Semipermanent volumization by an absorbable filler: onlay injection technique to the bone

Nonsurgical Temple Volumization with Soft-Tissue Fillers: A Systematic Review of the Literature

BACKGROUND

Facial aging leads to cosmetically unappealing volume loss in the temples. We systematically reviewed the available literature regarding nonsurgical temporal volumization with injectable fillers.

METHODS

On Sept 16, 2024, Medline, Scopus, Embase, and Cochrane databases were queried with relevant terms for all articles describing temporal volumization with injectable fillers, including those with temple-specific data within the context of full-face volumization. Studies unrelated to temporal volumization, using autologous fat or its derivatives, limited to temporal lifting via injection into the temporoparietal scalp, without novel clinical/patient data, or unavailable in English were excluded.

RESULTS

Database query yielded 680 unique articles. One additional article was found with citation searching. After screening and evaluation for duplicates and inclusion/exclusion criteria, 40 articles were included. Nineteen studies were prospective and 21 studies were retrospective, of which 9 were complication case reports. A total of 881 patients were treated with either hyaluronic acid (n = 783), calcium hydroxylapatite (n = 93), polymethylmethacrylate (n = 28), allograft adipose matrix (n = 10), and poly-L-lactic acid (n = 2). Pooled data demonstrated improvement in temporal hollowing and global aesthetic improvement scales, as well as subject satisfaction. Pain/tenderness/pressure (29.6%), ecchymosis (17.3%), and edema (15.5%) were the most common posttreatment adverse events. Vascular events and other serious adverse events were rare. Deeper (supraperiosteal or inter/intra-fascial) injection may be more commonly associated with masticatory pain/discomfort.

CONCLUSIONS

Temporal volume loss is a natural consequence of aging that can be safely and effectively improved with soft-tissue fillers.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Open-Roof Deformity: How to Avoid, How to Cure?

Objectives: Of all the face surgeries, rhinoplasty is known to be the most difficult. The aim of this paper is to review open-roof deformity. Methods: PubMed, EBSCO, UpToDate, Proquest Central at Kırıkkale University, and Google and Google Scholar were used in the literature review. The search was performed with the keywords "open roof deformity," "rhinoplasty," "fillers" between 2024 and 1980. Results: Rhinoplasty is a surgery that requires a combination of art and science, unlike other procedures that may have challenging anatomic access, requiring an excessive amount of physical strength, or a long operating period that causes surgeon fatigue. It is common for people undergoing primary rhinoplasty to have their hump removed, which can lead to open-roof deformity. Lateral osteotomies and the use of grafts are crucial in the prevention of open-roof abnormalities. It is common practice to perform lateral osteotomies to seal this space. However, lateral osteotomy becomes tricky when the patient's bony vault is small. Another well-known option is to shape and replace the hump or to use a spreader graft, flap, sliced cartilage, or some combination of these. HA filler can also be administered to achieve the same effect as a spreader graft. Along the length of the dorsum on both sides, HA is injected retrogradely. Conclusion: If there are dorsal irregularities after surgery or if there is a need to fix the look of nasal bridge, this therapy can help.

Surgical rhinoplasty after prior hyaluronic acid based nose remodeling

BACKGROUND

Medical rhinoplasty by hyaluronic acid injection (HA) has become nowadays a common practice. The number of patients requesting surgical rhinoplasty and having already undergone one or more injections of HA is increasing. However, the literature lacks publications regarding the management of these patients.

OBJECTIVES

The aim of this study is to discuss the management of patients who have been treated with previous nasal HA injections and who seek surgical rhinoplasty, and elaborate a treatment protocol and algorithm to standardize surgical plans.

METHODS

We are reporting case studies based on our clinical experience. We also reviewed the literature to suggest perioperative management for rhinoplasty with previous HA injections.

RESULTS

Hyaluronidase injection preoperatively allows to carry out an accurate preoperative analysis of the nasal deformities to treat, in order to make an adapted treatment plan. Postoperative course is similar to other rhinoplasty cases without the use of this enzyme.

