QUEBEC CITY A series of deep injections with hyaluronic acid fillers to lift the cheek and lower eyelid regions appears to provide long-term cosmetic results, Wayne Carey, M.D., said at the annual conference of the Canadian Dermatology Association.
Deep injections of hyaluronic acids have been thought conventionally to be quickly absorbed if injected below the dermis, but deeper bolus injections appear to have long-lasting effects, said Dr. Carey, director of dermatologic surgery at McGill University, Montreal.
Dr. Carey's "tri-site bolus technique" delivers a bolus of hyaluronic acid to tissue about 315 mm deep into subcutaneous, supraperiosteal areas, unlike other procedures that employ a threading or microdroplet technique to inject filler to a depth of only 12 mm.
"This is a treatment that addresses the midface aging that is not corrected by facelifts or blepharoplasty," he said.
The technique increases the cheek volume, allows sculpting of the cheek in the zygomatic region, lifts or ablates the palpebral sulcus, and may increase the nasolabial fold indirectly by volumetric expansion of the cheek, he explained. It often makes a lower eyelid blepharoplasty or standard facelift unnecessary.
During the procedure, Dr. Carey asks his patients to sit erect while he delivers a continuous deep injection without anesthesia, without moving the needle, and without massaging the injection area; this forms a nonvisible, subcutaneous nodule. Right-handers inject with the right hand and control the migration of the material with the left hand.
He typically injects 15 syringes (each is 0.8 mL) into the upper cheek area on each side, although on average he injects 2.53 syringes per side. The first site of injection is usually around the location of the infraorbital nerve, followed by the zygomatic and nasal-jugal sulcus areas.
The effects of the technique have lasted over 1824 months of follow-up and even up to 4 years in one woman, said Dr. Carey, who said he has no conflicts of interest regarding any hyaluronic acid products.
Although Dr. Carey has used only Perlane and Juvederm 30 in more than 75 patients he has treated with his technique, he suggested that deep, bolus injections with Restylane or Hylaform would theoretically give the same longevity seen in his patients, he said in an interview. Perlane and Restylane produce a more swollen appearance in the first few days after injection than other hyaluronic acid products, such as Juvederm, because they draw in more water from their surroundings.
The bolus technique may last longer than other procedures that inject hyaluronic acid products into the dermis because the nodule that is formed with the technique has a lower surface-area-to-volume ratio, making less hyaluronic acid available for hyaluronidase to break down. The body also might wall off the nodule, which would also make it less susceptible to hyaluronidase, Dr. Carey suggested. In a report, a biopsy of an injection site where Restylane persisted for 5 years showed a fibrotic reaction (Ophthal. Plast. Reconstr. Surg. 2004;20:3178).
Heavy bruising lasting up to 1 week has been a significant problem in most patients who received the injections. One patient had prolonged pigmentation, which might be deposits of hemosiderin or postinflammatory hyperpigmentation, he said. Another patient has had persistent, unilateral lymphedema for about 2 months, but has improved during the last few weeks, Dr. Carey said. He is considering injecting hyaluronidase into the treatment site to relieve the complication.
Before treatment, this patient had malar bags and considerable loss of subcutaneous tissue of the cheeks.
Final results were achieved after injection of 13 syringes of hyaluronic acid. Photos courtesy Dr. Wayne Carey