"The V effect - from wrinkle correction to volume"
Face International magazine of orofacial esthetics, 2/2012, Oemus Verlag
As part of the skin ageing process, in addition to the loss of elasticity and resilience, there is also a loss of volume in the superficial and deep fat compartments. Together with atrophy of the bone (e.g. the zygomatic region) with consecutive reduction of the bony support and the anterior projection, this results in traction on the skin and muscles. Combined with gravity, the proportions of the face are shifted in the sense of a reversal of the youthful V-shape.
These ageing changes to the face can also be characterised three-dimensionally using vectors.
In order to regain the youthful shape of the face, the facial vectors should be used for rejuvenation in the sense of a lateral and vertical lift for volume replacement.
A mineral substance class is ideally suited for volumising and recovering larger volume defects. Calcium hydroxylaptatite (CaHA), with the brand name Radiesse®, has been authorised in the EU since 2004 and in the USA since 2006. It consists of 30 % so-called microspheres, which are characterised by a small diameter with a round, smooth surface (Ø25-40 µm) (Fig. 1). These are embedded in a gel matrix (cellulose-based gel made of water and glycerine), which allows the preparation to be injected evenly. The gel carrier makes up the remaining 70 % of the product and also serves as a filler for immediate correction.
The substance has been classified by the FDA as GRAS (Generally Recognised As Safe). Radiesse® is physically characterised by high elasticity and high viscosity. This means that the material has a high resistance to stretching and is more resistant to negative vectors such as gravity and skin laxity. It also has an excellent lifting capacity, meaning that little volume is required. The filler remains where it was placed.
The slightly increased force required for distribution can be reduced by mixing with lidocaine. While this procedure is still an off-label use in the EU, it has been approved by the FDA in the USA since 2009.
Deep injections (deep dermis or upper subcutis) stimulate the skin to produce collagen. Too superficial an injection must be avoided at all costs, as the whitish material may be visible and can lead to irregular contours. Once the material has been implanted, it must be massaged out carefully and moderately in accordance with cosmetic requirements.
If an imaginary line is drawn from the ala nasi to the tragus, injections should be made supraperiosteally above this line and deeply dermally or subcutaneously below this line. Supraperiosteal application is also possible when contouring the mandibular chin line. It is advisable to draw these and other auxiliary lines with a white eyeliner pencil before treatment.
In addition to the usual injection with conventional, so-called pointed cannulas, facial rejuvenation with CaHA can also be introduced into the tissue in an atraumatic manner using so-called blunt cannulas. After injecting Radiesse®, the volume is immediately replaced at a ratio of 1:1.
In the further course of the process, the carrier matrix degrades and the microspheres form a scaffold in which the fibroblasts sprout and are stimulated to undergo collagen neogenesis. An increasingly firm network of collagen fibres forms in the dermis.
The microspheres gradually dissolve and are finally completely metabolised by myelophages. These processes have been demonstrated in numerous investigations, histopathological examinations and CT-controlled studies over time.
(Literature reference: Carruthers A et al, Radiographic and Computed Tomographic Studies of Calcium Hydroxylapatite for Treatment of HIV-Associated Facial Lipoatrophy and Correction of Nasolabial Folds, Dermatol Surg 2008, 34, 78-84. Berlin AL et al, Calcium Hydroxylapatite Filler for Facial Rejuvenation: A Histologic and Immunohistochemical Analysis; Dermatol Surg 2008;34: p. 64-p. 67)
The cheekbone/cheek region and the pronounced nasolabial and marionette lines are particularly suitable regions for volume build-up with CaHA. By changing the direction of traction of the elevators, the face is given a positive facial expression. The lifting effect also leads to a tightening of the ptotic areas of the face. In this way, an overall reversal of the negative vectors into positive vectors is achieved.
In addition to largely aesthetic indications, the successful treatment of HIV-induced lipoatrophy is also of particular importance. It should be noted that after extensive treatment with CaHA, apart from the patient's personal disposition, swelling can occur due to the special rheological properties, although this disappears again after a few days. As a prophylactic measure, the administration of cysteine proteases from the pineapple plant (Bromelain®) may be useful.
The preparation can also be used to treat minor nasal humps or volume deficits in the hands.
In conclusion, Radiesse® can be categorised as a synthetic, long-lasting, resorbable filler (alloplastic group). The above-mentioned mechanisms of the degradation process result in a longer shelf life of the preparation, which has been described in clinical studies as approx. 12 to 18 months.
Due to the current discussion regarding the health and safety of medical devices, it should be mentioned that Radiesse® has been tested by the FDA and comprehensive studies with a high number of patients - in comparison to other filling materials - are available. Nevertheless, the use of all types of filling materials should be applied against the background that they all have the potential to cause complications.
Source: face, 2_2012