The purpose of facial fillers is to make the appearance as natural as possible, in line with aesthetic requirements, and without skin scarring caused by improper cosmetic operations, etc. The principle of volumetric filler treatment is subtle and natural change in appearance. The reason for unnatural appearance is usually that volumetric fillers are mistakenly viewed as a cosmetic goal rather than a technical tool. Each person’s face is unique, but the facial shadows that change with age are relatively consistent. Facial shadows are a characteristic of aging facial skin. These shadows usually consist of several facial conjunctures, and once the facial skin volume is reduced, many of these features will form. The goal of volume restoration is to repair or eliminate age-related shadows and recreate the volume balance of a younger face. Dr. Lam et al. of Robert Wood Johnson University Hospital provided insight into the aesthetic goal of altering facial shadows for rejuvenation in an article published in Plastic and Reconstructive Surgery in 2015. Facial contours There are 3 important circular frames of the face that are important in determining facial rejuvenation It is also the true focus of rejuvenating aesthetics. This complete 3-circle frame is the overall facial frame, the mouth frame (containing the marionette and nasolabial folds) and the orbits (containing the eyebrows, upper and lower eyelids). The overall contour of the face strongly influences the perception of the patient’s age, gender and attractiveness. To have a youthful face, there is a particular need to build another oval face that looks perfect on the front. It is necessary to constantly evaluate the frontal image when performing volume rejuvenation, as this is the best view to ensure that the shadow of aging is eliminated as much as possible. However, it is often the case that surgeons often view the face from the side, which is a decisive advantage but not the best view. Many women worry that filling the temples and cheekbones will make their face appear wider or fatter, but if these areas are filled properly then there is nothing to worry about. When both of these areas and the cheeks as a whole are filled, the entire face is improved and actually looks thinner. The orbits are another area that is losing its color over time. Traditional facial rejuvenation techniques remove volume from around the eyes, instead making one appear older. In contrast, proper volume filler in the orbits can create a halo around the orbital area, restoring a youthful, attractive appearance. Imagine that the upper and lower eyelids form two opposing oblique triangles, which represent the physical signs of age. If the two sides of the triangle are filled in sufficiently so that the periorbital volume is at the same level, the appearance will look much younger. The mouth is another important area to fill. When filling it, we should consider not only the two typical signs of the nasolabial folds and marionettes, but also the entire circular circle around the mouth: in addition to those two typical signs, the anterior chin depression and the anterior jaw depression should be included. Failure to take into account the overall effect around the mouth will deepen those shadows of aging and the separation of the mouth and lips, resulting in a lot of strange lip shapes. Upper face The characteristic of a young face: full volume without shadows between the eyelids and eyebrows, and similarly between the lower eyelids and cheekbones. This is a characteristic of most people; in addition to this, there is a small group of people who have eyelid features where the upper eyelid margin has a deeper line and a shadow under the orbital rim. Patients should be treated for facial rejuvenation with reference to and respect for the features of their youth. Volume loss at the eye sockets and eyelids results in sunken and shadowed sockets and drooping of the upper eyelids, seen especially in the middle of the upper eyelids. As the medial border of the bone rises, the inner fold of the upper eyelid disappears when the eyes are closed and the medial skin in front of the eyelid is exposed. Volume reduction at the temples exposes the lateral orbital and superior lateral zygomatic margins. The height of the eyebrows is not a criterion for evaluating the youthfulness of the face; the ideal height of the eyebrows is defined in relation to the superior orbital rim, which is usually obscured by the full volume of the upper eyelid in young faces. Studies have shown that a decrease in soft tissue volume at the superior orbital rim elevates the superior orbital rim, so the strategy to rejuvenate the face is to fill in the volume under the brow rather than elevate it. Midface The lower eyelid to the corner of the mouth is the midface, where age-related changes are represented by changes in volume leading to changes in facial contours: facial volume shifts from the upper to lower midface region, heart-shaped