Abstract
Objective
To investigate the effectiveness, safety, and versatility of injections with the same hyaluronic acid (HA) filler type in patients with signs of aging in the cheeks, chin, and/or jawline.
Methods
In this single-arm, prospective case series study, patients aged ≥18 years with reduced midface volume, chin retrusion, and/or loss of jawline contour were administered HA filler (Y-Solution® 720 [20 mg/mL]) and followed through 12 months. Main outcomes included midface volume (Midface Volume Loss Rating Scale [MFVLRS]), chin retrusion (Chin Retrusion Rating Scale [CRRS]), loss of jawline contour (Jawline Contour Rating Scale [JCRS]), satisfaction (FACE-Q™ [1, worst; 4, best]), and safety.
Results
Nineteen patients received a combined total of 33 treatments with HA filler (total volume: 67 mL). The 19 patients demonstrated an immediate improvement in MFVLRS, CRRS, and/or JCRS score from 1 to 3 at baseline to 0 to 1 immediately post baseline, which was maintained overall through 12 months (scores 0–3; no attendance, n = 7). Satisfaction per FACE-Q was high from 1 month (score 3–4 for all questions, 10/19 patients), which was maintained in a proportion of patients through 12 months (score 3–4 for all questions, 5/19). Adverse events were considered procedural (most common: bruising post treatment, 3/19 patients), did not include swelling, and soon resolved.
Conclusion
These results indicate that injections of the same HA filler reduced multiple signs of aging in the midface, chin, and/or jawline through 12 months; the injections also resulted in no significant adverse events, including swelling.
Level of evidence: Case series of patients with a specific diagnosis; Level 4.
Keywords: Case series, Hyaluronic acid, Midface, Cheek, Chin, Jawline
Introduction
Hyaluronic acid (HA) is a natural component of the skin that plays a key role in water retention and the aging process.1,2 HA filler injections are an established, minimally invasive treatment for patients with volume loss and wrinkles who require facial rejuvenation.3 The safety and effectiveness of different HA filler injections have been reported in patients with various signs of aging, including reduced midface volume,4,5 chin retrusion,6,7 or loss of jawline contour.8 However, there is a scarcity of reports on the effectiveness and safety of the same type of HA filler injection in patients for the simultaneous treatment of reduced midface volume, chin retrusion, and/or loss of jawline contour, particularly the duration of effects over long periods of time.
The versatility of an HA filler for the rejuvenation of multiple areas of the face may depend on its individual properties.9 For example, HA fillers with low water uptake and minimal risk of swelling under the eyes may help to rejuvenate the midface,9 while those with high elasticity and cohesion that maintain a sharp vertical projection are considered to help rejuvenate the chin and jawline.7, 8, 9 YVOIRE Y-Solution® 720 (Y-Solution® 720; 20 mg/mL) is an HA filler injection manufactured via Stable–High Concentration equalized (S-HICE) technology, which provides the HA filler with properties of reduced early swelling, high elasticity, and relatively high cohesiveness.10
This case series study is the first to report on the effectiveness, safety, and versatility of injections with the same type of HA filler over 12 months across patients with reduced midface volume, chin retrusion, and/or loss of jawline contour.
Methods
In this single-arm, prospective case series study in the UK, consecutive patients with reduced midface volume, chin retrusion, and/or loss of jawline contour were administered HA filler (Y-Solution® 720 [20 mg/mL]) and followed up for 12 months (Figure 1). Written informed consent was received from all patients prior to them receiving any treatment. Eligible patients were those aged ≥18 years at the time of signing informed consent, with ≥1 of the following signs of aging or a natural deficit in aesthetic proportions, as assessed by the treating investigator: score ≥1 on the LG Chem Midface Volume Loss Rating Scale (MFVLRS), score ≥1 on the LG Chem Chin Retrusion Rating Scale (CRRS), or score ≥1 on the LG Chem Jawline Contour Rating Scale (JCRS).11 Further details of the injection technique, eligibility criteria, and assessment scores are included in Figure 1 and the Supplementary Material. Regarding diagnostic challenges, some patients presented with asymmetry to the treatment area. In these patients, the side with the highest grading was recorded during evaluation before and after treatment.
Figure 1.
Study overview. *Validated, 5-point score (none/minimal, mild, moderate, severe or extreme)1; †Validated, 4-point score (none, mild, moderate or severe)1; ‡See Supplementary Material for further details. HA, hyaluronic acid; MFVLRS, Midface Volume Loss Rating Scale; CRRS, Chin Retrusion Rating Scale; JCRS, Jawline Contour Rating Scale. 1. Lorenc ZPD, et al. Aesthet Surg J Open Forum 2021;3:ojab039.
