We present two facial filling techniques using hyaluronic acid and the results obtained with this method developed by us based on the physical principles of support, to optimize and rationalize the filling material and improve results, especially the cost-benefit ratio. We also make a general presentation of the basic principles to achieve reshaping the skin tissue using facial filling techniques. We point out the importance of clinical evaluation to reach a good diagnosis, emphasizing the limits of patient selection and enumerating the important and ethical points in the use of fillers.
We present two techniques of facial injectable resorbable filling, using hyaluronic acid (HA), and the different results obtained with both methods, based on physical principles of sustainability, intending to demonstrate how theese techniques can optimize and rationalize the use of the filling substance, contributing to enhance the results and cost-benefit relation.
We also make a general presentation of the basic principles that remodel the cutaneous tissue using facial filling methods, as well as the importance of the clinical evaluation to achieve a fine diagnostic, emphasizing the limits when selecting the patient, listing the important and ethical points related to the use of facial filling procedures.
Wrinkles are the most obvious sign of facial aging; are dermo-epidermal depressions, caused mainly by the sun (photoaging), by intrinsic aging and the influence of factors such as: gravitational force, repeated muscle movements of mimicry, disorganization of collagen and elastic fibers and by progressive loss of glycosaminoglycans ( 1-3).
At present, there are various treatment methods that should be indicated according to the degree and type of aging of the patient, using the different classifications described in the literature (Fitzpatrick, Glogau) (3-5).
On the face, and according to the degree of aging, we can find: lines, wrinkles, folds, furrows, hyperchromias, hypochromias, flaccidity, premalignant and malignant lesions, all of them typical of aging, which can converge and form complex signs of difficult treatment (5-8).
Assessment of aging
The Glogau classification continues to be very useful for the diagnosis of aging (Types I, II, III, IV) (4-9), but given that patients currently use more and more preventive methods, they often do not appear to be chronological age they really have. Therefore, in practice we should not diagnose aging by age, but it would be correct in any clinical evaluation to do so in relation to the alterations that each individual presents.
In all aesthetic treatment, the objective is the restructuring of the face, improving the so-called triangles of youth (open angle of the orbital lateral wall, malar and definition of the mandibular contour) (4-7).
For superficial wrinkles we indicate exfoliative methods and any procedure that increases the thickness of the epidermis and stimulates the organization of fibroblasts in the dermis.
For deep wrinkles, in general, there is a combination between surgical procedures and filling techniques, the latter being used either in a deep way (fat, dermis, hydroxyapatite,) or superficial or regenerating (hyaluronic Ac., Polylactic Ac., Ac. mandelic) .
The middle third of the face is where the greatest number of muscle groups are found that suffer the action of gravity, and it is also the region with the greatest difficulty to stay firm; As a consequence, the most serious signs of aging are formed at this level: wrinkles, pronounced furrows (nasolabial folds, lip corner), alterations of the mandibular contour, alterations of the lip (flat and long filtrum, sad mouth, vertical wrinkles, alterations of the vermilion) (8.9). This is why it is in this region where the greatest number of surgical and non-surgical aesthetic procedures can be performed and also, the region in which the use of filling materials is most indicated.
When we refer to treatment and prevention, we must give greater importance to the frontal and cervical areas, where we find unique and superficial muscular structures, more accessible to treat in conjunction with the skin. The strengthening and toning of these regions will form true muscular pillars (like columns that support the face), which provide greater firmness and support, especially to the middle third, preventing prematurely the appearance of the signs of aging (4-10).
The semiological analysis of a region is important to indicate on it a specific treatment and a preventive treatment. The preventive use of fillers is justified to support a flaccid area that in the future will be more depressed or more elastotic, in young patients who have mild or medium signs of aging (family biotype). When carrying out prevention, it is not indicated to use permanent materials, since we would not be complying with the concept of treatment that is to feed and nourish the aging tissue, denying the opportunity for it to naturally recover and maintain its structures (3-9).
Few filling techniques have been described in the last decade (3,11), but we have appreciated the large number of compounds and products that appeared on the market to carry out these procedures with publications that mostly deal with experiences with the use of different materials.
Selecting the patient for filling
Procedures based on the use of filling materials are indicated in all patients, regardless of lip fillers cost, who present marked signs of aging in the region of the upper lip, lower lip, flattening of the upper lip with alteration of the filtrum pillars, furrows nasolabial (SNG) and labial commissures (CMS), with or without alterations of the mandibular contour, especially in Glogau grade I, II and III patients. In grade III and IV aging, when surgery is indicated, it can also be accompanied by the use of filling techniques in these same regions.
We recommend performing a bidigital maneuver (7) (placing the thumb and index fingers in the region We recommend performing a bidigital maneuver (7) (placing the thumb and index fingers in the malar region, and the same fingers of the opposite hand on the upper lip and chin as indicated in , which allows us to verify the state of the area and the point of least and greatest depth of the folds; in addition, it indicates the need for a less or greater amount of filling along the depression This region corresponds to the strongest point of facial aging (skin depression), where clinically there is the greatest need for support (critical point of aging) .
Limits on the use of facial filler materials
They are directly related to:
-Type of skin
-Degree of aging
-Type of wrinkle
-Profile of the patient (diet, physical activity, habits, profession, diseases)
As there are several possible combinations of alterations produced by aging, it is indicated to combine filling techniques and / or surgical procedures, peeling, laser, pulsed light, carbon dioxide, long wave, radio frequency, infrared and other procedures. Each professional must have the experience to evaluate the patient and indicate one or another procedure.
In our experience, patients with a round face shape and / or oily or acneic skin tend to have poorer results or may have complications such as: longer inflammatory processes, risk of infection due to purulent lesions, or reactivation of intradermal cysts
Ethical Aspects of Using Facial Filler Materials
If we consider an effective treatment from all possible points of view, until now there is no optimal filler material that meets all the properties and characteristics necessary to be so. What exists are specific parameters that must be respected and complied with when we use a product (7,8), namely:
-That does not migrate
-That does not require a previous test
-That has a duration (between 8 to 18 months)
-That is not permanent.
Thus, when referring to the best possible facial filling material, we can say that it would be the one that complying with the specific parameters described, manages to effectively fill the depressed region, be it a line, a wrinkle or a furrow and that also favors or does not intervene in cutaneous metabolism.
The filling material cannot cause serious fibrosis or mimic muscle mobility alterations. Most of the time we observe that permanent materials alter the movement of the region, limiting and altering the normal aging process. Generally, when we perform rhytidoplasties in patients in whom this type of permanent fillers have previously been used, a fibrous process occurs that always interferes with the surgical act, limiting the mobility of the facial structures.
All possible precautions justify special care when treating the glabellar region, especially when we use permanent compounds, with specific characteristics and properties to be applied in the depth of the tissue (subcutaneous), so they can be wrongly applied in important vessels, reaching produce complications from mild to severe, with publications even of cases of blindness (12,13).
It is important to remember that in general, our body has a conditioned reaction when a filling is made, be it resorbable, permanent or semi-permanent; initially it will respond to the foreign body with transient inflammation and normal defense reactions , but from here on, the answer will depend on the type of compound used and its specific properties. Generally, permanent compounds are more susceptible to producing a chronic inflammatory reaction, with extrusion of the compound in most cases and disfiguring alterations in the skin, often with indication of en bloc excision of skin and tissues in all its planes, which can leave unsightly scars. These types of reactions when using permanent compounds can occur even after several months or years of applying the compound (18 to 36 months). In more serious cases, when the compound is incompatible with the body, it can cause serious systemic alterations.