When addressing the profile using dermal fillers (also known as profiloplasty) it is important to assess each patient individually, understand their expectations and treat appropriately.
By using this approach rather than a ‘paint by numbers’ technique, each individual’s full potential can be achieved using their own natural features to harmonise their profile without a dramatic, obvious transformation.
Patient background
A 26-year-old female patient first attended my clinic in November 2019, complaining of a retracted chin and unbalanced side profile. She works as a social media influencer/blogger and wanted to achieve a well-balanced, natural and refreshed look from every angle.
I conducted a full medical consultation where there were no indications to determine she was not appropriate for non-surgical treatments. The patient had not undergone previous aesthetic treatments and I gained a full understanding of her goals and expectations for treatment.
She presented with an angle class II bite, or overjet, where the maxilla lies ahead of the mandible and retrognatic (convex) profile with a mandibula that is too small, as it is underdeveloped.1 The zygomatic arch was quite flat and there was a grade 1 tear trough (TT) deformity with no significant pigmentation and good skin quality, making her a suitable candidate for tear trough filler.2
After assessment, I felt that this patient would benefit from mid-face correction, addressing the volume of her mid-cheek, enhancing definition of the zygomatic arch and correcting the TT. Also, augmenting the body of the mandibula and gonial angle would add definition to her lower face and result in a more balanced profile.
I determined that chin augmentation aiming for anterior projection would correct the convex profile. Combining these treatments would create a balanced side profile and general beautification, resulting in a more defined and fresher look. Even though the non-surgical rhinoplasty (NSR) is normally a part of profiloplasty, the patient presented with an upward-turned nasal tip and sufficient nasolabial angle.3 She was happy with her nose, therefore NSR was not indicated.
First treatment
With all patients, I carry out my routine of obtaining consent, photographs and prepping them for treatment. I choose to use a cannula technique for treating most indications as I find that patients experience less discomfort and have shorter recovery time.4
It also minimises the risk of serious complications such as vascular occlusion and blindness.5 As some research shows, using cannula doesn’t affect the precision of depth of the injections,6 and this has been my experience of treating many cases with consistently positive outcomes. I addressed the mid-face first as, in my experience, this indirectly helps improve and lift the lower face. I used a single insertion point for the cannula each side in the zygomatic region laterally to access and treat medial, lateral cheek and all aspects of the TT. A 25 gauge 50mm cannula was used, as smaller gauge cannulas could cause trauma to the blood vessels.7
To achieve definition of the zygomatic arch and to create a youthful and feminine convex ogee curve,7 I chose to use a hyaluronic acid (HA) filler with a high G prime with sufficient volumising capacity, but also high viscoelasticity, which allows the product to adapt to facial movements, yet remain at the site of injection.8
I used 1ml of Stylage XL in each cheek, augmenting the zygomatic arch by placing microboluses of 0.1ml along the cheek bone supraperiosteally. I also augmented the deep medial cheek fat compartment. This gave support to the lower lid-cheek junction, helping improve the appearance of the TT that would allow me to use less filler when directly treating it.
For TT correction, a less hydrophilic filler with low viscosity and HA concentration was needed in order to prevent the likelihood of oedema and the Tyndall effect.9 I chose to use Stylage S and placed 0.4ml per TT, injecting filler under the orbicularis oculi muscle in the suborbicularis oculi fat (SOOF), using a retrograde linear threading technique. I found this was a sufficient amount as, in my experience, undertreating this area reduces the risk of oedema when filler attracts water following the treatment.
I chose Stylage XXL to augment the chin, increase anterior projection and to create a defined, feminine facial shape to harmonise the features. It is a highly elastic product with high lift capacity.
Women tend to have narrower faces with single point light reflection on the chin.11 I approached the chin augmentation via a single insertion point in the midline of the chin, placing 1ml of product on the periosteum under the mentalis muscle and adding anterior projection to the chin. I then added 0.6ml of Stylage XL over the mentalis in the fat tissue to further project the chin and shape it.
I treated the whole jawline and gonial angle, using one insertion point for the cannula in the border of mandible each side, at least 1cm in front of anterior border of the masseter to avoid the facial artery. I used 0.5ml of Stylage XL on each side to shape the gonial angle subdermally, placing micro boluses to mimic the triangle shape of the gonial angle.
To further enhance and sharpen the jawline and correct the pre-jowl sulcus, I treated it with 1ml each side in a retrograde linear threading technique, creating a line of filler along the border of the mandible in posterior and anterior directions. The patient had good tissue quality, so there were no concerns of seeing product in the superficial plane after the placement.
The patient was pleased with the result achieved, found the treatment comfortable and reported no bruising or swelling at her post-procedure review two weeks later.
Second treatment
A year later, the patient contacted me again, seeking further treatment to address the profile and lips. On examination, the patient presented with a less-recessed chin than a year ago but would benefit from anterior projection.
The jawline and gonial angle had lost most of the definition and would need augmentation again. We also decided to add some volume to the chin laterally to correct the pre-jowl sulcus for a more uniform jawline.
The zygomatic arch was flatter, but she still had the ogee curve and sufficient malar volume, therefore less product would be needed to treat this. The TT did not need correction. My advice was that very light cheek enhancement would be beneficial, adding definition to the zygomatic arch.
The patient also presented with a slightly thin upper lip with deficient and inverted lateral tubercules and a large median tubercule and flat side profile that was not a concern for the initial treatment, but she wanted to address this for her second treatment. I felt that creating slight frontal projection, adding definition to the vermilion border and the vertical height to the upper lip, would benefit her profile harmonisation and beautification of the face as a whole.
The treatment plan was to address the lateral portion of the cheek, defining the zygomatic arch, add anterior chin projection, correct the pre-jowl sulcus and the labiomental fold, repeat the jawline augmentation, and also gently enhance the lips. I discussed this in detail with the patient and she was happy and consented for the treatment.
The cheeks were treated in exactly the same manner as before; this time I used 0.5ml of Stylage XL each side as it didn’t require as much volume as last time. In the chin, 1ml of Stylage XL was used supraperiosteally to add anterior projection. I used 1ml of Stylage XXL per side to augment the jawline and gonial angle in exactly the same manner as previous treatment, choosing this product as it is slightly more volumising.
The pre-jowl sulcus and labiomental fold was treated with 1ml of Stylage L via an insertion point that I used laterally in the middle of the border of mandible, just changing the direction of the cannula. I chose Stylage SL for lip enhancement. This product is very soft yet, at 18.5mg/g concentration, provides natural, soft and hydrated-looking results with enough volume. It contains mannitol, which is an antioxidant and aims to reduce the swellingafter injection.10
To augment the lips and correct their shape, I used a combined cannula and needle technique. I used a single insertion point for the 25 gauge 38mm cannula each side, lateral to the corners of the mouth, and placed 0.4ml in the upper and 0.3ml in the lower lip at a supramuscular depth using linear threads. I was careful to avoid the median tubercle. To correct the inverted lateral tubercules and add vertical height, I used a 30 gauge needle, placing vertical threads through the vermillion border. There was quite a bit of swelling on the upper lip, due to reinjecting with the sharp needle, and I warned the patient she will likely present with a bruise following treatment. Again, the patient reported no downtime post procedure and felt that the treatment exceeded her expectations.
Summary
Younger patients are becoming more aware of their profile so are seeking non-surgical profiloplasty options, which is becoming a more popular treatment. With appropriate assessment and correctly selected products and techniques, practitioners should be able to get consistently great results and returning patients. The results are long-lasting, and it is possible that less product can be used each time to achieve similar or better results.