CONCLUSION

Hyaluronidase should be used in all patients with nasal injections of HA (unless contraindications), who are willing to undergo a surgical rhinoplasty. The operation can be undertaken at one-week interval as soon as the edema subsides and no further treatments are necessary.

Hyaluronic Acid Filler Injection for Localized Scleroderma - Case Report and Review of Literature on Filler Injections for Localized Scleroderma

Introduction

Localized scleroderma, also known as Morphea, is a chronic inflammatory condition of connective tissue, the etiology of which is unknown. There is skin thickening with increased quantities of collagen in the indurative lesion. Skin hyperemia is seen in the early inflammatory stage. This is followed by fibrosis, sclerosis, and atrophy with hypopigmentation or hyperpigmentation. Therapeutic options include corticosteroids, oral or subcutaneous methotrexate, calcipotriol, imiquimod, tacrolimus, mycophenolate mofetil, medium-dose UVA1 phototherapy, and CO₂ fractional laser treatment. There is disfigurement in approximately 50% of patients. Surgical excision, autologous bone grafting, and autologous fat grafting have been performed with varying degrees of success in linear morphea. Hyaluronic acid, Calcium hydroxylapatite, Poly L lactic acid, and permanent fillers such as Silicone have been used to correct deformities that occur as a result of morphea. The aim of this case report was to establish hyaluronic acid fillers as an efficacious modality of treating stable localized morphea with facial disfigurement.

Case Report

A 35-year-old lady with stable localized scleroderma had an atrophic scar on the right side of her face extending from the labio-mental crease to the midline of the chin. The contour of the chin was lost leading to facial disfigurement. The atrophic scar was treated with 2 fillers with the same cross-linking polymer but two different G primes with excellent cosmetic outcome. A brief review of literature involving fillers for localized scleroderma is also discussed.

Conclusion

Hyaluronic acid filler can be used safely in cases of stable localized scleroderma with facial atrophies. It is an effective, minimally invasive treatment with minimal downtime. It is extremely important to inject fillers only in stable cases of localized morphea. This modality of treatment should be considered for a larger trial in patients with similar disfigurements.

An Italian Online Survey Regarding the Use of Hyaluronidase in Previously Hyaluronic Acid-Injected Noses Looking for Surgical Rhinoplasty

Background

Nonsurgical nasal reshaping (nSNR) with hyaluronic acid (HA) filler is a well-established procedure performed to ameliorate nasal appearance and is considered a valid alternative to surgical rhinoplasty in selected patients.

Objectives

The aim of our study is to evaluate the decision-making process and management of patients undergoing rhinoplasty, with previous HA filler injection, and evaluate if consensus could be achieved to recommend guidelines.

Methods

Between April and May 2021, an online survey was sent to 402 Italian surgeons of different specialties. The survey collected information regarding the types of treatment of patients who have previously undergone nSNR, who should undergo surgical rhinoplasty. For those surgeons using hyaluronidase, an additional information was collected.

Results

In a range of time of 2 months (April and May 2021), a total of 72 surgeons replied and completed the survey: out of the 402 questionnaires sent, the response rate was approximately 18%. The majority of respondents (61.5%) replied to inject hyaluronidase (HYAL) in patients who had to undergo a rhinoplasty but reported previous nSNR. Of the surgeons who use HYAL, 70% performed rhinoplasty after a waiting time of 3 to 4 weeks.

Conclusions

Either direct surgical approach or hyaluronidase injection first seems to be a viable options. The use of HYAL before surgery is the choice with the broadest consensus in our survey. However, a larger case-control study with long follow-ups is necessary to understand if in patient seeking surgical rhinoplasty who already received nSNR, the injection of hyaluronidase before surgery is mandatory, recommended, or not.

