Accepted Article After the Temporal Lifting Technique – What comes next?

Claudia A. Hernandez M.D.,1 Carolina Schneider M.D.,2 Michael H. Gold M.D., 3

Mariana Muniz M.D., 4 Jeremy B. Green M.D., 5 Michael Alfertshofer, 6
Konstantin Frank M.D., 6 Sebastian Cotofana M.D. Ph.D. 7

1 CH Dermatologia, Medellin, Colombia

2 Private Practice, Buenos Aires, Argentina
3 Gold Skin Care Center, Tennessee Clinical Research Center, Nashville, TN, USA.
4 Private Practice, Sao Paolo, Brazil
5 Skin Associates of South Florida and Skin Research Institute, Coral Gables, FL, USA
6 Department for Hand, Plastic and Aesthetic Surgery, Ludwig – Maximilian University Munich, Germany
7 Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, MN, USA

Keywords: Temporal hollowing, Facial anatomy, Soft tissue fillers, Facial lifting, Facial Volume

Running title: After the Temporal Lifting Technique – What comes next?

Conflict of interest: The authors declared no potential conflicts of interest with respect to the
research, authorship, and publication of this article.

Contribution: C.H., C.S., M.H.G., M.M., J.B.G., M.A., K.F. and S.C. made either substantial
contributions to the conception or design of the work, drafted the work or revised it critically.

Funding: The authors received no financial support for the planning or conducting of the research
presented in this article. All products utilized were self-funded. Merz Pharma GmbH & Co.KGaA
funded the conception of this manuscript.

Corresponding author:

Sebastian Cotofana MD, PhD, PhD

Associate Professor of Anatomy
Department of Clinical Anatomy

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1111/JOCD.14247
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Accepted Article Mayo Clinic College of Medicine and Science, Mayo Clinic,
Stabile Building 9-38, 200 First Street, Rochester, MN, 55905, USA
Email: cotofana.sebastian@mayo.edu

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Accepted Article
DR. MICHAEL H. GOLD (Orcid ID : 0000-0002-5183-5433)

DR. MICHAEL ALFERTSHOFER (Orcid ID : 0000-0002-4892-2376)

MR. KONSTANTIN FRANK (Orcid ID : 0000-0001-6994-8877)

PROF. SEBASTIAN COTOFANA (Orcid ID : 0000-0001-7210-6566)

Article type : Original Contribution

Abstract

Background: The temporal lifting technique can provide lateral facial lifting when
administering hyaluronic acid (HA) based soft tissue fillers into the subdermal plane of the
temple. However, the central facial oval is not influenced by this technique.

Objectives: To identify the safety and aesthetic effectiveness of additional midfacial injection
points (in addition to the temporal lifting technique) that can volumize the medial midface,
lift the lateral face, increase jawline contouring when included into a full-face injection
algorithm.

Methods: The patient records of nine consecutive patients (all females) with a mean age of
35.0 (8.4) years and a mean body mass index of 21.7 (2.4) kg/m2 were retrospectively
analyzed after a full-face injection algorithm was performed using HA based fillers. The
additional injection points target the supraperiosteal plane of the medial zygomatic arch, the
lateral infraorbital region and the pyriform fossa using both needles and cannula.

Results: No adverse events were observed during the 6-months retrospective observational
period. The volume of the medial midface increased, the volume of the lateral midface
decreased, and the contour of the jawline improved; all effects reached a highly statistically
significant level with p < 0.001.

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 Conclusion: Despite each in dividual injection is currently performed on a daily clinical basis
Accepted Article
the evaluated injection algorithm following the temporal lifting technique shows some
evidence that it is safe and aesthetically effective. Future studies will need confirm the results
presented herein in a larger sample and with objective outcome measures to guide safe and
effective aesthetic outcomes.

