Received: 15 April 2018 | Accepted: 27 June 2018

DOI: 10.1111/jocd.12722

ORIGINAL CONTRIBUTION

The posterior temporal supraSMAS minimally invasive lifting

technique using soft‐tissue fillers

Atchima Suwanchinda MD, MS1 | Katherine L. Webb2 | Christina Rudolph2 |

Casey Hladik2 | Amanda Custozzo2 | Justin Muste2 | Grant Schalet2 |
Hassan Hamade2 | Michael P. Smith PhD2 | Konstantin Frank3 |
Ashit Patel MBChB., FACS4 | Sebastian Cotofana MD, PhD2

1
Department of Dermatology, School of
Anti Aging and Regenerative Medicine, Mae Abstract
Fah Luang University, Bangkok, Thailand Background: To investigate the effectiveness of the posterior temporal supraSMAS
2
Department of Medical Education, Albany
minimally invasive lifting technique and compared it to experiments performed in fresh
Medical College, Albany, New York,
3
Department for Hand, Plastic and human body donors by applying skin vector displacement measurement technology.
Aesthetic Surgery, Ludwig – Maximilian Materials and methods: A total of 15 patients (14 females/1 male) with a mean age
University Munich, Germany
4
of 37.1 ± 9.4 years and a mean body mass index of 21.4 ± 3.3 kg/m2 were included
Division of Plastic Surgery, Albany Medical
Center, Albany, New York, into this observational analysis. The injection procedure was additionally performed
in 2 male and 1 female fresh body donors with a mean age of 85.67 ± 9.7 years
Correspondence: Sebastian Cotofana MD,
PhD, PhD, Associate Professor, Department and a mean body mass index of 23.83 ± 4.7 kg/m2. Different grades of skin laxity,
of Medical Education, Albany Medical
variable amounts of product, and the application with and without subcision were
College, 47 New Scotland Avenue MC‐135,
Albany, NY 12208 (cotofas@amc.edu). tested and measured via three‐dimensional reconstructions and surface displace-
ment vectors using Vectra software with VAM module.
Results: Esthetic outcome was rated by an independent professional observer and
by the patient immediately after the treatment (76.67% ± 17.6% vs
66.67% ± 18.1%) (P = 0.001) and after 1 month (80.00% ± 14.0% vs
75.00% ± 21.1%) (P = 0.19). Skin laxity, subcision, and the application of more than
1.0 cc per side resulted in our experimental setting in a smaller magnitude of skin
displacement vectors indicating a reduced lifting effect.
Conclusion: The posterior temporal supraSMAS minimally invasive lifting procedure
seems to be a valid technique to treat temporal volume loss and to reduce the signs
of age‐related changes in the middle and lower face, ie “marionett line” and jowl
deformity.

KEYWORDS
Face lift, Facial aging, Rejuvenation, Skin, Soft‐tissue fillers, Temple

1 | INTRODUCTION
The onset and the pace of the observed age‐related changes in each
Facial aging is a multifactorial process, resulting in a range of physiologic structure vary among different individuals, gender and ethnicity.1
and morphologic changes in both the skeletal and soft‐tissue compos- Most of the changes observed during facial aging occur in the
ites—the bones, ligaments, muscles, fasciae, subcutaneous fat, and skin. middle2 and in the lower face2 due to the effects of gravity,3 which

J Cosmet Dermatol. 2018;1–8. wileyonlinelibrary.com/journal/jocd © 2018 Wiley Periodicals, Inc. | 1

2 | SUWANCHINDA ET AL.

