic acid fillers.
                        Methods: A retrospective analysis of data from adult female patients undergoing treatment with
                        hyaluronic acid injections in the lower third of the face was performed. Injection techniques, relevant
                        anatomy of the anatomical area and rheological properties of the fillers to be used are highlighted.
                        Results: Thirty-six consecutive patients were enrolled (100% female; mean age: 45.7 years). A mini-
                        mum of 4 up to 7 vials of hyaluronic acid filler was injected to achieve the desired results. The visual
                        analogue scale was used to assess patient satisfaction. Thirty-two patients (88.8%) rated their appear-
                        ance post-treatment with a satisfaction score ranging between 85% and 100%. A total absence of
                        ecchymosis and/or swelling in the early postoperative days has been highlighted. There were no cases
                        of infection, paresthesia, hematoma or necrosis.




Original Article | Dermatol Pract Concept. 2022;12(3):e2022095                                                                              1
                        Conclusions: For those patients not willing to undergo surgery, the jawline remodelling with hyal-
                        uronic acid fillers seems to be a viable option for ameliorating the definition of the lower third of the
                        face. Nonetheless, it is mandatory to perform multilayer injections using fillers with different rheolog-
                        ical properties.




Introduction                                                         Moreover, HA fillers are even used to restore post-surgical
                                                                     facial deformities, showing a good profile of safety with long
Facial aging is a complex multifactorial phenomenon that             term stability [10-13]. The aforementioned issues paved the
embraces both hard and soft tissues. Over the years, there           way for the treatment of certain areas, such as the jawline,
is a progressive resorption of the facial skeleton character-        that were previously considered nonsuitable for HA filler in-
ized by the posterior displacement of the maxilla, and the           jections [14].
lateral-inferior shifting of the lateral and inferior orbital rim
creating a larger orbital aperture. In the aging process, there
is a sort of contraction of the lower jaw in a vertical and          Objectives
a horizontal plane induced by the resorption of the gonial
                                                                     This research aims to describe nonsurgical reshaping of the
angle, chin symphysis, body and ramus of the jaw. Moreover,
                                                                     aged lower jaw by means of hyaluronic acid fillers, highlight-
we should also consider a possible tooth loss that causes the
                                                                     ing the specifics of fillers and the technique with respect to
resorption of the alveolar process contributing thus to an
                                                                     facial anatomy.
aged appearance [1]. The loss of hard tissue support is ac-
companied by the overlying soft tissue slipping. Although
there are no fat compartments along the lower jaw, but only          Methods
subcutaneous fat tissue, the deflation of midfacial fat com-
partments induces soft tissue falling that, associated with the      This retrospective case series includes 36 consecutive ­patients,
loss of bony projection, contributes to the loss of definition       seeking nonsurgical lower jaw sculpting, treated by the se-
of the jawline [2,3].                                                nior author (RR) from January, 2014 to January, 2020. The
    Progressive atrophy of facial fat compartments is recorded.      study was conformed to the Strengthening the Reporting of
Moreover, the attenuation of the zygomatic-cutaneous,                Observational studies in Epidemiology (STROBE) statement
orbito-malar, and mandibular retaining ligaments gives the           for cohort studies. Every patient signed an informed consent
appearance of facial soft tissues descent. As some anatomical        for the procedure and scientific purposes. Only HA-based
studies have confirmed, it acts as a hammock between the             fillers were used, different brands with different cross-linking
atrophied fat compartments and the soft tissues of the face,         agents (1,4-butanediol diglycidyl ether [BDDE] or polyethene
contributing to the morphological appearance of the tear             glycol [PEG]) were employed (Nyuma Pharma; Neauvia; Te-
through deformity, malar bags, and jowling [4].                      oxane; Stylage, Laboratoires Vivacy). For each brand, differ-
    A deep plane facelift is the surgical gold standard to re-       ent fillers with different rheological properties were chosen
store a youthful and natural appearance of the face. Over            according to the anatomical layer to be injected.
the last years, an increasing interest in deep plane face lifting       Every procedure was performed at least 21 days after
techniques has been rising, highlighting the role of facial re-      the first consultation in an office setting and was not fol-
taining ligament release and facial fat compartments reposi-         lowed by or combined with any other aesthetic treatment.
tioning [5,6].                                                       No antibiotic, corticosteroid, painkillers, or other drugs
    However, during the last 20 years, nonsurgical anti-aging        were prescribed to the patients at the end of the procedure.
facial procedures have gained more and more popularity. Pa-          After the injections, an HA-based topical gel was applied
tients have been aiming for natural results with no need for         on the skin in the treated area, and a HA patch was placed
surgical interventions; for this reason, the use of hyaluronic       over for 20 minutes to reduce post-injection redness and
acid (HA) fillers has shown to be a mainstay among nonsur-           swelling. Due to the complexity of the injections, it is al-
gical facial aesthetic procedures [7].                               ways recommended to have the patients stay in the waiting
    Since their first introduction at the end of the 20th century,   room for at least 20-30 minutes after the procedure in order
the role of HA fillers has dramatically changed, shifting from       to exclude vascular impairments or any other early adverse
purely dermatologic treatments, such as fine lines filling, to       event. The patients were evaluated 21 days after the proce-
a total facial reshaping tool [8,9]. Nowadays, facial fillers        dure. At this time, the visual analogue scale (VAS) was used
are used for a wide range of procedures such as nonsurgical          to assess patient satisfaction from 100 (the best aesthetic
nose job, temple volumization, eyebrow repositioning, etc.           outcome possible) to 0 (the worst). In 3 cases a touch-up



