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Received: 10 August 2019    Revised: 24 October 2019    Accepted: 12 December 2019

DOI: 10.1111/jocd.13277

ORIGINAL CONTRIBUTION

Nonsurgical jawline rejuvenation using injectable fillers

Aria Vazirnia MD, MAS1  | André Braz MD2 | Sabrina G. Fabi MD, FAAD, FAACS3

1
Department of Dermatology,
Massachusetts General Hospital, Boston, Abstract
MA, USA Background: A well-defined jawline is a critical component in the perception of facial
2
Dermatology Division, Policlínica Geral do
attractiveness in both men and women. Dermal fillers offer a nonsurgical, temporary
Rio de Janeiro (PGRJ), Rio de Janiero, Brazil
3
Cosmetic Laser Dermatology, La Jolla, CA,
method of correcting mild-to-moderate mandibular bone resorption.
USA Aims: The authors discuss pertinent aspects of anatomy, pathophysiology of aging,

Correspondence
patient evaluation, gender considerations, injection technique, and complications in
Aria Vazirnia, MD, MAS, Department of jawline augmentation using injectable fillers.
Dermatology, Massachusetts General
Hospital, 50 Staniford St #250, Boston, MA
Methods: A brief review of the literature surrounding jawline augmentation using
02114, USA. injectable fillers in both men and women, as well as the authors’ experience in this
Email: [email protected]
area, is provided.
Funding information
Results: Nonsurgical jawline augmentation using injectable fillers can be performed
Dr Aria Vazirnia has no conflicts of interest
to disclose. Dr André Braz is an advisor & effectively and safely with adequate background knowledge of the regional anatomy
speaker for Allergan and Merz. Dr Sabrina
and appropriate patient selection. The authors discuss both injection techniques in the
Fabi is an investigator, advisor & speaker for
Allergan, Galderma, and Merz. published literature and their own approach. Potential complications are also reviewed.
Conclusion: Jawline rejuvenation is a key component to global facial aesthetic reju-
venation. Therefore, it is important for physicians to understand how to safely and
effectively perform nonsurgical jawline rejuvenation using injectable fillers.

KEYWORDS

aging, dermal filler, facial rejuvenation, jawline, non-surgical

1 |  I NTRO D U C TI O N volume and structural support.1,2 There is a shift in the 3-dimen-
sional structure of the face resulting from subcutaneous fat redistri-
The jawline is integral to the perception of attractiveness and facial bution and atrophy as well as skeletal remodeling and resorption.3,4
youth, as well as key to defining masculine vs feminine facial features. In the lower face, age-associated resorption of the mandibular
The aging face is a function of facial volume loss, resulting from a com- bone and the gravitational descent of the superficial mid-facial fat
bination of bony resorption, fat repositioning, and tissue laxity.1 In the compartments result in loss of the youthful jawline definition with
lower face, this age-associated volume loss leads to loss of definition of ptosis of the skin, jowling, and formation of prominent Marionette
the jawline.2 Therefore, a comprehensive approach to facial rejuvena- lines.1,2,5,6 Blunting of the jawline is worsened by the downward pull
tion should include an evaluation of the jawline in both men and women. of the depressor labii inferioris, depressor anguli oris, and platys-
mal muscle fibers, which find resting tone on resorbing mandibular
bone.3,7
2 |  LOS S O F JAW LI N E D E FI N ITI O N & To combat the signs of aging and help restore a more youthful
J OW L FO R M ATI O N appearance, multiple nonsurgical techniques have been utilized to
improve skin texture, skin laxity, and underlying volume and struc-
Facial aging is a multifactorial process that reflects gradual changes tural support. Ablative and nonablative lasers, microfocused ultra-
in skin texture, soft tissue volume and elasticity, and underlying bone sound, and subsurface monopolar radiofrequency have been shown

J Cosmet Dermatol. 2019;00:1–8. wileyonlinelibrary.com/journal/jocd© 2019 Wiley Periodicals, Inc.     1 |

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2       VAZIRNIA et al.