in general guides the healthcare provider to focus on these facial demographic and medical history data of the 15 patients included
regions in greater detail. If additional regions are affected, fi the tem- is given in Table 1.
ple, different therapeutic approaches, and multiple sessions are
needed to treat the face as a global esthetic unit.
2.3 | Injection procedure
Age‐related changes in the temple include temporal volume loss,
which can result from skin laxity, temporalis muscle atrophy, and/or After an initial examination of the patient and thorough assessment
from fat redistribution of the superficial and deep temporal fat and discussion of the risks for each patient, the following protocol
4–6
pads. Together with age‐related changes in the underlying skele- was followed for each procedure. Unilateral cleaning with disinfec-
ton, a more prominent appearance of the temporal crest, the lateral tant gauze of the preauricular area. Subdermal application of 0.1‐
superior orbital ridge, and the zygomatic arch can create the image 0.5 cc of 2% lidocaine with epinephrine. Perforation of the skin 0.5‐
of a skeletonizaton of the face.7–10 1.5 cm anterior to the tragus using a 21G needle, 0.80 × 50 mm, 1”
Techniques for treating temporal volume loss are primarily based (TSK Laboratory, Tochigi‐Ken, Japan). Insertion of a 22G cannula,
on the injection of soft‐tissue fillers into two different planes: super- 0.70 × 50 mm 2” (TSK Laboratory, Tochigi‐Ken, Japan). Advance-
ficial—into the subcutaneous plane, superficial to the superficial tem- ment of the cannula in cranial direction in the subcutaneous plane
poral artery and the motor branches of the facial nerve; and deep— past the zygomatic arch into the superficial upper temporal fat com-
into the temporalis muscle, in contact with the bone and deep to partment. Application of 0.5 cc of Belothero Intense (Merz Pharma
the motor branches of the facial nerve and deep to the medial zygo- GmbH & Co. KGaA, Franfurt Germany) in a retrograde manner along
matico‐temporal vein (sentinel vein).11 However, those techniques the pre‐formed injection canal without fanning. Slight massaging and
are aimed uniquely to treat the temple, but not to achieve any compression of the area where the skin performation occurred (Fig-
esthetic improvement in other parts of the face fi in the middle or ures 1 and 2). In 7 patients (46.7%) the left side of the face was
the lower face. injected, whereas in 8 patients (53.3%) the right side was injected.
Due to recent anatomic advances,2 our understanding of the lay-
ered arrangement of the face has expanded and new therapeutic
2.4 | Clinical assessment
options are being developed. We herewith describe a method to
improve temporal volume loss and to treat age‐related changes in The esthetic improvement was assessed by the patient using a mir-
the lower face including the jowl deformity, a prominent ror and by an independent professional observer using photographs
labiomandibular sulcus (“marionett line”), and a prominent nasolabial immediately after the treatment and after 1 month of follow‐up. The
sulcus by applying hyaluronic acid–based soft‐tissue filler in the tem- improvement was rated pairwise according to the following classifi-
ple superficial to the superficial temporal fascia (which is continuous cation: 1 = Little or no improvement (0%‐10% change when com-
with the superficial musculo‐aponeurotic system SMAS). Cadaveric pared to the pretreatment picture); 2 = Minute improvement (11%‐
simulations are being carried out to analyze the effectiveness of this 25% change); 3 = Fair improvement (26%‐50% change); 4 = Good
approach.

T A B L E 1 Demographic data and patient history information of

2 | MATERIAL AND METHODS the 15 patients included in this observational analysis

Baseline characteristics
2.1 | Total sample Age
Age/years (mean ± SD) 37.1 ± 9.4
The total sample of this study consists of 15 patients recruited at
Age range/yr 22‐53
the Department of Dermatology, School of Anti Aging and Regener-
ative Medicine, Mae Fah Luang University, Bangkok, Thailand, and Gender

of 3 fresh body donors from the body donation program of Albany Male (%) 1 (6.7)

Medical College, Albany, New York, USA. Female (%) 14 (93.3)

Body constitution
Body mass index/kg/m2 (mean ± SD) 21.4 ± 3.3
2.2 | Clinical sample
Body weight/kg (mean ± SD) 56.0 ± 12
A total of 15 patients (14 females/1 male) with a mean age of Injected filler volume (cc ± SD) 1.27 ± 0.6
37.1 ± 9.4 years and a mean body mass index of 21.4 ± 3.3 kg/m2 Allergies
were selected for the inclusion into this observational analysis.
Personal allergy (%) 1 (6.7)
Before the inclusion into this analysis, the participants gave writ-
Previous treatments
ten consent and agreed in the aims and scopes of this study and
Neuromodulators (%) 2 (13.3)
to the usage of their pictures for research and educational pur-
High‐frequency ultrasound (%) 6 (40.0)
poses. These observational analyses were conducted in accordance
Esthetic surgery (nose) (%) 1 (6.7)
with regional laws and good clinical practice. Information on
SUWANCHINDA ET AL. | 3

F I G U R E 1 Female patient before (left panel) and after (right panel) injection of 0.5 cc subdermally into the left temporal area. Note the
slight bruising anterior to the tragus indicating the location of cutaneous insertion

