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HA Filler & Skin Quality: Static Wrinkles, Radical Cheek Lines Injection Techniques

According to HA Filler Injection and Skin Quality–Literature Minireview and Injection Techniques by Jui-Hui Peng and Peter Hsien-Li Peng (2020) Aging of the face produces many changes in the structure and integrity of the skin and other anatomical aspects, the three major signs of which are volume loss, sagginess, and skin quality change.


Through surgical or nonsurgical procedures, it is possible to slow or even reverse these mechanisms through artificial means, including thread lifting, radiofrequency, or filler injection. Filler injections are particularly popular in recent years, owing to their convenience, efficacy, and long-lasting results.


Signs of Aging Face

Cosmetic intervention to the aging face includes surgical and nonsurgical approaches, of which there are a wide variety of options available, including lasers and energy-based devices (EBDs), cosmeceuticals, topical medications, botulinum toxin injections, thread insertions, and filler injections.


The five facial layers. Layers 1 to 5, ranging from superficial to deep, are as follows: Skin (epidermis and dermis); Subcutaneous layer (superficial fat); Facial muscles and SMAS; Retaining ligaments and spaces (deep fat); and Periosteum and deep fascia.


There are numerous well-studied signs of the aging face. In the upper face, expression lines may become more prominent, there may be signs of ptotic eyebrows and upper eyelids, and eye bags may form. In the midface, the lid–cheek junction may become elongated, cheeks may experience sagging, nasolabial folds may become more prominent, and the midface region may experience pronounced volume loss. In the lower face, tissue sagging may become more evident, and jowls may form along the jawline, contributing to its irregularity. These clinical findings may be related to the underlying changes in bony structure support, fat compartments, mimetic muscles, and skin. Laxity in the superficial muscular aponeurosis system (SMAS) and retaining ligaments may also be contributing factors.


These signs of aging are common targets of aesthetic correction. Currently, there are a wide variety of options available for treatment, such as lasers and EBDs (including monopolar and bipolar radiofrequency [RF], high-intensity focused ultrasound [HIFU], and the picosecond laser with fractional hand-piece, etc.), cosmeceuticals with clinically-effective active ingredients, topical medications (such as retinoic acid), botulinum toxin injections, thread insertions, and filler injections. Various injectable filler material, such as poly-L-lactic acid (PLLA), hyaluronic acid (HA), and hydroxylapatite, have shown the ability to induce new collagen formation after injection, thereby improving skin thickness or skin quality.


Static Wrinkles & Technique

Static wrinkles remain even when you are expressionless. They are are permanent, structural anatomical alterations, making neurotoxic agents such as botulinum toxins much less effective.



Instead, other modalities might be used, such as EBDs, skin tightening devices, or filler injection, for which reconstituted HA has produced satisfactory results.

The injection technique for the HA treatment of wrinkles has been described by numerous authors, which generally consists of utilizing serial puncture techniques over static wrinkles with tiny amounts of reconstituted HA filler.

Static wrinkles over the forehead, glabela, periorbital, and perioral areas can all be treated using this technique. The specific details of injection sequences vary in accordance with authors.




For example, one article recommended injection into the superficial dermis with a specially designed, less concentrated HA product, and a blanching technique for the improvement of static wrinkles. Another article recommended a method of “Skinboosting” for static wrinkles: nonanimal stabilized HA (NASHA) 20 mg (Restylane Vital, Galderma) or 12 mg (Restylane Vital light, Galderma), injected with 30G needles through serial puncture.



The glabela area is considered one of the most dangerous areas for filler injection, owing to the possibility of embolic vascular occlusion of supraorbital or supratrochlear artery of the internal carotid artery system, and the subsequent sequelae of blindness. The injection should be slow, gentle, in small amounts, and into the relatively safer plane of intradermal or superficial subdermal layers.


