Dr David Ong presents his preferred treatment technique for sculpting and shaping the jawline using hyaluronic acid dermal fillers.
Aesthetic patients often present with a loss of continuity that comes with a straight, youthful jawline, commonly associated with age-related jowling. Facial ageing is a result of fat atrophy and volume loss from both bone resorption and tissue descent.1 Facial jowling can be worsened by the attenuation of the mandibular septum leading to the descent of the superior and inferior jowl fat compartments.2
Considerations for sculpting the lower face
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 recreate an aesthetically youthful and structured jawline. When considering lower third treatments, I would recommend revolumising the upper and middle thirds of the face first, providing superior volumetric support to the jawline.2 The key areas to consider are the temples, cheeks and preauricular regions.
It is important to recreate the angular contours as the face transitions inferiorly from the jawline to the neck. In contrast to the mid-face, where soft transitions make for the aesthetical ideal,3 the jawline should demonstrate relatively sharp and angular transitions to the neck, as a sharp jawline frames the lower third of the face.
To create this look, I use a high G prime filler, in a superficial (subdermal) layer, to accentuate desired angulations and shadowing. Furthermore, a HA filler with good soft tissue integration is required to provide lift and superior support. A combination of Restylane Volyme, Restylane Lyft and Restylane Defyne are my products of choice here. There are alternative volumising HA fillers that may be suitable for jawline treatment such as Princess Volume, Belotero Volume and Juvéderm Voluma. Jawline sculpting can be divided into three main treatment subunits: the angle of the mandible, the chin and the peri-jowl region.
Key treatment subunit areas
Below are the three key areas practitioners should be looking to address, together with my treatment approach.
1. Angle of the mandible
The angle of the mandible is often an overlooked and undertreated area. It is on the lateral aspect of the face and is therefore less often noticed in self-portrait photography and patient self reflection.
The mandibular angle can be defined as an angle formed by the junction at the gonion (the midpoint) of the posterior border of the ramus and the inferior border of the body of the mandible.4
Radiological studies have demonstrated that females have an average gonial angle of 125 degrees however this is highly variable even between aesthetically attractive individuals.5,6 The angle of mandible is a superolateral structure relative to the jowl, and by creating shape and angulation with dermal fillers, volumetric support to the jowls is also provided. When sculpting the jawline, the aim should be to define and enhance a patient’s natural mandibular angle.
Technique
1. Identify any volume loss of the pre-auricular space
2. Palpate and mark the angle of the mandible
3. Create an entry point that is superomedial (often 0.5cm) to the angle of the mandible using a 23 gauge needle
4. Mark out the intended inferior border of the ramus and posterior mandibular body (Figure 1)
5. Treat using a 25 gauge 5cm cannula and aspirate prior to injecting to check for intravascular entry
6. Perform slow retrograde threads of dermal filler, tightly approximated (0.1ml per thread) to a total of 0.5ml-1ml per side
7. Gentle palpation between the edge of two fingers helps to shape the product for ideal angular contour
Potential difficulties
The facial nerve and parotid gland are at risk during shaping of the posterior mandibular ramus as they are both deep structures, located deep to the superficial musculo-aponeurotic system (SMAS). They can be avoided by injecting in the subdermal plane. When injecting the inferior border of the ramus, be mindful of the facial artery as it courses along the anterior border of the masseter. It is palpable at this point and should be identified and protected prior to injection.
Summary
Goal: To define and enhance the angle of mandible
Depth: Superficial/subdermal
Volume: 0.5-1ml per side
Technique: Cannula technique
Products of choice: Restylane Defyne, Restylane Volyme or Restylane Lyft
2. Chin contouring
For ideal facial proportions, the face is generally divided into equal vertical thirds (upper, middle, lower) and horizontal fifths (Figure 2). The ideally proportioned chin width is said to occupy the central horizontal fifth of the face.7 A one third to two thirds ratio should exist for the distance between the nasal and superior upper lip border to the inferior lower lip border to the pogonion.7 When contouring the chin, start with a focused assessment of chin length, anterior projection and the depth of the pre-jowl sulcus region. Ricketts’ Esthetic Plane connects the tip of the nose to the pogonion of the chin and states that the upper lip is an average distance of 4mm to this line and the lower lip is an average distance of 2mm.9 I use Ricketts’ Esthetic Plane9 as an assessment guide to the overall relationship between the tip of the nose, the lips and pogonion of the chin for lower third facial harmony. The rule of facial thirds can be applied to determine if the chin requires elongation.7 However, as a general principle, ageing causes mandibular resorption and is associated with hyperactivity of the mentalis.2 These factors all contribute to a shortened chin and a less projected lower facial third.
