Clinical validation of the upper face first principle—A clinical, prospective, interventional split‐face study

Abstract

Background Previous clinical and anatomic investigations have identified the clinical relevance of facial biomechanics. Based on this new understanding, principles for facial aesthetic procedures were established: Lateral Face First, Deep Layers First, and Upper Face First. Objective To test the upper face first principle by showing that an injection sequence, starting in the upper face is superior to an injection sequence starting in the lower face. Methods This study was designed as an interventional split‐face study administering the same amount and type of soft tissue filler for the upper, middle, and lower face but in a different sequence: upper, middle, lower face versus lower, middle, and upper face. A total of 15 patients (5 males and 10 females) with a mean age of 39.4 years (9.6) and a mean BMI of 23.4 kg/m2 (1.7) were studied. Follow‐up at D0, D30, and D90 was conducted utilizing semiquantitative scores and objective 3D imaging. Results Despite not reaching statistical significance, midfacial volume and jawline contouring were rated better at every follow‐up visit (D0, D30, D90) when treated with the upper versus the lower face first injection algorithm. The global aesthetic improvement scale showed statistically significantly better values for the upper face first algorithm when compared to the lower face first algorithm at all evaluated time points with all p < 0.001. Conclusion Applying the upper face first injection algorithm seems to result in better aesthetic outcomes when directly compared to the lower face first algorithm. Semiquantitative and objective outcome measurements confirm its clinical effectiveness.

Superficial versus deep injections of the upper midface—A prospective interventional split‐face study

“…This is in alignment with currently accepted treatment algorithms that predominantly target deep = supraperiosteal fascial layers to reshape and revolumize various facial regions including the midface. These observations are also in line with the previously established treatment principles for minimally invasive facial aesthetic procedures which were confirmed in independent clinical studies: lateral face first, upper face first, and deep layers first 1,5–7 …”

“…These observations are also in line with the previously established treatment principles for minimally invasive facial aesthetic procedures which were confirmed in independent clinical studies: lateral face first, upper face first, and deep layers first. 1,[5][6][7] Despite its global acceptance, the latter principle however (deep layers first) is being challenged by anatomic findings which investigated the superficial facial fat compartments individually and have reported that some superficial fat compartments move more (superficial nasolabial and jowl) whereas others are stable (superficial medial cheek and superficial lateral cheek) when experimentally tested and related to the underlying bone. Especially the superficial medial cheek fat compartment (which is also termed malar fat pad) seems to not undergo positional changes which might make this fat compartment also a target for superficial soft tissue filler injections in addition to the already established deep injections.…”