BERTOSSI

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Cosmetic Medicine
DOI: 10.1093/asj/sjaa179
www.aestheticsurgeryjournal.com
clinic and maxillofacial surgery department, Department of Oral 
and Maxillofacial Surgery, University of Verona, Policlinico G.B. 
Rossi, Verona, Italy.
Corresponding Author: 
Dr Dario Bertossi, Department of Oral and Maxillofacial Surgery, 
University of Verona, Policlinico G.B. Rossi, Piazzale L. Scuro 10, 
37134, Verona, Italy.
E-mail: pierfrancesco.nocini@univr.it; Instagram: @prof.dariobertossi
Nonsurgical Redefinition of the Chin and 
Jawline of Younger Adults With a Hyaluronic 
Acid Filler: Results Evaluated With a Grid 
System Approach 
Dario Bertossi, MD; Massimo Robiony, MD; Andrea Lazzarotto, MD; 
Giorgio Giampaoli, MD; Riccardo Nocini, MD ; and 
Pier Francesco Nocini, MD
Abstract
Background: Aesthetic treatment of the lower face is increasingly in demand, particularly owing to age-related changes 
in appearance. VYC-25L is a novel hyaluronic acid filler with high G′ and high cohesivity, specifically designed for sculpting 
and contouring of the chin and jaw.
Objectives: The aim of this study was to assess the use of a grid traced onto the chin and jaw for guiding treatment with 
VYC-25L.
Methods: This was a retrospective, single-center analysis of data from adult patients undergoing treatment of the lower 
third of the face with VYC-25L. A grid system of horizontal and vertical lines was used to systematize the process of treat-
ment planning and performance.
Results: Thirty subjects were enrolled (53.3% female; mean [standard deviation] age, 34.4 [2.8] years). The mean quantity 
of VYC-25L used was 4.0 [0.8] mL. Based on the 5-point Global Aesthetic Improvement Scale, 29 patients (96.7%) rated 
their appearance at 20 days posttreatment as “much improved” or “very much improved.” The only complications re-
corded were early transient soft-tissue edema (n = 14; 46.7%) and bruising (n = 6; 20.0%). There were no cases of infection, 
paresthesia, asymmetry, hematoma, necrosis, or skin discoloration.
Conclusions: Treatment of the chin and jawline with VYC-25L, with injection locations determined by a standardized 
grid-based approach, appears to be effective and safe with high rates of patient satisfaction. Injection of this filler offers a 
potentially high-impact approach for patients across a variety of biological and economic circumstances.
Level of Evidence: 4 
Editorial Decision date: June 16, 2020; online publish-ahead-of-print June 27, 2020.
© The Author(s) 2020. Published 
by Oxford University Press on behalf 
of The Aesthetic Society. All rights re-
served. For permissions, please e-mail: 
journals.permissions@oup.com
Dr Bertossi is an associate professor and head of the maxillofacial 
plastic surgery unit, Dr Giampaoli is a resident in maxillofacial 
surgery, and Dr R. Nocini is a resident in otolaryngology, Department 
of Oral and Maxillofacial Surgery, University of Verona, Policlinico 
G.B. Rossi, Verona, Italy. Dr Robiony is head of the maxillofacial 
department and Dr Lazzarotto is a resident in maxillofacial surgery, 
Department of Maxillofacial Surgery, University of Udine, Academic 
Hospital of Udine, Udine, Italy. Dr P.F. Nocini is head of the dental 
Aesthetic Surgery Journal
2021, Vol 41(9) 1068–1076
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mailto:pierfrancesco.nocini@univr.it?subject=
mailto:@prof.dariobertossi?subject=
http://orcid.org/0000-0001-5086-4390
Bertossi et al 1069
The jawline is defined by a curvilinear shadow from the 
mandibular angle to the anterior chin. In oblique view, the 
shadow framing the jawline has a “hockey stick” shape 
that is typically straight in young adults—a uniform shape 
that runs from the mentum to the angle of the mandible. 
