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976  |  wileyonlinelibrary.com/journal/jocd J Cosmet Dermatol. 2019;18:976–984.© 2018 Wiley Periodicals, Inc.
1  | INTRODUC TION
Facial nonsurgical esthetic treatment represents an alternative to 
more invasive procedures. In the context of a full‐face approach, the 
assessment of the relationship between forehead, nose, and chin, 
and the submental area are following the popularity of the evolving 
medical treatments. The comprehensive evaluation of facial esthet‐
ics is becoming thus more and more effective, and it should be con‐
sidered as a real opportunity toward successful esthetics results.1,2
Profile judgment is nevertheless not a constant entity; fac‐
tors such as age and culture may change the way it is interpreted. 
Although many researchers have adopted some parameters in their 
approach that would lead to “a beautiful” profile line, the results may 
not always be as expected,2,3 because the treatment of a single fa‐
cial area rather than of a whole face treatment can lead to less than 
satisfactory results.4‐10
Being this an evolving medical field, there is no clear standard re‐
garding the facial assessment and the following treatment. The aim 
 
Received: 24 July 2018  |  Accepted: 5 September 2018
DOI: 10.1111/jocd.12792
O R I G I N A L C O N T R I B U T I O N
Injectable profiloplasty: Forehead, nose, lips, and chin filler 
treatment
Dario Bertossi MD1  | Luca Lanaro MD1 | Irene Dell'Acqua MD1 |  
Massimo Albanese MD1 | Luciano Malchiodi MD2 | Pier Francesco Nocini MD3
1Maxillofacial Surgery, G.B. Rossi Hospital 
and Medical University of Verona, Piazzale, 
L.A. Scuro 10, 37134, Verona, Italy
2Oral Surgery, G.B. Rossi Hospital and 
Medical University of Verona, Piazzale L.A. 
Scuro 10, 37134, Verona, Italy
3Division of Dental and Maxillofacial 
Surgery, G.B. Rossi Hospital and Medical 
University of Verona, Piazzale L.A. Scuro 10, 
37134, Verona, Italy
Correspondence
Dario Bertossi, Department of Maxillo Facial 
Surgery, University of Verona “G.B. Rossi 
Hospital”, Piazzale L.A. Scuro 10, 37134 
Verona, Italy.
Email: dario.bertossi@univr.it
Funding information
English review assistance was provided 
to the authors by ClearView Medical 
Communications, LLC and funded by 
Allergan SpA SpA at the request of the 
investigator. All authors met the ICMJE 
authorship criteria. Neither honoraria nor 
payments were made for authorship.
Summary
Introduction: We propose a medical filler treatment algorithm of the profile which 
includes forehead, nose, and chin and to evaluate profilometric results and 
complications.
Materials and Methods: 83 case reviews of associated liquid forehead, nose, and 
chin plasty performed consecutively from 2014 to 2016. We monitored the horizon‐
tal and vertical sagittal stability into two age group: 40 y.o. using pro‐
filometric Arnett analysis measurements on the F, Gb, Na, Nd, Nt, Sn, ULA, LLA, B, 
Pg, and Gn soft‐tissue points.
Results: The results at both 3 and 6 months were consistent with the normal ranges 
indicated by Arnett, with a 0.8 mm maximum of defect/excess. Forehead treatment 
was performed in 51 (61.4%) patient. Patients >40 y.o. always needed a global correc‐
tion of the forehead profile. We performed nasal treatment in 83 (100%) patient, 
acute nasolabial angles was the more frequent nasal defect. The lips were injected in 
59 patients (71.1) more frequently >40 y.o. In 83 (100%) patients we perform a chin 
augmentation. The average advancement of the chin was 3 mm.
Conclusions: The correction of the projection of the forehead, of the profile and 
shape of the nose, of the lips and chin as well as an overall improvement in face aes‐
thetics and harmony gives a good solution in patients avoiding the need for a surgical 
intervention, scars and cost of general anesthesia, thus providing the optimum in 
patient satisfaction.
K E Y W O R D S
associated nose‐chin deformity, chin deformity, fillers, injectables, nose deformity, profile
mailto:
http://orcid.org/0000-0002-8635-9967
mailto:dario.bertossi@univr.it
http://crossmark.crossref.org/dialog/?doi=10.1111%2Fjocd.12792&domain=pdf&date_stamp=2018-11-15
     |  977BERTOSSI ET al.
of this paper was to suggest the use of a Profile Treatment Algorithm 
(PTA) which includes forehead, nose, lips, chin, and submental full‐
ness correction in 83 patients subjected to a combination treatment 
with different G’ cross‐linked Hyaluronic Acid (HA) and Deoxycholic 
Acid (DA) injections. Treatment outcomes were evaluated using the 
FACE‐Q questionnaire11 to assess patient satisfaction with the treat‐
ment received.