2                                                                        Original Article | Dermatol Pract Concept. 2022;12(3):e2022095
was performed after VAS evaluation, under the physician’s           the subcutaneous tissue over the body of the jaw, the cannula
suggestion to address minor asymmetries. Less than 1 mL             entry point was performed with a needle, 1 cm ahead of the
was required per touch-up.                                          anterior margin of the masseter, over the lower border of the
                                                                    mandible. Once the cannula is inserted, one or more passages
Filler Rheology                                                     were performed to fill the area with retrograde releasing.
To inject over the periosteum, a filler with a G’ over 400              Over the parotid, the ramus area was filled with the same
Pa was chosen. While, to inject subcutaneously, a filler with       low G’ filler. The entry point was performed ahead of the
lower G’ between 200 and 300 Pa was chosen. As a gen-               tragus. The cannula should not be inserted in the superficial
eral rule, the deeper the injections are (over/under the peri-      subcutaneous layer. The HA was retrogradely released, with
osteum) the higher the G’ (storage/elastic modulus) and             one or more passages, over the parotid fascia. In this area,
the G* (hardness) should be:. This is the ratio between G’          some resistance can be felt in the cannula movements due to
(storage/elastic modulus) and G’’ (loss/viscous modulus). On        the presence of the parotid fascia (Figure 1). Excessively su-
the other hand, the more superficial the injection has to be        perficial injections in this area usually make the filler visible,
(dermal layer), the higher the G’’ and the tan delta (G’’ and       leading to unpleasant results. The area between the masseteric
G’ ratio) should be [15].                                           cutaneous ligament and the mandibular septum was never in-
                                                                    jected in order to prevent a worsening of the jowling (Table 1).
Pre-operative Plan and Injection Technique
After face cleansing with 80% isopropyl alcohol, the sym-           Results
physis midline was identified on the lower edge of the man-
dible where the first deep bolus was released with a high G’        Thirty-six consecutive patients seeking nonsurgical reshap-
filler: about 1.5 cm apart in each side. One more point was         ing of the jaw-line were examined and treated. Every pa-
marked where the second bolus was released. If 3 points             tient was female, age ranging from 42 to 71 years (mean
were not enough and jowling was still observed, 1 more              45.7 years). Minimum follow-up was 3 months, maximum
point would be marked and injected at about 1.5 cm apart            2 years. A minimum of 4 and up to 7 vials of HA filler was
per side, paying careful attention not to go laterally to the       injected to achieve the desired results. Early or tardive ad-
mandibular septum. In order to achieve a straight jaw-line,         verse events were not reported. A moderate reduction of
the amount to inject over the periosteum should be higher           lower teeth display was recorded in all the patients. How-
in the midline compared to the laterally marked points in           ever, this issue was clearly explained to the patients before
an ideal pyramid shape (eg if 0.2 mL are injected into the          the injections (Figure 2). Patient satisfaction assessment re-
midline, 0.1 mL about 1.5 cm apart on each side has to be in-       sults reported no scores lower than 75. Twelve patients gave
jected). Deep perpendicular injections were carried out with        a score of 100, 8 patients rated 90, 12 patients indicated a
a 25 G, 4 cm long needle.                                           score of 85, 4 patients rated 80, and 2 indicated 75 (Table 2).
    Once deep injections were performed, an over-protruded          Whenever the procedure was carried out with fillers not con-
chin could be identified. In such a case, the labio-mental          taining a local anesthetic, patients reported more pain and
crease was marked, then 1 triangle per side with the apex           discomfort than patients who received fillers premixed with
pointing towards the labio-mental crease was marked and             a local anesthetic.
injected subcutaneously. Using a filler with a lower G’ com-
pared to the deep injections already performed, the injections
were carried out with a cannula, filling the labio-mental
crease and the 2 triangles previously marked to erase the
overprotruded aspect of the chin by pushing forward the soft
tissues of the surrounding area. During these injections, the
cannula usually encounters some resistance due to the fatty
fibrotic tissue represented under the skin of this anatomical
area. A 4-cm cannula was used for these 27G injections.
    On the gonial angle, a perpendicular injection was per-
formed over the periosteum with the same high G’ filler pre-
viously used for the chin. The injection was performed in the
most lateral part of the gonial angle to straighten the mandi-
                                                                    Figure 1. The black dot indicates the area to be filled with deep
ble posteriorly. Then, a lower G’ filler was used to restore the    injections over the periosteum, with a high G’ filler. The blue lines
mandible body and ramus. The low G’ filler was the same as          indicate the area to be filled subcutaneously with an hyaluronic acid
the one previously injected into the subcutaneous tissue. To fill   filler with a G’ ranging between 200 and 300 Pa.



