It is useful to understand how our faces change as we get older to appreciate the aesthetic benefits of a facial harmonisation.

Facial ageing is a complex three dimensional anatomical and physiological process broadly characterised by increased skin damage, skin thinning, fat and bone volume loss, fat redistribution and displacement, as well as skin and soft tissue laxity. These changes appear as poor quality skin, wrinkles, and facial sagging. The cheeks become less prominent, the nose to lip (nasolabial) folds deepen leading to marionette folds around the corners of the mouth, the jawline sags giving rise to jowls, and the skin of the neck begins to form loose folds.

Furthermore, as the different natural fat compartments begin to change in volume and displace, visible grooves and depressions start to appear on the face. The face becomes less defined as the facial structures lose their support, and the overall shape, dimensions and proportions change negatively. These age-related changes are principally controlled by our genetics. Still, they can be accelerated by illness and even stress, as well as certain lifestyle choices such as smoking, an unhealthy diet and particular medication. Photodamage caused by sunlight and artificial light (mainly in the UV spectrum) as well as environmental damage from, for example, pollution also play a major role in ageing (see skincare).

The essence of modern techniques of injecting is the strategic placement of specific types of fillers at certain key anchor points in the face. These filler injections create a combination of volumetric expansion to provide improved support for the overlying soft tissue as well as to smoothen and contour facial features and borders, and reduce the appearance of sagging. Fillers can also be used to reduce surface depressions and other contour irregularities (such as grooves, hollows and deep facial folds) that occur with ageing. Most importantly is that facial harmonisation procedures are designed to balance facial features and contours to achieve optimal proportions.These optimal proportions are gender-specific geometric dimensions that the human brain intrinsically interprets as being most attractive, independent of culture or ethnicity (a consequence of our neurobiological evolution). 

Facial harmonisation procedures therefore effectively deal with the appearance of facial ageing but more importantly overall facial proportions and aesthetics in a substantially different way to a surgical facelift. The basis of a surgical facelift is to excise excess skin and soft tissue in order to redrape, reposition and tighten the skin and soft tissue envelope. A facelift on its own primarily addresses the lateral cheeks and neck and is often combined with ancillary procedures including central facial augmentation typically with fat grafts to replace lost volume. Facial harmonisation inherently incorporates treatments that define and augment fundamental facial structures such as the chin, cheek and jawline as well as refine and rejuvenate specific facial features such as the lips, nose and eye area.  These individual steps represent alternatives to the traditional roles of surgical implants, fat grafts, surgical rhinoplasty and even blepharoplasty. In essence, therefore, facial harmonisation can be thought of as delivering non-surgically a global facial aesthetic enhancement that would have otherwise required multiple surgical procedures associated with considerably greater cumulative risk, cost and downtime. Consequently, while a surgical facelift and non-surgical facial harmonisation may overlap in certain ways, they are not interchangeable procedures, as they address different aspects of facial ageing and have differences in their aesthetic end goals, each being better suited for certain patients than others.

Myomodulation is the ability to use fillers to selectively modify (either decrease or increase) the pull and action of specific muscles depending on how and where the fillers are injected. By carefully altering the balance between opposing muscle groups in favour of the agonist or the antagonist, different facial expressions can be optimised to look more attractive and natural. Another important consequence of myomodulation is the concept of ‘indirect correction’ – the ability to improve the appearance of one area of the face indirectly by treating a neighbouring or distant region of the face first. This is observed, for example, when treating the under-eye hollows and tear troughs, which can be indirectly improved by treating the temples first. This indirect correction occurs because of a myomodulatory effect on the orbicularus oculi muscle (OOM), which is a circular sphincter muscle that, when constricts, closes the upper and lower eyelids, which also pulls the outer eyebrows down.

Hypertonicity of the OOM at rest can compress the eyelids closer to the globe of the eye, causing a deepening of tear troughs and hollows, as well as lowering the eyebrows and increasing wrinkles around the eye. The outer part of the circular OOM extends anatomically to the temple area, where there is often volume loss with age. By replacing lost volume in the temples, the OOM is expanded, which reduces the muscle tension at rest without affecting its ability to close the eyes themselves. In doing so, the tear troughs and hollows are therefore also slightly softened, with the additional benefit of elevating the tail of the brows and slightly reducing the wrinkles around the eyes. Although this effect is subtle, it is nevertheless beneficial as it allows less filler to be directly injected into the tear trough itself.    

