.........................................site officiel.Tous droits réservés. Docteur Joëlle Huth .................................

  It emerges from all the artistic, sociological, cosmetic or aesthetic studies and analyses that a rested and natural face with beautiful curves and lights are imperatives that we must find through our techniques of injections, chasing shadows and sad or tired looks.  Aesthetic acts remain primarily medical acts and must follow the rules of good practice.

Injectable filler products : Fillers (lipofilling non developed)

 Resorbable products are currently hyaluronic acids, and slowly resorbable products are L-polylactic acid and calcium hydroxyapatite. The consultation before the injection is a very important time of the medical procedure. The interview will look for medical history and will record previous cosmetic acts, especially the previously injected products nature and location. The act will be performed by a practitioner trained for this technique. The act’s traceability is mandatory (decree no. 2006-1497, decree of 26 January 2007). It is advised to give the product’s name and lot number to the patient and keep this information for at least 15 years in the medical record.

   1) Products: It is necessary to privilege the monophasic Hyaluronic Acids, well cross-         linked, with a minimum of BDE, and to well know the product that is injected.

   2) The position, the injection technique and the injectable category depend on the face’s anatomy and type you want to treat. Techniques are diverse:

 -  either with a thin needle: more precise but more often source of bruises and pain but allows injections in bolus or in retro tracing.

 - either with a cannula: prefer the cannulas of 25 Gauges in order to avoid perforating vessels and to keep a perfect asepsis. Injections will be retro-traced or/and fan-shaped for a napping.

 -  either superficial (mesotherapy) to treat irregularities or improve skin quality.

 - either deep under muscles and bone contact for excellent support and longer durabi- lity (because it will be less subject to the muscle’s movements and pressures).

  3)  Main injectable areas: malar cheekbones, dark circles and valley of tears, cheeks, nasolabial fold, corners, bitterness fold, chin, jowl, mandibular contour. Avoid injecting the cheeks above the mandibular median edge to avoid adding weight to the face. Injections for medical rhinoplasty are very useful and give beautiful results.

  4)  Injections risks:

  - harmless : redness, bleeding or bruises.

 - concerning: allergic reaction, skin whitening, Tyndall effect (especially in the ​​dark circles area), infection, granuloma (beware of the incompatibility between previously injected products), and the consequences of the use of the wrong product in the wrong place. Hyaluronidase injections are now authorized in France since July 2018, for example Hyalase®.

 - serious : cutaneous necrosis, vascular embolism, blindness, due to the filler’s migration into the external and internal carotid system (beware of the injections in the glabellar lines, nasal, or the nasolabial fold): requires immediate specialized management with always an injection of Hyaluronidase.

  5) Injections place according to the face: 8 types of faces (Fig 1) but in practice 6 types can be differentiated (Fig 2)

 Oval : (the most aesthetic and easy to treat), inject the cheekbones at a fairly high angle.

 Round : inject the cheekbones very diagonally with volume to hang the light.

 Narrow : inject the Bichat ball and the basilar edge of the oval of the face.

 Square : (masculine side that sometimes needs to be feminized), inject high and in a slanted direction.

 Pear shape : (often due to ageing). inject cheekbones and temples.

The injection’s purpose is to get closer to a perfect oval face.

In an inverted pear shape: (pointed down) inject the basilar edge.

Fig 1

Fig 2

Botulinum Toxin (BT) :

  Powerful neurotoxin produced by Clostridium Botulinium.

In 1993 the first “AMM” in France was obtained in ophthalmology and neurology for the correction of the face’s abnormal movements and spastic states. In 2002 the “FDA” approves the treatment of wrinkles with botulinum toxin injections. 4 types of toxins are available in clinical practice :

Botox®(100U)(medical),Vistabel®(50U)(cosmetic), type A, (Allergan)

Dysport®(medical),Azzalure®(cosmectic), type A, (Ipsen)

Xeomin®(medical) , Bocouture®(cosmetic)( 50U et 100U), type A ,(Merz)

Neurobloc®(medical), type B, (Elan).

   1°) The botulinum toxin’s mechanism of action (BT) : their structure has a heavy chain “H” of 100Kda (800AA) and a light chain “L” of  50 Kda for BOTOX® and VISTABEL® .

Heat inactivates the BT because it dissociates the 2 chains connected by a thermola- bile disulfide bridge except for Xeomin® or Bocouture® without complex protein. Neuromuscular transmission is therefore interrupted and the targeted muscle atro- phies itself in a reversible way. Muscle paralysis occurs between 24h and 5 days. Recovery is achieved in 14 weeks with the Vistabel® or Bocouture® and in 17 weeks with Azzalure®.