Design of an elastic porous injectable biomaterial for tissue regeneration and volume retention

Soft tissue reconstruction currently relies on two main approaches, one involving the implantation of external biomaterials and the second one exploiting surgical autologous tissue displacement. While both methods have different advantages and disadvantages, successful long-term solutions for soft tissue repair are still limited. Specifically, volume retention over time and local tissue regeneration are the main challenges in the field. In this study the performance of a recently developed elastic porous injectable (EPI) biomaterial based on crosslinked carboxymethylcellulose is analyzed. Nearly quantitative volumetric stability, with over 90% volume retention at 6 months, is observed, and the pore space of the material is effectively colonized with autologous fibrovascular tissue. A comparative analysis with hyaluronic acid and collagen-based clinical reference materials is also performed. Mechanical stability, evidenced by a low-strain elastic storage modulus (G') approaching 1kPa and a yield strain of several tens of percent, is required for volume retention in-vivo. Macroporosity, along with in-vivo persistence of at least several months, is instead needed for successful host tissue colonization. This study demonstrates the importance of understanding material design criteria and defines the biomaterial requirements for volume retention and tissue colonization in soft tissue regeneration. STATEMENT OF SIGNIFICANCE: We present the design of an elastic, porous, injectable (EPI) scaffold suspension capable of inducing a precisely defined, stable volume of autologous connective tissue in situ. It combines volume stability and vascularized tissue induction capacity known from bulk scaffolds with the ease of injection in shear yielding materials. By comparative study with a series of clinically established biomaterials including a wound healing matrix and dermal fillers, we establish design rules regarding rheological and compressive mechanical properties as well as degradation characteristics that rationally underpin the volume stability and tissue induction in a high-performance biomaterial. These design rules should allow to streamline the development of new colonizable injectables.

Non-Surgical Touch-Up with Hyaluronic Acid Fillers Following Facial Reconstructive Surgery

The use of hyaluronic acid (HA) injectable fillers has become increasingly widespread in facial recontouring and rejuvenation. We report our experiences to emphasize the role of HA fillers as tools beyond aesthetic treatments in cases of post-surgical facial sequelae. HA fillers are generally used for aesthetic rejuvenation, but one potential new horizon could be their application in trauma, reconstructive, and craniofacial surgery. This study was conducted retrospectively, evaluating medical reports of patients treated at the Maxillofacial Surgery Unit, University of Campania “Luigi Vanvitelli”, Naples, for lip incompetence, trauma, oncological, reconstructive, and craniosynostosis surgery sequelae. Visual analog scale (VAS) evaluation was performed to assess patient satisfaction. No major complications (i.e., impending necrosis or visual loss) were reported. Bruising and swelling was reported for 48 h after lip injection. At the immediate VAS evaluation, 67% of the patients were “extremely satisfied” and 33% “satisfied”. In those 33%, VAS scores changed to “extremely satisfied” at 6–9 weeks and 3–6 months of VAS evaluation (contextually to improvement in tissue flexibility, elasticity, and aesthetic appearance). Results indicate that this minimally invasive approach achieves a high level of aesthetic enhancement, improving patient satisfaction. The concept of HA filler applications could be a frontier that may be applicable to other areas of reconstructive facial plastic surgery.

Hyaluronic acid injections in post-enucleation or evisceration socket syndrome: a case series

Background

One of the primary goals of enucleation and evisceration surgery is the restoration of an adequate orbital volume through the use of appropriately sized alloplastic or autogenous tissues. In patients inadequately treated, post-enucleation or evisceration socket syndrome occurs. Fillers are an ideal alternative for eyelid and eyebrow arcade volume enhancement since their injection is easily performed in an outpatient setting avoiding several complications. The aim of this study is to report the use of hyaluronic acid (HA) fillers to treat volume deficits of the upper and lower eyelids, projecting the brow arcade and reducing the asymmetry.

