Myomodulation: Key Technique to Address Facial Rejuvenation

Historical focus on skin, fat, and bone changes in theories of facial aging, while muscle-related aging factors have been overlooked. It highlights the conventional use of injectable fillers for wrinkle correction and neuromodulators for muscle relaxation, emphasizing the separation of skin and fat from muscle action. However, long-term observations reveal that fillers can also influence muscle movement, introducing the concept of myomodulation as a tool in facial aesthetics. Structural deficiencies in bone or fat pads can lead to abnormal movement patterns affecting both appearance and function. Myomodulation introduces the use of fillers to modulate facial muscle action to address these imbalances, even without substantial volume loss.

The Concept of Myomodulation

Myomodulation is a strategic placement of dermal fillers in proximity to facial mimetic or sphincter muscles to either enhance or inhibit muscle actions. The theoretical foundation for myomodulation is supported by MRI findings in young individuals, demonstrating that deep facial fat compartments contribute to the convexity of levator muscles. With aging, the loss of fat and bone results in the straightening of these muscles, allowing depressor muscles to exert more influence. Myomodulation involves the use of fillers beneath muscles near their origin to recreate the lost structural support, acting as a fulcrum to restore muscle convexity and tension. Conversely, muscle action can be restrained by placing fillers either superficially in the subcutaneous layer or intramuscularly. Myomodulation can be used to address various facial areas, such as the nasolabial fold.

The concept of myomodulation has been applied in clinical practice for over a decade, leading to the development of the 3-Dimensional Dynamic Lift™ (3DD Lift) technique. This technique categorizes the face into eight major treatment areas and smaller aesthetic subunits and involves a strategic sequence of filler injections to build a structural foundation in the midface, contour the upper and lower face, and refine periorbital, nasolabial, and perioral areas. The 3DD Lift technique has yielded excellent aesthetic and functional results, benefiting not only patients seeking facial rejuvenation but also those with facial paralysis sequelae, such as synkinesis and muscular spasms.

How Myomodulation Works?

Mimetic muscles in the face have unique characteristics, such as originating in bone and inserting into the skin and other muscles without tendons. These muscles lack muscle spindles, which play a role in maintaining muscle tone. Understanding muscle movement in facial expressions involves three key factors: the length-tension relationship, muscle pulley and lever systems, and functional muscle groups. The length-tension relationship is crucial for muscle force production and is composed of a contractile component (active tension) and an elastic component (passive tension). In mimetic muscles, the skin and connective tissue provide the primary source of elasticity, and aging-related loss of skin elasticity can affect this relationship, leading to skin sagging and stretching of facial muscles.

Biomechanics of muscle movement within the face sheds the light on how various factors, including aging and structural deficiencies, can significantly impact our facial expressions. It underscores the pivotal role played by pulley and lever systems in influencing the actions of facial muscles. Additionally, it highlights the significance of functional muscle groups in maintaining a youthful appearance.

In the context of muscle movement, these pulley and lever systems function as mechanisms that can either alter or enhance the actions of facial muscles. An illustrative example is the patella in the body, which serves as a biomechanical system altering the angle at which muscles work. In the face, the lateral suborbicularis oculi fat pad (SOOF), acting as a pulley glide plane, works in conjunction with the bone to serve as a lever fulcrum for the zygomaticus major muscle. This lever effect provides mechanical advantage, assisting in the lifting of the corners of the mouth during a smile. However, in the aging process, the loss of supportive structures beneath the muscle, whether due to bone loss or fat ptosis, can diminish this lever effect, consequently reducing the muscle's force and its ability to lift the corners of the mouth.

Functional muscle groups are another critical aspect, wherein groups of muscles, including agonists and antagonists, work harmoniously to contribute to a natural, youthful facial appearance. These muscles often operate in opposition, and the balance between them plays a crucial role in dictating our facial appearance both at rest and during dynamic expressions. In youth, levator muscles tend to be stronger than depressors. However, imbalances can occur, either due to structural deficiencies in youth or due to bone and soft tissue loss as part of the aging process. When a levator muscle lacks the power to lift effectively, it allows its depressor antagonist to act with reduced opposition. This imbalance can lead to variations in facial expressions, such as the transition from a typical smile to a "DAO smile," where the corners of the mouth downturn.