2  | MATERIAL S AND METHODS
2.1 | Study design
A total of 83 patients were analyzed and treated by the first author 
between January 2014 and January 2016. This cohort included 27 
Caucasian males and 56 Caucasian females aged between 18 and 
57 years (mean 36.7). Subjects were divided into two different 
groups: group A patients 40 years old (n = 32). Group A included 18 males and 33 females, 
group B counted 9 males and 23 females.
An informed consent was obtained from each patient before 
treatment.
Exclusion criteria comprised the following: previous facial surgi‐
cal treatments, abnormal skin thickness and texture, previous facial 
trauma, facial scars, metabolic, immunological, and hematological 
diseases. None of the patients showed dental malocclusion.
Follow‐up clinical examinations were carried out on all of the 83 
patients after 3 and 8 months.
All the patients were subjected to an accurate profile analysis 
using photographs taken at rest position:12 frontal, lateral, 45 de‐
grees bilateral, basal, superior, above below views. Moreover, a 10‐
second video was recorded in which each patient was asked to smile 
and mime an angry face.
Since the head tilted backward or forward and this position can 
create a chin protrusion or a chin retrusion, all the profile pictures 
were taken in a Natural Head Position (NHP) which is relaxed head 
looking straight into an ideal horizon.13
Comprehensive clinical facial trait analysis should be used to 
enhance diagnosis treatment planning and quality of results. The 
Arnett analysis in soft tissue could provide a tool to optimally ana‐
lyze and correct esthetic disharmonies. Assuming that, the soft‐tis‐
sue Arnett analysis points have been used in this study, to perform 
clinical measurements.14 Taking as reference the true vertical line 
(TVL), a line running from the subnasal point in NHP,13,14 we moni‐
tored the sagittal pre‐ and posttreatment distance of the following 
soft‐tissue points: Forehead (F), Glabella (Gb), Nasion (Na), Nasal 
dorsum (Nd), Nasal tip (Nt), Subnasal (Sn), Upper lip anterior (ULA), 
Lower lip anterior (LLA), Soft‐tissue point B (B), Pogonion (Pg), and 
Gnathion (Gn) (Figure 1).
To evaluate the effect of the treatment on quality of life (QoL) 
and to assess patient satisfaction about the treatment, patients 
were given a FACE‐Q instrument to complete pre‐ and 90 days post‐
treatment. We use the FACE‐Q Satisfaction with Facial Appearance 
(Figure S1). Responses were scored on a 4‐point Likert Scale: 1, 
2, 3, and 4 denoted “very satisfied,” “satisfied,” “dissatisfied,” and 
“very dissatisfied,” respectively. The responses were standardized 
to a Rasch transformed summary score of 0 to 100, in which lower 
scores represented greater satisfaction with appearance. Stata 14 
F I G U R E 1   Arnett soft‐tissue points, related to TVL, used in our 
study
F I G U R E 2   Profile Arnett soft‐tissue ideal measures (green) 
compared to soft‐tissue analysis made on a 54‐year‐old patient (red)
978  |     BERTOSSI ET al.
(StataCorp LP, College Station, TX, USA) was utilized for statistical 
analyses.
2.2 | Defects classification
Pictures analysis allowed to identify the following defects in each 
patient:
1. overall facial profile view proportions (Figure 2);
2. forehead shape (Graph 1);
3. type of nose deformity: nasal hump, defectivenasal projection, 
acute nasolabial angle, hidden columella or tip drooping, crooked 
nose, deep radix of the nose, saddle nose, nasal base asymmetry 
(Graph 2);
4. type of chin deformity: sagittal defect, vertical defect, mixed de‐
fect (Graph 3).
2.3 | Treatment sessions
1. Product selection: HAs cross‐linked with Vycross technology 
(VYC‐15, VYC‐17.5, VYC‐20 Allergan Irvine USA) and Deoxycholic 
Acid (Belkyra Allergan Irvine USA) were used in this study.
2. No anesthesia was administered.
3. Skin disinfection was made with a 75% alcoholic solution.
4. Injection was performed with a top‐down method, from the top 
(forehead) to the bottom (submental area).
Treatment was performed using coded injection points to minimize 
vascular risks and complications. The injection methods, the devices 
used, and the expected results are shown in Table 1.
