Lee Walker Facial Aesthetics Academy

💉 GUMMY SMILE… UNDERSTAND THE MOVEMENT BEFORE CHOOSING THE POINT

🦷 Excessive gingival display can reflect several factors… vertical maxillary excess, altered passive eruption, dentoalveolar extrusion, a short upper lip or excessive lip elevation. The cause determines the treatment.

🧠 When excessive lip elevator activity contributes, botulinum toxin can temporarily reduce upper lip elevation during smiling. It does not correct the underlying skeletal or dental anatomy.

📍 The Yonsei point was described by Hwang and colleagues in 2009 following dissection of 50 hemifaces from 25 cadavers.

It represents a proposed surface target lateral to the nasal ala, associated with three upper lip elevators…

• Levator labii superioris
• Levator labii superioris alaeque nasi
• Zygomaticus minor

The original description places it at the centre of a triangle defined by surface landmarks… so it is more than simply the junction between LLS and LLSAN. This illustration highlights those two muscles for clarity.

🔬 What does the clinical evidence show?

A randomised trial involving 49 participants found that both Yonsei point injections and LLSAN injections reduced gingival display, with no significant difference between groups at the measured follow up points. The Yonsei point was effective… but was not shown to be superior.

👤 Individual anatomy matters. Cadaveric research in a White South African sample challenged the applicability of a single standardised point across populations.

Assess the cause. Observe the smile. Understand the muscles. Individualise the treatment.

📚 Hwang et al. Angle Orthod. 2009;79:70–77.
Gong et al. Plast Reconstr Surg. 2024;153:711e–721e.
Booysen et al. Clin Exp Dent Res. 2023. doi:10.1002/cre2.735

🧠 How well do you know your neck anatomy?

10 muscles … can you name them all?

🔎 Identify the structures numbered 1 to 10.
Two numbers appear twice … can you explain why?

For an extra challenge 👇

▪️ Which muscles lie above the hyoid?
▪️ Which lie below it?
▪️ Which muscle divides the neck into anterior and posterior triangles?
▪️ Can you name the nerve supply to each numbered muscle?

Recognising a muscle is the first step … understanding its attachments, relationships and function takes your knowledge further.

💬 Leave your numbered answers in the comments.
📌 Save this for your next anatomy revision session.
👥 Challenge a colleague.

Illustrative anatomy quiz.

🧠 Adding volume does not produce the same response in every facial fat compartment…

Schenck et al studied 30 cadaver heads using upright CT, additional MRI and anatomical dissection.

👇 Increasing injected volume was associated with greater downward displacement in the:

• Superficial nasolabial compartment
• Middle cheek compartment
• Jowl compartment

The medial cheek, lateral cheek and both superficial temporal compartments did not show the same significant relationship.

💉 My teaching takeaway…

Before adding volume, consider how the receiving compartment may respond. More volume should never automatically be interpreted as more lift.

📚 Keep the evidence in context…

This was an anatomical experiment in predominantly older donors. It does not establish long term filler migration, prove that injections cause facial ageing or predict every patient’s response.

Know the compartment… understand its behaviour… then plan the treatment.

Reference: Schenck TL et al. The Functional Anatomy of the Superficial Fat Compartments of the Face: A Detailed Imaging Study. Plastic and Reconstructive Surgery. 2018;141(6):1351–1359. doi:10.1097/PRS.0000000000004364

Image: illustrative redraw, not the original study scan.

🚨 Recognise the signs… !!!

Following filler vascular occlusion, skin changes reflect impaired perfusion and evolving tissue injury.

⚪ Blanching

May appear immediately and can be fleeting. Its disappearance does not confirm that circulation has recovered.

🟣 Livedo

A mottled, reticular pattern associated with deoxygenated blood accumulating in the cutaneous venous network. It can develop rapidly.

🔵 Dusky or grey discolouration

May accompany worsening ischaemic injury. This is a clinical appearance, rather than a separate stage in the published CMAC framework.

🔴 🟡 🔴 Pustulation and bacterial bioburden

Pustules are often described around 48 - 72 hours. Compromised skin can support bacterial overgrowth, although pustules alone do not establish infection.

🟤 Coagulation

Already represents coagulative necrosis… tissue death with initially preserved architecture. It can precede or overlap with pustulation.

⚫ Necrosis

Necrotic tissue may subsequently present as moist slough or dry eschar.

⏰ These timings are approximate… never a reason to wait..!!

The image is a teaching schematic. Patients do not necessarily progress through every appearance, and several changes may coexist.

Assess capillary refill, pain, colour and the full affected territory. Pain may be absent. Suspected vascular occlusion requires immediate assessment and prompt management.

Early recognition and restoration of perfusion can prevent progression to necrosis.

📚 References
Murray G, Convery C, Walker L, Davies E. J Clin Aesthet Dermatol. 2021;14(5):E61–E69.
Farmer A et al. J Clin Aesthet Dermatol. 2021;14(12 Suppl 1):S39–S48.

Same fold … different artery 🩸
The nasolabial fold is a visible landmark. The facial artery does not follow one predictable path beneath it..

In a CT angiography study of 252 classified facial arteries:
🔴 65.5% ran medial to the fold
🔴 12.7% crossed from lateral to medial 🔴 12.3% ran lateral to the fold
🔴 The remaining 9.5% crossed from medial to lateral

The images show the three most frequent patterns in that study.

📏 Median horizontal distances from the mouth corner to the artery were 7.3 mm, 9.3 mm and 10.6 mm for the three patterns shown.

These are study medians … not fixed coordinates for your patient. The ranges shown are interquartile ranges, not the full extent of variation.

