| beST prAcTIce | ArTIcLe
were set for treating patients with congenital conditions such as parry–romberg syndrome (progressive hemifacial atrophy) and maxillary hypoplasia. For aesthetic indications, it was recommended that patients be at least 18 years of age. If treating a younger patient — after parental assessment and informed consent is signed — a treatment plan might be discussed and explained clearly, as well as the potential for necessary repeated injections. Although no fixed upper age limit for treatment exists, it should be noted that substantial thinning of the skin and severe photoageing or environmental damage may make certain older patients unsuitable candidates. Injections must always be deep to avoid the product being visible or palpable as a result of thinner skin. In the absence of specific contraindications, patients of any skin colour (Fitzpatrick I–VI) and those who wish to avoid a surgical facelift, are also appropriate candidates for treatment with Juvéderm VOLUMA. regardless of the patient’s presentation, the first step in
developing a treatment plan is to conduct a comprehensive aesthetic evaluation and stratify the degree of volume loss. For this, a four-point scale has been proposed (raspaldo Scale) and may prove useful (Figure 3)4
. expert consensus
was that new users of Juvéderm VOLUMA, after appropriate training, should begin treating patients who are categorised as stage 2 on the four-point scale, and advance to the treatment of more severe volume loss as experience and proficiency are developed. It was noted that a five-point scale has also been used to describe facial volume loss18
. On this scale, grades 2 and 3 include
moderate degrees of facial volume loss, and grades 4 and 5 include more severe degrees of lipoatrophy, including progressively increasing visibility of underlying musculature and prominence of bony landmarks. As with other aesthetic treatments, patients with
to last from 12–18 months in most patients and longer in others. based on 3 years of clinical experience and his 102 case studies, one of the authors (Hr) noted that treatment effects may last at least as long as 22 months (Figure 4d).
Consensus recommendations before using Juvéderm VOLUMA, clinicians should refer to the instructions for use accompanying the product17
The following recommendations are based on the outcome of discussions among clinicians experienced in the use of Juvéderm VOLUMA for their patients.
Patient selection A broad range of patients qualify for Juvéderm VOLUMA treatment, encompassing those with facial volume loss resulting from ageing, significant weight-loss, underlying anatomic defects leading to an appearance of midfacial volume loss, HIV-associated lipoatrophy, and patients with sequelae of hemifacial paralysis (Table 4). It was suggested that the guiding principle in patient selection be the aesthetic presentation of the individual, rather than specific age limits. For example, no specific age limits
Figure 3 Staging volume loss on a four-point scale in which 1=normal (A); 2=evidence of early soft tissue ptosis or atrophy slightly visible (B); 3=visible depression or descent (C); and 4=severe depression or atrophy (D)
.
unrealistic expectations (e.g. those who may expect results equivalent to those of a surgical facelift) are not suitable candidates for treatment with Juvéderm VOLUMA. From an aesthetic perspective, neither patients with high cheekbones nor those with heavy or drooping skin are ideal candidates for volumising treatment in the malar area. However, it is possible to inject more medially or in the temporal area to reduce the impression of high cheek bones23
. patients with heavy skin may benefit from
surgical facelift, deep chemical peel, or laser resurfacing. In addition, clinicians should be alert to signs of body
Table 2 Results on the GAIS at 1 month and 6–18 months post-treatment with Juvéderm™ VOLUMA™
GAIS Categories 1
2 3 4 5
Very much improved Much improved Improved No change Worse
GAIS=Global Aesthetic Improvement Scale. 1 month
post-treatment n (%)
73 (71.6) 27 (26.5) 1 (0.9) 1 (0.9) 0 (0)
6–18 months
post-treatment n (%)
65 (64.4) 17 (16.8) 18 (17.8) 1 (0.9) 0 (0)
Source: Raspaldo4
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