Clinical Practice
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Jawline Sculpting
with Filler
Dr David Ong presents his preferred
treatment technique for sculpting and
shaping the jawline using hyaluronic
acid dermal fillers
Aesthetic patients often present with a loss of continuity that comes
with a straight, youthful jawline, commonly associated with age-
related jowling. Facial ageing is a result of fat atrophy and volume loss
from both bone resorption and tissue descent.1 Facial jowling can be
worsened by the attenuation of the mandibular septum leading to the
descent of the superior and inferior jowl fat compartments.2
Considerations for sculpting the lower face
The accurate placement of an appropriately selected hyaluronic
acid (HA) dermal filler at the mandibular angle, in the chin and
the peri-jowl region can recreate an aesthetically youthful and
structured jawline. When considering lower third treatments, I
would recommend revolumising the upper and middle thirds of the
face first, providing superior volumetric support to the jawline2. The
key areas to consider are the temples, cheeks and preauricular
regions.
It is important to recreate the angular contours as the face transitions
inferiorly from the jawline to the neck. In contrast to the mid-face,
where soft transitions make for the aesthetical ideal3, the jawline
should demonstrate relatively sharp and angular transitions to the
neck, as 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. A combination of Restylane
Volyme, Restylane Lyft and Restylane Defyne are my products of
choice here. There are alternative volumising HA fillers that may be
suitable for jawline treatment such as Princess Volume, Belotero
Volume and Juvederm Voluma. Jawline sculpting can be divided into
three main treatment subunits: the angle of the mandible, the chin
and the peri-jowl region.
Aesthetics | August 2018
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Key treatment subunit areas
Below are the three key areas practitioners should be looking to
address, together with my treatment approach.
1. Angle of the mandible
The angle of the mandible is often an overlooked and undertreated
area. It is on the 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 (the midpoint) of the posterior border of the
ramus and the inferior border of the body of the mandible.4
Radiological studies have demonstrated that females have an
average gonial angle of 125 degrees however this is highly
variable even between aesthetically attractive individuals5,6. The
angle of mandible is a superolateral structure relative to the
jowl, and by creating shape and angulation with dermal fillers,
volumetric support to the jowls is also provided. When sculpting
the jawline, the aim should be to define and enhance a patient’s
natural mandibular angle.
Technique
1. Identify any volume loss of the pre-auricular space
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 23 gauge needle
4. Mark out the intended inferior border of the ramus and
posterior mandibular body (Figure 1)
5. Treat using a 25 gauge 5cm cannula and aspirate prior to
injecting to check for intravascular entry
6. Perform slow retrograde threads of dermal filler, tightly
approximated (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
Potential difficulties
The facial nerve and parotid gland are at risk during
shaping of the posterior mandibular ramus as they are
both deep structures, located deep to the superficial
musculo-aponeurotic 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 the masseter. It is
palpable at this point and should be identified and protected
prior to injection.
Summary
Goal: To define and enhance the angle of mandible
Depth: Superficial/subdermal
Volume: 0.5-1ml per side
Technique: Cannula technique
Products of choice: Restylane Defyne, Restylane Volyme or
Restylane Lyft
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3. Peri-jowl region
By treating the angle of mandible first, followed by the chin, the soft
Upper tissues surrounding the jowl area (superolaterally and inferomedially)
third
will be slightly tensioned. Hence, less product is required when
focusing our attention to the jowls directly. In my experience, three
Middle perpendicular dermal filler threads can adequately shape the inferior
third
edge of the mandibular ramus.

