The SinghSculpt® dermal filler injection protocol aims to restore contours and vectors from the deep structures of the face all the way to the superficial, providing a holistic transformation through the four facial zones of the temple, cheek, mandible, and chin, creating a true S-shaped transformation with style, shape, structure, and support. It was born out of three frustrations I encountered in my clinical practice.
Like many other medical professionals, I was taught to divide the face into horizontal thirds and vertical fifths, then look at each area individually and work on your treatment plan, by dealing with the patient’s main concerns and dealing with each segment of the face independently. There was no explanation of how treating one area would affect other areas, whether to inject medially/laterally or where volume loss would be observed.
Like a good student, I believed in the key opinion leaders (KOLs) and started to implement their advice. Some results were fantastic, and some were very unsatisfactory. I decided then to research more, reading articles, watching webinars, and attending international conferences.
Since the goal of most of our treatments is to hide or slow down the effects of ageing, I investigated in detail how the face ages.
I looked at bone loss, fat redistribution, loosening of ligaments and thinning of the dermis. I asked myself how I can impact the complex ageing process in a systematic, organised, predictable and all-encompassing way. The longitudinal/vertical approaches didn’t make sense to me, which led to a shift in treatment away from simply reversing gravitational descent to adopting volumetric approaches to mid-face ageing.
SINGLE LAYER TECHNIQUES
The second problem I saw was that, for the most part, we injected one layer in a particular segment of the face. As mentioned above, the ageing process is multi-factorial and multi-dimensional; therefore, we need to undertake a multi-layered approach. We now know that areas of the face are connected and affect each other, and different depths of the face require different treatment modalities.
There is increasing awareness that structural and volume deficit, as well as vertical descent and ptosis, are critical components of facial ageing. Hence the ’S’ shape is threedimensional on the face.
The final problem I observed was how could we incorporate lifting of the face to provide shape, structure, and support, so I went back and looked at my thread training. If we are placing threads at a certain depth and place to lift the face, using them as vectors and anchors, could we not do the same with our fillers? I found there were certain areas in the face that would allow maximum structural support, which happened to make a ’S’ shape. There are four main facial zones that need support – temples, cheeks, chin, and jawline – which will give the structure and shape the clinician and the patient desires.
For each area and generally, we will look at seven aspects.
1. The ageing process in that area, in particular: bone, ligaments, fat, muscles, skin
2. The anatomical landmarks in that area, in particular, reference to: layers, fat pads, ligaments, blood supply
3. Do they need volume replacement, lifting, definition, profile enhancement or a combination of any of these
4. Making use of the line of ligaments 5. Treating laterally first, then medially 6. Treating deep first and then superficially.
7. 7 Procedure Plan®
I have looked over my last 20 years of experience and devised a simple way to plan treatment and get predictable results. I came up with certain parameters you must know and plan for before embarking on any treatment. This formed the basis of the 7 Procedure Plan®.
As you will see, it ended up being 7Ps!
• Particle size
LINE OF LIGAMENTS
The basic idea of the filler injection technique is that whenever addressing the different facial areas/compartments, the order in which one injects and where are crucial in optimising lifting and volumising effects, and to ultimately be more efficient by using less product with similar outcomes as with other filler injection techniques.
As mentioned previously, we will want to use vectoring techniques to our advantage and for this, we need to understand the line of ligaments.
The muscles of mastication are predominately located in the lateral face, whereas the muscles of facial expression are in the medial face. Facial movements are different in the medial and lateral face due to the presence of the line of ligaments.
Separating the mid and lateral face, the imaginary line of ligaments is the connecting trajectory between the four major facial ligaments including the temporal ligamentous adhesion, lateral orbital thickening, the zygomatic ligament, and the mandibular ligament.
Movement in the medial face is directed laterally and movement of the lateral face is directed medially converging at the line of ligaments. The lateral aspect is fixed (no facial muscles present) and the static part, while the medial aspect is mobile (due to the presence of facial muscles) and the movable part. However, passive mobility (due to gravity and age-related changes) is increased in the lateral face, when compared to the medial face.
The clinical behaviour of the filler you use depends on where you position it in the face. When you do the lifting, you should never start in the mid-face; but instead, always begin in the lateral face. The best way to respect the proportions and the anatomy is to address the ligaments first, and then contour the face and fill the mid-face according to the patient’s needs.
THE LINE OF LIGAMENTS
* Mainly skeleton muscle (SMAS)
* Minimal facial expression muscles and active mobility
* Injecting the stable/anchored tissue to life the face.
* Facial muscle and superficial fat pad
* Active mobility is affected by the muscles of the facial expressions
* Not a strategic zone to lift the face
* Give projection.
Injecting laterally, the lateral suborbicularis oculi fat ( SOOF) or fat pad is the most effective area to lift the mid-face. The key is to take advantage of the thick facial ligaments and tense them by placing points very close to the line of ligaments. This creates a very good effect in terms of eye correction and mid-face lifting and can optimise clinical outcomes.
When re-volumising the mid-face, the technique allows the clinician to reposition the facial structures while injecting only a little amount of filler product. After repositioning the fat pads, one can then volumise and contour the mid-cheek and face according to treatment goals.
SUMMARY OF INJECTION TECHNIQUES USING THE LINE OF LIGAMENTS
- Start from the top down, which will reposition the soft tissues to their original location and prevent soft tissue descent, starting with the temples
- Inject laterally first -lateral to the line of ligaments, which preconditions the mid-face, resulting in less product usage. So, first with temples and lateral zygomatic area
- Inject deep first -to restore the bone loss and lay the foundation of support to achieve a more localised effect.
I’d also advise starting with the worst part first, for a couple of reasons. We need to make sure we use enough product to restore symmetry, and the patient will see a bigger difference first.
The patient is concerned with looking older, sagginess in the lower half of the face and loss of definition.
Ageing processFull face. Descent of fat pads, especially marked in jowl areas.
Diagnosis Volume replacement - minimal Lifting - mid and lower faceDefinition - lips, jawlineProfile enhancement - chin
Treatment planningMaking use of the line of ligaments
This is not a paint-by-numbers tutorial or itemised injection pattern; the SinghSculpt® technique teaches you how to evaluate your patient’s face working through from three dimensions to five dimensions as you learn protocols to help you build structure and shape from the deep tissue to the skin’s surface, creating predictable, natural results.
Remember; - Know the anatomy to be safe - Refine your technique to be precise - Choose the appropriate product for the best result.
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-9Tan M, KontisTC. Midface volumization with injectable fillers. Facial Plast Surg Clin North Am. 2015;23:233-242. doi:10.1016/j.fsc.2015.01.009-Casabona G, Bernardini FP, Skippen B, et al. How to best utilize the line of ligaments and the surface volume coefficient in facial soft tissue filler injections.J Cosmet Dermatol. 2020 Feb;19(2):303-311. doi: 10.1111/jocd.13245. Epub 2019 Dec 15.
-Freytag L,Alfertshofer MG, Frank K, Moellhoff N, Helm S, Redaelli A, Voropai D, Hernandez CA, GreenJB, Cotofana S. Understanding FacialAgingThrough Facial Biomechanics:A ClinicallyApplicable Guide for Improved Outcomes. Facial Plast Surg Clin North Am. 2022 May;30(2):125-133. doi: 10.1016/j.fsc.2022.01.001. PMID: 35501049.