Another look at facial aesthetics

Natural facial beautification. About a model.

Jean-Pierre AMSELLEM, MD
French Association of Aesthetic and Anti-Aging Medicine

Rejuvenate, of course, but above all beautify: what's the point of rejuvenating a face that's never been beautiful before?
What our patients want above all is to regain their beauty, for those who have lost it, and to become beautiful, for those who never were.
Embellishing a face, giving it a new freshness, a second youth, should not remain a purely medical technical procedure, even if surgical skill is the first priority.
Creating or recreating Beauty is an art, just like painting a portrait or sculpting shapes.
35-year-old patient with no particular medical history.
Rhinoplasty at the age of 28.
Augmentation of oral lips with HA 4 months previously.
It is very important to separate the medical act from the artistic scheme that should precede any aesthetic procedure.
        -increase cheek size,
        -raise the lips,
        -treat bitterness folds.
        -confirmation of the patient's wishes.
        -other proposals :
                   - filling of the temporal fossa,
                   - treatment of dark circles,
                   - rhinoplasty correction,
                   - volumetric chin augmentation.
After consultation with the patient, we decided to perform all indications in the following order: cheeks, mouth, bitterness folds, forehead and temporal fossa, dark circles, nose and chin.
We have decided to perform each of these indications on different patients in order to see the different possible results, but of course in the end we will show the complete result of the model patient.



This is surely the most important area of the face, and requires special attention.
  • The cheekbones are the main structure of the middle third of the face.
  • The cheekbone is a relief centered on the malar bone.
  • The cheekbone area lies below the eyebrow ring, outside the nose and the corner of the mouth, and extends externally to the zygomatic arch.
  • The cheekbone is often hollowed out in the middle by an oblique groove that starts at the rim of the eye and extends downwards: the palpebro-jugal groove.
  • The relief of the cheekbone should be neither too high nor too low, but centered on the relief of the malar bone.
Recent studies by VAL LAMBROS have shown that, over time, the cheekbone loses its fatty mass and flattens. The other hypothesis is a vertical sagging of the face under the effect of gravity.
For my part, I believe that aging is due to facial fat delocalization, but also to gravity, which explains the vertical vector of aging. But to be precise, aging is also a latero-internal vector due to the anatomical fixed point of the lower 1/3 of the nasolabial fold, which explains the formation of nasolabial folds. You could say that the nasolabial fold is simply the result of the cheek sagging with internal rotation.
To obtain a natural result, we perform a vector face lift, which involves using the 4 anatomical fixed points of the face and repositioning the cheekbone in its aesthetic context.
A cross-linked HA is injected between these four fixed anatomical points to achieve a lifting effect, using a 22G, 70 mm-long cannula. Quantity injected 3 cc.



Well-hemmed, generous lips are a woman's charm.
Moreover, the volume of the lips sometimes reflects a person's character: lips that are slightly stretched upwards from the corners indicate gentleness, rounded lips denote seduction, while those that are very thin and drooping give the impression that the person is disdainful and arrogant.
The mouth also ages, losing volume and changing its curves, with a lengthening of the philtrum. But in my opinion, the most detrimental sign is the lengthening of the white lip due to gravity, which absolutely must be corrected.
The treatment consists of correcting the lip hemline and philtrum volume when justified. The most appropriate filler is undoubtedly hyaluronic acid.
For this patient, we use the Russian method, which consists of a vertical, superficial injection. Quantity injected 0.4cc.
The injection was made only in the upper lip to obtain an upper lip equal to the lower lip instead of 1/3- 2/3 as stipulated in all aesthetic medicine books.



This area is marked by a complex muscular zone associating the Orbicularis Oris, the Depressor Anguli Oris, the Mentalis and the Depressor Labii inferiori.
Botulinum toxin was injected into the DAO in 2 points, one superior and superficial at the level of the motor plate of 2 U and a second point one cm lower and deeper of 2 U as well.
15 days later, a top-up with HA to perfect the result.