Extending the concept of direct versus indirect correction further, it is evident that when treating the face as a whole, it is beneficial to treat regions of the face in a specific sequence that optimise the use of indirect correction. For example, before treating the tear troughs directly, the cheeks and temples may be treated first as these can indirectly improve the tear troughs, allowing less filler to be used in the delicate tear tough area than would have otherwise been needed. Indirect correction, therefore, is a fundamental concept in facial harmonisation and is the reason why treatments are planned in a specific sequence of stages, with each step designed to optimise the results of the next. This highly individualised approach to each patient’s treatment is essential in producing transformative results that remain natural-looking.

The mid-face and cheek area is the first stage in facial harmonisation as this area has the greatest indirect impact to other areas of the face, and provides a structural foundation for the soft tissue of both the mid-face and lower face. Treating both the medial cheek area under the eyes and lateral cheek area (including the subzygomatic region in front of the ears) with fillers can improve the nose to lip (nasolabial) folds. Treating the cheeks can also lift the corners of the mouth/lips and subtlety reduce the appearance of marionettes and jowls in the jaw area (which can then be corrected more extensively with jawline and peri-oral fillers). Similarly, providing soft tissue support in the medial and lateral cheeks, as well as temples (see above) can indirectly improve the tear trough and under-eye hollows, reducing the amount of filler needed for direct correction of the tear trough itself.

Once soft tissue structural support and volume is improved in the mid-face, the upper and lower face can then be addressed in the second stage of treatment. The principles of this stage are to improve the geometric dimensions of the lower and upper thirds of the face by addressing volume loss and defining the contours of the chin and jawline as well as the temples. The relative width of the jawline to the width of the mid-face is modified (see Jawline Enhancement) to optimise facial proportions closer to gender-specific aesthetic ideals, which are perceived as being more attractive.  The chin is reshaped also in a gender-specific manner to enhance projection and reduce submental fullness (double chin) as well as elongate the face if necessary to optimise facial proportions (see Chin Enhancement). Both the jawline and chin become better defined, smoother and more contoured, and the appearance of jowls and Marionette folds is substantially reduced.  Volume loss in the temples (evident as temple hollowing) is also addressed, to create a more youthful contour and to improve support for the lateral brow as well indirectly reducing the appearance of any tear troughs or under eye hollowing. 

Once the overall structure, proportions, contours and definition of the face is addressed through stages I and II, refinement of individual facial features then begins. Tear troughs and under-eye hollows, which by this stage have already been improved through stages I and II, are now addressed directly with volume replacement to fill out the grooves and hollows (an A-frame deformity of the upper peri-orbital area can also be treated at this stage). The lips may now also be directly reshaped after already improving the support for the upper and lower lips as well as the corners of the mouth through the preceding mid-face and lower face treatments. Following indirect correction through cheek enhancement, any residual excessive nasolabial folds are then also treated directly to soften the folds further if necessary. The nose may also be reshaped through a non-surgical rhinoplasty, and the brows and forehead are also contoured further through volume replacement if appropriate.

The final stage of treatment is to improve the surface eveness of the skin envelope by addressing any residual depressions or grooves on the skin surface that may cause unattractive or distracting shadows. This is achieved through more superficial injections in the upper fat layer and sometimes skin layer using lower density fillers. A non-crosslinked filler may also be injected into the skin to boost hydration.

Facial harmonisation provides profoundly beneficial long-term results. Modern hyaluronic acid fillers have well established long-term safety records with a high degree of predictability of treatment outcomes. Certain areas of the face may require occasional maintenance treatments as and when needed to preserve shape and definition. However even these maintenance treatments, with time, become less frequently required.  Indeed, for some regions of the face, the results can persist for years without needing further treatment.