3  | RESULTS
Overall, 35 (42.2%) of the 83 patients, 8 patients 40 years old (32.5%), received a complete 
treatment of the 12 analyzed points. A total of 50 patients (57.8%) 
received a partial treatment according to the sagittal analysis.
Table 2 illustrates the treatment frequency related to the facial 
areas and the treated soft‐tissue points, divided by groups of patients 
(group A = patients 40 years old), 
and the average amount of product injected (HA or DA) per single 
point (Graph 4).
The forehead treatment was performed in 61.4% of patients: 
Similarly, the facial analysis of 38.6% of patients was within the refer‐
ence values. In group A, 24 out of 51 (47%) patients were treated as 
follows: 17 received a pure Glabellar injection while 7 received a frontal 
G R A P H 1   Forehead defects classification in the two groups of 
patients; most of all patients >40 years old suffered of flat forehead
G R A P H 2   Type of nose deformity: 
nasal base asymmetry and saddle nose 
were the most frequent defect founded in 
our study population
     |  979BERTOSSI ET al.
treatment to correct prominent frontal bossing. Most of them experi‐
enced only an increase in the frontonasal region, perhaps this is because 
in younger patients there is a lower sagittal defect of the forehead, re‐
lated to the support and tension of the soft tissues.15‐17 Patients in group 
B (52.9%) always needed a global correction of the forehead profile.
In addition, multiple nasal defects were found. Indeed, to correct 
the midface profile, the entire nasal region was treated, including 
defects identifiable on the frontal or three‐quarter plane.18,19
Lips injection was performed in 59 patients (71.1%); treatment 
was more frequent in Group A. When sagittal deficiency was 
found, a treatment of both lips was performed. In our experience, 
patients of group B required a major amount of HA compared to 
group A.
Chin augmentation was performed in 100% of patients due 
to the low Pg value according to Arnett analysis. The average 
advancement of the chin was 3 mm: among patients, females 
achieved a greater augmentation likely due to the higher rate 
of microgenia. A vertical augmentation (Gn) was performed in 
a small part of the sample, more frequently in females and in 
elderly patients.20‐23
The submental DA treatment was performed in 42.2% of pa‐
tients. Patients treated in group A (15.7%) correlate with a horizon‐
tal and vertical augmentation of the chin profile: microgenia and 
submental fullness are frequently associated. DA injection in group 
B was performed in 84.3% patients. Among these, almost all the 
treated patients were overweight.
The soft‐tissue Arnett’s analysis was used to evaluate the es‐
thetic results. Almost all the values were consistent and approaching 
the normal ranges indicated by Arnett, with a 0.8 mm maximum of 
defect/excess, confirming that the desired results had been achieved 
(Table 3).
G R A P H 3   Chin defects in the two group of patients; 
sagittal + vertical chin defect does not show a relevant difference 
by the age
TA B L E 1   Type of HA—for each profile area is reported the technique used and the purpose we would reach with the treatment
Facial area
Soft‐tissue 
Arnett points Treatment Technique Purpose
Forehead F HA (VYC 15) Injections: deeply, over the periosteum, using a 
25 G, 5 cm cannula (TSK Laboratory Europe B.V. 
The Netherlands)
Increase forehead volume
Gb HA (VYC 17.5) Injections: deep to bone to avoid supratrochlear 
vessels using a 27 G needle 12 mm long (TSK 
Laboratory Europe B.V. The Netherlands)
Set the frontonasal sagittal 
point
Nose Sn HA (VYC 20) Injections: on midline and deeply, supra‐periosteal 
and perichondral, using a 27 G needle 12 mm long 
(TSK Laboratory Europe B.V. The Netherlands)
Define nasal base support and 
nasolabial angle
Nt Tiprotation and projection
Nd Reshape the nasaldorsum
Na HA (VYC 17.5) Injections: subdermal or deep to periosteal using a 
27 G needle 12 mm long
Set the frontonasal sagittal 
point
Lips ULA HA (VYC 17.5) Injections: in the subcutaneous at the oral 
commissures, along the philtrum columns and the 
vermilion, intramuscular in the lips body using a 
30 G needle, 12 mm long or better a 25 G 5 cm 
cannula (TSK Laboratory Europe B.V. The 
Netherlands)
Increaselips volume
LLA Increaselips volume
Chin B HA (VYC 20) Injections: supra‐periosteal using a 27 G needle 
12 mm long (TSK Laboratory Europe B.V. The 
Netherlands)
Set the labiomental angle
Pg Increase the horizontal volume 
of the chin
Gn Increase sagittal volume of the 
chin
Submental area DA Injections: subcutaneous using a 30 G needle 4 mm 
and injecting an average of 2 mL of Deoxycholic 
Acid (Belkyra Allergan Irvine USA) for treatment 
point according to the grid (1 cm2 average).