Radial Cheek Lines (RCL) & Technique

RCLs is the crepiness in the cheeks known as “radial cheek lines” to the nasolabial folds (the lines that extend from the bottom of your nose down toward your mouth).



It may appear as one of the aging signs concurrent with dynamic and static lines, and it may itself be classified as dynamic or static contains an example of static RCLs. Static and dynamic RCLs may necessitate different treatment. A study used VYC-17.5L (Juvéderm Volift, Allergan) with 25G cannula to treat dynamic RCLs; 53 female patients enrolled in the study, wherein a 45-day follow-up revealed improvement in 98% of cases, and significant improvement in both dynamic and static RCLs was recorded in terms of roughness, amplitude, and texture.



Although the term RCL was not used, another study using NASHA 20 mg or 12 mg with 30G needle, deposited using the serial micropuncture technique, also showed improvement of dynamic RCLs within its patient population.


Skin Quality & Technique


The aging skin may alter the mechanical properties of the skin through the loss of collagen, elastin, and ground substances, and may cause the deterioration of skin quality through dryness, thinning, loss of elasticity, and line and wrinkle formation.


A 2007 study demonstrated that cross-linked HA filler injections in vivo stimulates new collagen production in photoaged human skin. Collagen production was found to be related to the stretching of fibroblasts. Injected NASHA enhances structural support of the extracellular matrix, resulting in fibroblast elongation, subsequent increase in procollagen I and collagens I and III production, and an increase keratinocyte and fibroblast proliferation. The net result was overall epidermal thickening and the formation of new dermal vasculature.


The recommended protocol for improving skin quality is NASHA 20 mg or 12mg injected monthly for three sessions, which can retain efficacy for up to 6 months. This kind of injection treatment can significantly improve skin surface roughness and skin elasticity 4 months after the final injection session.



A 30G needle using serial puncture technique is preferred to spread out the filler over a larger area. Clinical results indicate not only the hydration effects of HA filler, but also new collagen formation and overall quality improvement. This holistic approach has been called the “Skinbooster” treatment. Other studies have found evidence of objective skin quality improvement after using a new cross-linked injectable product (VYC-12 HA; Juvéderm Volite, Allergan) via digital photographic analysis. This quality improvement effect can last up to 6 months, and the hydration retention effect can last for as long as 9 months after a single injection treatment.


One thing to keep in mind when injecting for skin quality is the depth of the injection; overly superficial injections can create persistent papules visible under the skin, which will last for as long as the HA filler is present. Immediately after each injection, massaging or molding with a cotton stick is recommended.


Conclusion

There is abundant literature support for the efficacy and wide-ranging applications of HA filler injection for a variety of aesthetic skin issues, in particular static lines, RCLs, and improvement of skin quality.


For static lines, VYC-15L ([Juvéderm Vobella, Allergan] with lidocaine) in the superficial dermal layer deposited through the serial puncture method has proven to be effective. For RCLs, VYC-15L or 17.5L combined with botulinum toxin in the superficial epidermal layer has proven to be effective. For skin quality improvement, 40 to 50 injections of VYC-12L ([Juvéderm Volite, Allergan] with lidocaine), deposited in the superficial subdermal layer, has proven to be effective.


In conclusion, for the best efficacy, HA injections for specific skin conditions should differ in depth, product, technique, and amount.


Reference

HA Filler Injection and Skin Quality–Literature Minireview and Injection Techniques by Jui-Hui Peng and Peter Hsien-Li Peng (2020)

Consensus on the Use of Hyaluronic Acid Fillers from the Cohesive Polydensified Matrix Range: Best Practice in Specific Facial Indications by van Loghem J , Sattler S, Casabona G, Cotofana S, Fabi SG, Goldie K, Gout U, Kerscher M , Lim TS , de Sanctis Pecora C , Sattler G, Trindade de Almeida A, Wanitphakdeedecha R , Werschler P, Pavicic T (2021)

What’s New in (Subtle) Fillers by goop.com (2022)

 

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