Choosing Juvéderm Volux™ to chin augmentation: Case report and flowchart for clinical evaluation

Abstract

Introduction

The development of filler biomaterials with high hyaluronic acid concentrations, cohesiveness, and elastic modulus has become an option for chin augmentation, as the balance of these rheological properties promotes high lifting capacity, providing minimally invasive perceptible improvements in patient appearance.

Presentation of case

The present study reviewed clinical and anatomical aspects of patients referred for chin augmentation and created a flowchart to assertively diagnose patients with an indication of Juvéderm® Volux™ for defining the lower third of the face.

Discussion

The chin is vital for facial proportions and attractiveness perception. Its relevance to facial appearance is noticed the most when chin size is less than ideal, making other facial areas seem larger or smaller. The adjacent soft tissues of the neck and jaw appear prematurely aged when chin projection or width is inadequate. Hyaluronic acid-based fillers have a confirmed history of safe and effective use for treating facial volume loss or deficiency.

Conclusion

Juvéderm® Volux™ is a safe, effective, and long-lasting alternative for restoring and creating facial volume and sculpting, shaping, and contouring the chin and jaw.

Highlights

• •Chin projection and width are vital for facial proportions and attractiveness perception.
• •Immediacy and predictability make HA fillers the treatment of choice for most clinical circumstances.
• •Juvéderm® Volux™ is a safe and effective alternative for restoring facial volume.

1. Introduction

The chin is vital for facial proportions and attractiveness perception [1]. When chin projection or width is inadequate, other facial areas seem larger or smaller, and the adjacent soft tissues of the neck and jaw appear prematurely aged [2]. Various treatment options are available to correct facial proportions and disharmonies. Identifying the deformity with an adequate analysis is essential to select the most appropriate procedure for each patient [3]. Facial profile evaluation using the Glabella/Subnasal/Pogonion (G'SnPog’) angle, as shown in Fig. 1, is among the quantitative measurements indicated for initial patient assessment. The flowchart in Fig. 2, based on Arroyo et al. [3], Olgivie et al. [4], and Dall'Magro et al. [5], contributes to the most appropriate and individualized clinical assessment of the need for chin augmentation for each case.

Fig. 1.

Image adapted from Dall'Magro et al. [5] Normal: between 165° and 175°; Retrognathism: lower than 165°; Prognathism: above 175°.

Fig. 2.

Flowchart of the clinical evaluation of the chin.

Patients with a retracted mandibular bone portion but normal occlusion may benefit from minimally invasive esthetic procedures [3]. In these cases, chin augmentation is possible with injectable fillers or autologous fat, alloplastic implant placement, or bone osteotomy (genioplasty) [2]. Genioplasty is a chin alteration through bone manipulation or augmentation with alloplastic implants, and the most described esthetic procedure in the literature to restore the balance between skeletal, soft tissue, and dental components of the lower third of the face [6]. Although this procedure is safe and definitive, the search for this treatment has declined in recent years due to the growing popularity of minimally invasive treatment options, such as using hyaluronic acid (HA)-based fillers [1].

HA-based fillers are safe and effective for treating facial volume loss or deficiency [4,7]. Immediacy and predictability also make these fillers the treatment of choice for most clinical circumstances, but understanding the rheological characteristics of HA is essential for correctly choosing each facial topographic region [8,9]. Recent studies comparing the rheological capabilities of HA gels indicate the therapeutic superiority of Juvéderm® Volux™ for filling the chin and mandibular contour compared to other HA gels. This material also has an ergonomic syringe that promotes a smooth and precise product delivery with favorable extrusion force. Its cohesiveness, elastic modulus, and high HA concentration (25 mg/mL) provide high lifting capacity, ideal for dynamic areas presenting bone and tissue support losses, and allowing sculpting, contouring, designing, and modeling the injected areas [4,9].

Given the above, the present study reviewed the clinical and anatomical aspects of patients referred for chin augmentation and created a flowchart to assertively diagnose patients with an indication for Juvéderm® Volux™ for defining the lower third of the face.

2. Presentation of case

This work has been reported in line with the SCARE criteria [10]. After a careful clinical evaluation of the patient, imaging exams, cephalometric analysis, and photography (Fig. 1), Juvéderm® Volux™ use was demonstrated in the clinical case below. The patient presented normal occlusion even though the cephalometric analysis showed the Gl'SnPog’ angle at 154°, confirming vertical and horizontal micrognathia (Fig. 3, Fig. 5).

Fig. 3.

(A-J) Initial photographs and (K) cephalometry: G'SnPog’ = 154°.

Fig. 5.

(A-J) Before/after 90 days and (K and L) cephalometry G'SnPog’: 154° (before) and G'SnPog’: 158° (90 days). Measurements increased by 4° compared to the initial ones.

The treatment plan included temporal and zygomatic structuring with Juvéderm® Voluma™ and mandibular angle definition with Juvéderm® Volux™ before filling the chin. The chin (C) was filled with 2 mL of Juvéderm® Volux™ following the clinical sequence (Fig. 4).

Fig. 4.

Treatment plan and clinical sequence of chin treatment: C1: 0.2 mL (each). Total: 0.6 mL; C2: 0.2 mL; C3: 0.3 mL (each). Total: 0.6 mL; C4: 0.2 mL; C6: 0.2 mL (each). Total: 0.4 mL.

The treatment was refined with Juvéderm® Voluma™ to promote the mechanical myomodulation of the depressor anguli oris and lower lip depressor muscles. Juvéderm® Volift™ was used to support the palpebromalar junction and minimize tear trough, followed by Juvéderm® Volbella™. The treatment ended with lip filling with Juvéderm® Volift™ and Juvéderm® Volbella™, as described in Table 1.