Original Article | Dermatol Pract Concept. 2022;12(3):e2022095                                                                         3
Table 1. Features of injection sites, hyaluronic acid dose, type of injection, the anatomical layer to be
                                  injected, and the needle/cannula use
                                 Hyaluronic Acid
      Injection Site            Injection (Range)           Type of Injection            Anatomical Layer            Needle/Cannula
 Symphysis                   0.2-0.3 mL                  Bolus release                Over the periosteum         Needle
 Para-symphysis              0.1-0.2 mL                  Bolus release                Over the periosteum         Needle
 Supplementary               0.1 mL                      Bolus release                Over the periosteum         Needle
 injections lateral to
 the para-symphisis
 (before mandibular
 septum)
 Gonial angle                0.3-0.5 mL                  Bolus release                Over the periosteum         Needle
 Mandibular ramus            0.5-1 mL                    Retrograde release           Subcutaneous tissue     Cannula
                                                                                      (between the SMAS
                                                                                      and the parotid fascia)
 Mandibular body             0.5-1 mL                    Retrograde release           Subcutaneous tissue         Cannula
                                                                                      (under the platysma)
 Cutaneous part of the       1-1.5 mL                    Retrograde release           Subcutaneous tissue         Cannula
 lower lip                                                                            (fatty fibrotic perioral
                                                                                      tissue)
SMAS = superficial musculoaponeurotic system.




Figure 2. (A) Pre-injection teeth display in a 46-year-old patient. (B) Reduction of teeth display due to the myomodulation induced by filler
injections in the areas of the depressor angulis oris and in the depressor of the lower lip muscles.



                         Table 2. Patient satisfaction with hyaluronic acid filler procedure*.
         VAS Score                     100                    90                    85                    80                    75
    Number of patients                  12                     8                    12                     4                     2
*Patients were asked to rate their satisfaction from 0 to 100, with 0 representing the worst possible aesthetic outcome, and 100 representing
the best possible aesthetic outcome.




Conclusions                                                              the facial anatomy and the HA fillers rheology. Using dif-
                                                                         ferent HA fillers for each facial anatomical layer is required
A well-defined jawline is an important aesthetic and anatom-             to avoid unnatural results, especially the “detection” of the
ical landmark to have a clear demarcation between the face               filler during facial dynamics [9].
and the neck [14]. To achieve natural and pleasant results, it              Several case series of lower jaw nonsurgical reshaping
is mandatory for the injector to have a deep knowledge of                with the use of fillers are published in medical literature,