Patients received ≥1 injection of HA filler in the midface (cheeks), chin, or jawline and were followed up through 12 months (Figure 1; Supplementary Material). There were no deviations, and the same methodology was maintained throughout the study. Main outcomes assessed at each visit included midface volume per the LG Chem MFVLRS, chin retrusion per the LG Chem CRRS, loss of jawline contour per the LG Chem JCRS, the FACE-Q satisfaction with outcome 4-point questionnaire (definitely disagree, 1; somewhat disagree, 2; somewhat agree, 3; or definitely agree, 4), and safety. A questionnaire was given at each follow-up visit to ensure the reporting of commonly occurring adverse events (AEs) related to dermal filler complications, including bruising, swelling, pain, nodules or lumps, infection, vascular compromise and occlusion, visual disturbance, or blindness.12, 13, 14 All data were reported using descriptive statistics.
Patients were advised to contact the study coordinator or clinic if they had any concerns or unexpected AEs. Patients were also advised to contact the clinic if they had any concerns following treatment, including signs and symptoms of infection, vascular compromise or occlusion, or visual disturbance or blindness.
Results
Patients and changes in MFVLRS, CRRS, and/or JCRS scores through 12 months
Nineteen patients (median age: 54 [range: 27–68] years; all Caucasian; 18 females and 1 male) with reduced midface volume, chin retrusion, and/or loss of jawline contour were enrolled in this study. All patients had received botulinum toxin treatment for aesthetic indications. Five of the patients had received HA filler; however, these procedures involved different areas of the face and were >12 months prior to enrolment in this study. None of the patients received aesthetic surgery or were undergoing any active skin treatments or using active topical agents during this study. All patients were fit and well, with no collagen or skin related medical conditions.
The 19 patients received a combined total of 33 treatments with HA filler (total volume: 67 mL). Overall, the 19 patients demonstrated an immediate improvement in MFVLRS, CRRS, and/or JCRS score from 1 to 3 at baseline to 0–1 immediately post baseline (Table 1). The improvement in these 19 patients for MFVLRS, CRRS, and/or JCRS scores was maintained overall through subsequent visits as follows: 1 month, range 0–1 (no attendance [NA], n = 3); 3 months, range 0–1 (NA, n = 5); 6 months, range 0–1 (NA, n = 9); and 12 months, range 0–3 (NA, n = 7). In addition, example photos of patient outcomes in the chin at baseline and 1 month and 12 months post injection of HA filler are shown in Supplementary Figure 1.
Table 1.
Patients, indications, HA filler syringe volumes (mL), and Grades (MFVLRS, CRRS, or JCRS; best [0] to worst [3]) through 12 months.
 |
 |
*This patient received injections on different dates, as follows: cheek and jawline injections on initial visit (4A); and chin injection 6 weeks later (4B).
Green, Grade 0; Yellow, Grade 0/1; Light orange, Grade 1; Dark orange, Grade 2; Red, Grade 3; Grey, no attendance.
BL, baseline; CRRS, Chin Retrusion Rating Scale; HA, hyaluronic acid; JCRS, Jawline Contour Rating Scale;
MFVLRS, Midface Volume Loss Rating Scale; PI, post-injection.
On analysis per the number of injections, four patients received HA filler injections in all three areas of the face (midface, chin, and jawline) (Table 1). These patients had MFVLRS, CRRS, and/or JCRS scores ranging from 1 to 2 at baseline, which decreased to 0–1 immediately post baseline. A reduction in all scores was mostly maintained through 6 months (score range of 0–1, n = 4). Six patients received HA filler injections in two areas of the face (midface, chin, and/or jawline) (Table 1). These patients had MFVLRS, CRRS, and/or JCRS scores ranging from 1 to 2 at baseline, which decreased to 0 in all patients immediately post baseline. A reduction in MFVLRS, CRRS, and/or JCRS scores was mostly maintained in the patients who attended through 6 months (score range of 0–1, n = 2; and NA, n = 4) and through 12 months (score range of 0–1, n = 6). The remaining nine patients received a single HA filler injection in only one area of the face (chin [n = 4] or jawline [n = 5]) (Table 1). These patients had CRRS or JCRS scores ranging from 1 to 3 at baseline, which decreased to 0 in all patients immediately post baseline. The reduction in CRRS or JCRS scores was mostly maintained in the patients who attended through 6 months (score range of 0–1, n = 8; and NA, n = 1), and to a lesser extent through 12 months (score range of 0–3, n = 8; and NA, n = 1).