🟢 Green dots mark the nasolabial fold
🔴 Red illustrates the arterial course

A surface landmark helps orientate us … it cannot confirm an individual artery’s position.

Know the patterns. Expect variation. Never mistake an illustration for your patient’s anatomy.

📚 Koziej et al. Anatomical Map of the Facial Artery for Facial Reconstruction and Aesthetic Procedures. Aesthetic Surgery Journal. 2019;39:1151–1162. DOI: 10.1093/asj/sjz028

WHICH LINE TO KISS? 💋

Before adding lip volume… assess where the lips sit within the whole facial profile.
Reference lines help us understand lip prominence, but skeletal relationships, teeth, lip thickness, age and ethnicity all influence interpretation.

📐 Ricketts’ E plane
Nasal tip to soft tissue chin.
Classical values: upper lip 4 mm behind the line… lower lip 2 mm behind.

📐 Burstone’s B line
Base of the nose to soft tissue chin.
Classical values: upper lip 3.5 mm in front… lower lip 2.2 mm in front.

The key difference? The E plane is directly influenced by nasal tip projection. Burstone’s line excludes the nasal tip… but both remain influenced by chin position.
Hsu found Burstone’s line the most consistent and sensitive of five lines for distinguishing profiles judged attractive from those judged unattractive.

These are reference values… not universal treatment targets !! 💋 👄

📚 References
Hsu. AJODO. 1993;104:355–360.
Reddy et al. Which Line to Kiss?? Ann Ess Dent. 2013;5:35–39.
Burstone. Am J Orthod. 1967;53:262–284.

Know your facial anatomy? 🧠🔍

10 ligaments … 10 question marks.

Can you name them all?

👇 Share your answers in the comments 💾 Save and test yourself again 👥 Tag a colleague who enjoys an anatomy challenge

📚 Further reading

• Alghoul & Codner. Retaining ligaments of the face: review of anatomy and clinical applications. Aesthetic Surgery Journal. 2013;33(6):769–782.

How long did it take you to find the most attractive soft tissue profile? 👀

Probably not very long…

Class I. Class II. Class III.

Three very different sagittal relationships… and our brains seem remarkably quick at deciding which one looks more balanced.

But why? 🤔

🦷 Class I… balanced maxillomandibular relationship with harmonious chin projection

🦷 Class II… mandibular retrognathia creates a more convex soft tissue profile with reduced chin projection

🦷 Class III… mandibular prognathism creates a more concave profile with increased chin projection

This matters in aesthetic medicine.

We spend a lot of time looking at lips, jawlines and chins in isolation… but they don't exist in isolation.

A chin that looks deficient may not simply need "more filler."

It may be reflecting the underlying skeletal relationship.

And once you recognise that… facial assessment starts to look very different.

👀 So… how long did it take you to choose the profile you found most attractive?

And more importantly… why did you choose it?

💉 HOW DEEP IS THE MENTALIS MUSCLE?

We often talk about treating the mentalis with botulinum toxin… but how deep is the actual muscle target?

📊 Cadaveric and ultrasound data give us some useful numbers.

At approximately 5 mm lateral to pogonion:

👉 Mean depth from skin to the superficial surface of mentalis
6.7 ± 1.4 mm

👉 Mean mentalis muscle thickness
4.0 ± 1.4 mm

👉 Mean distance between the deep surface of mentalis and bone
1.1 ± 1.0 mm

This means the mentalis occupied an approximate depth range of:

🔥 6.7 to 10.7 mm beneath the skin

The muscle was also found predominantly:

📍 5 to 10 mm lateral to the facial midline

📍 20 to 30 mm inferior to a horizontal line connecting the oral commissures

And interestingly… mentalis morphology was not identical between individuals.

🧠 86.4% demonstrated a three dimensional dome shaped morphology
🧠 13.6% demonstrated a flatter morphology

So why does this matter?

Because the mentalis is not simply a superficial chin muscle.

A very superficial botulinum toxin injection may influence the superficial fibres… but may not optimally target the deeper muscle belly.

Conversely, touching bone does not mean you are necessarily intramuscular… there is approximately 1 mm of tissue between the muscle and periosteum in the studied population.

💡 Depth matters. Anatomy matters. And anatomy varies.

These measurements should guide our understanding… not become another rigid injection recipe.

REFERENCE

Choi DY, Bae JH, Youn KH, et al. Effective locations for injecting botulinum toxin into the mentalis muscle: cadaveric and ultrasonographic study. Toxins. 2021;13(2):96.

🧬 CAN BEAUTY REALLY BE CALCULATED?

Look at these two faces… 👀

One is the original.
The other has been digitally altered towards supposedly more “ideal” facial proportions.. including symmetry.. facial proportion and "golden ratio"

But which is actually more beautiful?

📐 For centuries we’ve tried to define facial beauty mathematically…

✨ Facial thirds
✨ Facial fifths
✨ Symmetry
✨ Neoclassical canons
✨ The Golden Ratio… 1.618

The problem?

There is no universally accepted mathematical formula for facial beauty.

Research suggests attractiveness is influenced by multiple interacting factors including symmetry, averageness, sexual dimorphism, skin quality, age, ethnicity and individual preference.

And the famous Golden Ratio?

Despite its popularity in aesthetics, evidence that attractive faces consistently conform to φ = 1.618 is far from convincing.

Perhaps the biggest danger in aesthetic medicine is believing that every face should be moved towards the same mathematical ideal.

💉 We shouldn't be treating numbers. We should be treating faces.

Beauty may have proportions…

But it doesn't have a formula. 🧬

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