F I G U R E 2 Female patient before (left panel) and after (right panel) injection of 0.5 cc subdermally into the left temporal area. The
cutaneous insertion is here hidden by the hair

improvement (51%‐75% change); and 5 = Excellent improvement

2.6 | Experimental anatomical procedures
(>75% change; Table 2).
The body donors were positioned upright and secured to simulate
the effects of gravity of the facial soft tissues. Injections procedure
2.5 | Anatomical sample
was carried out using the exact same technique as described
The sample for the anatomical analysis consisted of 2 male and 1 above for the (living) patients. Preinjection and postinjection pic-
female fresh body donors with a mean age of 85.67 ± 9.7 years and tures were taken using a Vectra H1 camera (Canon, EOS Rebel
2
a mean body mass index of 23.83 ± 4.7 kg/m . Both sides of the T61, Tokyo, Japan). Three‐dimensional reconstructions and surface
face were injected in each of the body donors. displacement vectors were computed using Vectra software with
4 | SUWANCHINDA ET AL.

T A B L E 2 Pairwise rating of the esthetic improvement according The esthetic results were rated better after 1‐month follow‐up
to the following classification: 1 = Little or no improvement (0%‐10% when compared to immediately after the treatment with a change of
change when compared to the pretreatment picture); 2 = Minute 8.3% (P = 0.02) for the patient assessment, and with 3.33%
improvement (11%‐25% change); 3 = Fair improvement (26%‐50%
(P = 0.16) when performed by the independent professional obser-
change); 4 = Good improvement (51%‐75% change); and
5 = Excellent improvement (>75% change) ver.

Immediate 1‐month follow up

Outcome n (%) n (%) 3.2 | Anatomical
Esthetic improvement graded by independent professional observer
Little/No improvement 0 0 3.2.1 | Vector direction
Minute improvement 0 0
Injection of 1 cc into the temple resulted in a general orientation of
Fair improvement 7 (46.7) 5 (33.3)
skin displacement vectors toward the temple including the
Good improvement 6 (40.0) 5 (33.3)
labiomandibular sulcus and the jawline. Less directed vectors were
Excellent improvement 2 (13.3) 5 (33.3)
observed for the nasolabial sulcus (Figure 3).
Esthetic improvement graded by patient
Little/No improvement 0 0
Minute improvement 0 0
3.2.2 | Skin laxity
Fair improvement 3 (20.0) 1 (6.7) Increased skin laxity (n = 1, female) was observed to result in no skin
Good improvement 8 (53.3) 10 (66.6) displacement, whereas the absence of skin laxity resulted in a direc-
Excellent improvement 4 (26.7) 4 (26.7) ted skin displacement and vector orientation (n = 2 males) (Figure 4).

3.2.3 | Increased amount of injected material

VAM module (Canfield Scientific, New Jersey, NY, USA; Figures 3, Increased amount of injected material, ie more than 1 cc (=3 or
4, 5, and 6). 4 cc), resulted in a reorientation of skin displacement vectors toward
the jawline and the angle of the mandible indicating the effects of
gravity on the amount of injected product (Figure 5).
2.7 | Analytic procedure
Different amounts of material were injected (1 cc, 3 cc, and 4 cc)
3.2.4 | Fanning vs no fanning technique
and different injection techniques (with and without fanning) were
performed in the body donors to evaluate the effectiveness of the When applying the material using a fanning technique and perform-
applied injection technique. Effectiveness in the clinical setting was ing a local subcision in the area at and above the zygomatic arch
evaluated by comparing the immediate and the 1‐month postinjec- resulted in a reorientation of the skin displacement vectors toward
tion assessment (in percent) performed by the patient and by the the jawline and the angle of the mandible indicating a nonfavorable
independent professional observer. affect of the skin displacement as no lifting effect of the lower face
was achieved (Figure 6).

3 | RESULTS
4 | DISCUSSION
3.1 | Clinical
In this observational analysis, we investigated the effectiveness of
No adverse events including bleeding, persistent pain, infections or the posterior temporal supraSMAS minimally invasive lifting tech-
injection‐related visual compromise (IRVC) was observed immediately nique and compared it to experiments performed in fresh human
or 1 month after the treatment. body donors by applying skin vector displacement measurement
The rating of esthetic improvement (pre‐ to postinjection facial technology. Fifteen patients were treated unilaterally without
appearance) immediately after the treatment was 66.67% ± 18.1% adverse events using a cannula to apply hyaluronic acid into the sub-
when assessed by the patient, and 76.67% ± 17.6% when assessed dermal plane of the temple. The esthetic improvement was evalu-
by the independent professional observer with a statistically signifi- ated by the patient and by an independent professional observer
cant difference among them of 10% (P = 0.001). The rating of immediately after the treatment and after 1 month of follow‐up.
improvement in performance at 1 month after the treatment was Albeit the independent professional observer rated the esthetic
evaluated by the patients to be 75.00% ± 21.1%, whereas it was outcome better as compared to the patient at both time points (imme-
80.00% ± 14.0% when assessed by the independent professional diate: 76.67% ± 17.6% vs. 66.67% ± 18.1%; 1 month:
observer representing no significant difference between the two rat- 80.00% ± 14.0% vs. 75.00% ± 21.1%) no significant difference in the
ings 5% (P = 0.19) (Figures 1 and 2). rating of the improvement was observed after 1 month (P = 0.19).
SUWANCHINDA ET AL. | 5