This is usually considered to be an aesthetically pleasing 
feature in both men and women.1
Assessment of the jawline is complex because there 
are many variables to consider, including anatomic fea-
tures relating to facial type, sex, race, and age-associated 
changes. In particular, facial aging leads to lost skin elas-
ticity; relaxation of ligaments and displacement from their 
original site, causing a prominent labiomandibular sulcus; 
and jowl deformity and submental laxity, leading to the for-
mation of a double chin (sagging jawline).2 Simultaneously, 
irregularities in jawline definition arise from volume de-
scent of midface fat compartments and mandibular bone 
loss, with soft-tissue ptosis at the jowl resulting in fullness 
inferior to the mandibular border.3 Loss of bone and soft-
tissue volume accentuates the pre-jowl sulcus.
These alterations convert the youthful “hockey 
stick” shape of the jawline to an irregular “W” shape.3 
Furthermore, a genetically underdeveloped or recessed 
chin is also associated with a less aesthetically pleasing 
facial profile and can contribute to early loss of definition 
of the jawline.
There are several surgical and nonsurgical options 
for correcting the jawline, which can address underlying 
bone loss and soft-tissue displacement and rejuvenate the 
skin.3-5 In patients who do not wish to undergo surgery, the 
use of hyaluronic acid (HA) fillers is becoming increasingly 
popular. Techniques and physiologic concepts have been 
developed with these products that facilitate the achieve-
ment of outcomes comparable to those achieved with sur-
gery.5,6 For example, the MD Codes recently developed by 
Dr Mauricio de Maio provide a standardized framework of 
treatment subunits and techniques within individual facial 
areas. In a similar vein, we have used facial grids traced 
onto patients’ faces to demarcate discrete treatment units 
and standardize our approach.7-9
The Vycross portfolio of HA fillers provides a versatile 
range of products that can be used across all areas of the 
face. These fillers contain varying concentrations of HA 
to achieve different levels of firmness.10 The safety and 
efficacy of these treatments have been demonstrated in 
a number of studies, with key outcomes including resto-
ration of volume, filling of lines and wrinkles, and hydra-
tion of the skin.11-21 Results typically last for 9 to 24 months 
depending on the product used.
The latest addition to the Vycross portfolio is VYC-25L, 
which has the highest G′ (stiffness) and highest cohesivity 
in the range, and was designed to allow sculpting and con-
touring of the chin and jaw area. In a recent randomized 
trial in patients with chin retrusion, VYC-25L improved 
glabella-subnasale-pogonion facial angle and overall pa-
tient well-being, with no serious treatment-related adverse 
events (AEs).22 The aim of the present study was to assess 
the use of a chin and jawline grid traced onto patients’ skin 
to guide nonsurgical treatment with VYC-25L.
METHODS
Study Design
This was a retrospective analysis of data from patients with 
varying degrees of mandibular hypoplasia undergoing 
treatment of the lower third of the face with VYC-25L at 
a single center between February and April 2019. The 
study was conducted in accordance with the Declaration 
of Helsinki. All enrolled patients provided written informed 
consent.
Eligible subjects were adult females or males wishing 
to undergo nonsurgical correction of the lower third of 
the face. Exclusion criteria included chronic corticosteroid 
therapy, local infection, diabetes, bleeding disorders, his-
tory of systemic autoimmune or oncologic conditions, or 
psychiatric conditions that could affect treatment. Smokers 
and pregnant women were also ineligible.
Patient Evaluation and Treatment System
The key aspect of diagnosis was clinical examination of 
the lower face from the anterior, lateral, and three-quarter 
views, to allow assessment of the facial soft-tissue rela-
tions between jawline, chin, and midface. Pretreatment 
photographs were taken from frontal, lateral, three-quarter, 
andbasal angles.
With regard to the jawline, diagnostic assessments in-
cluded: cervicomental angle (which should be between 
105° and 120°); chin height, width, and projection; man-
dibular body height and length; gonial angle prominence 
and measure (which should be around 120° in males and 
120°-130° in females); and soft-tissue thickness. Additional 
features considered included scarring, previous surgeries, 
parotid gland pathologies and dimensions, submandibular 
gland protrusion and dimensions, and muscle asymmetries.
Volume loss was assessed anterior and posterior to 
the jowl. Treatment decisions were made based on in-
dividual patient anatomy and desired results. Generally, 
in patients with minimal jowl ptosis (typically younger 
individuals), the addition of pre-jowl volume was used 
for jawline restoration; a more ptotic jowl usually re-
quired a greater degree of volumizing to camouflage its 
presence.
