Aesthetic patients often present with the loss of continuity of a straight youthful jawline which is commonly associated with age related jowling. Facial aging stigmata can results from volume loss from bone resorption and facial fat compartment changes¹. Facial jowling can also be worsened by the attenuation of the mandibular septum leading to the descent of the superior and inferior jowl fat compartments².

The accurate placement of appropriately selected dermal filler at the mandibular angle, in the chin and the jowl region can recreate an aesthetically youthful, structured jawline. Prior to consideration of lower third treatments, it is recommended to revolumize the upper and middle thirds of the face to provide superior volumetric support to the jawline. The areas to consider are the temples, cheeks and preauricular regions.

It is important to recreate the angular contours and definition as the face transitions inferiorly from the jawline to the neck. In contrast to the midface, where ogee curves and soft transitions make for the aesthetical ideal, the jawline should demonstrate relatively sharp and angular transitions to the neck. A sharp jawline frames the lower third of the face.

To create this look, I use a high G prime filler, in a superficial (subdermal) layer, to accentuate desired angulations and shadowing. Furthermore, a HA filler with good soft tissue integration is required to provide lift and superior support. Jawline sculpting can be divided into three main treatment subunits: the angle of the mandible, the chin and the jowl region.

I. Angle of the Mandible

The angle of the mandible is often an overlooked and undertreated area. It is on lateral aspect of the face and is therefore less often noticed in self portrait photography and patient self-reflection.

The mandibular angle can be defined as an angle formed by the junction at the gonion of the posterior border of the ramus and the inferior border of the body of the mandible³.

Radiological studies show females have an average gonial angle of 125° that is statistically significantly higher than their male counterparts^4,5. However, the gonial angle also differs between significantly between attractive female individuals and as such, the aim should be to define and enhance a patient’s natural mandibular angle.

The angle of mandible is a superolateral structure relatively to the jowl, and by creating shape and angulation with dermal fillers, volumetric support to the jowls is also provided.

Technique
1. Identify any volume loss of the pre-auricular space and correct it
2. Palpate and mark the angle of the mandible
3. Create an entry point that is superomedial (often 0.5cm) to the angle of the mandible using a 23G needle
4. Mark out the intended inferior border of the ramus and posterior mandibular body
5. Treat using a 25G 5cm cannula and aspirate prior to injecting to check for intravascular entry
6. Perform slow retrograde threads, tightly approximated, of dermal filler (0.1ml per thread) to a total of 0.5ml – 1ml per side.
7. Gentle palpation between the edge of two fingers helps to shape the product for ideal angular contour

Summary:
Goal: To define and enhance the Angle of Mandible
Depth: Superficial / Subdermal
Volume: 0.5-1ml per side
Technique: Cannula Technique

Dangers:
The facial nerve and parotid gland are at risk during the treatment of the posterior mandibular ramus. They are both deep structures, located deep to the superficial musculoaponeurotic system (SMAS). They can be avoided by injecting in the subdermal plane. When injecting the inferior border of the ramus, be mindful of the facial artery as it courses along the anterior border of masseter. It is palpable at this point and should be identified and protected prior to injection.

II. Chin Contouring

In ideal facial proportions, the face can be divided into equal vertical thirds (upper, middle, lower) and horizontal fifths. The ideally proportioned chin width is said to occupy the central horizontal fifth of the face⁶. A 1/3rd to 2/3rd ratio should exist for the distance between nasal and the superior upper lip border to the interior lower lip border to the pogonion⁷.

When contouring the chin, start with a focused assessment of chin length, anterior projection and the depth of prejowl sulcus region. I prefer to use Rickett’s Esthetic Plane⁷ as an assessment guide to the overall relationship between the tip of the nose, the lips and pogonion of the chin for lower third facial harmony.

The rule of facial thirds can be applied to determine if the chin requires elongation. However, as a general principle, aging causes mandibular resorption⁸ and is associated with hyperactivity of the mentalis. These factors all contribute to a shortened chin and a less projected lower facial third.

Technique:
1. Assess the contour deformity in the prejowl sulcus, the mental crease, and the mentalis muscle
2. Palpate and mark the pogonion of the chin
3. Improve the projection and length of the chin with deep dermal fillers via sharp needle using a high G prime product in the deep periosteal plane
3. For cannula treatment, choose an entry point that allows access to the prejowl sulcus
4. Aspirate to check for intravascular cannulation
6. Slow retrograde threads, in a spread fanning technique (0.1ml per thread) to a total of 0.5 - 1ml per side
7. Gentle palpation helps to smooth the treated area

Summary:
Goal: To Shape and contour the Chin
Depth: Subdermal and Periosteal
Volume: 1-2ml total
Technique: Cannula for Subdermal and Needle for Periosteal

Dangers:
The inferior alveolar artery and nerve exit from the mental foramen which is commonly located between the first and second premolar teeth⁹ and should be protected during direct injections.

III. Jowl Region

By treating the angle of mandible first, followed by the chin, the soft tissues surrounding the jowl area (superiolaterally and inferomedially) have been slightly tensioned. Hence less product is required when focusing our attention to the jowls directly. Commonly, three perpendicular dermal filler threads can adequately to shape the inferior edge of the mandibular ramus.

Technique:
1. Identify the borders of the jowls and be mindful not to volumize the jowls as this can worsen the appearance of aging
2. Mark and palpate the pogonion of the chin and mandibular angle
3. Mark out lines that connect the angle of mandible to the pogonion of the chin, representing the inferior edge of ramus
4. Aspirate to check for intravascular cannulation
6. Slow retrograde threads tightly approximated of dermal filler product of 0.1ml per thread to a total of 0.5ml per side
7. Gentle palpation between the edge of two fingers helps to shape the product for ideal angular contour

Summary:
Goal: To straighten and sharpen the jawline by camouflaging the jowl
Depth: Subdermal
Volume: 1ml total
Technique: Cannula for Subdermal

Dangers:
Be careful not to place any volume within the jowls as this will act to worsen the aging appearance. The mental artery and nerve and the facial artery have to also be considered during treatment of this subunit and have been previously discussed.

Difficulties and Potential Complications

Jawline sculpting is a demanding treatment area. The heaviness and descent of the upper two thirds influence the lower third⁸, often requiring the cheeks, temples and pre-auricular regions to be pre-treated. It is a large treatment area, requiring a sufficient volume of dermal filler for complete treatment. This is reflected in higher financial cost to patients, who will in turn demand a higher aesthetic outcome. It should only be performed after adequate training.

The risk of intravascular injection can be minimized by remaining in the superficial (subdermal) plane or the deep (periosteal) planes. Furthermore, I believe aspiration prior to injection can also minimize intravascular risk. A benefit of performing treatment with hyaluronic acid dermal fillers, in contrast to more permanent fillers, is the ability to reverse treatment with the use of hyaluronidase. HCPs should be well versed in the use and application of hyaluronidase when treating the jawline.

Conclusion

A straight, youthful jawline is a treatment area commonly requested by aesthetic patients. At the same time, it is a demanding area that should be approached by experienced injectors with suitable training. The Jawline Sculpting technique describes a treatment progression from the Angle of Mandible to Chin Contouring and to the Jowl Region. With a focus on anatomical dangers, this technique can provide a safe treatment guide to achieving a good aesthetic outcome for patients.