Muscle recovery is done thanks to the budding of axonal nerve endings on the targe- ted muscle (around the 2nd day) and by regenerating motor plaques. A recent con- cept proposes favorating injections in the motor plates for a better precision and efficiency. In order to avoid the development of "antibodies", it is advised to space injections by at least 12 weeks using the lowest recommended dose for the chosen injection zone. “AC” would be directed against complexing proteins.

   2°) Cosmetic clinical indications of botulinum toxin allows reducing facial wrinkles : lion wrinkles or glabelars, front wrinkles, crow’s feet wrinkles, or periocular, nose wrinkles or bunny lines, orange peel chin, reduces the bitterness fold by moving up the corners (“DAO” injection), platysmal chords, scars.

   3°) More specialized indications : upper and lower lip wrinkles, gingival smile, late- ral-commissural vertical wrinkles in the Risorius muscle, jaw lines, Fine neck muscle (Nefertiti), neckline.

4) Risks of side effects

Headache, facial pain, erythema, localized muscle weakness : rare and of short duration.

Pain on injection : unsuitable solvent to reconstitute the solution . ( EPPI )

Mephisto : Too important evaluation of the tail of the eyebrow. The patient should be seen again and it is proposed to inject the upper frontal muscle with 2 to 3 units . TB.

Ptosis of the eyelid: injection error by diffusion from the glabella or supraorbital area; it can appear from 48 h to 6 days after injection, persists for 3 to 6 weeks. Treatment: iopidine O,5% or Neosynephrine hydrochloride 2.5%, which acts on Muller's muscle located under the eyelid elevator muscle.

Radiofrequency of the skin 

 1 °) The skin radiofrequency uses a high frequency electric current that generates through the subcutaneous tissue a heat that will allow to break the collagen fibers, and the synthesis of neo collagen. and the synthesis of neo collagen. It thus allows skin resurfacing by improving the tone and quality of the skin (fine lines and enlar- ged pores), subtly reshaping the volumes of the face.

The principle of monopolar radio frequency requires a powerful 4 Mhz device.

 Its use is rather in line with the prevention of aging and the natural rejuvenation of the face of the neck and décolleté.There is a reorganization of the skin tension lines , resulting in a reduction in sagging skin. However, this effectiveness depends on the type of skin that is treated.

 The result will be less and more random on a very wrinkled skin with sun abuse and tobacco and better on skin rich in collagen, thick and dense.

  Usually 3 sessions of cutaneous radiofrequency are needed of about twenty minutes, at intervals of 3 weeks, with a visible effect especially from the 3 rd month, and persistent 12 months. There are no restrictions based on phototypes or season.

 2 °) The contraindications are few: pace maker, a cochlear implant, so as not to dis- disturb them, pregnancy, the presence of subcutaneous foreign bodies such as sus- suspension threads, skin tumor.

 3°) Protocol: After careful make-up removal, the doctor places a neutral conductive gel (ultrasound gel type) on the areas to be treated. A probe, whose diameter of the head is chosen according to the area to be treated, is passed by performing rapid circular movements, over the entire area.  It is necessary to stay well in contact with the skin to avoid creating an electric arc to avoid a superficial burn. No anesthesia is done.. This achieves a skin temperature of about 41 to 42 °C. The greater the heat delivered, the more effective the treatment. 

 CO² ablative fractional lasers :

   These lasers allow tissue vaporization leaving healthy skin intervals to achieve faster healing and less social eviction and more predictable side effects. They also allow to treat keloid scars

Course of treatment: It comes in 1 to 3 sessions spaced at least 2 months apart, which may require topical anesthesia or forced cold air.

  On a skin of phototype less than V, cleansed, cleaned and dried, (eye protection by shell mandatory) the handpiece is placed perpendicular to the skin, the shots are joined and cover the entire area to be treated. The session lasts about ten minutes for a face.

 The consequences can be minimal with little or no socio-professional eviction or more important, with edema, redness and oozing that can last more than 8 days depending on the duration of impulse chosen. Pre-laser treatment includes the application of contact anesthetic ointment at least 1 hour before the session. During the session the application of an ice pack is pleasant.

  Post-treatment care includes saline cleaning, then the application of healing cream and Fucidine until the crusts disappear. A solar eviction is essential for 2 months  and sun protection application afterwards. All areas of the face can be treated except the neck.

Conclusion : all techniques can be combined and effective provided they are well mastered.

Conception of the evolution of aesthetic medecine. Read