Analysis per the baseline grades of the three validated scales resulted in the following subgroups: reduced midface volume (MFVLRS), n = 7; chin retrusion (CRRS), n = 11; and loss of jawline contour (JCRS), n = 15. Improvements in MFVLRS, CRRS, or JCRS scores were mostly maintained across subgroups through 12 months (Supplementary Figure 2). In the reduced midface volume subgroup (n = 7), baseline MFVLRS scores were as follows: score = 1, five patients; and score = 2, two patients (Table 1). Following HA filler injections, all patients had an MFVLRS score of 0 immediately post baseline, which was maintained through 1 month in six patients, with a score of 1 being observed in one patient. The reduction in MFVLRS score versus baseline score was mostly maintained through 6 months (score = 0, two patients; score = 1, three patients; and NA, two patients), and to a lesser extent through 12 months (score = 0, one patient; score = 1, three patients; score = 2, one patient; and NA, two patients).
In the chin retrusion subgroup (n = 11), baseline CRRS scores were as follows: score = 1, four patients; score = 2, six patients; and score = 3, one patient (Table 1). Following HA filler injections, all patients had a CRRS score of 0 immediately post baseline, which was mostly maintained through 3 months in eight patients, with a score of 1 being observed in two patients and with one patient not attending. A reduction in CRRS score versus baseline score was mostly maintained through 6 months (score = 0, five patients; score = 1, four patients; and NA, two patients), and to a lesser extent through 12 months (score = 0, one patient; score = 1, six patients; score = 2, one patient; and NA, three patients).
In the loss of jawline contour subgroup (n = 15), baseline JCRS scores were as follows: score = 1, seven patients; score = 2, six patients; and score = 3, two patients (Table 1). Following HA filler injections, a JCRS score of 0 was observed immediately post baseline in 13 patients, and a score of 1 was observed in two patients. A reduction in JCRC score versus baseline score was mostly maintained through 6 months (score = 0, three patients; score = 0/1, two patients; score = 1, five patients; and NA, five patients), and to a lesser extent through 12 months (score = 0, one patient; score = 1, eight patients; score = 2, one patient; score = 3, two patients; and NA, three patients).
FACE-Q questionnaire scores through 12 months
Patient-reported satisfaction per the FACE-Q questionnaire was high from 1 month and maintained in a proportion of patients (n = 19) through 12 months, albeit with slight decreases from 3 months (Table 2). At 1 month, ten patients reported a FACE-Q score of 3 or 4 for all questions, seven reported a score of 2 for ≥1 question, no patients reported a score of 1 for any question, and two were NA. At 3 months, nine patients reported a FACE-Q score of 3 or 4 for all questions, four reported a score of 2 for ≥1 question, two reported a score of 1 for any question, and four were NA. At 6 months, six patients reported a FACE-Q score of 3 or 4 for all questions, six reported a score of 2 for ≥1 question, three reported a score of 1 for any question, and four were NA. At 12 months, five patients reported a FACE-Q score of 3 or 4 for all questions, five reported a score of 2 for ≥1 question, five reported a score of 1 for ≥1 question, and four were NA. No clear trend was observed regarding FACE-Q scores in patients who received injections in more than one area of the face compared with those who received one injection only.
Table 2.
FACE-Q questionnaire scores* through 12 months.
 |
*Scores: (1) definitely disagree; (2) somewhat disagree; (3) somewhat agree; (4) definitely agree.
†Questions: (a) I am pleased with the result; (b) the result turned out great; (c) the result was just as I expected; (d) I am surprised at how good I look in the mirror; (e) the result is fantastic; (f) the result is miraculous.
Safety
Immediately post baseline in the overall patient group (n = 19), cannula site bruises were experienced by two patients, redness by two patients, and right jowl bruises by two patients. At 1 month post baseline in the overall patient group (n = 19), a slight lump in the mental crease (not visible, only palpable) was experienced by one patient, filler palpable right jawline angle by one patient, and bruising post treatment by three patients. There were no cases of swelling. The AEs observed were considered procedural, resolved shortly thereafter, and no other prolonged AEs were reported by the patients who attended follow-up visits through 12 months. All AEs were classified as minor, and there were no consequent changes in therapeutic intervention.
Discussion
The results of this case series indicate that injections of HA filler reduced multiple signs of aging, including reduced midface volume, chin retrusion, and/or loss of jawline contour through 12 months. In addition, swelling was not observed, and all AEs were considered procedural and resolved shortly thereafter.