Methods

Thirteen patients (2 male, 11 female, mean age 32.7 years) were treated from June 2012 to May 2020. Non-surgical treatment by HA filler injection for aesthetic rehabilitation of deep superior sulcus, inferior tear trough deformity, and scleral show was performed.

Results

No complications as orbital-ache and/or vasovagal response were reported during the injections. Minor complications such as light swelling at the site of injection, self-resolved within 2 days, were recorded. Stable results were observed at follow-ups. In two cases, two successive treatments were required at 3 and 6 years from the first injection.

Conclusions

Hyaluronic acid fillers offer a versatile and safe method for replacing soft tissue lost from the upper eyelid/brow complex in cases of post-enucleation or evisceration socket syndrome.

Level of evidence: Level IV, therapeutic study.

Facial Rejuvenation With Fat Grafting and Fillers

Facial rejuvenation requires a multi-modality approach to address the sun damage, volume loss, and thinning of skin that occurs with aging. With age, the collagen fibrils that provide strength become fragmented and fibroblasts connections become weak, leading to skin laxity and loss of youthful skin. Fillers can lead to a more youthful appearance by providing volumetric support. Synthetic fillers such as hyaluronic acid products, calcium hydroxyapatite, polylactic acid, and polymethylmethacralate have bio-stimulatory affects, ranging from small effects on fibroblast production to prolonged stimulatory effects on dermal thickness and blood supply. Fat grafting is also an ideal technique for facial rejuvenation because it is readily available, natural, and has regenerative effects. This review describes a new technique of fat grafting for the face called Injectable Tissue Replacement and Regeneration that specifically addresses the different anatomic compartments of the face with volume loss. With this brief review, we aim to evaluate the currents trends of fat grafting and fillers in the management of facial rejuvenation, including the cellular changes that occur with facial aging, the bio-stimulatory effects of fillers, and the anatomic replacement of tissue with fat grafting. >Level of Evidence: 4.

Complications Following Non-Surgical Aesthetic Treatments in HIV+ Patients Receiving Antiretroviral Therapy: A 12-Years Experience

Since the advent of HIV antiretroviral therapies at the end of the 20th century, the morbidity and mortality rates associated with HIV infection have decreased dramatically. Unfortunately, these benefits are associated with substantial morphologic changes in the body, such as abnormal fat distribution with peripheral lipohypertrophy and facial lipoatrophy. Facial wasting is considered the major stigma for HIV–infected people and may result in reduced antiretroviral adherence. Patients suffering from the stigmata of HIV infection can benefit from non-surgical aesthetic treatments performed with fillers or lipolytic agents that provide a quick and reliable service for facial rejuvenation, with high patient satisfaction and a low risk of complications. In the present paper, a retrospective analysis of complications following non-surgical aesthetic treatments (calcium hydroxyapatite-based filler, hyaluronic acid filler, polyacrylamide hydrogel filler and dehoxycholic acid injections), in a cohort of 116 consecutive HIV+ patients, treated over a period of 12 years, was performed. With the exception of the tardive swelling reported after calcium hydroxyapatite injections, complications were recorded just after polyacrylamide hydrogel treatment as small, palpable, nonvisible nodules or aseptic abscess. Our experience is consistent with those already published in the literature and the complication rate seems to be comparable to non-infected patients.

Skin Necrosis and Vision Loss or Impairment After Facial Filler Injection

Purpose of the present study is to objectively evaluate the number of severe vascular complications, represented by skin necrosis and vision loss or impairment, following facial filler injection. The investigators implemented a review of the literature including articles published on PubMed database without limitation about year of publication, including all reports concerning skin necrosis and vision loss or impairment related to the injection of fillers for cosmetic uses. The search highlighted 45 articles and a total of 164 cases of skin necrosis and vision loss or impairment after injection of different substances. The injection site most frequently associated with complications was the nose (44.5%), followed by glabella (21%), nasolabial fold (15%), and forehead (10%). Results of the present study suggest that injectable filler can cause severe complications even in expertized hands. Treatments in the new defined "Dangerous triangle" must be carefully carried out. Despite our expectations, the highest rates of sever adverse events have been associated with autologous fat transfer practice.