How light is reflected off the surface of our faces can substantially influence the perception of beauty as well as emotional attributes. This concept has long been understood by photographers and more recently, social media enthusiasts and the “selfie” generation. Excessive or undesirable shadowing can appear in certain facial areas such as under the eyes or in the lower face under common light conditions. These shadows are caused by skin surface depressions or concavities such as grooves, hollows and deep facial folds, which reflect light away from the observer (whether an individual or camera lens). Undesirable shadowing in turn can amplify the perception of the loss of smooth transitions between different facial regions, making the subject’s appearance look worse.

By changing the direction of the light source, more or less light can be reflected towards the observer, reducing or increasing the shadows, respectively, thereby influencing the aesthetic appearance of the subject as perceived by the observer. In this way, for example, under-eye hollows can be made to look worse by shifting the light source to above the subject’s head, which enhances the shadows. Conversely, the appearance of the hollows can be improved by moving the light source to in front of the subject’s face, which floods the face with light and reduces shadows (hence the common use of ring lights by social media influencers).

While shadows in certain facial areas are undesirable, shadows at junctions between specific regions of convexity and concavity are beneficial in helping to enhance the perception of definition in facial contours. For example, a degree of shadowing is desirable between the jaw and neck, or in the subzygomatic area of the outer cheeks, which can reinforce the impression that the jawline and cheekbones are more defined respectively and create the classic youthful modelesque appearance. Conversely, a loss of these areas of shadow can contribute to the perception that those structures are poorly defined and aesthetically suboptimal.      

The concept of light and shadow balance discussed in the previous section is a crucial aspect of facial harmonisation. Many of the procedures that are incorporated into this process are designed to reduce surface depressions or concavities such as grooves and deep folds, as well as both smoothen and enhance facial contours. In turn, these steps reduce areas of undesirable shadows, highlight other areas by improving light reflection, and enhancing the shadows at intersections of concavity and convexity. The improved balance between light and shadow enhances the perception of facial definition and beauty. However, the concept of light and shadow can be taken further and utilised as a form of ‘higher-level thinking’ in treatment planning. In essence, the question becomes which areas of the face can be treated to optimise the way light reflects to enhance beauty? For example, by identifying and optimising ‘light reflective points’ or LRPs at specific areas of the cheekbones, we can not only enhance the appearance of the cheeks but also can do so with smaller volumes of filler that would have otherwise been needed. Different facial areas, including the jawline, chin, lips and nose, also have optimal LRPs that can significantly improve the perception of beauty.

Facial harmonisation globally enhances the aesthetic appearance of the face at rest. As important, however, is that this procedure also improves the aesthetic appearance during facial expressions, such as smiling. In an ideal smile, the bottom of the upper lip should rest just above the top of the teeth, with very little of the upper gum being visible. The bottom row of teeth should also ideally not be visible during smiling, and the corners of the mouth should gently pull both outwards and upwards. Some patients have upper lips that retract excessively upwards when smiling (“gummy smile’’) showing too much of their upper gums. Other patients have a ‘snarly’ smile showing too much of their bottom teeth, with limited outward movement of their mouth corners and excessive flaring of their nostrils. Some patients have a smile dominated by their risorius muscles that pull the mouth corners outwards leading to excessive widening of their smile (akin to a “Joker’ type of smile). All of these smiles are resultant from an imbalance between the elevator and depressor muscles of the lip and mouth that act as agonists and antagonists to each other. This imbalance is often due to a lack of structural support in the soft tissue and sometimes bone, giving one muscle group a mechanical advantage over the other. 

During facial harmonisation, cosmetic fillers can be injected adjacent or within these smile muscles to alter their action and direction of pull. This myomodulation effect can reposition the upper lip to prevent excess retraction during smiling by mechanically blocking the lip elevator muscles, such as in a gummy smile. Myomodulation can also reposition the lower lip in patients with a ‘snarly’ smile by blocking the muscles that pull the lower lips downwards so that the lower set of teeth are no longer visible. Fillers can also help widen a narrow smile by improving the pull of the zygomaticus major muscles that move the corners of the mouth upwards and outwards. This is done by injecting the filler under the belly of the muscle so that it can act as a fulcrum lending the muscle a mechanical advantage over muscles acting in opposition. This effect can also soften a risorius-dominated “Joker’ smile by creating a more natural-looking smile that slants more upwards than outwards (especially if combined with fillers over the risorius muscle area that can limit the action of this muscle).