F I G U R E 1   Right-sided view (A), right

3/4 view (B), and left 3/4 view (C) of a
woman before (left photo) and after (right
photo) injection with 4 mL of a 20 mg/mL
highly cohesive HA filler to the mandibular
angle, jawline, and chin

(A)

(B)

(C)
VAZIRNIA et al. |
      3

to significantly improve age-related skin wrinkling and laxity.8 In (A)

addition, dermal fillers are an effective noninvasive modality to lift
facial soft tissues and improve jawline contour (Figure 1).5,9 In the
subsequent sections, we discuss the anatomy of the jawline and pro-
vide our experience on the use of injectable fillers for jawline rejuve-
nation and contouring.

3 | A N ATO M I C A L CO N S I D E R ATI O N S

3.1 | Bone and soft tissues

The primary structural component of the jawline is the mandible,

which provides structural support for overlying soft tissues. From
superficial to deep, the soft tissues overlying the mandible are ar- (B)
ranged in layers. A different arrangement of layers can be identified
posterior to vs anterior to the labiomandibular sulcus (Marionette
line).
Posterior to the sulcus, the following arrangement of soft tis-
sues can be identified along the jawline (from superficial to deep):
skin, superficial subcutaneous fat, platysma, deep fat, parot-
ideo-masseteric fascia, masseter muscle, and periosteum of the
mandible (Figure 2). Anterior to the sulcus, the layered arrangement
is as follows (from superficial to deep): skin, subcutaneous fat, mus-
cles of facial expression (superficial to deep—depressor anguli oris,
platysma, depressor labii inferioris, mentalis), deep fat consisting of
the labiomandibular fat and the deep mental fat pad in the chin.
The inferior margin of the labiomandibular sulcus is formed by
the mandibular ligament, which can create a dermal depression im-
F I G U R E 2   Cadaveric dissection showing the superficial
mediately anterior to the jowls. The subcutaneous fat is arranged in
subcutaneous fat (A) and deep fat (B) soft tissue layers.
fat compartments laterally, while there is a diffuse interplay of mus-
Photographs contributed by Sebastian Cotofana, MD, PhD
cle fibers, adipose cells, fibrous connective tissue, and elastic fibers
medially. This difference in subcutaneous tissue arrangement allows parotideo-masseteric fascia. Posterior to the antegonial notch and
for the formation of jowling lateral to the labiomandibular sulcus and anterior margin of the masseter muscle, branches of the facial nerve
hallowing/volume loss with age medial to the sulcus. can be found about 1-2 cm below the inferior mandibular border13,14;
however, anterior to the masseter, branches can be located above
the mandibular border.13,15
3.2 | Neurovasculature In detailed layer-by-layer anatomical dissections of the lower
face, Suwanchinda et al7 noted no major neurovascular structures
Important neurovascular structures traverse the inferior border of in the subdermal plane overlying the platysma. While the subdermal
the mandible. These include both the facial artery and vein as well plane along the jawline is relatively devoid of important neurovascu-
10
branches of the facial nerve. According to Lee et al , the facial ar- lar structures, it is important to understand the location of the facial
tery is located about 27 mm anterior to the apex of the mandibu- artery, facial vein, and branches of the facial nerve when performing
lar angle. The facial artery and vein cross the mandible anterior to dermal filler injections.
the masseter muscle and are located in the deep fat, deep to the
platysma (Figure 3). The facial artery courses deep to the platysma
inside the buccal space and is connected to the modiolus at the cor- 3.3 | Parotid gland
ner of the mouth. Here, it branches into the superior and inferior
labial arteries while continuing as the angular artery.11,12 Within the The parotid gland is located within the preauricular area and cov-
nasolabial sulcus, the artery becomes more superficial and is located ers the posterior aspect (and sometimes extends more anteriorly
superficial to the muscles of facial expression. and covers about 75%) of the masseter.16,17 The parotid duct is usu-
Branches of the facial nerve, particularly the marginal mandib- ally located on an imaginary line connecting the ear lobe to the oral
ular nerve, are located in between the masseter muscle and the commissure.16,17 The parotid duct arises from the anterior portion
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4       VAZIRNIA et al.