Differences in normal anatomy between men and 
women are also a key factor in assessing and treating 
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the lower face, and particularly the jawline.23-25 In males, 
the mandible is often relatively large with broader 
bigonial width, the gonial region is more squared, and 
the ramus drops down relatively vertically from the ear 
region and turns anteriorly with a mildly pronounced 
gonial angle; in females, the jawline typically shows a 
more gentle curve running from the ear region to the 
chin. Thus, male faces generally exhibit greater angu-
larity, whereas female faces show less angularity and 
increased “softness” of the jawline. Angularity of the fa-
cial contour lines in women can sometimes diminish per-
ceived attractiveness.
A grid system of horizontal and vertical lines was used 
to systematize the process of treatment planning and per-
formance. The exact positions of these lines are described 
in Table 1 and are summarized graphically in Figure 1. Lines 
were traced onto individual patients’ faces with skin pen-
cils to allow precise recording of defects and to generate 
reproducible injection points that could be precisely quanti-
fied. Details of these injection points are provided in Table 2. 
Points B, M, C, RLM, and LLM were for female patients; points 
B, M, C, RMLM, and LMLM were for male patients. Other 
points ( jowl 1-4 and 5-7) were used to further redefine the 
jawline. Equivalent MD Codes, as defined in de Maio’s stand-
ardized approach to treatment, are also shown in Table 2.
Before finalizing the treatment plan, a full patient his-
tory was taken, with particular focus on previous filler treat-
ments. As far as possible, patients were advised to avoid 
blood-thinning agents for 1 week prior to treatment to re-
duce bruising.
Injection Procedures
Patients were treated in the lower third of the face with the 
high-G′ and high-cohesivity dermal filler VYC-25L (25 mg/
mL HA; Volux) from the Vycross range (Allergan, Dublin, 
Ireland). Key treatment areas were the chin, labiomental 
sulcus, jawline, and marionette lines. Filler quantities 
per injection point are provided in Table  2. Broadly, the 
chin apex and vertex were injected with 0.5 to 1.5 mL of 
VYC-25L through a 27G 13-mm cannula (TSK Laboratory, 
Tochigi, Japan) deep to the bone, and the labiomental 
sulcus was treated with 0.3 to 0.7 mL of VYC-25L injected 
into the superficial fat compartment with a 25G 5-cm can-
nula (TSK). The jawline was injected with 0.5 to 1.5 mL of 
VYC-25L, and marionette lines with 0.5 to 1.0 mL of VYC-
25L, each with a 25G 5-cm cannula into the superficial fat 
compartment. A  detailed description of the approach to 
these areas is provided in Appendix.
The lower face was not injected in isolation, and defi-
ciencies in the upper and midface were also treated, as 
required.
Special attention was always paid to danger areas. In 
particular, the facial nerve and parotid gland are at risk 
during shaping of the posterior mandibular ramus/angle; 
they are both deep structures and hence can be avoided 
by injecting into the subdermal plane. When injecting in 
the peri-jowl region, mandibular ligament area, or mandib-
ular body, care was taken to avoid the facial artery. This 
should always be identified and protected prior to injec-
tion. After crossing the inferior mandibular border, the fa-
cial artery curves around it, passes in front of the anterior 
edge of the masseter muscle, pierces the deep fascia, and 
enters the face. At this point, the facial artery (with its ac-
companying vein) lies immediately under the platysma and 
crosses the mandibular branch of the facial nerve lying un-
derneath. It was avoided by injecting in the subdermal or 
subperiosteal plane.
Assessments
Assessments of treatment outcome and complications 
were included in clinical examinations at 3 days, 1 week, 
1 month, and 6 months postinjection. Clinical photographs 
were taken prior to treatment and at designated times 
after the procedure.
Twenty days posttreatment, patients were asked to 
evaluate their satisfaction with results compared with 
pretreatment according to the 5-point Global Aesthetic 
Improvement Scale (GAIS) as very much improved, much 
improved, improved, no change, or worsened.
Statistical Analyses
Descriptive statistics are provided throughout. This in-
cludes mean, standard deviation, and range for continuous 
variables, and frequency and percentage for categoric 
variables.