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 Introduction
Accepted Article In 2018, various publications have identified the subdermal plane of the posterior superior
temple as a potential target for soft tissue filler volumization procedures 1,2. Based on the
biomechanical characteristics of the superior and inferior superficial temporal fat compartments it was
postulated that the subdermal plane of the temple can be utilized for facial lifting when injecting
hyaluronic acid (HA) based soft tissue fillers. The rationale behind this assumption was an anatomic
study by Schenck et al. which utilized contrast-agent enhanced computed tomographic scanning of
filler injected cadaveric specimen, which revealed that increasing amounts of filler material does not
result in tissue descent when positioning the cephalic specimen in a fixed upright position 2. Applying
this anatomic knowledge, it was hypothesized that increasing amounts of soft tissue filler can lift
more inferiorly located facial regions, like the lateral cheek and the jawline: this was showcased in a
small sample of Asian patients1.

In 2020, this hypothesis was confirmed by Hernandez et al.3 in a clinical interventional study
treating patients with lateral face soft tissue decent. The results of that independent study revealed that
the volume of the lateral midface decreased due to soft tissue repositioning and that the contour of the
jawline was more accentuated based on the effects following the subdermal product application of the
temple. The authors explained their findings based on the stable and firm position of the subdermal
temporal fat compartments which are capable to elevate more inferiorly located soft tissues if targeted
with HA based fillers.

Despite multiple filler injection techniques have been described for the temple4 and full-face
effects have been objectively confirmed5, the general perception is that additional injections are
needed to complete a full-face treatment and to harmonize the entire face. The rationale behind this
perception is supported by the underlying anatomy of the facial layers. In the lateral face, the fascial
layers are arranged in parallel orientation whereas medial to the line of ligaments6,7, the layers are
obliquely arranged following the course of the muscles of facial expression. This change in anatomic
layered arrangement and the presence of the line of ligaments limits the transmission of aesthetic
effects from the lateral face to the medial face and vice versa.

Therefore, it would be of great clinical benefit to identify additional injection points, which
can in addition to the temporal lifting technique help to complete a full-face treatment which
combines lateral facial lifting (resulting from the temporal lifting technique) and medial facial
volumizing. To identify such additional injection points, a retrospective data analysis was performed
of patients treated with a standard injection algorithm which extends the temporal lifting technique by
a medial midfacial injection component.

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 Materials and Methods
Accepted Article
Study participants

The patient records of nine consecutive patients (all females) with a mean age of 35.0
(8.4) years and a mean body mass index of 21.7 (2.4) kg/m2 were retrospectively analyzed.
Study participants had the following distribution of Fitzpatrick skin type: Type I, n = 1
(11.1%); Type II, n = 3 (33.3%); Type III, n = 4 (44.4%); Type IV, n = 1 (11.1%) and were
analyzed from consecutive patients of CH Dermatologia, Medellin, Colombia and requested
aesthetic treatment of their full-face. Study participants were treated following a standardized
injection algorithm if their clinical assessment revealed lateral facial sagging with loss of
jawline contour AND medial facial volume loss especially in the central facial oval (medial
cheeks, infraorbital and nasolabial sulcus). No age, BMI or other restrictions were regarded
as exclusion criteria for this full-face treatment.

Treatments were conducted in accordance with good clinical practice following

standard operating procedures at the treatment providing clinic. All patients provided written
informed consent for the treatment received and for the use of their personal and imaging
data for this retrospective data analysis. Patient records were not accessed if patients declined
their participation in this study.

Injection technique

All patients were treated bilaterally following a standard injection algorithm which is
composed of four individual injections of the temple and the middle face and is termed B.UP
technique (Figure 1).

The injection technique applied first in every patient was the temporal lifting
technique as published previously3. In brief, a 22 G, 50 mm cannula (Feeltech CO Ltd, Seoul,
Korea) was introduced into the subdermal plane of the posterior superior temple located
behind the hairline and administered 1.0 (0.0) cc of high G-prime HA based soft tissue filler
(here: Belotero Volume; Merz Pharma, Frankfurt/Main, Germany).