F I G U R E 3   Cadaveric dissections showing the vasculature of the lower face. The facial artery and facial vein cross the mandible anterior
to the masseter muscle and are located in the deep fat, deep to the platysma (A & B). The masseteric veins (C)

(A) (B) F I G U R E 4   Men have a bizygomatic

to bigonial distance that is approximately
1:1 (A). A youthful woman's face has a
bizygomatic distance that is wider than
the bigonial distance (B)

of the gland and then runs in between the masseter muscle and the injectable fillers. Special focus should be given to the prominence
parotideo-masseteric fascia. At the anterior border of the masseter, of the mandibular angle, jawline, chin projection and length, prejowl
the parotid duct then passes through the buccinator muscle where it sulcus, and Marionette line. 21 There should be awareness of impor-
18-20
then enters the oral cavity. tant neurovascular and anatomical structures near injection sites,
which include the facial artery and vein, the marginal mandibular
nerve, the parotid gland and duct, and the masseter muscle. 21
4 |  E VA LUATI O N Patients should be examined at rest and in animation while in
an upright position.6 The examiner should have flexibility in mov-
As with most facial rejuvenation procedures, it is important to ing around the patient to analyze the face from different angles. 21
conduct a careful aesthetic evaluation of the patient prior to using Photographs at baseline and after treatment should be taken at the
VAZIRNIA et al. |
      5

F I G U R E 5   Supraperiosteal injection
at the inferoposterior aspect of the
mandibular angle in a patient (A) and
cadaveric section (B). In the cadaveric
section (B), note the location of the
parotid gland, parotid duct, and masseter
muscle in relation to the injection point

F I G U R E 6   Authors' injection strategy

for fillers along the female jawline using
cadaveric sections. A blunt-tipped
22-gauge, 1.5-inch cannula is inserted
into the lateral cheek fat compartment
(LCFC) to create a mandibular sweep
along the mandibular angle. In general,
it is important to maintain the cannula
within the LCFC above the superficial
musculoaponeurotic system (SMAS)

anterior, oblique, and lateral positions. Validated scales, such as the men have a bizygomatic to bigonial distance that is approximately 1:1,
Merz Jawline Grading Scale and the Global Aesthetic Improvement a youthful woman's face is characterized by the inverted “triangle of
Scale, may be used to evaluate the jawline and objectively assess youth,” with a bizygomatic distance that is wider than the bigonial dis-
treatment efficacy. 22,23 tance (Figure 4). In women, this is considered the ideal and should be
The aesthetic goal in jawline rejuvenation is to straighten the jaw- maintained to avoid masculinizing the female face.24
line, to smooth the transition between the mentum and the jowls, and As with other cosmetic procedures, it is important to set realistic
to lift the jowls upwards and posteriorly.18 However, gender differ- expectations of results with patients. Jawline rejuvenation with in-
ences must be taken into account. The aesthetic endpoint in men and jectable fillers may not achieve the same results as a surgical neck or
women differ in that the male jaw is more angular and more prominent face lift procedure, and therefore there should be a discussion about
than that in women.2,18 Other masculine facial features include a wider combination procedures with monopolar radiofrequency, microfo-
interorbital distance, wider nose, more prominent mental subunit, cused ultrasound, and laser devices in those who prefer noninvasive
thicker and lower-positioned eyebrows, and thinner lips.24,25 While treatment modalities.18
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6       VAZIRNIA et al.

