FPSAM - Roundtable 2021 - 6

face). I will then inject along the gnathion if volume
between both of these points is deficient. I'll avoid the
menton if they don't need facial elongation, and I'll
avoid the pogonion if they don't need any more forward
projection of their chin. With that said, I usually
start in the midline-that is where I put most of my
product-and then I build laterally from there using
smaller aliquots as I move out, and not really having a
chin that is wider than the intercanthal distance in
women, and not having one that is wider than the oral
commissures in men. In men, I do not create as much
of a central sphere as I do in women, therefore, my
aliquots are equally placed throughout the entire width
of the chin, to preserve a more flat and square chin.
Dr. Dayan: Dr. Durairaj, how do you manage the
mentolabial sulcus between the lip and the chin,
when you're treating the chin, so as not to make it
too deep? How do you navigate the lower lip and
Dr. Durairaj: I find that to be quite a challenging
area-the labiomental sulcus. I end up treating mostly
the etched line. As that labiomental sulcus increases,
we lose our lip projection, so you need to have that
support for the lip to look attractive and projected. I do
careful measurements of the chin, and I always discuss
with patients whether they are interested in more
projection or more vertical length, and typically I estimate
about a centimeter of projection for each syringe
of filler that we use. An average chin in my hands
needs one to two syringes and I end up using at least a
quarter of that in the labiomental sulcus area.
Dr. Dayan: Dr. Rosengaus, when you're treating
the chin, can you comment a little bit about your
technique? How do you approach the labiomandibular
sulcus and the deep marionette line?
Dr. Rosengaus: Normally, treating the chin includes a
combination of techniques. I will first address the oral
commissure and marionette line; it's important to get a
very even area below the lower lip. Then I will assess
the chin. My approach is usually to first create a
space-very similar to what we do in surgery. If I'm
going to insert an implant, I tend to place implants that
have lateral extensions, because I have to take care of
that prejowl sulcus, too. I realize that there are classifications,
and sometimes you do not really want to
project, but you still want to give a very specific
convexity to the chin, not too low or too high. These
are things that I consider.
Dr. Dayan: Can you tell me a little bit about how
many cubic centimeters of product you will use for
what you are describing to get that prejowl area,
marionette lines, chin, what's on average for you,
and do your start here first and work your way up
to the lip, or do you go to the lip, work your way
down to chin?
Dr. Rosengaus: That is a very good question. Okay,
let's say we start by using the Ricketts' line to establish
a relationship between the nose, lips, and chin. It is
something that is very common and it will give you
information if the lips are retracted or protruding and
too projected. If retracted we will volumize the lips. If
profile balance is not yet achieved, you know you have
to address the nose, the chin, or both. If the chin needs
to be volumized, probably 1mL of Defyne will allow
me to get a very good projection of the chin, and then I
will probably have an extra milliliter of Defyne on the
prejowl. Two milliliters would be average.
Dr. Dayan: Dr. Fabi, can you comment on the direction
you take when you are treating this area?
Dr. Fabi: I usually start from the chin and I work my
way up; as mentioned previously, if you support this
area, the lip will follow. I'll probably use about 1 cc
of Defyne to really give a meaningful level of projection
to the chin. Then, I usually will take another
additional cc and divide it between the prejowl sulcus
and work my way up those marionette lines and the
oral commissure, because I see this area as a unit. The
chin is not an island living by itself, it's interconnected
to the sides by the marionette lines and
above by the lips.
Dr. Dayan: Dr. Cotofana, could you comment a
little bit about avoiding the ''danger zones'' of the
chin area and into the prejowl sulcus, specifically
where the mandibular ligament is, and how we are
able to best treat that area?
Dr. Cotofana: Of course-let's start with the arteries
in the chin area. The chin area includes several arteries.
The most prominent arteries are those that emerge from
the mental foramen, which are roughly 1.5 cm lateral to
themidline at the level of the labiomental sulcus. This is
where we have the foramen, which gives rise to the
mental artery and the respective nerve. The mental artery
has some small branches that connect laterally to
the facial artery in the deep plane. There is, however,
another artery termed the ascending mental artery that
travels vertically in the paramedian plane; this indicates
they are not in the midline. We can use the arteries as a
roadmap to determine exactlywhere we can go. Around
the midline, we can inject deep, and laterally we can
inject superficial. Despite there being a plethora of arteries
in the chin, by understanding and respecting
anatomy, all aesthetic needs can be addressed.
ยช 2021 by American Academy of Facial Plastic and Reconstructive Surgery, Inc.

FPSAM - Roundtable 2021

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