For certain medical aesthetic items mentioned in this document, based on product-specific characteristics, please reference and apply them in accordance with the approved indications of the products within your respective jurisdictions.
1. Mendelson BC, Wong CH. Anatomy of the aging face. Ch. 6. Volume 2 Aesthetic. In: Warren RJ, Neligan PC, eds. Plastic Surgery. 3rd ed. Elsevier; 2013:79–92
2. Fritz E B, Aesthetic Surgery of Face and Neck. Aesthet Sur J;29:449-463
3. Wong CH, Mendelson B. Newer Understanding of Specific Anatomic Targets in the Aging Face As Applied to Injectables : Aging Changes in the CranioFacial Skeleton and Facial Ligaments. Plast. Reconstr. Surg. 136:44S, 2015
Fig. 2. The areas of the facial skeleton that selectively resorb with aging, with the size of the arrows indicating relative tendency for bone loss. These locations are the areas that should be specifically targeted for the use of injectables for skeletal augmentation. Reprinted with permission from Dr. Bryan Mendelson & Dr. Chin-Ho Wong from Changes in the Facial Skeleton with Aging: Implications and Clinical Applications in Facial Rejuvenation.Aesth Plast Surg (2012) 36:753–760. ©2012 Mendelson, Wong.
Fig. 1. The facial skeleton resorbs significantly with aging. This loss of support from the “foundation” of the face results in retrusion and “sagging” of the overlying soft tissues. Reprinted with permission from Dr. Bryan Mendelson & Dr. Chin-Ho Wong from Changes in the Facial Skeleton with Aging: Implications and Clinical Applications in Facial Rejuvenation.Aesth Plast Surg (2012) 36:753–760. ©2012 Mendelson, Wong.
1.MendelsonBC, Wong CH. Anatomy of the aging face. Ch. 6. Volume 2 Aesthetic. In: WarrenRJ, Neligan PC,eds. Plastic Surgery. 3rd ed. Elsevier; 2013:79–92
2.FritzE B, Aesthetic Surgery of Face and Neck.AesthetSur J;29:449-463
3.WongCH, Mendelson B. Newer Understanding of Specific Anatomic Targets in the AgingFace As Applied to Injectables : Aging Changes in the CranioFacialSkeleton and Facial Ligaments. Plast. Reconstr.Surg. 136:44S, 2015
Fascia manifests in region- andfunction-specific forms, categorized anatomically into: true ligaments, falseligaments, skin retaining ligaments, septa, and fusion zones, etc
1. Mohammed Alghoul, MD.Retaining Ligaments of the Face : Review of Anatomy and Clinical Applications. Aesthetic Surgery Journal 33(6) 769-782
Braz A , Eduardo C . The Facial Shapes in Planning the Treatment with InjectableFillers[J]. Indian Journal of Plastic Surgery, 2020, 53(6).
Swift A , Liew S , Weinkle S , et al. TheFacial Aging Process From the "Inside Out"[J]. Aesthetic SurgeryJournal, 2020(4).
S. C. Rhee, Differences between Caucasianand Asian attractive faces, 2017
Fig. 3. a Frontal and b lateral views of an Asian female face illustrating some of the morphologic features (wide bitemporal, bizygomatic, and bigonial distances; retruded and concave media maxilla; puffy upper eyelids; epicanthal folds) listed in Table 2. (Photos courtesy of Dr. Steven Liew)
Consensus on Changing Trends, Attitudes, and Concepts of Asian Beauty
Aesthetic Plast Surg. 2016; 40: 193–201.
Steven Liew, Woffles T. L. Wu, Henry H. Chan, Wilson W. S. Ho, Hee-Jin Kim, Greg J. Goodman, Peter H. L. Peng, and John D. Rogers
Cotofana, Sebastian & Gotkin, Robert &Frank, Konstantin & Lachman, Nirusha & Schenck, Thilo. (2019). AnatomyBehind the Facial Overfilled Syndrome: The Transverse Facial Septum.Dermatologic Surgery. 1. 10.1097
When doctors use excess fillers at inner face.