In a next step, the supra-periosteal plane of the zygomatic arch lateral to the line of
ligaments was targeted using a 27 G, 15 mm needle (TSK Laboratory, Tochigi-Ken, Japan).
A series of three consecutive bolus injections were administered at a volume of 0.1 – 0.2 cc
per bolus following pre-injection aspiration with a medium G-prime HA based filler product

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 (here: Belotero Intense; Merz Pharma, Frankfurt/Main, Germany). The total amount of
Accepted Article
volume applied per facial side was 0.38 (0.08) cc [range: 0.3 – 0.5].

In a next step, the lateral infraorbital region was targeted utilizing a 25 G, 50 mm

cannula (Feeltech CO Ltd, Seoul, Korea) with product application into the supraperiosteal
plane. A bolus of 0.1 – 0.2 cc of high G-prime product was administered (here: Belotero
Volume; Merz Pharma, Frankfurt/Main, Germany). The total amount of volume applied per
facial side was 0.14 (0.05) cc [range: 0.1 – 0.2].

In a final step, the deep pyriform fossa was targeted utilizing a 27 G, 15 mm needle
(TSK Laboratory, Tochigi-Ken, Japan) with product application in constant contact with the
bone. Following pre-injection aspiration, a bolus of 0.1 – 0.2 cc of a medium G-prime HA
based filler product was administered (here: Belotero Intense; Merz Pharma, Frankfurt/Main,
Germany). The total amount of volume applied per facial side was 0.14 (0.07) cc [range: 0.05
– 0.2].

Outcome assessment

The aesthetic outcome following the complete full-face treatment was evaluated by
the patient immediately after the treatment and at a consecutive follow-up screening visit.
The aesthetic improvement was rated by the patient and by an independent observer (other
than the treating physician) following the global aesthetic improvement scale (GAIS) ranging
from 0 (much worsened) to 4 (much improved)8.

Additional outcome assessment was obtained via semi-quantitative scoring on the

lateral midfacial volume, medial midfacial volume and jawline contouring utilizing validated
5-point Likert scales ranging from 0 (no volume loss/no sagging) to 4 (very severe volume
loss/sagging)9. This rating was conducted by the treating physician and by an independent
observer during patient assessment (before the initial treatment) and during the follow-up
visit.

The follow-up visit relevant for the evaluation of the above described treatment
algorithm was the last patient contact which occurred at 24.4 (7.1) weeks [range: 8 – 28]
after the initial injection procedure i.e. on average 6 months.

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 Statistical analysis
Accepted Article Differences between baseline and follow-up values were calculated as paired analyses
using a paired Student’s t-test for continuous variables and using Wilcoxon signed rank test
for ordinal variables. To relate the consistency (= reliability) in the assessment between raters
(patient vs. independent observer vs. treating physician) on the same outcome, the interclass
correlation coefficient (ICC) was calculated based on a two-way mixed effect model with
absolute agreement for k = 2 and 2 raters, respectively. Analyses were performed using SPSS
Statistics 23 (IBM, Armonk, NY, USA) and differences were considered statistically
significant at a probability level of ≤ 0.05 to guide conclusions.

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 Results:
Accepted Article The total amount of soft tissue filler product utilized with this algorithm was per
patient on average 3.41 (0.22) cc for the entire face of which 2.30 (0.1) cc was a high G-
prime HA based filler (Belotero Volume) and 1.11 (0.15) cc was a medium G-prime HA
based filler (Belotero Intense).

Aesthetic improvement
The aesthetic improvement as evaluated by the global aesthetic improvement scale
(GAIS) was rated by the patient and by an independent observer. Results showed that the
patients perceived the injection outcome to have very much improved their facial appearance
with 3.78 (0.4) on a scale 0 – 4 = much worsened – much improved, whereas the independent
observer rated the injection outcome with 3.86 (0.4) (Figure 2 & 3). This reveals a
statistically significant agreement between the ratings with an ICC of 0.653 and p = 0.020.

