BACKGROUND
The aging face is characterized by skin laxity and volume loss as a result of various intrinsic and extrinsic factors. Attenuation and elongation of the facial retaining ligaments is one of the main causes of skin sagginess as well as an indirect cause of perceived soft tissue volume loss.

OBJECTIVE
The authors have designed a prospective cohort study to quantitatively assess the efficacy of using hyaluronic acid (HA) injections to strengthen the facial retaining ligaments and adjunct injections of poly-L-lactic acid (PLLA) for a synchronous volumizing effect.

MATERIALS AND METHOD
A total of 12 Asian women were treated with HA injections to the orbital, zygomatic, buccal-maxillary, and lateral mandibular retaining ligaments. Adjunct injections of PLLA to the forehead and midface were given at the same time both supraperiosteally and subdermally in the forehead, temporal fossa, malar region, tear trough, buccal region, and nasolabial fold. Cephalometric measurements were done before treatment and at 2, 4, 12, and 24 weeks post-procedurally.

RESULTS
The eyebrow peak and eyebrow tail angles increased from 20.0° ± 3.8° to 21.0° ± 3.8° (p < 0.05) and from -2.9° ± 4.2° to -1.3° ± 3.3° (p < 0.001) at week 12, respectively. The eyebrow-to-orbital-rim distance increased from 1.9 ± 2.0 mm to 3.9 ± 1.5 mm (p < 0.001) at week 12. The eyebrow-to-upper-eyelid distance also increased from 11.6 ± 3.0 mm to 12.7 ± 3.2 mm (p < 0.001) at week 24. The eyebrow-peak-to-lateral-limbus distance decreased from 6.1 ± 3.1 mm to 5.3 ± 2.4 mm (p < 0.05) at week 4. The tragus-oral commissure length and lower facial contouring length decreased from 281 ± 11 mm to 275 ± 10 mm (p < 0.01) and 297 ± 14 to 292 ± 11 mm (p < 0.05) at week 12, respectively.

CONCLUSION
HA injection for the strengthening of facial retaining ligaments with adjunct doses of PLLA is a viable and effective method of facial rejuvenation as supported by quantitative data.

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