Facial aging is a complex, multi-layered process influenced by structural and physiological changes across various facial components. These changes include loss of skeletal support, elongation of facial ligaments, redistribution and descent of fat compartments, thinning of the superficial musculoaponeurotic system (SMAS), and atrophy of subcutaneous and dermal tissues. Among these, the elongation of true facial ligaments plays a pivotal role in soft tissue descent and the development of an aged appearance.
Various polymer-based fillers have been studied for their potential to achieve subtle and long-lasting rejuvenation effects. Among these, Poly-L-lactic acid (PLLA) has emerged as a promising option. This biocompatible, biodegradable, and bio-stimulatory filler works by stimulating collagen production within the dermis to address soft tissue volume loss. While PLLA’s effectiveness in treating striae, acne scars, and general skin rejuvenation has been well documented, its specific impact on facial ligament support remains underexplored. This study aims to evaluate the safety and efficacy of PLLA injections at the zygomatic ligament site and explore its potential in facial rejuvenation.
A female patient experiencing mild gravitational ptosis on both cheeks due to aging underwent bilateral PLLA injections. The product used was Devolux® Vital (Dermax), an innovative ready-to-use PLLA filler. Each vial contains 240 mg of Poly-L-lactic acid, 20 mg of Hyaluronic acid, and 140 mg of Mannitol, with particle sizes ranging from 20 to 30 μm. Unlike traditional lyophilized PLLA powders, Devolux® Vital is a liquid formulation that can be prepared within five minutes. It is reconstituted using 5 mL of sterile water for injection mixed with 2 mL of lidocaine hydrochloride.
The patient received four treatment sessions, each involving 3 mL of Devolux® Vital product injected at the zygomatic ligament. The injection point was located at one-third of the line between the lateral canthus and the base of the ear. A linear retrograde injection technique was used, with a 23G needle inserted perpendicularly (90°) to the skin and slowly withdrawn to distribute the filler evenly along the ligament. Post-injection molding was performed to prevent swelling or lump formation. No adverse reactions were reported throughout the course of treatment.
Figure 1: Injection technique targeting the zygomatic ligament. Injection point marked at one-third of the line connecting the lateral canthus and the infratragal notch. Four sessions utilized a 3 mL retrograde injection at a 90-degree angle. No adverse events were observed.
Standardized clinical photographs and ultrasound images were captured at baseline and follow-up to monitor outcomes. All imaging was conducted under controlled lighting and consistent patient positioning. Both physician and patient evaluated the results using the Global Aesthetic Improvement Scale (GAIS). The patient reported high satisfaction, with a GAIS score of 3 (Figure 2). Ultrasound examination performed three weeks after the final session showed increased ligament density and thickness (Figures 3 and 4).
Figure 2: Patient before (A) and after (B) four PLLA treatments.
One of the most influential factors in facial aging is the elongation of facial ligaments, which contributes significantly to the downward migration of facial structures. Anatomical studies emphasize the role of true retaining ligaments in maintaining facial integrity. These ligaments extend from the periosteum through the SMAS to the dermis, providing structural support to the overlying facial tissues.
There are four main true retaining ligaments responsible for facial support: the orbital retaining ligament (ORL), the zygomatic ligament, the upper masseteric ligament, and the mandibular ligament. Among these, the zygomatic ligament plays a critical role due to its anatomical positioning and its function in supporting mobile subcutaneous tissues in the midface.
The zygomatic ligament originates from the lower margin of the zygomatic arch and extends toward the junction of the arch and body. It appears as fibrous septa posteriorly and cylindrical fibers near the origin of the zygomaticus major muscle. Classified as a true ligament due to its dermal attachment, its precise positioning corresponds with key facial expression muscles.
Figure 3: Horizontal ultrasound images of the zygomatic ligament before (A) and after (B) treatment.
Elongation of these true ligaments results in tissue descent and facial sagging. Anti-aging treatments targeting ligament reinforcement can indirectly elevate the SMAS and contribute to facial rejuvenation.
Injectables such as hyaluronic acid and PLLA have shown potential in supporting ligament structure. PLLA, when used as a polymer with a specific stereochemistry and particle morphology, offers favorable rheological and bio-stimulatory properties.
Figure 4: Vertical ultrasound images of the zygomatic ligament before (A) and after (B) treatment.
In this study, Devolux® Vital, a liquid PLLA formulation, was administered in a linear retrograde fashion using a 23G needle along the zygomatic ligament. Each of the four sessions spaced three weeks apart involved 3 mL injections. The results demonstrated increased echogenicity and structural reinforcement of the ligament without altering its smooth contour.
The findings suggest that PLLA injections can effectively reinforce ligament structure and induce new collagen formation. The procedure offered noticeable lifting and support without adding excessive volume, making it suitable for patients with mild to moderate ptosis. High patient satisfaction and absence of adverse effects highlight the potential of this technique.
However, limitations include the short follow-up duration, which restricts long-term efficacy assessment. Future studies should involve larger cohorts and incorporate objective evaluation tools such as 3D imaging and histological analysis to validate these results. Optimal dilution protocols also require further investigation to maximize treatment outcomes.
In conclusion, PLLA injections—specifically using ready-to-use products like Devolux® Vital—present a promising method for enhancing facial ligament integrity and achieving non-surgical facial rejuvenation. If you're interested in learning more about PLLA injection techniques or exploring the benefits of the baby face needle, click here to contact us and our team will be happy to assist you.
Source: https://www.devoluxplla.com/blogs/Here-Comes-the-Proof-PLLA-Injection-Thickens-Facial-Ligaments