4                                                                            Original Article | Dermatol Pract Concept. 2022;12(3):e2022095
even though most of them are not focused on the treatment           identified the role of HA fillers in modifying facial mus-
of the aging mandible [14,16-18]. In a recent paper, Bertossi       cles contractions in the peri-oral region to achieve natural
et al described their experience in the nonsurgical definition      and pleasing results and solve aesthetical problems such as
of the chin and jawline in younger adults, using a grid system      gummy smiles or asymmetrical smiling [23]. In the present
approach.                                                           case series, we identified a reduction of lower teeth displays
    In 2020, also Mastroluca et al focused on the lower third       in all the injected patients; this was easily understood thanks
definition in male patients to achieve a more masculine iden-       to De Maio findings [24,25]. When HA is injected with a
tity; even in this paper, the focus was not on the reversal of      cannula in the triangles marked between the chin and the
the facial aging process of the lower third [18]. Most pub-         lower lip, the filler thus reduces the capability of contrac-
lished articles about nonsurgical chin and jawline definition       tions in the depressor angulis oris and in the depressor of the
are focused on the use of a single filler, usually with a high      lower lip muscles. This “secondary” effect mimics the mouth
G’ [17,19]. Nonetheless, it is a demanding treatment that           corner lift, usually achieved with botulinum toxin injections
should be approached only by experienced injectors with             into the aforementioned muscles [26].
suitable training. If compared to other face areas there is not        The VAS scale evaluation revealed a high mean of patient
so much research focused on it.                                     satisfaction, also related to the absence of required days off
    The results on our patients show neither early nor tardive      after the procedure and/or swelling in the early postoperative
adverse events. This is explained by the injection pattern that     days (Figures 3-8).
focuses on relevant anatomical landmarks. Indeed, every                Consultation plays a key to achieve high patient satis-
deep injection is performed along the anterior edge of the          faction, especially with naive patients [18]. Usually, patients
mandible. Consequently, the knowledge of vascular pedicles          consider HA fillers as just an “injection” due to information
and nerves of this area is of paramount importance to avoid         found on the internet or in ads. It is mandatory during the
vascular impairments as well as sensorial and/or motor pa-          first consultation to let them understand the type of injec-
resis. As regards the facial artery and mandibular marginal         tions performed, potential risks such as vascular impair-
nerve, the use of a cannula is recommended when the body            ments, and eventually secondary effects such as lower teeth
of the mandible has to be injected. The needle “entry point”        display reduction that can be detected postoperatively [27].
should be performed superficially above the platysma [20].             After advanced filling procedures, it should be manda-
Perpendicular injections above the lower edge of the mandi-         tory to have the patients waiting in the office for at least
ble allow to easily avoid ascendant mental artery or mental         30 minutes following the injections. This has already been
nerve injuries.                                                     described for others areas rich in vascular networks such as
    In order to achieve natural results, we approached the          the nose [10]. In the present case series, after the injection,
lower third using different fillers, with different rheological     an HA-based topical gel was applied over the skin in the
properties. A similar approach was suggested by Salti, de-          treated area, and an HA patch was placed over it for 20
spite he focused on facial mid-third restoration [9]. The use       minutes. This care is performed to calm the patient and to
of fillers with different rheological properties in different an-   have time to detect early complications, such as vascular
atomical facial layers can be considered an anatomical con-         impairments that may require early hyaluroindase (HYAL)
cept that supports the golden rule “like with like” of facial       injections [28-30]. However, the application of early HYAL
reconstruction [21]. When a filler is implanted deeply over         injections always needs to be discussed with patients prior to
the bone to give projection, it needs to have enough strength       proceeding with the treatment because if the patient opts out
to support the overlying tissue (muscles, fat, etc.), avoiding      of them, then it would be best not to perform the procedure.
deformation in the facial dynamics. In turn, if soft tissues           Some papers regarding the use of a single filler or a single
have to be filled in or pushed forward to avoid the filler vis-     brand of fillers to reshape the mandible have been published
ibility in facial animations (in smiling, speaking, etc.), it is    [14,16-18]. However, in the present paper, we focused on the
suggested that the same deeply injected filler not be used but      meaning of knowing the rheological properties of the filler
one with a lower G’ so as not to detect it in facial muscle         independently from the brand. Almost all facial filler brands
contractions. The role of deep injections with high G’ over         have different types of fillers, a correct knowledge of the rhe-
the chin could be compared to the role of chin implants: as         ological properties of the filler based on the anatomical layer
shown in literature, alloplastic chin implantation can help         to be injected allows the physician not to focus only on a
strengthen and further define a retrusive chin and a weak           certain brand.
jawline [22].                                                          Published papers on the same topic mainly address
    Furthermore, an interesting role of this kind of filler is      “young adults.” Indeed, Braz et al. concluded that this tech-
the myomodulation detected at the site of depressor angulis         nique is for patients around 40-45 years old with a beginning
oris and depressor of the lower lip muscles. De Maio firstly        of sagging of the lower face (small jowl and visibility the



Original Article | Dermatol Pract Concept. 2022;12(3):e2022095                                                                    5
Figure 3. Lateral view of a 68-year-old patient before (above), and 1 month after injections (below).