Lower
third
Technique
1. Identify the borders of the jowls and be mindful not to
Figure 2: The division of the face into vertical fifths and horizontal thirds8
volumise the area (Figure 3)
2. Palpate and mark the pogonion of the chin and the angle of
2. Chin contouring mandible
For ideal facial proportions, the face is generally divided into equal 3. Mark out lines that connect the angle of mandible to the
vertical thirds (upper, middle, lower) and horizontal fifths. The ideally pogonion of the chin, representing the inferior edge of
proportioned chin width is said to occupy the central horizontal fifth of ramus
the face.7 A one third to two thirds ratio should exist for the distance 4. Aspirate to check for intravascular cannulation
between the nasale and superior upper lip border to the inferior lower 5. Slow retrograde threads tightly approximated of dermal filler
lip border to the pogonion.7 When contouring the chin, start with a product of 0.1ml per thread to a total of 0.5ml per side
focused assessment of chin length, anterior projection and the depth 6. Gentle palpation between the edge of two fingers helps to
of the pre-jowl sulcus region. Rickett’s Esthetic Plane connects the tip shape the product for ideal angular contour
of the nose to the pogonion of the chin and states that the upper lip is
an average distance of 4 mm to this line and the lower lip is an average Potential difficulties
distance of 2 mm.9 I use Ricketts’ Esthetic Plane9 as an assessment Be careful not to place any volume within the jowls as, in
guide to the overall relationship between the tip of the nose, the lips my experience, this will act to worsen the pre-jowl sulcus.
and pogonion of the chin for lower third facial harmony. The rule of The mental artery, nerve and the facial artery must also be
facial thirds can be applied to determine if the chin requires elongation.7 considered during treatment of this subunit and have been
However, as a general principle, ageing causes mandibular resorption previously discussed.
and is associated with hyperactivity of the mentalis.2 These factors all
contribute to a shortened chin and a less projected lower facial third. Summary
Goal: To straighten and sharpen the jawline by camouflaging
the jowl
Technique Depth: Subdermal
1. Assess the contour deformity in the pre-jowl sulcus, the Volume: 1ml total
mental crease, and the mentalis muscle Technique: Cannula for subdermal
2. Palpate and mark the pogonion of the chin Products of Choice: Restylane Volyme or Restylane Lyft
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
4. For cannula treatment, choose an entry point that allows
access to the pre-jowl sulcus
5. 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
Be careful not to place any
Potential difficulties
volume within the jowls as,
The inferior alveolar artery and nerve exiting from the mental
foramen are the main dangers in this area. The mental foramen
in my experience, this will
is commonly located between the first and second premolar
teeth and should be protected from direct injections.10
act to worsen the pre-jowl
Summary
sulcus
Goal: To shape and contour the chin
Depth: Subdermal and periosteal
Volume: 1-2ml total
Technique: Cannula for subdermal and needle for periosteal
Products of Choice: Restylane Volyme or Restylane Lyft

52 Aesthetics | August 2018


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Figure 1: The cannula entry points and the filler thread placement. The arrows indicate the
direction of the cannula.
Before After
Figure 4: Before jawline sculpting and after treatment. Results show improved
angulation, contours and definition. Angle of mandible: 1ml Restylane Lyft per side (2ml
total) chin contouring: 0.5ml Restylane Lyft per side (1ml total).
Considerations and complications
Jawline sculpting is a demanding treatment area. The heaviness
and descent of the upper two thirds influence the lower third,2
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 be looking for
a higher aesthetic outcome. It should only be attempted after
adequate training.
The risk of intravascular injection can be minimised by remaining
in the superficial (subdermal) plane or the deep (periosteal)
planes. Furthermore, I believe aspiration prior to injection can also
minimise intravascular risk. A benefit of performing treatment with
HA dermal fillers is the ability to reverse treatment with the use of
hyaluronidase. Practitioners 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 the mandible to chin contouring and
to the peri-jowl region. With a focus on anatomical dangers, this
technique can provide a safe treatment guide to achieving a good
aesthetic outcome for patients.
Aesthetics | August 2018
Clinical Practice
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Figure 3: The pre-marking of the jowls. It is important not to volumise the jowls, represented
by the area between the lines. The white dots represent the cannula entry points.
Before After
Figure 5: Before jawline sculpting and after treatment. Results demonstrate a lessening
of the jowls and a sharper, more youthful jawline. Angle of mandible: 1ml Restylane
Defyne per side (2ml total) chin contouring: 0.5ml Restylane Lyft per side (1ml total)
peri-jowl treatment: 0.5ml Restylane Lyft per side (1ml total).
Dr David Ong is the medical director and masterclass
trainer at the Facial Aesthetics Centre for Excellence
(FACE) Academy in Brisbane, Australia. He graduated
from the University of Western Australia in 2009 and
proceeded to specialise in cosmetic injectables in
California in the US before returning to Australia.
REFERENCES
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aging-implications for facial rejuvenation. Plast Reconstr Surg. 2008; 121(4): 1414-1420.
3. Coleman SR Grover R. The anatomy of the aging face: volume loss and changes in 3-dimensional
topography. Aesthetic Plast Surg 2006; 26: S4-S9.
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merriam-webster.com/medical/mandibular%20angle>
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ideal fibula wedge osteotomy to re-create the mandibular angle for microvascular reconstruction. J
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