Treating the double chin with hyaluronic acid injection

Submental fullness (SMF), or the double chin, is a condition regarded as undesirable. Many treatment modalities are available for SMF reduction, such as energy‐based devices, injection lipolysis, or surgery. However, of minimal invasive modalities, hyaluronic acid (HA) injection has not been explored for possible SMF treatment.

comprehensive effect, and required multiple (3, 4) sessions for adequate improvement.After cost-benefit analysis and discussion with the patient, she elected to undergo HA filler injection treatment for whole-face rejuvenation.For this patient, a systematic approach was undertaken, utilizing MD Codes 16 as a treatment guideline.
Telephone follow-up at 6-and 9-months posttreatment revealed durable effect and a sustained level of high patient satisfaction.
Informed consent was obtained from the patient for the publication of her treatment photographs.Ethical review was deemed unnecessary owing to the high safety profile of HA injections and its frequent use in similar anatomic areas (albeit for different conditions such as chin augmentation 17 or lip contouring 18 ).

| DISCUSS ION
As with all aesthetic procedures, patients with milder initial presentation tend to respond better to nonsurgical or minimal invasive treatment.[5]9 Cryolipolysis with specially designed Coolmini applicators can improve SMF after 1-2 session of treatment. 7,8A recent publication detailing sequential treatment with cryolipolysis followed by ATX-101 injection showed good safety and improved efficacy (up to 2 grades of improvement). 10SMF with prominent platysma bands have also been treated successfully with a combination of ATX-101 and botulinum toxin. 11Ds treat SMF via several mechanisms and are suitable for mild to moderate severity.Monopolar or percutaneous radiofrequency (RF), 12,14 high intensity focus ultrasound (HIFU), [12][13][14] or fractional lasers 12 function by tightening the skin.3][14] Severe to extreme SMF cases, on the other hand, often require liposuction, which may then be augmented by EBDs.3][14][15] Naturally, the percentage of patients receiving more invasive procedures are notably less than those receiving noninvasive or minimal invasive ones.According to the CONTOUR study, 12 which enrolled 1029 adults treated for SMF at 91 sites across the US and Canada, of the 676 patients who underwent treatment, 84% of patients were treated by ATX-101.In contrast, only 11.4% were treated by EBDs, 3.4% by surgical liposuction, 0.7% by laser liposuction, and 1.3% by another treatment modality.
Compared to the above-mentioned modalities, fillers have not been reported as a possible treatment option for SMF in past literature, and to the best of the authors' knowledge, this represents the first report of filler-treated SMF.Since the traditional role of fillers is to compensate for areas of volume deficiency, it may seem like an odd choice for treating SMF.However, fillers can also be used to provide supportive structure, which can affect the surrounding facial anatomy in interesting ways; for example, the authors have previously reported a case of thick lips reduction through filler injection in the lower lip. 19In cases of SMF, filler injections over the chin and jawline augment structural support and indirectly strengthens and tightens the skin over the submental region, resulting in reduced SMF prominence.Furthermore, the prevalence of short or retruded chin (microgenia) is very high in Asian populations, with one recent study in China reporting 60%-80%. 20Microgenia may contribute to lower face and neck sagging, which can worsen SMF appearance; 21 fillers can simultaneously correct microgenia, producing a synergistic effect on patients with both microgenia and SMF.
Another reason to consider HA filler over other minimal invasive modalities lies in the filler's low rate of adverse events.][6]9 Although most of the adverse events resolved within 1 month, swelling may last up to 40 days. 9On the other hand, HA fillers are usually associated with fewer adverse events and minimal to mild swelling, which usually subside within 1-7 days.3][24] Vascular occlusion and their sequelae are among the most serious events, with the most devastating being vision loss, in which prompt management can improve outcomes. 25Fortunately, complications remain rare, and are mostly associated with injection to the mid-or upper-face (including the nose, nasolabial fold, eyebrows, forehead, and glabella), 23 with the nasolabial fold being especially high-risk. 24Contraindications of HA include the presence of infection or cutaneous disorders near the injection site, and hypersensitivity to the filler material or to lidocaine (which is frequently mixed with the filler). 26 terms of cost, filler injections compare favorably to ATX-F I G U R E 1 A 52-year-old East-Asian woman with SMF (submental fullness).The frontal (A,B) frontal smiling (C,D) and profile (E,F) views depict the patient before and 1 month after hyaluronic acid (HA) filler injection treatment, respectively.Note the reduction in SMF prominence, improvement in cheek and jawline sagging, and improvement of the periorbital fatigued appearance.

F I G U R E 2
The MD Codes system 16 which outlines filler injection locations, courtesy of Dr. Mauricio de Maio.Injection amounts at each point (in mL) are labeled accordingly.