F I G U R E 3 Male body donor after injection of 1 cc into the left temporal subdermal plane (left panel). Scatter plot (right panel) showing the
vectors of the skin displacement. Note the positive magnitude of the values on the x and y axis indicating the posterior (toward the ear) and
upwards (toward the temple) displacement of the skin. Skin displacement vectors affect also the nasolabial sulcus, the jawline, and the
labiomandibular sulcus

F I G U R E 4 Female body donor with skin laxity after injection of 1 cc into the left and right temporal subdermal plane. Note the limited
amount of skin displacement indicated by the small vectors on both sides

Cadaveric simulations of the presented technique revealed that in skin displacement. Subdermal fanning revealed in the cadaveric model
body donors without skin laxity, skin displacement vectors in the a reduced length of skin displacement vectors indicating a reduced
labiomandibular sulcus and along the jawline (but less in the nasolabial lifting effect of the labiomandibular sulcus and of the jawline.
sulcus) were detected, pointing posterior (toward the auricle) and The strengths of this study is that we verified the effectiveness
upwards (toward the temple). Increased amount of injected volume, ie of the presented injection technique, performed in 15 patients
more than 1 cc, did not cause longer vectors which indicates more (Tables 1 and 2), in 3 fresh human body donors in order to provide
skin displacement but caused smaller vectors which indicates lesser scientific validity of the rational behind this approach. We were able
6 | SUWANCHINDA ET AL.

F I G U R E 5 Right panel showing a male body donor without skin laxity after injection of 1 cc into the left temporal subdermal plane. Note
the large positive magnitude of the skin displacement vectors pointing toward the temple. Left panel showing a male body donor after
injection of 4 cc into the right temporal subdermal plane. Note the reduced magnitude of the skin displacement vectors and the large volume
increase in the temporal area indicated by the yellow arrows as compared to the green vectors

F I G U R E 6 Male body donor after injection of 1 cc into the right temporal subdermal plane. Note that here extensive subcision procedures
were performed during the injection resulting in a reduced magnitude of the skin displacement vectors due to the disruption of the supporting
septae of the subcutaneous temporal compartment

to show that application of volumizing material into the subdermal between before vs after the injection of the product. In this way an
plane of the temple results in a skin displacement of the lower face objective measurement is obtained that does not rely on the subjec-
(Figures 3, 4, and 6) which can be interpreted based on the direction tive assessment of the patient or on the observer. We were able to
of the calculated vectors as a lifting effect of this area. Another confirm the esthetic outcome as the vectors started at the
strength of the present investigation is that we used up‐to‐date labiomandibular sulcus, spanned across the jawline and included the
imaging‐based analytic tools to measure skin displacement vectors midface (Figures 3 and 5). The direction of the skin displacement
that reliably calculate the movement of specific skin characteristics vectors shows thus conclusively that injection of the temple can
SUWANCHINDA ET AL. | 7

