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ARTICLE | VOLUMISING TECHNIQUES | Key points


■ Successful volumisation of the mid-face requires an understanding of anatomy, physiology and the morphological changes induced by ageing


■ Targeted injections of appropriate hyaluronic acid can enhance or restore soft tissue volume in the mid-face


■ When sagging is moderate, volumising is an effective alternative to surgery


■ Technical administration of hyaluronic acid can additionally improve the skin’s surface, texture, hydration and luminosity


■ The harmony of the volume is more important than the volume itself


superficial injection of hyaluronic acid induces a


reaction that stimulates these fibroblasts in the dermis. By doing this there can be an increase in the different components produced by these same fibroblasts (i.e. elastin, collagen, proteoglycans, structural glycoproteins), resulting in improved skin texture. This stimulation can occur as a result of the filling of


the product itself, but also by the mechanical trauma caused by a fine needle or cannula. It is possible to speculate, therefore, that the increased tissue resistance caused by subdermal tunnelling with a blunt cannula causes a greater amount of trauma than a sharp needle, and hence a greater tissue response. This tissue response can induce a very slight tightening effect, which would add to the hyaluronic acid hydrating power itself.


Is it enough to have a lifting effect? There isn’t always a lifting effect in the case of minimal volume injections; however, there will be an improvement in the skin’s surface, texture, luminosity and hydration. To have a lifting effect, a sufficient volume needs to be injected. Adequate volumisation is very effective at giving the impression of a mini-facelift. The benefit is similar to that of lip augmentation using hyaluronic acid8


,


or breast augmentation. Some authors have used this superficial stimulation to describe a technique of vectors9


. For these authors,


superficial injections of products in the same direction as a surgical lifting vector give a lifting effect. In the authors’ opinion, we do not believe that there is any vector in the eventual tightening effect following


40 ❚ It is important


to remember that when injecting fillers, the harmony of the volumes produced is often more important than the volume itself.


References


1. Belhaouari L, Gassia V. The Art of Botulinum Toxin in Aesthetics. France: Arnette Wolters Kluver France, 2006


2. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg 2007; 119(7): 2219–27


3. Rohrich RJ, Pessa JE. The retaining system of the face: histologic evaluation of the septal boundaries of the subcutaneous fat compartments. Plast Reconstr Surg 2008; 121(5): 1804–9


4. Niforos RF. Midfacial ageing. Ann Chir Plast Esthet 2009; 54(5): 408–10


5. Lambros V. Observations on periorbital and midface aging. Plast Reconstr Surg 2007; 120(5): 1367–76


6. Lelouarn C. La région médiofaciale. Ann Chir Plast Esthet 2009; 54: 411–20


7. Belhaouari L. How to enhance lips with hyaluronic acid. Prime 2011; 1(1): 14–21


8. Elbaz JS, Costagliola M, Belhaouari L. La chirurgie de la senescence du visage: Report of the 18th national congress of the French Society Plastic Surgery: Paris, 1983


9. Goldie K. New techniques of 3D vectoring using atraumatic cannulae. Prime 2011; 1(4): 24–34


10. Meyer K, Palmer JW. The polysaccharide of the vitreous humor. J Biol Chem 1934; 107: 629–34


11. Belhaouari l. Mid face rejuvenation. Presented at AMWC, Monaco: April 2011


12. Ascher B, Cerceau M, Baspeyras M, Rossi B. Soft tissue filling with hyaluronic acid. Ann Chir Plast Esthet 2004; 49(5): 465–85


13. Delmar H. Anatomy of the midface. Ann Chir Plast Esthet 2009; 54(5): 399–407


14. Mendelson BC, Hartley W, Scott M, McNab A, Granzow JW. Age-related changes of the orbit and midcheek and the implications for facial rejuvenation. Aesthetic Plast Surg 2007; 31(5): 419–23


15. Rouvière H. Delmas A. Anatomie Humaine tome 1. 13th edn. Masson, 1991


16. Raspaldo H, Aziza R, Belhaouari L et al. How to achieve synergy between volume replacement and filling products for global facial rejuvenation. J Cosmet Laser Ther 2011; 13(2): 77–86


17. Sadick NS, Carniol PJ, Roy D, Wiest L. Illustrated Manual of Injectable Fillers. Informa Healthcare: London, 2011


stimulation of fibroblasts. The response of the fibroblasts after stimulation has no vector, but works in all directions. Rather than how to inject (vertical vector lifting or


horizontal vector; Figure 7), it is the placement area of these injections which will have an eventual tightening in all directions from fibroblast stimulation. The single vector that may exist can address key areas by placing the right product in the right place, and by using an effective technique. It is undeniable that superficial injections of hyaluronic acid have a beneficial effect on the skin’s surface — it is more hydrated and radiant. This is in addition to the slight tensor effect described above, to ‘boost’ the skin. It is also undeniable that the volumisation of key areas gives an apparent mini lifting effect, in addition to a volumising effect.


Conclusions A beautiful smile lights up the face. Enhancement and rejuvenation of the mid-face will embellish the luminosity of the smile and overall appearance. The use of hyaluronic acid products, the quality of which is constantly evolving, achieves this result. However, it is important to remember that when injecting fillers, the harmony of the volumes produced is often more important than the volume itself. The confidence of our patients and our credibility as physicians, respecting the rules of safety and quality, combined with our knowledge and expertise are essential.


 Declaration of interest None for this publication. Dr Lakhdar Belhaouari is a consultant for Allergan Inc., and has received grants for conferences, masterclasses and video presentations.


 Figure images 2-7 © Belhaouari


January/February 2012 | prime-journal.com


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