Understanding facial anatomy with the Art Codes Framework

We all know that facial anatomy knowledge is the cornerstone of good medical aesthetic practice, but do you know how fat pads, bone, muscles and other tissues truly integrate and associate beneath the skin to create a beautiful female or male face?

In this blog, Dr Tim Pearce will discuss understanding the underlying tissue types and anatomical structures within facial anatomy in the context of the Art Codes Framework to consider the Defining Points, Defining or Inverse Lines, and Connecting Plans of the face.

How does understanding the underlying bone, fat pads, and soft tissues guide the application of the Art Codes Framework?

The most important aspect when delivering a facial aesthetic treatment is identifying the tissue you are trying to emulate. This helps determine where and how to inject, and the choice of product. All visible facial elements are composed of multiple tissues, including fat, bone, and muscle.

• Defining Points: Usually bony structures that provide projection and stability.
• Connecting Planes: Typically involve fat pads that require harmonisation.
• Defining Lines: Often a mix of fat and bone, usually linked to bony structures.

Ligaments are often the underlying cause of disruptions in Connecting Planes. These structures become more visible when fat pads shift in position or proportion; since ligaments hold onto the skin’s surface, shadows can form.

Learn more about fat pad anatomy and why are superficial fat pads key to aesthetics and the upper, middle & lower face deep fat pads.

Which anatomical structures are primarily associated with Defining Points, Defining Lines, Inverse Lines, and Connecting Planes?

Let’s break down the anatomical structures within the upper, middle and lower face.

Defining Points

In the upper face, there are several bony Defining Points.

• The frontal projection – the bony projection which defines the shape of the skull that is rarely injected,
• The periorbital ridge – part of the frontal bone, underneath the eyebrow, marking the outward bony projection of the orbit, and
• The angle of the zygoma which is more prominent (laterally enhanced) in women – as the zygomatic bone becomes the temple bone it projects more, often barely visible in men.

Alongside soft tissue Defining Points.

• The anterior cheek is a soft tissue projection visible from the side, created from subcutaneous fat with a combination of some deep fat pad, providing structure to the cheek.

Moving down into the mid-face, we find,

• The alar base – a low point of the face, that is soft but reflects the bony piriform fossa, as an Inverse (Defining) Point. The strength of the maxilla also influences the likelihood of nasolabial folds in this area.

Good shape, structure and strength are important Defining Points in the lower face.

• Gonial angle – differently shaped in men with a reduced Defining Line that runs between the oral commissure and the ear compared to its visibility in women because men have a larger mandible and stronger muscles that obscure the line. In men, the Defining Line runs straight from the cheek to the angle where the masseter projects outward. This is the most distinctly different part of the face between men and women – the interaction (Defining Points) between the cheek, mandible, and masseter in the lower face.
• The chin – a bony projection aligned to the natural shape of the bone that is more angular in men but rounder and narrower in women. If you were to overlay two mandibles on top of each other, one male and one female, you would see the male almost framing the female shape because it is larger in all proportions.

Defining Lines

Defining Lines connect Defining Points together. In the upper face, this is the periorbital ridge.

The Defining Line of the cheek is key to the mid-face. This is made up of the shape of the bone with a fat pad over the top of it. With ageing, the fat pads shrink – the lateral subcutaneous fat appears to get smaller compared with the medial cheek fat pad, shifting the projection from lateral to a more medial, anterior, and inferior projection.

In the lower face, the jawline is the Defining Line. Again, with ageing, this line becomes disrupted by various factors – the medial cheek fat pad can become larger (especially in Western societies where some weight gain is expected with ageing), or it repositions lower down, alongside skin laxity. Consequently, the chin repositions, projecting outwards and pulling upwards because the fat pads that would resist this movement have become smaller; this disrupts the Defining Line. The Defining Point is raised, and the bone underneath is lost, with a jowl competing with the chin to define the jawline, creating a much rounder aspect to the whole face.

Inverse Lines

Inverse lines are the natural low points that should be present on the face, which are rarely injected.