This is probably the most important area after the cheekbones, because as we age, fat melts from this region, inverting the beauty triangle. In fact, the young face is a triangle whose base is represented by a line passing through the two temporal areas, the apex being represented by the chin. As the fat melts from the temporal area, the beauty triangle is inverted, which is why it's so important to fill out this area in order to recreate the lost beauty.
The temporal fossa can be injected in two ways: either with a minimum 25G cannula deep into the temporalis muscle, or with a 27G needle in contact with the temporal bone. The needle is preferable if the temporal fossa is small, and the cannula if larger, to avoid iterative injections.
For the forehead, after a truncal anesthesia of the supraorbital and supratrochlear nerves, we perform a hydrotomy, then after a 20-minute latency period, we inject a reticulated HA to naturally curve the forehead, creating that perfect continuity between the forehead and the temporal fossa that represents a beauty criterion for the upper 1/3 of the face.
The forehead is the largest anatomical unit of the face, and plays an important role in facial balance and harmony.
A beautiful, youthful forehead is one that is wide and, above all, forms a perfect curve with the temporal region. Sometimes there's a break between the temporal area and the forehead, and we need to work hard to transform this break into a perfect curve.
AH 2CC was injected with a 22G 70 mm cannula.



The appearance of dark circles or tear troughs gives the face a tired look that our patients don't like. The loss of volume at this level leads to a skeletonization of the eyes, resulting in aging of the area. It's not enough just to fill in the dark circles, but also to create a new curve between the lower eyelid and the nasolabial fold, the beauty criterion of the middle third of the face.
Bone-contact needle injection, slightly cross-linked AH injected with a 30G needle. Alternatively, use a 50 mm-long, 25 G cannula. Quantity 0.3 cc per side.



The injection must be made with a needle in contact with the bone, but the cannula is also very useful in this area when you want to enlarge the volumization zone.
The beauty criterion for the lower 1/3 of the face: the chin must be in line with the upper lip.
The chin plays a very important role in the beauty of the lower 1/3 of the face, which is why it's so important to examine our patients in profile too.
In addition, projecting the chin will significantly improve the oval shape of the face, which is a concern for our patients from their fifties onwards.
Quantity injected: 0.3 cc.



The nose plays a major role in the beauty of the face. Over the years, there is a moderate ptosis of the tip, and simply raising the tip by even 2 mm will significantly rejuvenate and beautify the face.
The nose is a highly vascularized anatomical zone, so the 25G 50mm cannula is the preferred choice, especially to avoid the risk of necrosis.
The criterion of beauty must be a straight nose, for men as well as women, whereas 20 years ago all women wanted a little snub nose.
The nose and chin are extremely closely linked in the beauty of the lower 1/3 of the face, and there is a real harmony between these 2 anatomical zones that needs to be respected or corrected.
Quantity injected: 0.2 cc.


All these areas were treated on the same patient, with a very natural result.
For the entire face, we used 6.5 cc of Hyaluronic Acid and 4 units of Botulinum Toxin.


We must never forget that a detail can change everything for the better or for the worse. Didn't Leonardo da Vinci say: "Details make beauty, but beauty is not a detail.
In conclusion, hollow means shadow, and shadow means ageing, while volume means light, and light means beauty and youth.
Beauty pleases the eye and charm pleases the heart. In other words, when we find someone beautiful, it's our eyes that speak, and when we find someone charming, it's our heart that speaks.
Fournier PF. Facial recontouring with fat grafting. Dermatol. Clin. 1990; 8: 523
Pitanguy Yvon. Aesthetics of the face. Revista Medica. March 2003
Ramirez OM. Full face rejuvenation in three dimensions: A "face-lifting" for the new millennium. Aesth Plast Surg 2001; 25: 152-164.
Coleman S.E. Facial recontouring with lipostructure. Clin. Plast. Surg. 1997; 24: 347.
Amsellem J.P. La lipoplastie cervico-faciale. Journal de l'AFME.
Amsellem JP. Beauty is in the fat. Book 2010
Amsellem JP. Beauty sublimated. Book 2018
Amsellem JP. Angular rhinomodulation. Book 2009
Amsellem JP. The vector face lift. Book 2011
Amsellem JP. Ombre et lumière. Book 2010
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