RESULTS
A total of 30 patients were enrolled: 16 females (53.3%) and 
14 males (46.7%). The mean [standard deviation] age was 
34.4 [2.8] years (range, 20-45  years). Nineteen patients 
(13 female; 6 male) were aged 20-35 years, and 11 were 
aged >35 years (3 female; 8 male). None had received pre-
vious aesthetic treatment in the chin or jawline, and none 
received concurrent treatment in this area of the face with 
other therapies apart from fillers.
Subjects were injected with a mean volume of VYC-25L 
of 4.0 [0.8] mL. Example before-and-after images are pro-
vided in Figures 2 and 3.
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Bertossi et al 1071
Patient satisfaction with treatment was high. Based on 
the 5-point GAIS, 29 out of 30 patients (96.7%) rated their 
appearance after treatment as “much improved” or “very 
much improved” (Table 3).
Patients were followed up for a mean of 8  months 
(range, 6-10 months). Complications are listed in Table 4. 
The only AEs reported were early transient soft-tissue 
edema (n = 14; 46.7%) and bruising (n = 6; 20.0%). There 
were no cases of infection, paresthesia (transient or 
permanent), asymmetry, hematoma, necrosis, or skin 
discoloration.
DISCUSSION
This analysis demonstrated the safety and patient satis-
faction resulting from chin and jawline treatment with the 
HA filler VYC-25L administered according to a grid-based 
methodology, in a relatively young cohort of patients with 
varying degrees of mandibular hypoplasia.
Jawline sculpting is a particularly demanding form of 
treatment because it plays such an important role in facial 
aesthetics.2,3,5,6 The jawline should be well defined, pro-
viding distinct separation of the lower face from the neck. 
Table 1. Chin and Jawline Grid
Frontal view
Vertical lines
1 Vertical line M (midline), through point M (midline interpupillary) to point Sp (subnasal point)
2 Vertical line MC (medial canthal), at the medial palpebral commissure on point Mc
3 Vertical line P (pupillar), running through the pupil midline 
4 Vertical line LC (lateral canthal), at the lateral palpebral commissure on point Lc
5 Vertical line T (tragus), at a distance of 1 cm from the lateral palpebral commissure6 Vertical line Ocr (right oral commissure) 
Horizontal lines (perpendicular to line M)
1 Horizontal line Sn (subnasal point), on the columellar insertion 
2 Horizontal line Il (interlabial), on the labial rim 
3 Horizontal line b, on the b point (labiomental point)
4 Horizontal line m, on the most protruding point of the chin soft tissue
5 Horizontal line c, on the lowest chin soft tissue point
Side view
Vertical lines
1 Vertical line TVL (true vertical line), passing the subnasale perpendicular to the ground with 
patient looking into mirror
2 Vertical line Loc (lateral oral commissure), at the lateral oral commissure 
3 Vertical line LC (lateral canthal), at the lateral palpebral commissure on point Lc
4 Vertical line AM (anterior masseter border), on the anterior border of the masseter muscle
5 Vertical line T (tragus), at a distance of 1 cm from the lateral palpebral commissure 
Horizontal lines (perpendicular to line M)
1 Horizontal line hSn, on the columellar insertion (subnasal point) 
2 Horizontal line hIl (interlabial), on the labial rim 
3 Horizontal line hb, on the b point (labiomental point)
4 Horizontal line hm, on the most protruding point of the chin soft tissue
5 Horizontal line hc, on the lowest chin soft tissue point
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A B
C
Figure 1. Illustration of the chin and jawline grid. (A) A frontal view of a 33-year-old female, and side views of (B) a 36-year-old 
male and (C) a 33-year-old female.