faces become square, and dark shadows appear on the face layering the mid-stop. In old age, there is a general decrease in midface volume, which, together with the action of those ligaments of the face, gives the signature midface of old age (see Figures 8 and 9): the decrease in volume at the edge of the lower eye sockets creates a depression and dark shadow, separating the cheeks from the eyelids; the midface is depressed and the dark shadow appears parallel to the nasolabial folds; the decrease in volume on the lateral cheeks leads to a distinct dark shadow under the cheekbones; and the nasolabial folds deepen. The main points of midface reshaping are to restore volume to the midface, reshape the pointed face and reduce dark shadows: filling in the lower orbital rim should take into account the unity of the eyelid and cheek articulation, with prominent and shiny cheekbones. The surgery prevents overfilling of the eyelids and the front of the cheeks, which would otherwise result in overfilling of the face; conversely, if the appearance of the lower eyelids is not completely improved, as well as the necessity of filling the front of the face is neglected, sometimes filling the side of the cheeks can affect the overall result. The Lower Face Although facial volume migrates substantially down the face with age, targeting the volume of the lower face is an integral part of a facial rejuvenation strategy. A young face is smooth from the cheeks to the chin, with no dark shadows in the jaw and a smooth curve from the jaw to the front of the chin, and its shape looks like a field hockey stick shape from the side. The volume reduction of the oral mandibular sulcus causes a shadow from the corner of the mouth to the front of the jaw, and the anterior mandibular sulcus appears due to progressive volume loss in the mandible and cheek. If the chin is full and prominent at this time it will aggravate the shadows of the oral mandibular sulcus and anterior mandibular sulcus. The anterior and lateral jaws lose volume at the same time, and the “clubbed” chin becomes an irregular “W” shaped chin when the chin protrudes (Figure 10). Congenital hypoplasia of the lower face usually occurs in the chin and mandibular angle region, presenting an aged appearance at a young age. This condition is better treated early on with a strategy that uses a small and concentrated volume filling area. In the 40s and 50s, it is not enough to fill in the chin alone. At this point, chin reshaping becomes critical. However, it is also critical to address potential volume loss. If the volume of the anterior mandibular sulcus is not restored at the time of reshaping, then the patient’s chin is not fully corrected postoperatively, and in addition to this, attention should be paid to proper filling of the mandibular angle volume as well. Focus of Opinions Clinically, many doctors ignore the limitations of volume filling, resulting in a series of dispute problems without prior communication with the patient. For example, in the case of facial fat grafting, the fat absorption rate after grafting is different for each person, which should be considered in advance. Any alteration of the facial contour can add or exacerbate shadows on the face, so it is necessary to take into account the conversion of light in the operative and paracomial areas before surgery. This is especially important when filling the subzygomatic area, cheek area or temple area, where any small imperfection can be noticeable. Although the front of the cheek is a critical area for volume fillers, it is potentially risky if not handled properly. Filling the front of the cheek alone without treating the adjacent areas tends to make the appearance unnatural and, more importantly, the current trend of overfilling makes many people’s faces look too full and bloated when they smile. Facial symmetry is another particularly important issue for pre-operative communication. Not only does cosmetic surgery not correct asymmetry, but it can be exacerbated by volume fillers, so it is important to communicate with patients before surgery that correcting asymmetry is an unrealistic expectation. Dr. Lam mentioned that his aesthetic criteria are: (1) how much better the patient looks at first glance; (2) how much the patient is appreciated from elsewhere; and not just from the patient’s own perspective, as many women usually use their left brain to evaluate the results of surgery. Dr. Lam focuses more on preoperative communication with the patient than on the cosmetic procedure, letting the patient know that he may not be able to change asymmetrical issues, etc., but can professionally enhance their appearance overall. This article is a personal opinion or view based on Dr. Lam’s own observations and clinical experience, and is not strictly a case study, but is intended to help plastic surgeons in improving patient-practitioner communication, aesthetics of youth and aging, and methods of facial rejuvenation.