• Tear trough – underneath the eye, a little bit of a tear trough is beneficial to avoid too much blending in the area.
• Side of the nose – a slight shadow running down the side of the nose.
• Mental crease – this should not be a crease, but without a mental ‘dip’ lip definition is lost because the chin will merge in with the lip.
• Nasolabial fold – you could argue this is a Defining Line, but a subtle nasolabial fold that creates a light shadow rather than a crease is an Inverse Line.
• Jawline – the interaction between the planes of the neck and the lower face – the inverted structure of the neck – frames the whole face making it the most important Inverse (Defining) Line.

Connecting Planes

Connecting Planes connect Defining Points and Defining Lines to shape the facial contours, starting with the upper face.

• Forehead – made from three planes – a central plane and two lateral planes – which predominantly consist of subcutaneous and deep fat pads naturally creating volume underneath the muscle. However, deep fat pads are often not mentioned in textbooks, despite reference in some published papers, because they are not always present, particularly noted with ageing and cadaveric sampling. Volume loss typically occurs laterally first, by the temples, then medially, at the glabella. You will encounter a point just above the eye that defines the glabella – a T-shape. If this loses volume, the forehead begins to appear divided in half.
• Temples – If you correct the medial and lateral planes of the forehead, it will often highlight depletion in the temple. This can be harmonised using various needle or cannula injection placements, including the deeper, so-called gunshot technique.

In the mid-face, we move to the Connecting Planes in the under-eye area.

• Lid-cheek junction – between the projecting point of the cheek and the lower eyelid.
• Tear trough – this area can be considered part of a plane that we want to neutralise, although, without complete deletion, it can look unnatural if there is a lack of contour. The tear trough has a role in providing an Inverse Line, and the tear trough ligament is a Defining Point. A little bit of shadow is expected and a natural feature.
• Under the zygoma – particularly in females, a loss of structure in the Defining Line and Connecting Plan can create an outward curvature. The roundness develops because the fat pad dominates and pushes the plane outwards. In very thin individuals who appear gaunt, inward collapse of the Connecting Plane occurs, resulting in accordion lines and a hollowness underneath, requiring cannula-delivered volume restoration of the subcutaneous fat that forms the Connecting Plane. The added volume elevates the tissue to restore the Defining Line that runs from the zygoma to the chin without an inward curve.

Within the lower face, we also find Connecting Planes.

• Nasolabial fold – ideally, this should be almost flush with the cheek, continuing very gently as a small, subtle transition between the lip and cheek.
• The chin – if this plane is disrupted, it may be referred to as the ‘bowtie’ region because the fat pad shrinks creating a triangular formation on either side of the chin creating undesired definition to the melolabial folds.
• Sub-mental area – this plane is often hidden with ageing by increased submental fat that catches the light instead and hides the definition. It should be an area that neatly frames the shape of the lower edge of the face, to show where the face starts and ends, being heart-shaped in women and more hexagonal in men.

One of the principles I use a lot in aesthetic practice is blending. When a patient presents, they have increased complexity in their face, instead of having defined Connecting Planes, there may be multiple because the fat pads have changed angle; the goal is to reduce or soften the differences between the Connecting Planes.

How do ligaments influence defining points and their placement in the Art Codes Framework?

Ligaments tend to form Inverted Defining Points; they are still defining points, but they are the low point of the face in that region.

For example, lateral canthal thickening is a subcutaneous ligament. It runs lateral to the eye to the surface of the skin; you can feel the attachment. With ageing, it becomes associated with a shadow and a slight downturn to the corner of the eye. Treating and elevating this area, reducing the slight shadow, often achieves beautiful results, particularly in a female patient, where it starts to catch the light again and frame the eyes perfectly. Similarly, the tear trough ligament is a low point of the medial aspect of your face. Treatment should aim to maintain a subtle contour change, removing shadow whilst maintaining its presence as a low point.

There are other points which are not natural low points of the face, but become more apparent as you get older, including the zygomatic ligament, the nasolabial fold (a ligament), and the mandibular retaining ligament. In summary, ligaments tend to be low points and are required to achieve a natural appearance, but they should not dominate the face.

Buy a deep fat pads and ligaments poster as part of Dr Tim Pearce’s collection of individual artistic anatomy posters for your clinic.

By understanding and applying all these anatomical principles as part of The Arts Codes Framework, we can achieve balanced, natural results when treating the face.

• Introducing the Art Codes Framework for patient consultation
• Choosing dermal fillers that align with the Art Codes Framework

If you have any questions or other topics for discussion, you can find Dr Tim Pearce on Instagram.

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