Safety and Efficacy of Dermal Fillers in Patients With Connective Tissue Disease: A Review

BACKGROUND

Dermal fillers such as hyaluronic acid, poly-l-lactic acid, and polymethyl-methacrylate are often used to treat cutaneous defects such as lipoatrophy. However, concern exists regarding their use in patients with a connective tissue disease (CTD) because of a theoretical risk of disease reactivation or exacerbation. Evidence regarding their use in patients with CTD also remains limited.

OBJECTIVE

This review intends to summarize and evaluate the available literature regarding the use of dermal fillers in patients with CTD.

MATERIALS AND METHODS

A literature search until May 2020 was conducted through PubMed, Ovid MEDLINE, and Ovid Embase to identify articles discussing the treatment of cutaneous defects secondary to CTD. Articles discussing the use of autologous fat transfer alone were excluded.

RESULTS

Twenty-three articles were reviewed. The amount of available evidence varies between the type of CTD and type of filler with morphea having the most published evidence out of the CTDs discussed and hyaluronic acid having the most published evidence out of the fillers discussed. Most studies demonstrated positive results with no report of disease reactivation or exacerbation.

CONCLUSION

Despite limited available evidence, dermal fillers seem to be safe as an adjunctive treatment for cutaneous defects in patients with CTD.

The Correction of Facial Morphea Lesions by Hyaluronic Acid: A Case Series and Literature Review

INTRODUCTION

The aim of the study is to assess the long-term safety and efficacy of hyaluronic acid (HA) administration in correction of facial morphea lesions and to review the literature on the subject. Morphea is a chronic inflammatory disease of the connective tissue which may lead to serious deformations. The lesions located on the face particularly affect patients' quality of life and self-esteem; thus, there is a demand for safe and effective methods of treatment.

CASE PRESENTATION

The paper presents three female patients aged 16, 17 and 70 with facial morphea lesions who had HA preparation Juvéderm® Voluma or Volux, Vycross® technology, Allergan, injected. One of the patients had additionally fractional ablative CO2 laser (FAL) therapy.

DISCUSSION

The literature provides reports on successful use of HA, polymethylmethacrylate and poly-L-lactic acid for the correction of facial defects in localized scleroderma. HA is a natural component of the extracellular matrix and it therefore minimizes the probability of immunogenicity. The application technique also plays an important role. On the other hand, FAL therapy leads to the degradation of the abnormal collagen and the induction of normal collagen synthesis.

CONCLUSIONS

HA injection and combination of HA application with FAL are minimally invasive, effective and safe therapeutic options for patients suffering from morphea.

Hyaluronic Acid Injections as Nonsurgical Alternative in case of Delayed Diagnosis of Malar Arch Fracture: Case Report and Literature Review

Background

In this article, we describe a nonsurgical approach based on hyaluronic acid filler injection to restore the facial features of a delayed diagnosis of malar fracture. We analyze the differences between surgical and nonsurgical solution: in case of early detection, the surgical approach is the gold standard of treatment. However, in cases of delayed facial fracture diagnosis without functional impairment, nonsurgical procedures could be considered an alternative tool as we show in the present case report.

Aims

The aim of this study is to underline the importance of a complete aesthetic restoration in patients treated for noncosmetic purposes.

Patients/Methods

We present a case of a 26-year-old male patient with a delayed diagnosis of malar fracture without functional impairment that was treated with hyaluronic acid (HA) filler injections.

Results

The patient was followed up for 1 year showing stable results for the first 8 months; at the 12-month follow-up, a touch-up was suggested due to partial resorption of the filler.

Conclusion

This is the first case describing a facial fracture treated with HA injections for only recontouring purposes. We assess that nonsurgical cosmetic procedures could be considered a "new" tool in the process of facial rehabilitation but only when functional problems are not associated with facial trauma.