Semi-quantitative scoring of facial volume and jawline contouring

The average volume of the medial and lateral midface and the contour of the jawline
was rated both by the treating physician and by an independent observer based on a 5-point
Likert scale ranging from 0 – 4 (best to worst). The mean volume in the medial midface was
before the treatment 1.28 (0.4) and increased statistically significantly after the treatment to
0.17 (0.3) with p < 0.001 (Figure 4).
The volume in the lateral midface was at baseline 0.89 (0.4) and decreased at follow-
up to 2.61 (0.9) which represents a statistically significant change with p < 0.001 (Figure 5).
The contour of the jawline increased statistically significantly from 1.44 (0.7) at
baseline to 0.44 (0.7) at follow-up with p < 0.001 (Figure 6).

Discussion:

The scope of this study was to evaluate the aesthetic outcome of additional midfacial
injection points which can be included into a standard algorithm following the temporal
lifting technique. The rationale behind additional medial midfacial injection points is that the
temporal lifting technique has been shown to be able to improve jawline contouring and
reduce lateral midfacial volume based on the re-positioning effect following subdermal soft
tissue filler deposition into the subdermal temporal fat compartments1,3,4. However, lifting the
lateral face is limited in its aesthetic outreach due to the presence of the line of ligaments and

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 due to the change in the fascial arrangement of the medial vs. the lateral midface. Aesthetic
Accepted Article
treatments therefore lacked a medial midfacial volumizing component in addition to the
lateral midfacial lifting component after the temporal lifting technique has been performed.

This study retrospectively analyzed the patient data of nine consecutive patients
treated with a standard injection algorithm which targeted the medial midface following the
temporal lifting technique. These additional injection points targeted the zygomatic arch, the
lateral infraorbital area and the pyriform fossa. These three injections points have in common
that they target the supraperiosteal plane using both needle and cannula and utilize either a
medium or a high G-prime product with specific rheologic characteristics.

The three bolus injections performed with a needle along the zygomatic arch were
utilized based on previous publications by Casabona et al.6,10 which have provided objective
evidence that targeting the immediate area lateral to the line of ligaments has the ability to
pre-condition the medial midface and to results in less volume usage if lateral injection points
are administered before medial injection points. This is supported by the underlying anatomy
and the biomechanical behavior of the fascial layered arrangement. The multiple bolus
injection performed with a cannula of the lateral infraorbital area are based on a previous
publication which has introduced for the first time in the aesthetic literature the surface
volume coefficient11. This coefficient is a reflection of anatomic regions and fat
compartments was designed to evaluate the effectiveness of soft tissue filler injections by
comparing the amount of injected volume to the resulting change in surface projection.
Amongst the plethora of investigated facial regions and fat compartments, the lateral
infraorbital area was shown to have the greatest effectiveness with a coefficient of 0.94 which
indicates that 94% of the injected volume translate into surface projection. It is questionable
whether the effectiveness could be increased if this area is targeted with needle as opposed to
a cannula, like evaluated in this study. Future studies will need to elaborate on this aspect.
The bolus injection performed with a needle into the deep pyriform space aimed to target the
upper aspect of the nasolabial fold and to additionally help to reposition the medial cheeks
and to reduce the depth of the nasolabial sulcus.

Because these additional medial midfacial injection points were administered into the
supraperiosteal plane the safety profile is of clinical relevance. It is known that the
subcutaneous plane of the medial midface is highly vascularized and that the facial arteries
vary highly in their 2D course. Regarding the 3D course of facial vessels i.e. the depth of the

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 arteries it was revealed that the supra-periosteal plane seems to be a safer plane, especially in
Accepted Article
the medial midface12,13. Targeting this plane can provide a certain degree of safety but
additional safety measures like slow injection speed, administration of small amounts of
product and performing pre-injection aspiration should be respected14. Especially the
injection into the deep pyriform space should be regarded as a high-risk injection especially
because in this location in 33.3% of a Russian Caucasian sample of n = 156 study participants
it was revealed that the angular artery was locate deep15.