5 |  AU TH O R S ' TEC H N I QU E

Fillers used for jawline rejuvenation include hyaluronic acid (HA), cal-
cium hydroxylapatite (CaHA), poly-L-lactic acid (PLLA), and autologous
fat.6,18 The authors recommend use of HA or CaHA fillers (Juvederm
Voluma XC, Allergan, Inc; Restylane Lyft; Galderma SA; Radiesse (+),
Merz North America, Inc) due to the stiffer gel characteristics of
these products that allow them to provide more structure along the
jaw. Of note, Juvederm Voluma XC has less elasticity and viscosity than
Restylane Lyft and Radiesse (+) yet is more significantly cross-linked.
It is important to thoroughly cleanse the face with an antiseptic
preparation that extends below the jawline and onto the preauricu-
lar region. The authors begin with a supraperiosteal depot injection
of HA or CaHA filler at the inferoposterior aspect of the mandibular
angle (Figure 5), followed by small 0.1 mL-0.2 mL supraperiosteal ali-
quots injected superiorly along the ramus of the mandible. Aspiration
is recommended to avoid intravascular injection. In female patients,
a blunt-tipped 22-gauge, 1.5-inch cannula is then used to create a
sweep along the mandibular angle that has now been augmented
to the earlobe, within the subdermal plane to avoid injection into
the parotid (Figure 6). The cannula entry point is 4 cm medial to the
mandibular angle (as the facial artery and vein are ~3 cm medial or
anterior to the mandibular angle). In male patients, the cannula is not
directed toward the earlobe but superiorly directed in the direction
F I G U R E 7   Authors' injection strategy for fillers along the male
of the ramus from the mandibular angle to create a squarer, angular
jawline, where larger dots indicate larger depots supraperiosteally
appearance (Figure 7). A blunt-tipped 22-gauge, 1.5-inch cannula along the mandibular angle and up the ramus, black arrows indicate
is used to deposit product in the subcutaneous plane, immediately linear threads of product in the subdermal plane and broken arrows
subdermal, as there are many veins that course over the masseter. indicate the optional placement of product in the subdermal
From the same entry point along the jawline, the cannula can be di- plane in men to widen the jawline and add to a more masculine
appearance (maintaining a bizygomatic distance that is the same as
rected anteriorly in both men and women. Special care should be
the bigonial distance)
taken to avoid broadening the jaw in a woman by avoiding placing
filler over the masseter, which is more of an aesthetic endpoint in
the male face (Figure 8). However, to masculinize and widen the male
face, filler can be placed subdermally over the masseter with caution glabella, nasal bridge, and nasolabial folds, yet filler-induced vascular
to avoid inadvertent injection into the parotid gland or facial vein.6,18 injury can occur anywhere on the face.18,26 At the onset of any warning
sign of vascular occlusion, the practitioner should immediately infiltrate
the area of pending necrosis with injectable hyaluronidase, apply warm
6 |  CO M PLI C ATI O N S compresses, and consider administering aspirin, topical nitroglycerin,
hyperbaric oxygen, and/or low molecular weight heparin.18,26 Aside
The most common complications from nonsurgical rejuvenation of from vascular injury, superficial injections over the masseter muscle
the jawline with injectable fillers include redness, bruising, ten- carry risk of injury to the parotid gland and duct. Trauma to the parotid
1,5
derness, and swelling. Other potential complications, although gland may result in infection or injury to branches of the facial nerve
rarer, include infection and foreign body granuloma formation. running through the gland.5,6 Injury to the parotid duct may result in
Granulomas can develop months to years after the original injec- infection, ductal obstruction, mucocele formation, and/or or salivary
tion.1 Although the subdermal plane along the jawline is relatively fistulas.27 No intravascular occlusion, infection, granuloma formation,
free of important neurovascular structures, the facial artery and or parotid gland/duct injury has been experienced by patients using
vein as well as the marginal mandibular nerve traverse the lower the “Authors’ Technique” as described above.
border of the mandible supraperiosteally; therefore, it is impor-
tant to be aware of the dangers of vascular occlusion with intra-
vascular injection of filler. 5 7 | CO N C LU S I O N
Intravascular injection of filler results in pain and blanching along
the distribution of the artery, which leads to tissue ischemia, necro- Use of injectable dermal fillers is an effective nonsurgical treatment
sis, and rarely stroke and blindness.18,26 High-risk areas include the modality in jawline rejuvenation. Treatments may be combined with
VAZIRNIA et al. |
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F I G U R E 8   Frontal view (A), right 3/4

view (B), and left 3/4 view (C) of a man at
baseline (left photos) and after a series
of injections with hyaluronic acid filler
(Juvederm Voluma XC) to the chin, prejowl
areas, jawline, and mandibular angle
(right photos). This patient received 1cc
to the chin, 1cc to each of the prejowl
areas (2cc total), 1.5cc to each side of the
jawline (3cc total), and 1.5cc to each side
of the mandibular angle (3cc total). Note
the broadening of the jaw, which is an
aesthetic endpoint in the male face

other noninvasive modalities, such as neuromodulators, radiofre- 8. Dendle J, Wu DC, Fabi SG, Melo D, Goldman MP. A retrospective
evaluation of subsurface monopolar radiofrequency for lifting of
quency devices, and ultrasound devices, to not only improve con-
the face, neck, and jawline. Dermatol Surg. 2016;42(11):1261-1265.
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ORCID 2016;15(9):1107-1110.
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Aria Vazirnia  https://orcid.org/0000-0002-5421-7323
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11. Markiewicz MR, Ord R, Fernandes RP. 43 - local and regional flap
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