Table 1.

Treatment plan and products.

Anatomical area	Action	Product application plan	Technique and device	Volume
Temporal (T)	Restoring volume Eyebrow lifting	Juvéderm® Voluma™ Supraperiosteal	Bolus 27G needle	0.2 mL (each application point) TOTAL: 0.8 mL
Zygomatic Arch (Ck1)	Cheek lifting Supporting the lower eyelid	Juvéderm® Voluma™ Supraperiosteal	Bolus 27G needle	0.1 mL (each application point) TOTAL: 0.6 mL
Anteromedial malar (Ck3)	Supporting the palpebromalar junction Attenuating tear trough	Juvéderm® Volift™ Deep malar fat	Fanning 25G cannula	0.3 mL (each application point) TOTAL: 0.6 mL
Nasolabial Fold (NL)	Maxillary projection	Juvéderm® Voluma™ Supraperiosteal	Bolus 27G needle	0.3 mL (each application point) TOTAL: 0.6 mL
Lateral orbicularis thickening	Cheek lifting Supporting the lower eyelid	Juvéderm® Voluma™ Supraperiosteal	Bolus 27G needle	0.1 mL (each application point) TOTAL: 0.2 mL
Tear trough (Tt)	Infraorbital region improvement	Juvéderm® Volbella™ Supraperiosteal	Micro stitch 25G cannula	0.1 mL (each application point) TOTAL: 1 mL
Mandibular angle (Jw1)	Setting the angle Enlarging the face	Juvéderm® Volux™ Supraperiosteal	Bolus 27G needle	0.5 mL (each application point) TOTAL: 1 mL
Chin definition (C)	Height and projection	Juvéderm® Volux™ Supraperiosteal chin fat pad	Bolus 27G needle	C1: 0.2 mL (each application point × 3) Total: 0.6 mL C2: 0.2 mL C3: 0.3 mL (each application point × 2) Total: 0.6 mL C4: 0.2 mL C6: 0.2 mL (each application point × 2) Total: 0.4 mL TOTAL: 2 mL
Lip (Lp)	Volume and definition	Juvéderm® Volbella™ Vermilion body (Lp1) Mucosa	Lp1: upper and lower Micro stich 30 G needle	0.05 (each application point × 20) TOTAL: 1 mL
Lip (Lp)	Volume and definition	Juvéderm® Volift™ Mucosa: •Lip border: Lp3 •Oral commissure: Lp6	Lp3: upper and lower Retro injection 30G Needle Lp6: Bolus 30 G needle	0.1 mL (each application point × 4) 0.1 mL (each application point × 2) TOTAL: 1 mL

Ethical approval for this study (approval number 6.508.613) was provided by the Ethical Committee of University of Passo Fundo, RS, Brazil, on 16 November 2023.

3. Discussion

Injectable fillers are minimally invasive, require minimal or no downtime, incurring minimal risk, and allow practitioners to model the chin in horizontal, transverse, and vertical dimensions [2,11]. VYC-25 L (Juvéderm® Volux™) is the first HA filler developed for chin augmentation to be systematically analyzed. According to Olgivie et al. [4], VYC-25 L significantly improved the G'SnPog’ angle and the self-assessment/patient satisfaction scales. Although the described case illustrates the result after three months of treatment, the literature confirms through randomized controlled trials that the objective and subjective benefits of VYC-25 L treatment were sustained and remained clinically significant for up to 24 months.

The choice of Juvéderm® Volux™ for the mandibular region is based on its rheology, which provides high lifting capacity due to HA concentrations, G prime, and cohesiveness without similarity with other fillers [4,9,12]. Usually, VYC-20 L and other fillers from the Vycross collection are necessary for a treatment plan focusing on esthetic improvements following the concepts of facial architectural rehabilitation. When planning treatments for lower third definition, applying fillers in the upper and middle thirds of the face can precede this therapeutic step for promoting lifting and facial volume, aiming to improve facial anteroposterior relationships and three-dimensional support to ligament, fat pads, and muscle dynamics balance [13]. Furthermore, fillers can modulate muscle activity depending on the application plan and rheological properties, and the lower third facial muscles have a significant capacity for functional response to this myomodulator [14].

4. Conclusion

Juvéderm® Volux™ is a safe, effective, and long-lasting alternative for restoring and creating facial volume and sculpting, shaping, and contouring the chin and jaw. The treatment can be performed incrementally according to patient needs and desires, but patients' functional and esthetic characteristics must be carefully assessed before treatment.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

The case meets all applicable standards with regard to the ethics of experimentation and research integrity. Ethical approval for this study (approval number 6.508.613) was provided by the Ethical Committee of University of Passo Fundo, RS, Brazil, on 16 November 2023.

Author contribution

Author's contributions: Alessandra Kuhn Dall'Magro: Conceptualization, Investigation, Methodology, Supervision, Roles/Writing - original draft; Eduardo Dall'Magro: Conceptualization, Methodology; James Olding: Investigation, Methodology; Letícia Copatti Dogenski: Investigation, Roles/Writing - original draft, Writing - review & editing; Felipe Gomes Dallepiane: Investigation, Roles/Writing - original draft, Writing - review & editing João Paulo De Carli: Supervision, Investigation, Writing - review & editing.

Guarantor

Dra. Alessandra Kuhn Dall'Magro.

Declaration of competing interest

Dra. Alessandra Kuhn Dall'Magro is a consultant and speaker for Allergan/AbbVie. Dr. James Olding is a speaker for Allergan/AbbVie.