Introduction

In the early 1980s, when soft tissue augmentation began its meteoric rise to become one of the
most important procedures in cosmetic dermatology, bovine collagen was the only product
available, and treatment focused solely on filling lines and furrows that marked the onset and
progression of the aging face. Intradermal injections were performed superficially in the epidermal–
dermal junction, whereas more stabilized preparations were recommended for ‘deeper’ injections
into the dermis. After piercing the surface of the skin, the needle was positioned parallel to the skin;
examples of horizontal injections include the multiple puncture or linear threading technique, either
singularly or in a fan-like manner.
Further developments in soft tissue augmentation – among them the recognition of the
importance of volume loss – have led to a better understanding of what is needed to rejuvenate and
restore the individual potential beauty of an aged or ‘mature’ human face. As new materials have
become available and greater anatomical knowledge is gained, clinicians now have a better
opportunity to restore volume lost through the aging process using innovative, vertical injection
techniques that aim to provide optimal structural support.

Anatomical considerations

Initial treatment approaches for volume restoration did not focus on the existing facial anatomy. As
a result, dynamic muscular activity led to pronounced compression of all soft tissues, negatively
affecting the superficial appearance of the surface of the skin resulting in a possible overcorrection.
With the transition to more vertical injection techniques, augmentation results have become more
predictable. However, it has become increasingly obvious that precise knowledge and
understanding of the subcutaneous facial anatomy are prerequisites for successful volume
restoration in facial rejuvenation.
The facial skin and subcutaneous tissue (referred to as the soft tissue ‘flap’) comprise a
dense, superficial formation of connective tissue that makes up the dermis and epidermis, a
honeycomb web-like subdermal structure of connective tissue embedded in fat lobules, and muscle,
which traverses the soft tissue flap (Fig. 25.1). Anatomical studies show that the immediate
subdermal layer contains a large connective tissue network made up of small fat lobules with many
septa, whereas the deeper subdermal layer features large fat lobules with only a few septa.
Dynamic musculature presents in sometimes overlapping, multiple layers, and may even form entire
complexes – as in the brow area where the frontalis, corrugator, and orbicularis muscles merge into
one complex with the ability to move medially, proximally, and distally (F. Anderhuber, personal
communication).
Figure 25.1 Facial skin and subcutaneous tissue.

The analysis of the anatomical composition of the connective tissue is of greatest interest in
volume augmentation. The soft tissue flap is attached to the underlying bony structure via
connective tissue bands called retinacula or real retaining ligaments (Fig. 25.2), which show no or
very limited elasticity. So-called false retaining ligaments – the most important of which include the
nasolabial fold, the zygomatic ligament, and the maxillar–buccal ligament (Fig. 25.3) – add to the
character of the flap surface. Although false retaining ligaments have no bony attachment, they act
in a fence-like manner, compressing dynamic muscular activity and influencing the appearance,
shape, and correction of the skin surface.
Figure 25.2 Real retaining ligaments.
Figure 25.3 False retaining ligaments.

A brief description of the soft tissue anatomy of the human face is not complete without a
discussion of the fat compartments, which are located around and below the eye, in the cheek, and
in the perioral region (Fig. 25.4). The suborbicularis oculi fat (SOOF) and retro-orbicularis oculi fat
(ROOF) pads are the dominant features of the periorbital region. As the most proximal entity in the
mid-facial region with the least coverage of musculature structures, the SOOF pad plays a key role
in the process of facial aging and has a direct impact on the clinical presence of the medial and
lateral infraorbital hollow. Another important, shape relevant structure in the submalar area is
induced by an indented groove from the medial orbital hollow to the lateral lower midface caused by
the zygomatic ligament.
Figure 25.4 Fat compartments of the face. SOOF, suborbicularis oculi fat.

Biological characteristics of filler materials

Autologous fat or other biodegradable materials, such as hyaluronic acid (HA), calcium
hydroxylapatite (CaHA), or poly-l-lactic acid (PLLA), are the most frequently used agents in volume
replacement soft tissue augmentation today. All agents differ with respect to interaction with the
recipient site and therapeutic effect in the tissue. In this respect, the main characteristics of interest
include overall duration of effect, neocollagenesis, and water retention.

Autologous fat

Although autologous fat is almost always harvested from a tumescent donor site, the hydrated fat
tissue will dehydrate after injection at the recipient site. Owing to the microanatomical structure of
fat tissue, injections must be performed using 18-gauge cannulas, or larger. After transplant,
neofibrogenesis and neocollagenesis occur; no significant additional water retention can be
observed.

Hyaluronic acid

Today, multiple formulations of HA are available for different purposes in soft tissue augmentation.
For volume replacement, preparations with concentrations of 20–24 mg/mL are produced. Aside
from the primary effect of volume contribution through implantation of the physical material, HA
leads to marked water retention; this additional accumulation of fluid due to the binding capacity of
the filler leads to a biological change in the atrophied subcutaneous tissues, wherein the rehydration
at the site of injection is followed by a secondary redistribution of subcutaneous fluids. Theoretically,
shrunken and atrophied fat lobules – from severely diminished blood supply during the aging
process – will reinflate (F. Anderhuber, personal communication). In 2007, Wang et al found that
degradation depends on the stabilization of HA; highly stabilized products can produce a secondary
neofibrogenesis.

Calcium hydroxylapatite

CaHA is a long-lasting, biodegradable filler that can also accumulate water, but only to about 10%
of the amount that HA is capable. The persistence of its augmentative effect is due to the mass of
filler material injected, which, as it degrades only slowly, affords long-term correction, also due to
neofibrogenesis.

Poly-L-lactic acid

PLLA induces neofibrogenesis and leads to a reinforcement of connective tissue fibers that have
undergone the process of elastosis. The interaction between tissue and filler material spurs the
production of new collagen fibers by fibroblasts without any relevant fluid retention.