The Consultation: A Story of Volume Lost and Found
When Zoe sat down, she described a feeling many people know all too well. After having her little boy, she looked in the mirror and didn't recognize the reflection staring back. "My whole face has dropped," she said, pointing to the area around her mouth where jowls had started to form, making her look tired, older, and somehow less like herself. Her main concern was clear: the face she saw in the mirror no longer matched the one she felt inside. But the story of aging is not simply about skin sagging. It is a story of what lies beneath—a quiet loss of volume in the deep structures that once supported the face like a sturdy scaffold. This understanding transforms how we treat aging, and it became the foundation of every decision made that day.
The plan unfolded over three stages. First, we would address the root causes of what Zoe was seeing: the gradual resorption of bone and the shrinking of deep fat compartments. Then, in a few weeks, we would stimulate the skin's own elasticity with bio-remodeling treatments. Finally, we would add a few finishing touches with filler. But the work we were about to do was all about the deep layers—the architecture, not the finishing coat.
The Temple: Rebuilding the Framework
We began at the temples. The temple is not just a hollow area; it is a critical landmark with boundaries defined by the temporal crest above, the orbital rim in front, the zygoma below, and the hairline behind. Zoe had diffuse hollowing here, and the first injection targeted the deep temporal compartment. The landmark was precise: one centimeter up from the temporal crest and one centimeter inward—what we call "one up, one over." Before injecting, we palpated carefully to feel for the superficial temporal artery, ensuring it was well out of the way. This area is considered higher risk because it connects with the internal carotid circulation through anastomoses, so we took extra precautions. Instead of the typical 27-gauge needle, we used a 25-gauge needle—slightly larger, yes, but it increases the sensitivity of aspiration and, despite feeling a bit sharper, lowers the overall risk profile.
Injecting slowly is crucial everywhere, but especially here. A slow injection reduces the risk of product displacing into unwanted areas and lowers the chance of vascular compromise. Also, we injected at a 45-degree angle rather than straight on. Research has shown that a steeper angle helps trap the filler beneath the deep temporal fascia, preventing it from spreading too close to the skin surface. As the filler went in—a slow, steady injection after aspirating for a full five seconds—the temple began to soften. The temporal crest and the orbital rim, which had been starkly visible before, became less prominent. And on this side, the tail of the brow lifted ever so slightly, a beautiful early sign of how restoring volume in one place can transform a whole region.
The Cheek Apex: High-Impact Projection
Moving inferiorly, we next turned to the apex of the cheek. The apex is an aesthetic point—it aligns with the suborbicularis oculi fat, or SOOF, which is an anatomical target. Finding it requires a trained eye, but for those starting out, a practical method is to locate the orbital rim, feel for its medial and lateral borders, then draw a vertical line down from the midpoint. Then draw a horizontal line out from the ala of the nose. Where they intersect is almost always the apex—though for women it tends to be a little more lateral and higher, for men a bit more medial and lower. If the lines don't look right, sit the patient upright, look from another angle, and let your eye decide where the projection needs to be.
For this injection, we returned to a 27-gauge needle. The technique is interesting: we place the skin under tension by pinching it, then we must let go of that pinch once the needle is through the skin. If you hold the tension too long, you lengthen the distance between skin and bone, losing the ability to feel layer five, the periosteum. This balance between traction and relaxation is something many newer injectors struggle with, but it's essential to minimize product displacement. The apex is a high-impact area. Even a small amount of volume—just 1 ml of filler—can produce a remarkable result here. For a patient who has limited budget or is unsure where to start, this single point can make a world of difference.
The Gonial Angle: Creating Structure and Tension
Staying lateral but moving down, we arrived at the mandibular angle, often called the gonial angle. When Zoe turned her head, the definition was already quite nice on one side, but the other side showed some blunting. Our injection point here is deep, about 1 cm inward from the angle. Although the target of the needle is the bone, most of the product actually ends up within the masseter muscle. This is a fascinating injection because it does two things: it adds projection to the jawline, and it creates lateral tension across the lower face. That tension helps lift the soft tissues that have descended with aging—the jowls, the heaviness. Interestingly, we often use neuromodulators to relax the masseter, but that can lead to a loss of support in the lower face. Here we are doing the opposite: adding volume to the masseter to provide structure.
Patients should be warned that for a day or two after, the injection site may feel tight or achy when chewing, since we are working within a muscle. But the result is a stronger, more defined jawline, and a visible improvement in the sense of lower face descent.
The Deep Pyriform Space: Softening the Nasolabial Fold Without Direct Treatment
We then moved to the deep pyriform space, a region just beside the nose where the maxilla can resorb over time. A quick test: press down in this area. If there's no support under the finger, it's a sign of bony loss. The injection target is deep, within a small triangular shadow at the corner of the nose. This area requires caution because the facial artery runs from the anterior border of the masseter, giving off branches to the lips, and then typically courses superficially within the nasolabial fold fat pad. By pulling the skin laterally as we inject, we move that artery out of harm's way, staying medial and deep. We aspirate for five seconds, again using a 25-gauge needle for greater sensitivity.
This injection tends to be a bit uncomfortable because of the nerves from the infraorbital foramen that supply the upper lip. It's normal for the patient to experience some reduced sensation in the upper lip for about half an hour after. But the effect is remarkable: the nasolabial fold softens, even though we haven't placed any filler directly into it. The deep volume restoration lifts and supports the midface, diminishing that aging fold naturally.
The Chin: A Delicate Balance of Projection and Proportion
Finally, we treated the chin. The chin is an expression of sexual dimorphism. In female patients, adding too much width can make the face appear more masculine. We must be careful to keep the width of the chin within the width of the nose, and not overproject it. From the side, we look for the ideal anteroinferior projection—the point that gives the mentalis muscle something to contract over, supporting the lower face.
For the chin, we used a single midline injection with a 25-gauge needle. When using a firm product like Restylane Shape, the pressure can feel quite tight. By applying gentle pressure just above the injection point, we can reduce the spread of product superiorly, ensuring the volume goes where it's needed. The chin is another higher-risk area, so the larger needle and careful aspiration are vital.
Halfway There: The Power of Treating the Cause, Not the Symptom
With the chin done, we were a little more than halfway through the deep treatments. We sat Zoe up and looked at the results. Starting from the top, the temple was fuller, with less shadow. The cheek apex, best viewed in the oblique, now had a lovely fullness compared to the still-flatter opposite side. And remarkably, the nasolabial fold had softened even though we never injected it directly. The perioral lines were less pronounced. The jawline was beautifully contoured, with a sharp, structured line. The untreated side still had good contours, but some blunting was evident.
This is the heart of the story: the signs of aging that worry us—the heaviness of the lower face, the deep nasolabial folds, the tired look—are often just symptoms. The root causes are deeper: the loss of volume in the bones and fat compartments that once held everything in place. By restoring that volume, we do not simply fill wrinkles; we rebuild the architecture. We lift, support, and rejuvenate from the inside out. And in doing so, we give people like Zoe back the reflection they remember.
"How did that all feel, Zoe?" "It was easy," she said with a smile. And that, perhaps, is the most telling part of the story.