The presence of injectable fillers provides a means to manipulate muscle movement mechanically. Fillers can facilitate muscle actions by acting as fulcrums or impede muscle movement by blocking their actions. This strategic use of fillers can effectively modify muscle actions and restore balance in facial expressions, as demonstrated in the described cases. Understanding the intricate biomechanics of facial muscle movement is crucial for addressing issues related to aging and structural deficiencies. Injectable fillers can serve as a valuable tool in reestablishing the balance of muscle actions, thereby enhancing overall facial aesthetics and contributing to a more youthful appearance.

Deficits in facial structure can lead to abnormal muscle actions, which are visible on the skin and affect overall facial appearance. It underscores the importance of understanding the interactions between facial structure and muscle movement, especially the imbalances between muscle synergists and antagonists. These imbalances can impact facial appearance both at rest and during animation.

The presented cases offer evidence supporting the use of myomodulation with injectable fillers to address facial structural deficiencies. Injectable filler treatments can be employed to either support muscle movements or block overaction, whether these imbalances are due to structural deficiencies or the natural aging process. Clinicians do not necessarily need to isolate the specific factors contributing to these imbalances to use fillers effectively in treatment.

Myomodulation with fillers should be considered when structural support is lacking, before resorting to neurotoxin injections. Injectable fillers can help correct structural deficiencies, support weak muscle actions, and hinder extreme muscle excursions and depressor contractions. While neurotoxins are a crucial tool for modulating facial muscle activity, injectable fillers have a unique role in supporting and fine-tuning muscle actions, ultimately helping clinicians restore natural structural conditions and balance facial appearances.

Past Research on Myomodulation

Cross-Case Research on Myomodulation (2017)

This study is conducted in 2017 by Mauricio de Maio. The study has 7 patients with different cases to compare the efficiency and the reliability of myomodulation.

For the first case, the patient received Juvederm Voluma injections on both sides of her face. A bolus was injected deep under the zygomaticus major muscle on her right side, providing structural support and enhancing muscle lifting action. On her left side, two boluses were injected at the same plane, achieving a similar effect. Additionally, Voluma was injected superficially to mentalis, depressor labii inferioris, and DAO along the labiomental angle on her left side. This created a mechanical obstacle to DAO movement, reducing its downward pulling effect and allowing the zygomaticus major to lift the corner of her mouth.
The second case involved a young Asian patient with a gummy smile due to a lack of projection of the anterior nasal spine and premaxilla. Voluma injections were used to compensate for the bone deficiency, resulting in a reduction of upper lip levator movement during a smile and decreased upward retraction of the upper lip.
The third case featured a patient with no apparent structural deficiency at rest, but chin instability became evident during animation, causing mentalis over-contraction and skin wrinkling when pouting. After treatment with Voluma in her chin, the patient's pouting movement improved, and the chin's skin wrinkling was reduced.
The fourth case featured a patient with facial asymmetry showed distortion of the chin at rest and during lip-pursing. Injectable fillers were used to correct the excessive movement of mentalis, leading to improved chin appearance both at rest and during animation.
The fifth case involved a patient who lacked support at the labiomental angle and chin, resulting in distortion during kissing and pouting. Injectable fillers in the chin and lips improved the stability of these areas, allowing more balanced and stable muscle contraction during kissing and pouting.
In the sixth case, a man with mild facial asymmetry and facial nerve function issues received filler injections to support the muscles, resulting in improved nasolabial fold, lip alignment, and zygomatic smile. His facial expressions were notably enhanced.
The final case showcased the use of injectable fillers in a patient with facial palsy resulting from surgery. Fillers were strategically injected to support muscles and create a lever effect to increase muscle movement on the affected side. This approach significantly improved muscle coordination and facial symmetry over time.

These cases highlight the effectiveness of injectable fillers in addressing structural deficiencies and improving muscle function, ultimately leading to more natural and balanced facial expressions.