The outer facial contour of Asians typically presents a more elongated overall structure compared to Europeans, characterized by smoother outlines and a shape of “wide at the top and narrow at the bottom”.
Aged face
Outer contour: “narrow at the top and wide at the bottom” shape
Inner Face: soft tissue sagging
“Square-shaped face”
Freytag David L., Alfertshofer Michael G., Frank Konstantin., Melnikov Dmitry V., Moellhoff Nicholas., Swift Arthur., Heisinger Stephan., Gotkin Robert H., Ehrl Denis., Cotofana Sebastian.(2022). The Difference in Facial Movement Between the Medial and the Lateral Midface: A 3-Dimensional Skin Surface Vector Analysis. Aesthet Surg J, 42(1), 1-9. doi:10.1093/asj/sjab152.
For certain medical aesthetic items mentioned in this document, based on product-specific characteristics, please reference and apply them in accordance with the approved indications of the products within your respective jurisdictions.
Freytag David L., Alfertshofer Michael G., Frank Konstantin., Melnikov Dmitry V., Moellhoff Nicholas., Swift Arthur., Heisinger Stephan., Gotkin Robert H., Ehrl Denis., Cotofana Sebastian.(2022). The Difference in Facial Movement Between the Medial and the Lateral Midface: A 3-Dimensional Skin Surface Vector Analysis. Aesthet Surg J, 42(1), 1-9. doi:10.1093/asj/sjab152.
For certain medical aesthetic items mentioned in this document, based on product-specific characteristics, please reference and apply them in accordance with the approved indications of the products within your respective jurisdictions.
Soft tissues are lifted following injection into the ligaments within the medial facial kinetic zone of the midface.
Casabona Gabriela., Bernardini Francesco P., Skippen Brent., Rosamilia Gianna., Hamade Hassan., Frank Konstantin., Freytag David L., Sykes Jonathan., Onishi Emy C., Cotofana Sebastian.(2020).
How to best utilize the line of ligaments and the surface volume coefficient in facial soft tissue filler injections. J Cosmet Dermatol, 19(2), 303-311. doi:10.1111/jocd.13245
Injection into ligaments improves medial facial folds while fixing and lifting soft tissues.
Cong L Y , Duan J , Luo C E , et al. Injectable Filler Technique for Face Lifting Based on Dissection of True Facial Ligaments[J]. Aesthetic Surgery Journal, 2020.
For certain medical aesthetic items mentioned in this document, based on product-specific characteristics, please reference and apply them in accordance with the approved indications of the products within your respective jurisdictions.
Injection into the temporal subcutaneous fat layer improves the outer contour of the temple while lifting the sagging soft tissues of the midface, particularly the lateral cheek.
Casabona G, Frank K, Koban K C, et al. Lifting vs volumizing—The difference in facial minimally invasive procedures when respecting the line of ligaments[J]. Journal of Cosmetic Dermatology, 2019.
Suwanchinda A, Webb K L, Rudolph C, et al. The posterior temporal supraSMAS minimally invasive lifting technique using soft‐tissue fillers[J]. Journal of Cosmetic Dermatology, 2018.
Fillers injected in the outer contour (temporal area, cheeks and jawline) have a pronounced regional lifting effect.
Haidar R, Freytag M D DL, Frank K. Quantitative Analysis of the Lifting Effect of Facial Soft-Tissue Filler Injections. Plast Reconstr Surg. 2021 May 1;147(5):765e-776e.
Atchima Suwanchinda, et al. The posterior temporal supraSMAS minimally invasive lifting technique using soft-tissue fillers. J Cosmet Dermatol. 2018 Aug;17(4):617-624.
Claudia A Hernandez, et al. Clinical validation of the temporal lifting technique using soft tissue fillers. J Cosmet Dermatol. 2020 Oct;19(10):2529-2535.
Freytag L, et,al. Understanding Facial Aging Through Facial Biomechanics: A Clinically Applicable Guide for Improved Outcomes. Facial Plast Surg Clin North Am. 2022 May;30(2):125-133.
Right side:
Superolateral superficial injection → medial layer injection
This protocol can effectively enhance the outer contour while achieving a lifting effect with less volume.
