Mastering Midface Rejuvenation: A Proposal for a New Three-Layer, Ultrasound-Guided Technique

Abstract

Introduction: Aging affects all facial layers: deep fat atrophy reduces midface projection, superficial fat changes alter facial contour, and dermal thinning compromises skin texture. Midface rejuvenation aims to restore malar projection, cheek volume, and youthful contours, thereby improving the nasolabial fold and suborbicular region. Conventional multilayer techniques address both deep and superficial fat compartments using fillers with distinct rheological properties, but often neglect skin quality and the advantages of ultrasound guidance. The approach we propose is grounded on three core principles: the comprehensive anatomical knowledge, the use of high-frequency ultrasound to ensure precise and safe injections, and the selection of hyaluronic acid fillers specifically tailored to each tissue plane-deep, superficial, and dermal. The aim of our work was to present our technique as a proof of concept for a three-layer, ultrasound-assisted technique, which enhances safety, precision, and aesthetic effectiveness, representing a significant advancement in modern facial rejuvenation.

Methods: A three-layer, ultrasound-guided midface rejuvenation technique employs tailored hyaluronic acid fillers for each plane. Firm, high G' fillers target deep compartments through supraperiosteal injections for structural support. Elastic, moldable fillers, directly injected into superficial fat, enhance superficial layers while preserving natural mobility. Non-cross-linked formulations, used subdermally, by using a cannula, hydrate and improve skin quality, ensuring precise integration with minimal risk.

Conclusions: The multilayer technique combines different fillers in deep, superficial, and dermal layers, tailored to the patient's anatomy. This three-layer method restores volume and preserves natural expression, simultaneously improving skin quality, particularly benefiting hollow or mature faces. Unlike single-plane injections, it addresses all aging aspects. Although not yet routine, ultrasound integration in multilayer treatments promises higher efficacy and safety. This approach marks a significant advancement in modern facial rejuvenation standards.

Keywords: facial ultrasound; fillers; skin booster; skin layers; three‐layer; three‐layer injection.