Evaluation of the In Vivo Kinetics and Biostimulatory Effects of Subcutaneously Injected Hyaluronic Acid Filler

BACKGROUND

Because subcutaneously injected hyaluronic acid filler is absorbed over 6 months to 1 year after the treatment of facial wrinkles, frequent retreatment may be required. However, persistent long-term effects are often clinically observed when hyaluronic acid filler is injected as a bolus for facial augmentation. Therefore, the authors investigated, over time, the changes in volume and histologic features of subcutaneous bolus injections of hyaluronic acid.

METHODS

Hyaluronic acid filler was subcutaneously injected as a bolus into the dorsum of 6-week-old rats. At several time points (immediately after injection and 4, 8, 16, 32, and 64 weeks thereafter), magnetic resonance imaging was introduced to observe morphologic changes and to measure volume. Histologic examination of sectioned tissues was also performed.

RESULTS

The average volume increased for up to 4 weeks after injection and then gradually decreased, with 74.8 percent of the injected volume remaining after 64 weeks, with no statistical difference compared to the initial volume. Histologic analysis revealed that lattice structures were created by fibroblasts and collagen fibers, and blood vessels and adipocytes were also generated in the filler.

CONCLUSIONS

Although subcutaneous bolus injections of hyaluronic acid filler exhibited flattening, the total volume was maintained even after 64 weeks. Histologically, hyaluronic acid filler acted as a scaffold for autogenous tissue replacement by means of fibroblast migration and proliferation, collagen induction, and angiogenesis, followed by proliferation of adipocytes. This study demonstrates that the total volume is maintained long-term by replacing part of the injected hyaluronic acid filler with autologous tissues.

Physiochemical Characteristics of Calcium Hydroxylapatite (CaHA)

The clinical performance of fillers in soft tissue augmentation depends upon their physiochemical properties, anatomical areas injected, interaction with the recipient, and the skill and experience of the physician. Scientific measures of filler properties facilitate appropriate selection of treatments for optimal treatment outcomes, and inform adjustments to treatments that improve patient safety and aesthetic outcomes. The rheological properties of calcium hydroxylapatite (CaHA), elastic modulus (G') and viscosity, coupled with its capacity to offer both immediate results and continued stimulation of collagen type I deposition, support its distinction as an ideal treatment for the volume loss characteristic of aging. Furthermore, the comparatively higher G' of CaHA offers a physiochemical basis for the clinical performance observed by the authors, especially in regions such as the temple and chin, where the force exerted by CaHA against bone permits expansion of overlaying tissue, permitting it to behave as a liquid implant.

The Hyaluronic Acid Fillers: Current Understanding of the Tissue Device Interface

The article is a detailed update regarding cosmetic injectable fillers, specifically focusing on hyaluronic acid fillers. Hyaluronic acid-injectable fillers are used extensively for soft tissue volumizing and contouring. Many different hyaluronic acid-injectable fillers are available on the market and differ in terms of hyaluronic acid concentration, particle size, cross-linking density, requisite needle size, duration, stiffness, hydration, presence of lidocaine, type of cross-linking technology, and cost. Hyaluronic acid is a natural component of many soft tissues, is identical across species minimizing immunogenicity has been linked to wound healing and skin regeneration, and is currently actively being studied for tissue engineering purposes. The biomechanical and biochemical effects of HA on the local microenvironment of the injected site are key to its success as a soft tissue filler. Knowledge of the tissue-device interface will help guide the facial practitioner and lead to optimal outcomes for patients.

Safe Planes for Injection Rhinoplasty: A Histological Analysis of Midline Longitudinal Sections of the Asian Nose

BACKGROUND

Dorsal nasal augmentation is an essential part of injection rhinoplasty on the Asian nose. Aesthetic physicians require detailed knowledge of the nasal anatomy to accurately and safely inject filler.