CasabonaGabriela., Frank Konstantin., Koban Konstantin C., Freytag David L., SchenckThilo L., Lachman Nirusha., Green Jeremy B., Toni Sabiha., Rudolph Christina.,Cotofana Sebastian.(2019). Lifting vs volumizing-The difference in facialminimally invasive procedures when respecting the line of ligaments. J CosmetDermatol, undefined(undefined), undefined. doi:10.1111/jocd.13089
Facial Content (solid line): Eyes, nose, lips
Anterior Facial Frame (black dotted): Contour Line from the
trichion, the temporal line of the frontal bone, lateral orbital rim, the most lateral line of the anterior part of the zygomatic body, the anterior border of the masseter muscle, and to the inferior border of the chin
Posterior Facial Frame (white dotted): Contour Line from the hairline, the zygomatic arch, ramus and gonial angle of the mandible
Asians’ Posterior Facial Frame : congenital temple hollowness, poorly developed mandible profile, prominent lateral orbital rim & zygomatic arch,
Multiple facial layers aging (ie. Bone, Soft Tissue, Skin) exacerbates facial aesthetics
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Effects of Facial Hard Tissue Surgery on Facial Aesthetics : Changes in Facial Content and Frames. J CranioFac Surg 2012 Nov. Jin Young Choi, DDS, MD.
The Anatomy of the Aging Face : Volume Loss and changes in 3D topography. Aesth Surg. J 2006;26(1S):S4-S9. Coleman SR.
Area four technique : An effective injection approach to the posterior facial frame aesthetic treatment with injectable hyaluronic acid fillers. J Cosmet Dermatol.2023;00:1-8
Technique proposed for Posterior Facial Frame Treatment
GAIS : 88% of patients - exceptional + moderate improvement (Score 1,2)
Improvements in lateral cheek fullness, jawline contouring, PFF scale, lateral cheek lifting
Effects of Facial Hard Tissue Surgery on Facial Aesthetics : Changes in Facial Content and Frames. J CranioFac Surg 2012 Nov. Jin Young Choi, DDS, MD.
Area four technique : An effective injection approach to the posterior facial frame aesthetic treatment with injectable hyaluronic acid fillers. J Cosmet Dermatol.2023;00:1-8
Zone 1 (red): lifting, lateral tensioning, targeting areas lateral
to the line of ligaments, including lateral hairline.1,4,5,6
Zone 2 (blue): volumization, targeting the lateral, superior fat pads to replenish fat compartments and address bone resorption.1,5,7
Zone 3 (green): 3D enhancement (T-zone, chin), addressing medial facial flattening through projection and contouring. (important in Asians)1,2,3
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1. Hairline Polycaprolactone Injections for Facial Lifting: An Anatomical-Based Approach (ELLANSE) J CranioFac Surg 2025 Apr 25 Isaac KJW
2. Enhancing Facial Projection: Efficacy and Safety of a Novel Filler Combining Cross- Linked Sodium Hyaluronate Gel With Poly- L- Lactic Acid- b- PEG Microspheres for T
Zone Augmentation J Cosmet Dermatol 2025 Mar 25 Shiwei Wang https://doi: 10.1111/jocd.70003
3. Consensus Recommendations for Optimal Augmentation of the Asian Face with Hyaluronic Acid and Calcium Hydroxylapatite Fillers Plast Reconst Surg 2015 Nov Nov 15
Nark-Kyoung Rho
4. How to best utilize the line of ligaments and the surface volume coefficient in facial soft tissue filler injections JoCD 2019 Casabona
5. Full-face effects of temporal volumizing and temporal lifting techniques JoCD 2020 Casabona
6. Lifting vs volumizing—The difference in facial minimally invasive procedures when respecting the line of ligaments JoCD 2019 Casabona
7. The Surface-Volume Coefficient of the Superficial and Deep Facial Fat Compartments: A Cadaveric Three-Dimensional Volumetric Analysis Plast Recon Surg June 2019 Cotofana
- High G’ (1000Pa) & High lifting power –> minimum product, highest effect (prevent FOS)
- High cohesivity –> No breakage nor migration
- High viscosity -> Mimic bone support
- Stimulates own Type I Collagen for NATURAL REGENERATIVE result
- Longest lasting collagen stimulator (great for active lifestyle)
