MD Codes™: A Methodological Approach to Facial Aesthetic Treatment with Injectable Hyaluronic Acid Fillers

Abstract

Background: Patients often seek aesthetic correction of facial deficiencies (e.g., lines and folds) that are rarely the underlying cause of dissatisfaction with their appearance. Use of a more holistic approach focused on improving the emotional messages of the face (e.g., looking less sad) may improve patient satisfaction with treatment outcomes. The MD Codes™ system was developed to increase clinician success rates by reducing variability in the technical aspects of hyaluronic acid (HA) filler treatment and focusing on addressing unfavorable emotional attributes of the face.

Methods: The MD Codes, or medical codes, represent specific anatomical subunits for injection of HA fillers. Each MD Code includes information regarding the target depth of injection, the proper delivery tool (needle or cannula) and delivery technique (e.g., aliquot, bolus, fanning), and the minimum product volume recommended to achieve visible, reproducible results (active number). During treatment planning, the appropriate MD Codes are selected using algorithms focused on lessening unfavorable facial attributes (a saggy, tired, sad, or angry look) and enhancing positive attributes (an attractive, younger, more contoured, or feminine [soft] or masculine look).

Results: Three case studies are presented to illustrate how the MD Codes and their algorithms were used to address sagginess, tiredness, and sadness in two women and one man.

Conclusions: MD Codes provide a universal symbolic language for reducing variability in injection technique. The platform provides user-friendly algorithms to help clinicians increase patient satisfaction by going beyond treatment of lines and folds and to focus on reducing unfavorable facial attributes.

Level of evidence iv: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Keywords: Aesthetics; Dermal fillers; Hyaluronic acid; Rejuvenation; Skin aging; Skin wrinkling.

Fig. 1

MD Codes anatomical correlates (a) and in relation to the topographical anatomy of the cheek (b). Red codes denote alert areas. Reprinted with permission from Allergan plc, Dublin, Ireland

Fig. 2

Algorithm for deciding which MD Codes to use to provide midface foundation by (a) treating saggy cheeks, to contour the upper face by (b) treating sunken temples, and to provide periorbital refinement by treating (c) the tear troughs and (d) the eye bags. Ck1, zygomatic arch; Ck2, zygomatic eminence; Ck3, anteromedial cheek–midcheek; Ck4, lateral lower cheek/parotid area; Ck5, submalar area; T1, anterior temple; T2, posterior temple; Tt1, central infraorbital; Tt2, lateral infraorbital; Tt3, medial infraorbital. Reprinted with permission from Maurício de Maio, MD, PhD

Fig. 2

Algorithm for deciding which MD Codes to use to provide midface foundation by (a) treating saggy cheeks, to contour the upper face by (b) treating sunken temples, and to provide periorbital refinement by treating (c) the tear troughs and (d) the eye bags. Ck1, zygomatic arch; Ck2, zygomatic eminence; Ck3, anteromedial cheek–midcheek; Ck4, lateral lower cheek/parotid area; Ck5, submalar area; T1, anterior temple; T2, posterior temple; Tt1, central infraorbital; Tt2, lateral infraorbital; Tt3, medial infraorbital. Reprinted with permission from Maurício de Maio, MD, PhD

Fig. 3

Improvement in emotional attributes of the face, with increasing volume over successive treatment steps using the MD Codes. This 53-year-old Asian woman presented with facial signs of sagginess in the midface and lower face, a tired look, and a sad look (left image). She is shown before treatment and immediately after receiving 4 mL total, 8 mL total, and the full 17 mL treatment, within a single session. The patient received a total of 17 syringes of Juvéderm products (Allergan plc), administered as 13 mL of Voluma, 3 mL of Volift, and 1 mL of Volbella. Reprinted with permission from Maurício de Maio, MD, PhD

Fig. 4

Case 1: A 43-year-old woman with a saggy appearance in the midface and lower face, tiredness around the eyes, and sadness in the periorbital and perioral areas. Images show the patient before treatment and immediately after the last treatment step from (a) the frontal view and from the oblique view, with (b) neutral and (c) animated facial expressions. The MD Codes, volumes, and products injected are summarized in panel d. The patient received Juvéderm products administered as 12 mL of Voluma, 3 mL of Volift, and 1 mL of Volbella, with a total of 16 syringes injected. ^aThe patient needed additional treatment of C6 and Jw1 during the third and fourth steps to provide additional contour to the lower face. Reprinted with permission from Maurício de Maio, MD, PhD

Fig. 5

Case 2: A 44-year-old women with facial signs of sagginess, tiredness, and sadness represented by the presence of saggy cheeks, eye bags, and marionette lines. Images show the patient before treatment and immediately after the last treatment step from (a) the frontal view and from the oblique view, with (b) neutral and (c) animated facial expressions. The MD Codes, volumes, and products injected are summarized in panel (d). The patient received 11 mL of Voluma, 3 mL of Volift, and 1 mL of Volbella, with a total of 15 syringes injected. Reprinted with permission from Maurício de Maio, MD, PhD

Fig. 6

Case 3: A 42-year-old man with saggy cheeks, a poorly defined jawline, and a double chin. Before and after images are shown from the frontal view with (a) neutral and (b) smiling expression, from (c) the oblique view, and from (d) the frontal view with the head tilted downward. The MD Codes, volumes, and products injected are summarized in panel e. The patient received a total of 20.0 mL of Juvéderm Voluma. Reprinted with permission from Maurício de Maio, MD, PhD