The identified injection points are not novel by themselves as most of these injection
locations are targeted on a daily clinical basis across the globe administering soft tissue fillers
for aesthetic purposes. However, the combination of those three additional midfacial injection
points in combination with the initially performed temporal lifting technique can provide a
useful algorithm to lift the lateral midface and to volumize the medial midface. The results of
this retrospective investigation provide evidence for its effectiveness despite is small sample
size. The volume of the medial midface increased, the volume of the lateral midface
decreased and the contour of the jawline improved; all effects reached a highly statistically
significant level. The increase in medial midfacial volume is a reflection of the injected
volume into the lateral infraorbital region and into the deep pyriform space. The injections
along the zygomatic arch help to increase the lateral infraorbital volume but support
additionally the pre-conditioning of the medial midface. Because the temporal lifting
technique was performed as a first step of this algorithm, the lateral midfacial volume
decreased following repositioning of the lateral face soft tissues. This was reflected by the
decrease in lateral midfacial volume and by the increase in jawline contouring.

Another limitation of this retrospective investigation, beside the small sample size, is
the lack of objective outcome measures like facial volumetry and facial skin displacement. It
can be argued that the rating of the GAIS which included the patient is subjective and that the
rating of the volume and facial sagging scores is biased because they were partially
performed by the treating physician. Future studies will need to address these limitations and
conduct analyses in an adequately sampled clinical scenario and utilize objective outcome
measures to provide reliable evidence that the performed injection algorithm is beneficial and
safe. This study however provides some guidance toward this direction and reveals that the
treated patients have had an aesthetic benefit from the treatments performed. Whether these
results are applicable to a larger population with different ethnicities and other characteristics

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 than the sample retrospectively investigated remains elusive and should be subject to further
Accepted Article
clarification.

Conclusion

The results of this retrospective analysis evaluated the aesthetic outcome of an

injection algorithm which addresses the medial midface following the temporal lifting
technique. The additional injection points target the supraperiosteal plane of the medial
zygomatic arch, the lateral infraorbital region and the pyriform fossa. It was revealed that the
injection algorithm increases the volume of the medial midface, decreases the volume of the
lateral face and improves the contour of the jawline. Future studies will need confirm the
results presented herein in a larger sample and with objective outcome measures to guide safe
and effective aesthetic outcomes.

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 References:
Accepted Article
1. Suwanchinda A, Webb KL, Rudolph C, et al. The posterior temporal supraSMAS minimally
invasive lifting technique using soft-tissue fillers. J Cosmet Dermatol. 2018;17(4):617-624.
doi:10.1111/jocd.12722
2. Schenck TL, Koban KC, Schlattau A, et al. The Functional Anatomy of the Superficial Fat
Compartments of the Face: A Detailed Imaging Study. Plast Reconstr Surg.
2018;141(6):1351-1359. doi:10.1097/PRS.0000000000004364
3. Hernandez CA, Freytag DL, Gold MH, et al. Clinical validation of the temporal lifting
technique using soft tissue fillers. J Cosmet Dermatol. Published online July 2020:jocd.13621.
doi:10.1111/jocd.13621
4. Cotofana S, Gaete A, Hernandez CA, et al. The Six Different Injection Techniques for the
Temple Relevant for Soft Tissue Filler Augmentation Procedures – Clinical Anatomy and
Danger Zones. J Cosmet Dermatol. Published online 2020. doi:10.1111/jocd.13491
5. Casabona G, Frank K, Moellhoff N, et al. Full-face effects of temporal volumizing and
temporal lifting techniques. J Cosmet Dermatol. 2020;19(11):2830-2837.
doi:10.1111/jocd.13728
6. Casabona G, Frank K, Koban KC, et al. Lifting vs volumizing-The difference in facial
minimally invasive procedures when respecting the line of ligaments. J Cosmet Dermatol.
Published online August 2019. doi:10.1111/jocd.13089
7. Cotofana S, Lachman N. Anatomy of the Facial Fat Compartments and their Relevance in
Aesthetic Surgery. JDDG J der Dtsch Dermatologischen Gesellschaft. 2019;17(4):399-413.
doi:10.1111/ddg.13737
8. Carruthers A, Carruthers J. A validated facial grading scale: The future of facial ageing
measurement tools? J Cosmet Laser Ther. 2010;12(5):235-241.
doi:10.3109/14764172.2010.514920
9. Carruthers J, Flynn TC, Geister TL, et al. Validated assessment scales for the mid face.
Dermatologic Surg. 2012;38(2 PART 2):320-332. doi:10.1111/j.1524-4725.2011.02251.x
10. Casabona G, Bernardini FP, Skippen B, et al. How to best utilize the line of ligaments and the
surface volume coefficient in facial soft tissue filler injections. J Cosmet Dermatol.
2020;19(2):303-311. doi:10.1111/jocd.13245
11. Cotofana S, Koban CK, Frank K, et al. The Surface-Volume-Coefficient of the Superficial and
Deep Facial Fat Compartments – A Cadaveric 3D Volumetric Analysis. Plast Reconstr Surg.
2019;In Print(6):1. doi:10.1097/PRS.0000000000005524
12. Cotofana S, Lachman N. Arteries of the Face and Their Relevance for Minimally Invasive
Facial Procedures: An Anatomical Review. Plast Reconstr Surg. 2019;143(2):416-426.
doi:10.1097/PRS.0000000000005201