- Versatile (bolus support on bone, cannula threading for collagen stimulation)
Neocollagenesis of mainly type I collagen was evidenced at 9 months and maintained at 21 months with Ellansé M
Neocollagenesis of mainly type I collagen was evidenced at 15 months with Ellansé S
The ratio for type I vs type III was 85/152
Collagen production with Ellansé was demonstrated in humans
PCL microspheres were maintained in their original state 13 months post-injection
Ellansé - smooth, spherical PCL microspheres
Sculptra® - irregular-shaped particles
Radiesse® microspheres generally less spherical and uniform than Ellansé’s microspheres
Rough and irregular-shaped particles are more likely to initiate an inflammatory reaction1,2
Ellansé - smooth, spherical PCL microspheres Sculptra® - irregular-shaped particles Radiesse® microspheres generally less spherical and uniform than Ellansé’s microspheresRough and irregular-shaped particles are more likely to initiate an inflammatory reaction1,2
•Ellansé offers immediate results,unlike PLLA-based fillers such as Sculptra
•Results from Ellansé last longerthan those from CaHa-based fillers such as Radiesse
PCL injection into subcutaneous tissue in rats VS Saline
Increased collagen, elastin in fat tissue of PCL subjects in both juvenile and aged rats
Type I collagen produced was much more than Type III Collagen
Increased upregulation of collagen-related genes Col1a1 and Col3a1
Downregulation of aging genes (P16INK4a)
Significant ADSC activity (CD34 positivity) (95%)
Increased Fibroblast proliferation 55%
Angiogenesis activity (CD31 positivity) increased 55%
Low Inflammation (Low CD45 levels) – controlled immune response, reducing fibrosis risks
PCL activates ADSC, promoting collagen synthesis without inflammatory side effects
Slow biodegradation of PCL allows for sustained ADSC activity
CaHA can cause inflammatory reactions, inconsistent collagen stimulation
PLLA can lead to granuloma due to inflammatory activity of fibroblasts
PCL offers alternative, regenerative pathway of stem cells activation to reduce adverse events associated with other biostimulators
FIGURE 1 | The two sides of the face appeared as an uncoordinated phenomenon after injection during the 180 days of follow-up (A). The left and right lateral faces were cut and re-synthesized (B, C). The lifting effect of the right face injected with PCL remained stable for 180 days (D). The lifting effect of the left face injected with HA was weakened on day 45 (E).
1. Comparision of Materials for Posterior Facial Frame Injection : Hyaluronic Acid or PCL, a case report. J Cosmet Dermatol 2025 June. Liping Hu, MD.
Temple
- Shaping the outer contour of temporalhairline.
- Subcutaneous fat layer + middle temporalfascia + periosteum layer
- Single line/point injection of0.05-0.1ml.
Buccal
- Tighten the PAF, Improving the buccal depression；Subcutaneous fat layer, < 1ml/ side/ time.
Mandibular margin
- Mandibular margin lifting and contouring
- Subcutaneous fat layer, < 1ml/side/time.
- Supraperiosteal injection, single point < 0.2ml
Entry point：2-3cm medial to tragus
Injection layer：Subcutaneous fat or the fourth layer (between deep and superficial temporal fascia) of posterior temporal part (deep hairline)
Injection method：0.05-0.1ml/line, multiple lines, fanning
Entry point：2cm above zygomatic arch, outside the lateral edge of orbit
Injection layer：Between superficial and deep temporal fascia (IF)
Injection method: Single line/point injection of 0.05-0.1ml.
Entry point: 1cm posterior to the tail of the eyebrow and the frontotemporal ridge
Injection level: Supraperiosteal injection.
Injection method：Multi-point (3-5 points) injection, single point less than 0.2ml.
Improving the cheek depression
Injection method：Subcutaneous fat layer, < 1ml/ side
Injection method：
Subcutaneous fat layer, < 1ml/side/time.
Supraperiosteal injection, single point < 0.2ml.
Past Appointment: Asia Ellanse Advisory Board Member 2016