Table 2. Injection Points
Point MD codea Filler quantity, mL per side Notes
B C1 0.7 Labiomental area, injection in superficial fat compartment, not a danger 
area
M C2 0.3 Most protruding chin soft tissue, deep on bone, not a danger area
C C4 0.2 Lowest chin soft tissue, deep on bone, not a danger area
RLM / LLM C3 0.2 Most protruding chin soft tissue, at the intersection of MC line with hm 
line, deep on bone, danger area, for female patients
RMLM / LMLM C3 0.2 Most protruding chin soft tissue, at the intersection of Loc line with hm 
line, deep on bone, danger area, for male patients
Jowl 1-2 M1-2-3 0.5 1 lateral, and 2 medial to Loc line between Il line and hm line
Jowl 3-4 Jw4-5 0.5 3 below hm line lateral to Loc line, and 4 the most anterior point of the 
jawline, 1 cm in front of the oral commissure
5 Jw3 0.3 Mandibular line in front of LC line, superficial fat compartment, cannula, 
danger area (facial artery)
6 Jw1 0.5 Mandibular angle, below Il line behind LC line, superficial fat compartment 
(over SMAS), cannula, not a danger area
7 Jw2 0.5 Pretragal and upper gonial angle area, superficial fat compartment (over 
the SMAS), cannula, danger area
aMD codes: C, chin; Jw, jawline; M, marionette lines. Il, interlabial; Loc, lateral oral commissure; LC, lateral canthal; MC, medial canthal; SMAS, superficial muscular 
aponeurotic system. See Table 1 for definition of hm line.
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Bertossi et al 1073
This region may be relatively unattractive in the absence 
of clear demarcation—whether due to skeletal factors (eg, 
increased gonial angle, reduced mandibular body length, 
atrophy, or under- or overdevelopment of the mandible) or 
soft-tissue factors (eg, increased cervical facial adiposity, 
or redundant lower facial soft tissue).
Treatment of the jawline is increasingly in demand, 
owing to changes that occur with advancing age.3,5 For ex-
ample, volume loss in the labiomandibular fold can mani-
fest as a shadow anterior to the jowl from oral commissure 
to jawline. Furthermore, the pre-jowl sulcus may become 
increasingly visible as volume loss progresses at the infe-
rior portion of the mandible anterior to the jowl. Cephalic 
retraction in the pre-jowl sulcus is due to fixation of the skin 
to the underlying resorbing bone via the mandibular liga-
ment. Shadowing in the labiomandibular fold and pre-jowl 
sulcus may be accentuated by increased fullness and de-
scent of the jowl.
Fillers provide a valuable nonsurgical option for correc-
tion of the jawline. However, compared with other areas of 
the face, there have been relatively few published studies 
focusing on treatment of the jaw and chin with fillers.
The semipermanent filler calcium hydroxylapatite has 
been studied in jawline treatment and results have been 
positive.26,27 In a recent study, use of this treatment in the 
jaw was associated with significant restoration of volume; 
however, patients reported only “moderate” aesthetic im-
provements.27 Furthermore, these treatments cannot be 
removed if positioned in the wrong area.
In our experience, HA fillers are a better option, not 
least because they can be removed with hyaluronidase 
if the patient is dissatisfied with the result or if there are 
A B
C D
E F
Figure 3. Nonsurgical redefinition of the chin and jawline 
with VYC-25L based on a grid system approach. (A, C, E) 
A 41-year-old female before and (B, D, F) and 24 weeks after 
treatment with 6 mL of VYC-25L in the lower face.
A B
C D
E F
Figure 2. Nonsurgical redefinition of the chin and jawline 
with VYC-25L based on a grid system approach. (A, C, E) 
A 33-year-old female before and (B, D, F) 38 weeks after 
treatment with 8 mL of VYC-25L in the lower face.
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complications.28 Furthermore, HA acts like a rejuvenating 
agent because it integrates itself into the extracellular ma-
trix; biopsies taken at 6  months post-HA injection have 
confirmed that HA can reorganize and integrate into the 
extracellular matrix, giving greater compactness and firm-
ness to the tissue.29
HA products with high G′ and high cohesivity may be 
particularly well suited to use in the jawline. VYC-25L 
contains an HA concentration 25 mg/mL and was specif-
ically designed for sculpting and contouring of the chin 
and jaw. In a randomized trial of 119 patients with chin 
retrusion, injection of VYC-25L in the chin and pre-jowl 
area improved the glabella-subnasale-pogonion facial 
angle and was associated with high rates of investigator- 
and patient-assessed aesthetic improvement and overall 
patient satisfaction.22 Treatment benefits remained ap-
parent at study completion at 18  months.30 Given the 
long-lasting effects of VYC-20,13,14 which has similar phys-
ical properties to VYC-25L, it is reasonable to expect that 
the effects of VYC-25L should last for at least 24 months. 
