November 20, 2020- Since 2007, I began to understand the importance of the mid-facial volume loss and how that dramatically impacts the periorbital region (around the eyes), the temples, and especially the lower face around the mouth area.

Most patients come to me with complaints such as “I am seeing the shadows under my eyes” or “I see these deepening folds around my mouth” or “I have the puppet lines or frown lines but I am not angry, Doctor.” What is so important to explain to the patient, is that these aging complaints are the results of mid-facial volume loss and that must be addressed first as the foundation of our treatment.

The mid face area is our lateral and mid-cheek areas, and there are nine fat pads located here. As the face begins to age in the early thirties, we begin to lose fat within these fat pads and thus these fat pads flatten and even separate. Sometimes, there is a notable line in the mid-cheek of very thin people where there is separation of two of the larger fat pads. As the fat pads in the cheek flatten and shrink, the three fat pads in the lower eyelid are doing the same thing, and patients complain of “dark circles” or “aging” under the eyes. The reality is they are experiencing volume loss.

Patients see themselves in a mirror daily in a 2D fashion. They do not see themselves in 3D. Thus, they focus on the results of the volume loss in the mid-face, rather than the actual problem. If we address the problem—mid-face volume loss with an appropriate hyaluronic acid filler that has the ability to lift and hold the mid face up and retain it in the proper position, we now correct the problem. Some of the appropriate HA fillers to use in the mid face include Allergan’s Juvederm Voluma, Galderma Lyft and now the brand new Revance Teoxane RHA4.

By addressing the mid-facial volume first, patients will find that they will then require much less volume of other hyaluronic acid filler in the actual tear troughs, temples, nasolabial folds, marionette lines and perioral lines because we have addressed the foundation of the aging process in the correct order. Thus, if a patient asks me, “What do we do first, Doctor?” it is a very simple answer. We must always begin in the midface with a more robust hyaluronic acid product, and then move to other areas.

Jawline and chin contouring with hyaluronic acid filler has become a new favorite procedure in my arsenal to fight the aging process. Juvederm Voluma has now been approved by the FDA for the chin indication. When one injects the jawline and chin, there is a lifting and contouring effect in the lower face and neck which is very flattering and creates a youthful look in both men and women. The flabby, weakened neck and jawline is strengthened by placing filler directly on the bony mandible and within the chin.
We now have the ability to literally create a liquid facelift in a matter of minutes. Typically, these sessions require between 8-14 syringes of hyaluronic acid filler (each syringe is typically 1.0-1.1cc of product). I explain to patients that these sessions do not have to completed at one time. Due to cost constraints, patients can be educated on their overall aesthetic plan, and then can perform 2-4 sessions spaced out over a few months.

I have sometimes heard patients proclaim, “I think I just need an actual facelift rather than all this filler” and my response to them is “Absolutely not!” Think about what a facelift is doing—it is literally taking tissue from the framework of the bony structure and lifting and stretching and pulling it up. What we are not doing with a facelift is providing much needed volume. Even after a facelift, gravity begins to immediately take over and the tissue begins to descend. But what a facelift or a necklift never does is address volume loss. Thus, patients who undergo a facelift or a necklift must always continue to receive filler and toxin injections beyond cosmetic surgery. A facelift is never a “once and done”. This is a gross misconception.

The liquid facelift can be easy to achieve and is very natural in its final result, because it will transform the face back to its original appearance when an experienced injector with the proper understanding of facial anatomy, volume loss and the aging process is able to inject appropriate amounts in the correct order. If you are interested in learning more about contouring with fillers such as Voluma, Teoxane RH4 or Lyft, contact the Dermatology Office of Dr. Ellen Turner at 214-373-7546 or view our photo gallery at