Treatment of Mid-Face Aging with Calcium Hydroxylapatite: Focus on Retaining Ligament Support

Abstract

The mid-face has been rendered as the cornerstone of facial aesthetic improvement, since treating the mid-face has also beneficial effects on neighboring esthetic units and therefore should be one of the first areas to be assessed. Retaining ligaments (RL) bind soft tissue layers of the face to the underlying facial skeleton. It remains controversial whether RL suffers laxity with aging or if changes in 42 bone and other structures where ligaments are inserted lead to altered mechanical function of the latter. Enhancement of the supportive effect of the ligaments could help restore the soft tissues to their original anatomical positions and achieve a lifting effect. While injectable hyaluronic acid implants have been used to improve ligament support, calcium hydroxylapatite has one of the highest viscoelasticities when compared with other dermal fillers and can induce collagen synthesis, which could provide long-term laxity correction. In this preliminary report of a case series, our goal was to describe the use of calcium hydroxylapatite in different dilutions and combinations for different aging profiles to treat the midface as an alternative for hyaluronic acid injections and to describe the ultrasonographic behavior in the long run.

Keywords: aging pattern; calcium hydroxylapatite; hyaluronic acid; rejuvenation; retaining ligaments; soft tissue repositioning.

Figure 1

String of Pearls technique. (A) Delineation of the antero-inferior border of the zygoma and the palpebro-malar groove. (B) From an entry point below the apex of the zygoma, inject 1 supraperiosteal bolus of 0.3mL of CaHA(+) in the transition of the palpebral malar groove and the antero-inferior border of the zygoma, and while retracting the cannula, 1 bolus of 0.2mL in the deep subcutaneous plane and another 0.2mL bolus in the superficial subcutaneous plane. (C) Retroinjection of subcutaneous microboluses of CaHA(+) along the whole zygoma area.

Figure 2

Variation of the technique for heavy faces. (A) Delineation of the antero-inferior border of the zygoma and the palpebro-malar groove. (B) For severe cases or in broader faces, more than one supraperiosteal bolus of 0.3mL may be needed, totaling 4 boluses (2 supraperiosteal, 1 deep subcutaneous, 1 superficial subcutaneous). (C) Retroinjection of subcutaneous microboluses of CaHA(+) along the whole zygoma area. (D) Injection of 1mL of CaHA (Dilution: 1.5mL + 0.5mL of lidocaine 2% without epinephrine) parallel to the zygomatic arch to create a posterior-lateral vector for further tissue support.

Figure 3

Variation of the technique for cases with associated skin laxity with atrophy. (A) From an entry point below the apex of the zygoma, injection of 4 boluses (2 supraperiosteal, 1 deep subcutaneous, 1 superficial subcutaneous). (B) Retroinjection of subcutaneous microboluses of CaHA(+) along the whole zygoma area. In males, to avoid broadening and feminization of the face, point the cannula to the insertion of the orbicular ligament. (C) non-volumetric bio stimulation with CaHa diluted 1:1 in the subcutaneous plane to improve skin collagen content, with minimal volumization.

Figure 4

(A) Quantificare vector analyses to evaluate soft tissue repositioning. (B) Arrows demonstrate direction of tissue displacement and red color indicates degree of displacement. Red arrows in the malar area demonstrate the lifting effect post-treatment.

Figure 5

Ultrasound image highlighting the dual plane approach. CaHA(+) observed as hyperechogenic images right next to the periosteum (blue star; (A), in the deep subcutaneous plane and also in the superficial subcutaneous plane (blue stars; (B).

Figure 6

Coalescence of injected boluses. (A) CaHa (+) boluses right after injection (blue stars). (B) 2-month follow-up: Boluses have coalesced as a hyperechogenic homogeneous strip (blue stars).

Figure 7

Build-up effect. (A) One year after the 1st treatment the hyperechogenic band is still present (black stars). (B) Right after re-treatment, new boluses (blue stars) are observed below the band (black stars). (C) Build-up effect: 2 months from re-treatment, a new thick hyperechogenic band (blue stars) is observed below the previous band (black stars).