The present analysis lends support to the data from the 
randomized trial, and adds to it by extending the treat-
ment to the full length of the jaw. Outcomes were favor-
able and rates of patient satisfaction were particularly 
high. This makes redefinition of the jawline a potentially 
high-impact aesthetic procedure that can be offered to 
patients with a wide variety of biologic and economic 
circumstances.
A grid system was used to standardize our approach 
to treatment. We have previously shown that similar grid 
systems in other areas of the face are simple to use and 
lead to positive treatment outcomes with low complication 
rates.7-9
Indeed, the potential for improved patient safety 
through greater systematization of approach may be a key 
advantage of grid systems. In the present analysis, AEs 
were confined to transient soft-tissue edema (46.7%) and 
minor bruising (20.0%). Nonetheless, even with a standard-
ized approach, good injection technique remains essential 
to prevent complications. In particular, the risk of intravas-
cular injection can be minimized by remaining in the super-
ficial (subdermal) or deep (periosteal) planes. Alternatively, 
the use of blunt-tipped cannulas of various sizes and 
small boluses per injection can be applied to reduce AEs.Furthermore, aspiration prior to injection may help to mini-
mize the risk of intravascular injection31 and should be con-
sidered, particularly in high-risk injection areas.28
We should acknowledge the limitations of the present 
work, in particular its retrospective, single-center design. 
Further prospective, multicenter, randomized trials of 
VYC-25L treatment in the lower face, in addition to that 
of Ogilvie et  al,22 would of course be valuable—particu-
larly if they incorporate longer follow-up than the present 
analysis (6-10 months). Nonetheless, our study is the first 
demonstration of the efficacy and safety of VYC-25L in a 
“real-world” clinical setting, with the added innovation of 
the novel grid system used. In addition, the Ogilvie et al 
study only injected the chin and pre-jowl area, and hence 
the present study is the first to assess treatment of the full 
length of the jaw with VYC-25L. An additional limitation of 
our study is that the cohort was relatively small and young 
(mean age, 34.4 years); nonetheless, it is representative of 
our practice in this indication.
CONCLUSIONS
The sculpting of a straight, youthful jawline is com-
monly requested by patients. However, it is also a de-
manding treatment that should be approached only by 
experienced injectors with suitable training. We have de-
scribed a chin and jawline sculpting technique based on 
progression from chin contouring to the peri-jowl region 
to the angle of the mandible. With a focus on anatomic 
Table 3. Patient Satisfaction at Day 20 Posttreatment
Patient GAIS rating Patients, n (%)
Very much improved 26 (86.7)
Much improved 3 (10.0)
Improved 1 (3.3)
No change 0 (0)
Worsened 0 (0)
N = 30. GAIS, Global Aesthetic Improvement Scale.
Table 4. Complications
Complication Patients, n (%)
Transient (24-hour) soft-tissue edema 14 (46.7)
Bruising 6 (20.0)
Infection 0 (0.0)
Paresthesia 0 (0.0)
Asymmetry 0 (0.0)
Hematoma 0 (0.0)
Necrosis 0 (0.0)
Skin discoloration 0 (0.0)
N = 30.
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Bertossi et al 1075
danger zones, the use of a grid system can provide a safe 
treatment guide for achieving good aesthetic outcomes.
Overall, treatment of the jawline and chin with the novel 
filler VYC-25L appears to be effective and safe for the cor-
rection of genetic and aging-related volume loss, with high 
rates of patient satisfaction.
Supplemental Material
This article contains supplemental material located online at 
www.aestheticsurgeryjournal.com.
Acknowledgments
The authors thank Dr Timothy Ryder from Biological 
Communications Limited (London, UK) for assistance in ed-
iting and submitting the final draft, funded by Allergan (Dublin, 
Ireland) at the request of the investigator.
Disclosures
Dr Bertossi is a consultant and speaker for Allergan (Dublin, 
Ireland). The other authors declared no potential conflicts of 
interest with respect to the research, authorship, and publica-
tion of this article.
Funding
Writing and editorial assistance was provided to the authors by 
Dr Timothy Ryder (Biological Communications Limited, London, 
UK) and funded by Allergan (Dublin, Ireland) at the request of 
the investigator. All authors met the ICMJE authorship criteria. 
Neither honoraria nor payments were made for authorship.
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