Figure 4. Three-quarter view of a 68-year-old patient before (above) and 1 month after the injections (below).




6                                                                            Original Article | Dermatol Pract Concept. 2022;12(3):e2022095
Figure 5. Three-quarter view of a 44-year-old patient before (upper) and 2 years after the injections (below).




Figure 6. Three-quarter view of a 44-year-old patient before (above) and 2 years after the injections (below).




Original Article | Dermatol Pract Concept. 2022;12(3):e2022095                                                   7
Figure 7. Three-quarter view of a 46-year-old patient before (above) and 3 months after the injections (below).




Figure 8. Three-quarter view of a 46 year old patient before (upper part) and 3 months after the injections (lower part).




8                                                                            Original Article | Dermatol Pract Concept. 2022;12(3):e2022095
mandibular ligament fixed point and a little retrogenia) or                   2013; 1(1):e8-e15. DOI: 10.1097/GOX.0b013e31828ed1da.
young patients with retrogenia who do not want to undergo                     PMID: 25289202. PMCID: PMC4174174.
                                                                         5.   Jacono AA. A Novel Volumizing Extended Deep-Plane Facelift:
surgery [31]. During this case series, we also evaluated older
                                                                              Using Composite Flap Shifts to Volumize the Midface and Jaw-
patients (Figure 3 shows a treated 72-year-old patient) re-
                                                                              line. Facial Plast Surg Clin North Am. 2020;28(3):331-368.
porting a high score in patient satisfaction. Naturally, not                  DOI:10.1016/j.fsc.2020.03.001. PMID: 32503718.
all older patients can benefit from these tridimensional in-             6.   Jacono AA, Bryant LM, Ahmedli NN. A Novel Extended Deep
jections. When a patient complains about facial aging, the                    Plane Facelift Technique for Jawline Rejuvenation and Volumiza-
first suggested option should be a surgical facelift. However,                tion. Aesthet Surg J. 2019;39(12):1265-1281. DOI:10.1093/asj/
                                                                              sjy292. PMID: 30418482.
if the patient does not want to undergo surgery but desires
                                                                         7.   ASAPS. Available from: . https://www.surgery.org/sites/default/
to ameliorate the appearance of the jawline, then multilayer
                                                                              files/ASAPS-Stats2016-11-12.pdf Accessed 2nd of September,
HA injections represent a viable option.                                      2021.
    The present case series is limited by the evaluation of              8.   Andre P. Hyaluronic acid and its use as a “rejuvenation” agent
the results done comparing pre and post-treatment photos                      in cosmetic dermatology. Semin Cutan Med Surg. 2004;23(4):
and a VAS scale filled out by the patients. Clinical photo-                   218-222. DOI:10.1016/j.sder.2004.09.002. PMID: 15745228.
                                                                         9.   Salti G, Rauso R. Facial Rejuvenation with Fillers: The Dual
graphs are useful for scientific records and research, despite
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                                                                              DOI:10.4103/0974-2077.167264. PMID: 26644734. PMCID:
positions for the clinical evaluations reliability and reproduc-              PMC4645140.
ibility, the variability is still a matter of fact [32]. Regarding      10.   Rauso R, Tartaro G, Chirico F, Zerbinati N, Albani G, Rugge L.
the results of patients’ evaluation, self-perceived aesthetical               Rhinofilling with hyaluronic acid thought as a cartilage graft.
improvement is one of the most debated issues in aesthetic                    J Craniomaxillofac Surg. 2020;48(3):223-228. DOI:10.1016/j.
                                                                              jcms.2020.01.008. PMID: 32107120.
surgery [33]. The VAS evaluation is widely used in literature
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and clinical practice. It was used in this work thanks to its
                                                                              taro G. Hyaluronic Acid Injections to Correct Lips Deformity Fol-
simplicity, quickness, smartness, and adaptability. However,                  lowing Surgical Removal of Permanent Implant. J Craniofac Surg.
seeking measurement bias is crucial, principally when pa-                     2020;31(6):e604-e606. DOI:10.1097/SCS.0000000000006689.
tient satisfaction is taken as an outcome [34].                               PMID: 32657979.
    Multilayer HA injection treatment for lower jaw ag-                 12.   Mashiko T, Mori H, Kato H, et al. Semipermanent volumiza-
                                                                              tion by an absorbable filler: onlay injection technique to the
ing represents a viable option for ameliorating the jaw-line
                                                                              bone. Plast Reconstr Surg Glob Open. 2013; 1(1):e4-e14.
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