Injectable Filler Procedures

Injectable Filler Procedures Marbella Ocean Clinic

Do facial ligaments affect injectable filler procedures?

Lifting vs Volumising - A Study Led by Gabriela Casabona MD, Ocean Clinic.

Injectable fillers are becoming more and more popular and a regular treatment for helping to alleviate the signs of ageing, especially in the face where volume has been lost over time (in varying layers from bone to skin), and soft tissue begins to sag.

The application of soft-tissue filler replaces this lost volume reflating the targeted facial fat compartments, restoring tension in ligaments, and giving the face a fuller, back-to-youth appearance. The science behind injectables is intricate and ever-evolving and continuously being studied to perfect the art.

Recently the concept of the line of ligaments has been introduced as a factor to consider when trying to achieve optimum results. The facial layers are arranged differently - medial vs lateral - to the anatomical makeup of ligaments. Medial layers are angled obliquely and lateral are parallel to the skin surface. Placing soft-tissue fillers respecting these anatomical landmarks could possibly result in different effects. Medial injections could result in volume, and lateral injections could produce lifting effects.

To test this theory, our head of aesthetics department, Gabriela Casabona MD, recently published a study on soft-tissue facial fillers and the difference between lifting and volumising in minimally invasive procedures when respecting the facial ligaments.

The focus of the study was to analyse soft-tissue facial fillers applied, to a split face, in varying sequences. The analysis looked at applying different methods to either side of the same face in order to actually see and monitor the difference, if any.

Twelve patients (9 female, 3 male - 32-48 years old) from the Ocean Clinic received injectable soft-tissue fillers, as treatment for a lack of volume in the midface area. The patients were given the same fillers all at the same six sites on the face but in different sequences in order to see if this had any effect on the results. Half the face was treated in one sequence, the other half using a different order of sequence, but always at the same 6 points. All twelve patients had never received any previous surgical or non-invasive procedures to the area in question.

On each side of the face three points were targeted lateral to the natural line of ligaments, and then three more points were located medial to the line of ligaments. On the right side of the face the lateral points were injected first and the medial second, on the left side of the face the medial points were injected first and the lateral second. Basically the same procedure was carried out on either side of the face but in reverse order to see if the sequencing itself had any effect on the results.

The products used during the study for the volumizing procedure were JuvédermVolbella® (palpebromalar groove and tear trough) and JuvédermVoluma® (all other facial regions) (Allergan®).

Gabriela, the physician for the procedures, treated and analysed the hollowness and fullness before and after the treatment. The score of which was part of the assessment as was the GAIS scale, also assessed by Gabriela. All analyses were performed using SPSS Statistics 25 (IBM, Armonk). The volume injected was measured overall and for each individually injected location.

The Results

There was no aesthetic difference to the sides of the face post-treatment - both sides of the face looked equal both before and after the procedure in all patients. However there were some differences noted as to the amount of filler required to achieve the results in the varying sequences.

The study revealed thst if the lateral injections are performed first, the volume needed to be injected into the medial points is significantly less. The same phenomenon was observed for the laterally located injection points. The total injected was significantly less when the lateral points were performed first. Often an injection point is chosen specifically for the aesthetic outcome and does not consider the local underlying anatomy, during this study the anatomy was a factor in the desired otcome to specifically investigate the layered arrangement of the face. The targeted injection points were based on the specific arrangement of the underlying anatomy of the face in combination with a desired (aesthetic) outcome.


The results of the study emphasise the importance of respecting the underlying anatomy of the face, the layered arrangement of the facial soft tissue and ligaments, when performing minimally invasive soft-tissue filler injections. Target injection points lateral to the line of ligaments first reduces the volume needed to symmetrically and aesthetically appealing fashion, and volumizes the infraorbital and upper cheek region. Injections lateral to the line of ligaments result in a stretching effect of the midfacial fat compartments. Conversely, injecting the midface medial to the line of ligaments requires an increased amount of product required to achieve a desired aesthetic outcome if lateral injection points were not targeted first.

For more information on our aesthetic department or injectable fillers please contact Ocean Clinic today.