Reshape the submental area 
and reduce the fullness
980  |     BERTOSSI ET al.
We evaluated the treatment satisfaction index by subjecting 
patients to completing the FACE Q questionnaire; comparing the 
scores found before and 90 days after the treatment, we can ob‐
serve that post‐treatment scores were significantly lower than pre‐
treatment scores (P 40 years old)
Average amount 
of product per 
site in group A
Average amount of product 
per site in group B
Forehead 51 (61.4%) F 7 27 0.3 0.5
Gb 17 0.05 0.1
Nose 64 (77.1%) Sn 34 22 0.125 0.25
Nt 25 29 0.1 0.225
Nd 32 25 0.15 0.2
Na 36 25 0.15 0.15
Lips 59 (71.1%) ULA 36 23 0.4 0.45
LLA 36 23 0.35 0.4
Chin 83 (100%) B 44 25 0.3 0.35
Pg 47 29 1 0.85
Gn 16 28 0.45 0.45
Submental 
area
35 (42.2%) 8 27 2 mL for treatment point
G R A P H 4   Averaged amount of dermal 
filler used in each group of patients by 
area treated. More filler is needed to treat 
patients >40 years old except in upper lips 
defects and in labiomental depression
Sagittal 
(mm) F Gb Na Nd Nt Sn ULA LLA B Pg Gn
Arnett ideal 
values
−15 −10 −12 1.5 15 0 3 1.5 −5 −3 −5
Observed −17 −7 −13 2.5 12 0 1.5 0.5 −7 −7 −9
Differences 2 −3 1 −1 3 0 1.5 1 2 4 4
Results −16 −10 −13 2 15 0 2.5 1 −6 −4 −6
TA B L E 3   Soft‐tissue Arnett analysis: 
We reported ideal values compared to the 
values observed in our patients. The 
results show a 0.8 mm maximum 
difference between the ideal values and 
those observed, confirming the 
achievement of good results
     |  981BERTOSSI ET al.
Bruising occurred in 6% of patients where a “waitand see” approach 
was successfully adopted with rapid resolution. Compression with 
gauze after injection and ice application were used. Mild pain was 
recorded in only 12% of the patients (injections in Sn, Nt, Nd) and 
disappeared in 1.5‐2.5 hours. Hematoma was noted in 0.9% of nasal 
dorsum. Hot and wet packs were prescribed 2 days after injection 
with a resolution average of 6 days after treatment. No cases of skin 
necrosis or skin loss were observed. None of our patients reported 
distress for being treated simultaneously in forehead, nose, and chin 
area (Graph 5).
4  | DISCUSSION
Treatment planning of facial esthetic changes is challenging and cur‐
rent literature provides a fragmented description of profile treat‐
ment with HA,9,10,24 mostly focusing separately on each area15‐17,25‐27 
rather than on the simultaneous treatment of forehead, nose, lips, 
chin, and submental area. Ricketts described the ideal position of the 
TA B L E 4   Mean pretreatment and posttreatment scores from 
FACE‐Q questionnaire
FQ
Summary Statistics
Mean ± SD 95% CI
Pretreatment 53.2 ± 9.3 50.5‐55.8
Posttreatment 43.1 ± 8.9 40.6‐45.7
Por entity with 
any financial interest (such as honoraria; educational grants; partici‐
pation in speakers’ bureaus; membership, employment, consultan‐
cies, stock ownership, or other equity interest; and expert testimony 
or patent‐licensing arrangements) or nonfinancial interest (such as 
personal or professional relationships, affiliations, knowledge, or be‐
liefs) in the subject matter or materials discussed in this manuscript.
ORCID
Dario Bertossi http://orcid.org/0000‐0002‐8635‐9967 
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SUPPORTING INFORMATION
Additional supporting information may be found online in the 
Supporting Information section at the end of the article. 
How to cite this article: Bertossi D, Lanaro L, Dell'Acqua I, 
Albanese M, Malchiodi L, Nocini PF. Injectable profiloplasty: 
Forehead, nose, lips, and chin filler treatment. J Cosmet 
Dermatol. 2019;18:976–984. https://doi.org/10.1111/
jocd.12792
http://www.surgery.org/sites/default/files/ASAPS-Stats2016.pdf
https://doi.org/10.1097/SCS.0000000000003150
https://doi.org/10.1007/s00266-015-0518-4
https://doi.org/10.1007/s00266-015-0518-4
https://doi.org/10.1111/jocd.12792
https://doi.org/10.1111/jocd.12792