Myomodulation with Injectable Fillers Updated Study (2020)

This study is the update of the previous research, This study involved a 21-year-old Caucasian woman sought treatment for a gummy smile affecting both her upper and lower dental arches. This condition was a result of excessive movement in the upper lip levators, including the levator alaeque nasi (LAN), levator labii superioris (LLS), and zygomaticus minor (ZMi). Additionally, the depressor septi nasi (DSN) and the lower lip depressors (depressor labii inferioris [DLI] and depressor anguli oris [DAO]) were contributing to the gummy smile. The goal of the treatment plan was to address the gummy smile by reducing the excursion of the upper lip levators, which would lower the smile line and elongate the upper lip. This approach aimed to balance the activity of antagonistic depressors (DAO and DLI) and increase the resistance of the orbicularis oris (OO) to prevent upper lip inversion.

The treatment plan involved a series of injections in various facial areas to achieve these goals, following the MD Codes and MD DYNA Codes. These codes are tools used to guide hyaluronic acid (HA) filler placement for the mechanical modulation of muscle action.

The treatment process included:

Injection of Juvéderm Voluma® XC (1.0 mL per side) at the anteromedial cheek (Ck3) above the LAN, LLS, and ZMi to reduce their contraction.
Injection of Voluma (0.2 mL per side) beneath the DSN, at the bone level of the premaxilla area at the nasolabial angle (N1) to block the muscle's contraction, reducing the downturn of the nose tip and the lifting of the central part of the lip.
Injection of Juvéderm Volift XC above the LAN and LLS at the upper and central nasolabial fold (NL1 [0.5 mL per side] and NL2 [0.3 mL per side]) in the subcutaneous layer, and at the cutaneous part of the upper lip (Lp8; 0.25 mL per side), as well as in the subcutaneous layer above the ZMi at the lower nasolabial fold (NL3; 0.2 mL per side) to further reduce levator activity.
Injection of Volift under OO at the upper lip (Lp1; 0.25 mL per side) to support the muscle and increase its resistance against the pull of the upper lip levators.
Injection of Voluma above depressors at the labiomental angle (C1 [0.7 mL per side]; DLI), lower prejowl (Jw4 [0.5 mL per side]; DAO and DLI), and lower anterior chin (Jw5 [0.5 mL per side]; DLI) at the subcutaneous level to stretch muscle fibers and reduce contraction, rebalancing the activity with the upper lip levators.

As a result of the treatment, the movement of the upper lip levators and lower lip depressors during a smile was reduced, leading to decreased retraction of the upper and lower lips. These changes were noticeable immediately after HA filler injection and persisted the day after.

This case demonstrates how the concepts introduced in the 2018 "Myomodulation with Injectable Fillers" paper are being practically applied using MD Codes and MD DYNA Codes to guide HA filler placement for mechanical modulation of muscle action. This study's ideas are now being put into clinical practice through techniques that leverage an understanding of the potential effects of HA filler injections on facial mimetic muscles and their potential to enhance facial aesthetics. Future studies will continue to explore and refine these concepts, providing valuable guidance to clinicians in the field of facial aesthetics.

Myomodulation Retrospective Case Series (2022)

This study involved 1,352 adults (1,108 women, 82%; 244 men, 18%), 3DD Lift myomodulation treatment was administered using hyaluronic acid-based fillers. Some patients underwent multiple treatment sessions over a 5-year study period. The average age of patients at their first myomodulation treatment was 51 years, with men having an average age of 47 years (ranging from 21 to 78 years), and women having an average age of 52 years (ranging from 20 to 94 years). Generally, older patients received more treatment sessions. Out of 9,355 treatment sessions performed, 463 sessions (5.0%) lacked data on the treated areas and were excluded. The total number of included sessions was 8,892, with 7,468 performed in women and 1,424 in men.

The most commonly treated areas on the face were located lateral to the line of ligaments, encompassing subunits 1A+1B+1C+3A+5A, illustrated in picture above, which constituted 53% of all treatment sessions. Subunit 1A was the most frequently treated site, with 68.7% of patients undergoing treatment (70.4% women and 61.1% men), and it was often re-treated in patients who had multiple sessions.

Reference:

Myomodulation with Facial Fillers: A Comprehensive Technical Guide and Retrospective Case Series (2022)

Myomodulation with Injectable Fillers: An Update (2020)

Myomodulation with Injectable Fillers: An Innovative Approach to Addressing Facial Muscle Movement (2018)

MD Codes™: a methodological approach to facial aesthetic treatment with injectable hyaluronic acid fillers (2021)

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