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Facial rejuvenation treatment of the lower third of the face with hyaluronic acid (HA) fillers in elderly patients can result in the development of fibrous tissue especially after several procedures have been performed.

Many patients present with concerns over the loss of facial contour and also flaccidity in the jaw area. To address these problems, we must consider how they develop. As in many aesthetic conditions the cause is multifactorial with a combination of factors playing a role including:


  • Lipodystrophy of deep and superficial fat compartments.
  • Bone reabsorption and reduction of bone mass causing imbalance between the bone and soft tissues.


  • Changes in hormone levels can lead to changes both in skin tone and connective tissue elasticity.


  • Muscle spasms leading to shortening of the muscle accompanied by the displacement of the superficial and deep fat compartments.
  • Chronic inflammatory processes in the temporomandibular joint area causing fibrotic changes.
  • Bad posture.
  • Chronic stress.
  • Chronic diseases.

To achieve a successful outcome practitioners should adhere to the following protocol:

  1. Establish the relevant medial history.
  2. Physical examination, particularly of the lower third of the face, to identify the causes of age-related changes in this area, as well as to exclude or identify the consequences of previous invasive procedures.

Patient selection

It is very important to diagnose the type of ageing of the patient and to choose the appropriate procedures and products. In my experience I achieve the best results in patients with lipodystrophy and mild and moderate ptosis without an inflammatory component.

It is also necessary to choose the correct product with the following properties:

  • High elasticity will help to preserve facial expression.
  • Good cohesive characteristics should achieve better results with minimum injected volumes.
  • Products with maximum integration in the treated tissues will minimise adverse effects.
  • It is very important that HA behaves well in the tissues during its degradation, without the formation of hard fibrous tissue and calcification.
  • The most important advantage of the latest developments in HA fillers is their ease of injection, which allows the most complex manipulations to be performed with the minimal incidence of side-effects.

I now present a practical case and the technique that was used. A 60-year-old woman wanted to improve jaw contour, reduce the presence of wrinkles from the Marionette lines and improve the general appearance of the area. We identified that she had had previous polylactic acid treatments four years previously and as an adverse effect had developed the presence of fibrosis and slight deformation of the mandibular area with displacement of soft tissue. The patient did not have a severe postural component but did have moderate lipodystrophy and ptosis. She had previously been treated with HA in the mid-face and so we recommended waiting for three to four weeks before treating the lower third of the face.


Figure 1.


Procedure (Figure 1)

Step 1: The point for introduction of the cannula was marked. This was 4cm lateral to the midline of the face (central point of the chin). Local anaesthetic was injected at this point (0.1ml of lidocaine 0.5% or procaine 0.5%).

Step 2: Using a 22G, 7mm cannula 1ml of 0.5% procaine solution was infiltrated on each side of the face, following the yellow lines in the drawing. This helped to reduce the discomfort of the treatment of the fibrosis.

Step 3: With Hyabell® Ultra and the 27G needle that comes with the syringe, we made an injection by depositing 2 boluses of 0.1 in the zygomatic line, 1 bolus of 0.2ml in the central line of the chin and 1 bolus of 0.2ml in the mandibular angle (in the drawing marked as purple points) in deep level touching the periosteum at all points.

Step 4: With Hyabell® Ultra (22G 7mm cannula) following the blue lines we distributed HA in the form of a 0.5ml backward fan on each side.

Step 5: With Hyabell® Deep (22G 7mm cannula) we fine-tuned the design of the area using 1ml for each part of the face following the yellow lines.


Patients are instructed to avoid baths, saunas, facial massage and other cosmetic manipulations for 10 days following the procedure. In addition, patients are advised to return if there should be any symptoms or signs of infection / inflammation, specifically redness, tenderness, pain or swelling.


Figure 2.


Figure 3.



With careful patient selection and the careful application of filler products as described above, a dynamic, satisfying and lasting result can be achieved. Figures 2 and 3 show the patient before the treatment and one year afterwards.

Declaration of competing interests: None declared.



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Sofya Gilmanova

S-clinica, Valencia, Spain.

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