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 13. Freytag DL, Frank K, Haidar R, et al. Facial Safe Zones for Soft Tissue Filler Injections: A
Accepted Article Practical Guide. J Drugs Dermatol. 2019;18(9):896-902.
14. Tseng FW, Bommareddy K, Frank K, et al. Descriptive Analysis of 213 Positive Blood
Aspiration Cases When Injecting Facial Soft Tissue Fillers. Aesthetic Surg J. Published online
2020. doi:10.1093/asj/sjaa075
15. Gombolevskiy VA, Gelezhe P, Morozov S, et al. The Course of the Angular Artery in the
Midface: Implications for Surgical and Minimally Invasive Procedures. Aesthetic Surg J.
2020;Online Ahe.

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 Figures:
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Figure 1: Illustration of the utilized injection points: yellow: 22 G 50 mm cannula into the subdermal
plane, green: 27 G 15 mm needle into the supraperiosteal plane, orange: 25 G 50 mm cannula into the
supraperiosteal plane. The white asterisk indicates the dermal access for the cannula injections.

Figure 2: Pre- and post-injection images of a female study participant after treatment with the
investigated injection algorithm. The volume increase (blue area) corresponds with the soft tissue
filler application. The skin vector displacement is shown for reference purposes.

Figure 3: Pre- and post-injection images of a female study participant after treatment with the
investigated injection algorithm. The volume increase (blue area) corresponds with the soft tissue
filler application. The skin vector displacement is shown for reference purposes.

Figure 4: Assessment of the medial midfacial volume as assessed on a 5-point Likert scale ranging
from 0 – 4 (no volume loss – very severe volume loss). The difference between baseline and the
follow-up assessment is indicated by the probability value (p-value). Note: a highly statistically
significant increase in medial midfacial volume was revealed.

Figure 5: Assessment of the lateral midfacial volume as assessed on a 5-point Likert scale ranging
from 0 – 4 (no volume loss – very severe volume loss). The difference between baseline and the
follow-up assessment is indicated by the probability value (p-value). Note: a highly statistically
significant decrease in lateral midfacial volume was revealed.

Figure 6: Assessment of the the contour of the jawline as assessed on a 5-point Likert scale ranging
from 0 – 4 (no sagging – very severe sagging). The difference between baseline and the follow-up
assessment is indicated by the probability value (p-value). Note: a highly statistically significant
improvement in jawline contouring was revealed.

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