result in an improvement of the “marionett line” as well as of the the magnitude of the vectors (Figure 6). This is plausible as the fibrous
jowl deformity (Figures 1 and 2), if the technique and the amount septae are destroyed and their connection to the skin is disrupted by
injected is respected. the movement of the cannula in the subdermal plane. This causes a
A limitation of the study, however, is the reduced sample size disjunction phenomenon between the walls of the compartment and
(n = 15) and the relatively short follow‐up period of 1 month. Inter- the skin and the increase in volume inside of the compartment cannot
estingly, rating of the improvement according to the patient assess- be transmitted to the overlying skin. This was likewise observed in our
ment increased from immediately after the treatment to 1 month vectorial analyses, as negative vectors were observed on the y‐axis
significantly by 8.3% (P = 0.02), which indicates that this short fol- when 1 cc of product was injected using the fanning technique, indi-
low‐up period is sufficient to achieve an excellent esthetic outcome. cating that the skin did not move upwards, albeit moving toward the
If the observed change persists for a longer period of time, should auricle, which is indicated by the negative vectors on the x‐axis.
be subject to further investigations. An increased volume inside the injected compartment (4 cc
12
The layers of the temple have been recently updated and in total instead of 1 cc) resulted in an reduction in the magnitude of the vec-
10 layers of the temple have been described. The superficial temporal tors (Figure 5). This is again plausible as too much injected product
artery is the most cranial branch of the external carotid artery and pen- exceeded the stability of the fibrous septae and the effects of grav-
etrates the parotideo‐masseteric fascia 1 cm anterior and 1 cm supe- ity shifted the material and thus the complete compartment inferi-
13
rior to the tragus to enter the superficial temporal fascia. The artery orly. This phenomenon should be respected in a clinical scenario and
then travels within the superficial temporal fascia, which is classified smaller amounts of product (0.5 to 1.0 cc) might have a greater lift-
as layer 3, until the temporal crest, where it connects to the supraor- ing effect than 3.0 or 4.0 cc. In this case “less is more” seems to be
bital artery within the superficial lateral forehead fat compartment. As applicable.
the artery is located in layer 3, subdermal insertion, ie into layer 2, and Skin laxity was observed to result in minimal skin displacement,
advancement of the cannula in the subdermal plane in the temple, ie as the amount of injected product was unable to fill a compartment
layer 2, are superficial to the artery, the risk for an arterial penetration, and was thus unable to cause a shift in the overlying skin (Figure 4).
and thus for an injection‐related visual compromise is reduced when This finding is of clinical relevance, as this treatment might show
respecting the correct plane. Our results have revealed no injection‐re- minimal‐to‐no effects in patients with skin laxity or excess of skin of
lated visual compromise in the series of the 15 patients included into the temple, the middle or the lower face. Thus, a careful patient
the study, which is plausible, as the plane for penetrating the skin and evaluation should be performed when intending to use the posterior
positioning the material is superficial to the artery. In the described temporal supraSMAS minimally invasive lifting technique. Likewise,
plane (layer 2), no major neurovascular structures are expected as the the amount of product should be chosen carefully in order not to
12
frontal branches of the facial nerve run in layer 4 and the medial apply an exceeding amount of product and the application technique
zygomatico‐temporal vein is located in layer 6.14 should be respected as well, as fanning with consecutive disruption
The subdermal plane of the temple contains the superficial (sub- of the sepate might lead to a less desired esthetic outcome.
cutaneous) superior and inferior temporal fat compartments15 which
are bounded by fibrous septae and reside on the superficial temporal
fascia which is a continuation of the midfacial SMAS. These fibrous 5 | CONCLUSION
septae form the walls of the fat compartments and provide support The posterior temporal supraSMAS minimally invasive lifting proce-
for the content (ie the fat) inside the compartment. An increase in dure seems to be a valid technique to treat temporal volume loss
volume inside the compartment by the application of hyaluronic and to reduce the signs of age‐related changes in the middle and of
acid–based volumizing material results in a shift of roof of the com- the lower face, ie “marionett line” and jowl deformity. Skin laxity,
partment, ie of the skin toward upwards, if the bounding septae are subcision, and the application of more than 1.0 cc per side resulted
intact. This movement of the skin was detected by the skin displace- in our experimental setting in an smaller magnitude of skin displace-
ment vectors and is shown in Figure 5. An increase in volume inside ment vectors indicating a reduced lifting effect.
the compartment causes additionally a change in the orientation of
the bounding fibrous septae from pointing downwards to pointing
horizontal or even upwards, causing the adjacent skin and the skin
6 | AUTHOR DISCLOSURES
in lower facial regions to move likewise upwards in the same direc-
tion. This phenomenon was detected by our skin displacements vec- None of the authors listed have any commercial associations or
tor and we were able to provide evidence that even the skin at the financial disclosures that might pose or create a conflict of interest
labiomandibular sulcus, the jawline, and the midface (but not the skin with the methods applied or results presented in this study.
of the nasolabial sulcus) follow this movement (Figures 3, 5, and 6).
Clinically this can be observed by an improvement in the “marionett
ORCID
line” and of the jowl deformity as shown in Table 2.
Disruption of these fibrous septae which was achieved by the fan- Atchima Suwanchinda http://orcid.org/0000-0002-3432-7090
ning and the subcision procedure caused in our analyses a reduction in Sebastian Cotofana http://orcid.org/0000-0001-7210-6566
8 | SUWANCHINDA ET AL.

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