In the patients who received HA filler injections across the three areas of the face (reduced midface volume, chin retrusion, and loss of jawline contour), the results indicate that the filler was versatile and that effectiveness was maintained in all areas through to 6 months and to a lesser extent at 12 months. In addition, the total volume of HA filler injected across these three areas of the face per patient was relatively low at 5–7 mL, and some patients who received only 1 mL of HA filler in one area of the face exhibited clinical improvement to Grade 0, maintaining some improvement to 12 months. Regarding the versatility of other HA fillers, another study has reported on the versatility of the resilient HA (RHA) filler regarding the efficient lifting of tissue in the midface, whether deep or superficial.15 Further investigation in a higher number of patients with longer follow-up is required to confirm and further characterize the versatility of HA filler injections across these three areas of the face, including patient satisfaction.
Patient-reported satisfaction per the FACE-Q questionnaire was high at 1 month and maintained in a proportion of patients through 12 months. Although slight decreases in FACE-Q scores were reported from 3 through 12 months, the overall trend was in keeping with the author’s expectations for HA filler injections. Notably, in some cases, a very high level of satisfaction was still reported at 12 months.
The AEs reported in the present case series were broadly consistent with previous reports of bruising, pain, and swelling post injection, with resolution soon thereafter; notably, swelling was not observed in patients who received HA filler injections in the present case series. In this regard, however, a systematic review and network meta-analysis of six randomized controlled trials of patients (n = 579) receiving HA fillers for cheek volume augmentation has identified differences in safety profiles among the respective fillers.16 Further investigation in a higher number of patients is therefore needed to help further characterize the safety profile of multiple HA filler injections, including the potential lack of swelling.
The results of the present case series indicate several potential benefits of administering the same type of HA filler in ≥1 area of the face, including effectiveness, safety, and patient satisfaction. The effectiveness and safety of HA filler observed in patients who received an injection in ≥1 area of the face in the present case series are consistent with those reported in patients who received an HA filler injection in a single area for either reduced midface volume,4,5 chin retention,6,7 or reduced jawline.8 Notably, these studies employed different types of HA filler (Art Filler Volume, Restylane, or VYC-20 L) compared with the present case series.4, 5, 6, 7, 8 The effectiveness of administering the same HA filler in multiple areas of the face in the present case series may have been facilitated by the specific properties of the filler, which includes resistance to external stress and retention of its original shape, relatively high elasticity and cohesion for molding on different areas of the face, and relatively high lifting capacity.10 In addition, the absence of swelling in patients who received HA filler injections in multiple areas of the face may be in part due to the HA concentration of the filler, which has reduced water absorption after administration in the skin and in turn reduces swelling (particularly early swelling). However, no clear trend was observed regarding FACE-Q scores in patients and the number of injections that they received, and further investigation in a higher number of patients may be required to identify such a trend.
The strengths of the present case series include the use of validated visual grading scores11 and longitudinal follow-up for 12 months. Notably, however, the limitations of the present case series include the relatively low number of patients and lack of statistical analyses, patients who did not attend follow-up visits, lack of a control group, and that all patients were Caucasian. These limitations may limit the generalizability of the findings.
In conclusion, this is the first report to indicate that injections of the same HA filler reduce multiple signs of aging in the midface, chin, and/or jawline through 12 months; the injections may also result in AEs that do not include swelling, are considered procedural, and resolve shortly thereafter.
Medical writing, editorial, and other assistance
Medical writing support was provided by Nicholas Crabb on behalf of MIMS Co., Ltd., in compliance with Good Publication Practice 2022 ethical guidelines (DeTora et al. Ann Intern Med. 2022; 175: 1298–304), and funded by LG Chem Co., Ltd. (Seoul, Korea).
Funding
This case series was funded by LG Chem Co., Ltd., Seoul, Korea. The funder had no role in the design, data collection, data analysis, or reporting of this study.
Data availability
All data are available upon request from the corresponding author.
Statement of ethics
This study was conducted in accordance with the World Medical Association Declaration of Helsinki. Written informed consent was obtained from all patients for publication of the details of these medical cases, including their photos. Research Ethics Committee review was not required for this case series study, per the decision tool of the National Health Service Health Resource Authority (https://hra-decisiontools.org.uk/ethics/EngresultN1.html). The study adheres to the STROBE guidelines (http://www.strobe-statement.org/).
Author contributions
Vikram Swaminathan confirms responsibility for the conception and design of this study; the collection, analysis and interpretation of data; and the critical revision and final approval of this manuscript.
Declaration of competing interest
Financial support for the conduct of this study was provided by LG Chem Co., Ltd. (Seoul, Korea).
Acknowledgments
None.
Footnotes
Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.jpra.2025.06.018.
Appendix. Supplementary materials
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
All data are available upon request from the corresponding author.