Areas of correction

Mid-facial volumisation

Volume loss in this area is caused by a diminishing of volume in the bone structure of the malar process of the zygoma, atrophy of the superficial fat compartment, and weakening of the system of ligaments in the mid-facial area10,11.

Volume restoration in this area is conducted at the periosteal level in the malar region and at the deep fat pad level in the case of the mid-face.

Contour restoration of the lower jaw

This implies the insertion of product supraperiosteally with the goal of repairing the involution of the bone structure of the lower jaw. To restore this zone in men it is preferable to use a cannula and a monophasic highly cohesive dermal filler that consists of cross-linked hyaluronic acid with low molecular weight.

Chin volumisation

This age-related deformation is linked to the resorption processes of the bone tissues, muscle hyperactivity (m. mentalis, m. depressor anguli oris, m. depressor labii inferioris), and atrophy of the superficial fat pad. Correction includes a restoration of the chin protuberance combined with the alignment of a more expressive (forceful) shape in this area in men. The product of choice for this is hyaluronic acid inserted supraperiosteally by needle for a crisper formation of the chin protuberance.

Nasolabial folds

These are formed as a result of muscle hyperactivity, excess skin under the nasolabial folds, and bone atrophy in this area. Inject the product at the level of the deep layers of the subcutaneous fat pad to create a base for the upper subcutaneous fat pad and skin of this area. One of the dangers in working with the nasolabial fold in men is the possibility of creating an unnatural look, caused by using too much product. This can lead to the compression, by a large volume of viscous and thick product, of the angular artery with the subsequent development of ischaemia in the mid-facial tissues. As a preventive measure against such a development, it is vital to combine the treatment of the nasolabial folds with mid-facial treatment and distribute the appropriate volume of product in the nasolabial folds at various levels of tissue, and to maintain constant control of this area of injection during the procedure.

Marionettes

This a defect that forms as a result of hyperactivity of the muscles and redistribution of the subcutaneous fat pad in the lateral and medial superficial fat compartments of the chin. Correction of the marionettes should be accompanied by the essential volume restoration of the chin, achieved by injecting the product in this area.

The temporal area

Lifting and volumisation of the temporal region is one of the basic stages of contour correction, which helps to achieve a significant visible rejuvenating effect—even when performed as a separate procedure 12. The degree of atrophy in the temporal region is, by and large, higher among men than women. Correction in this area alone produces an effect, which is not only one of rejuvenation of the upper face and lifting of the mid-face, but also a significant improvement in the condition of the periorbital area. It is always worth remembering that there is a risk of perforating the temporal artery when working at the sub-dermal level, and also of traumatising and compressing the deep temporal artery when inserting hyaluronic acid in this area supraperiosteally (Figure 3).

Figure 3 Location of the temporal and deep temporal arteries

Figure 3 Location of the temporal and deep temporal arteries

Products and instruments for volumisation

For volumisation of the face, the preferred choice is a hyaluronic acid gel with high durability and viscosity, which is characterised by its concentration and effectiveness for cross-linking. This allows the filler to produce a lifting effect and remain in the corrected area’s tissues for a long period, creating the effect of a natural volume restoration immediately after the procedure 7. The author’s preference is 20 mg/ml of smooth, cohesive, low molecular weight (short chain) hyaluronic acid volumising filler 13, in accordance with the usual practice.

The product of choice for volume restoration is biostimulatory fillers based on poly-L-lactic (PLLA) acid and calcium hydroxylapatite (CaHA). However, the downside of these is difficulty in removing them in cases of an adverse reaction.

Figure 4 Optimal programme for the female patient (left) before and (right) after 3 months of the two stages treatment: 4 ml of hyaluronic acid filler of high cohesivity and viscosity, 0.8 ml medium cohesive filler, and 20 units of botulinum toxin A

Figure 4 Optimal programme for the female patient (left) before and (right) after 3 months of the two stages treatment: 4 ml of hyaluronic acid filler of high cohesivity and viscosity, 0.8 ml medium cohesive filler, and 20 units of botulinum toxin A

The practice of using a cannula is one of the basic tendencies in contour correction, owing to its atraumatic nature and the opportunity to work with tissues at varying depths. Depending on the depth required for insertion and the characteristics of the tissues, cannulae of varying diameters and lengths can be used. It is obvious, that, when considering a deep insertion of thick and viscous hyaluronic acid, it is expedient to use a rigid cannula with a diameter of between 22 and 25 G. The length should be no less than 5 cm, such that, in accordance with the concept of levers, there is no possibility of deforming the cannula under the impact of the mass of the tissue. Furthermore, the likelihood of loss of a thick gel when forcing it through a thin cannula or needle increases significantly. Despite the lack of a stinging effect when using cannulae, there remains the possibility of rupturing brittle vessels in ageing patients when passing cannulae through tissue. This can also occur when using a needle, but bruising is less widespread.

Despite the advantages of working with cannulae, chin correction, and in some circumstances the mid-face area, require the more obvious use of a needle using the bolus and dot8 technique, which are more accurate.

Figure 5 Minimum programme for the male patient (left) before and (right) after 1 ml per side of monophasic highly cohesive hyaluronic acid filler, combination of dot 8 and bolus technique

Figure 5 Minimum programme for the male patient (left) before and (right) after 1 ml per side of monophasic highly cohesive hyaluronic acid filler, combination of dot 8 and bolus technique

It follows from the above principle of classic volume correction in men that the volume of product inserted into facial tissue in the course of one procedure can amount to 6–7 ml, and in some circumstances may even exceed that level. The volume of product is determined on an individual basis for each patient according to the evidence of age-related changes within the tissues, the condition of the lymphatic system, and the microcirculation in the area of correction.

To prevent complications in the case of a classic volume correction, the best solution is to perform the correction in stages.