Technique
1. Assess the contour deformity in the pre-jowl sulcus, the mental crease, and the mentalis muscle
2. Palpate and mark the pogonion of the chin
3. Improve the projection and length of the chin with deep dermal fillers via sharp needle using a high G prime product in the deep periosteal plane
4. For cannula treatment, choose an entry point that allows access to the pre-jowl sulcus
5. Aspirate to check for intravascular cannulation
6. Slow retrograde threads, in a spread fanning technique (0.1ml per thread) to a total of 0.5-1ml per side
7. Gentle palpation helps to smooth the treated area
Potential difficulties
The inferior alveolar artery and nerve exiting from the mental foramen are the main dangers in this area. The mental foramen is commonly located between the first and second premolar teeth and should be protected from direct injections.10
Summary
Goal: To shape and contour the chin
Depth: Subdermal and periosteal
Volume: 1-2ml total
Technique: Cannula for subdermal and needle for periosteal
Products of Choice: Restylane Volyme or Restylane Lyft
3. Peri-jowl region
By treating the angle of mandible first, followed by the chin, the soft tissues surrounding the jowl area (superolaterally and inferomedially) will be slightly tensioned. Hence, less product is required when focusing our attention to the jowls directly. In my experience, three perpendicular dermal filler threads can adequately shape the inferior edge of the mandibular ramus.
Technique
1. Identify the borders of the jowls and be mindful not to volumise the area (Figure 3)
2. Palpate and mark the pogonion of the chin and the angle of mandible
3. Mark out lines that connect the angle of mandible to the pogonion of the chin, representing the inferior edge of ramus
4. Aspirate to check for intravascular cannulation
5. Slow retrograde threads tightly approximated of dermal filler product of 0.1ml per thread to a total of 0.5ml per side
6. Gentle palpation between the edge of two fingers helps to shape the product for ideal angular contour
Potential difficulties
Be careful not to place any volume within the jowls as, in my experience, this will act to worsen the pre-jowl sulcus. The mental artery, nerve and the facial artery must also be considered during treatment of this subunit and have been previously discussed.
Summary
Goal: To straighten and sharpen the jawline by camouflaging the jowl
Depth: Subdermal
Volume: 1ml total
Technique: Cannula for subdermal
Products of Choice: Restylane Volyme or Restylane Lyft
The jawline should demonstrate relatively sharp and angular transitions to the neck, as a sharp jawline frames the lower third of the face
Considerations and complications
Jawline sculpting is a demanding treatment area. The heaviness and descent of the upper two thirds influence the lower third,2 often requiring the cheeks, temples and pre-auricular regions to be pre-treated. It is a large treatment area, requiring a sufficient volume of dermal filler for complete treatment. This is reflected in higher financial cost to patients, who will in turn be looking for a higher aesthetic outcome. It should only be attempted after adequate training.
The risk of intravascular injection can be minimised by remaining in the superficial (subdermal) plane or the deep (periosteal) planes. Furthermore, I believe aspiration prior to injection can also minimise intravascular risk. A benefit of performing treatment with HA dermal fillers is the ability to reverse treatment with the use of hyaluronidase. Practitioners should be well versed in the use and application of hyaluronidase when treating dermal filler.
Conclusion
A straight, youthful jawline is a treatment area commonly requested by aesthetic patients. At the same time, it is a demanding area that should be approached by experienced injectors with suitable training. The jawline sculpting technique describes a treatment progression from the angle of the mandible to chin contouring and to the peri-jowl region. With a focus on anatomical dangers, this technique can provide a safe treatment guide to achieving a good aesthetic outcome for patients.
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