METHODS

One hundred and thirty-five histological cross sections were examined from 45 longitudinal strips of soft tissue harvested from the midline of the nose, beginning from the glabella to the nasal tip. Muscles and nasal cartilage were used as landmarks for vascular identification.

RESULTS

At the nasal tip, a midline longitudinal columellar artery with a diameter of 0.21 ± 0.09 mm was noted in 14 cadavers (31.1 %). At the infratip, subcutaneous tissue contained cavernous tissue similar to that of the nasal mucosa. The feeding arteries of these dilated veins formed arteriovenous shunts, into which retrograde injection of filler may be possible. All of the nasal arteries present were identified as subcutaneous arteries. They coursed mainly in the superficial layer of the subcutaneous tissues, with smaller branches forming subdermal plexuses. A substantial arterial anastomosis occurred at the supratip region, in which the artery lay in the middle of the subcutaneous tissue at the level of the major alar cartilages. These arteries had a diameter ranging between 0.4 and 0.9 mm and were found in 29 of 45 specimens (64.4 %). This was at the level midway between the rhinion above the supratip and the infratip. This anastomotic artery also crossed the midline at the rhinion superficial to the origin of the procerus on the lower end of the nasal bone. Here the arterial diameter ranged between 0.1 and 0.3 mm, which was not large enough to cause arterial emboli. Fascicular cross sections of the nasalis muscle directly covered the entire upper lateral cartilage. The subdermal tissue contained few layers of fat cells along with the occasional small artery. The procerus arose from the nasal bone and was continuous with the nasalis in 16 cadavers (35.6 %). There was fatty areolar tissue between the procerus and the periosteal layer and no significant arteries present. The procerus ascended beyond the brow to insert into the frontalis muscle with very few cutaneous insertions. The supratrochlear vessels and accompanying nerve were occasionally found on the surface of the frontalis muscle.

CONCLUSION

Most nasal arteries found in the midline are subcutaneous arteries. Filler should be injected deeply to avoid vascular injury leading to compromised perfusion at the dorsum or filler emboli at the nasal tip.

LEVEL OF EVIDENCE V

This journal requires that the authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Perpendicular Strut Injection of Hyaluronic Acid Filler for Deep Wrinkles

Supplemental Digital Content is available in the text.

Although various injection techniques of hyaluronic acid (HA) filler for facial rejuvenation have been developed, correction of deep wrinkles/grooves, such as the nasolabial fold (NLF), with intradermal or subdermal injections remains difficult. We tested the intradermal HA injection method to place multiple HA struts by (1) inserting a small needle perpendicularly to the wrinkle and (2) injecting HA as intradermal struts with the skin fully stretched by the practitioner’s fingers. The results of both NLFs in 10 patients suggest that this technique improves NLFs and maintain the effects more consistently than conventional techniques, although the effects of both methods were almost lost after 6 months. Selective and/or combined application of this technique may enhance the current approach to facial rejuvenation with dermal fillers.

Facial Rejuvenation with Fillers: The Dual Plane Technique

BACKGROUND

Facial aging is characterized by skin changes, sagging and volume loss. Volume is frequently addressed with reabsorbable fillers like hyaluronic acid gels.

MATERIALS AND METHODS

From an anatomical point of view, the deep and superficial fat compartments evolve differently with aging in a rather predictable manner. Volume can therefore be restored following a technique based on restoring first the deep volumes and there after the superficial volumes. We called this strategy "dual plane". A series of 147 consecutive patients have been treated with fillers using the dual plane technique in the last five years.

RESULTS

An average of 4.25 session per patient has been carried out for a total of 625 treatment sessions. The average total amount of products used has been 12 ml per patient with an average amount per session of 3.75 ml. We had few and limited adverse events with this technique.

CONCLUSION

The dual plane technique is an injection technique based on anatomical logics. Different types of products can be used according to the plane of injection and their rheology in order to obtain a natural result and few side effects.