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By Wayne D. Carey, MD
Division of Dermatology, McGill University, Montreal, Canada
Tri-Site Bolus® Technique for a long-lasting cheek and lower eyelid lift using deep large volume hyaluronic acid injections
The upper cheek and lower eyelid region is an important reference area for determining the youthfulness of a face. With the onset of the aging process, some of the first telltale signs of senescence can be detected in the midface region. In the past, this has been a difficult area to rejuvenate, and has been neglected by aesthetic surgeons. The classic facelift does not address this region; and lower lid blepharoplasties, although they may remove the protruding fat pads, do not restore the loss of cheek fat or the youthful projection 1. The latter procedure may actually create a more hollow appearance to the area.
The author wishes to report on a novel technique called the Tri-Site Bolus®. Using this technique with commercially available HA gels Teosyal Ultra Deep and Ultimate and a specially designed 27 gauge needle, one is able to raise, soften or eliminate the tear trough; sculpt the cheeks to restore a youthful projection; and in many cases, eliminate the need for a lower lid blepharoplasty by creating a natural continuum between the lower eyelid and cheek.
Rather than using the feathering or microdroplet technique, the material is injected perpendicular to the skin as a confined bolus, into the deep subcutaneous tissue or supraperiosteal region, to create deep deposits in three specific sites, forming support structures, or pylons. These HA pylons create a suspension bridge that lift the tissues superiorly and restore the projection anteriorly in the midface region. Using HA, 1–5 syringes are injected per side, depending on the degree of atrophy. Over years of durability have been documented using this technique.The needle is inserted at a 90 degree angle to the skin surface at three specific sites into the deep subcutaneous tissue or supraperiosteal region. The needle remains in a stationary position during the injection; the other hand is placed on the patient’s face to controlmigration of the material. The material is injected very slowly from the syringe. It often takes 2–3 minutes to empty the entire syringe in one location, creating a deep non-visible subcutaneous deposit. There is no massaging of the tissue unless too much material has been injected. The degree of atrophy determines the amount of material required.
One is able to sculpt the region by using an average of 1–5 syringes per side. This rebuilds the cheek and zygomatic area, and softens or often removes lower eyelid bags by eliminating the transition between the cheek and lower eyelid. The tear trough area is also improved and raised to a higher position or eliminated. In large volume cases there is often a softening and improvement of the nasolabial groove as the tissue is lifted by the volumetric expansion of the cheek.
The first injection is usually around the infra-orbital nerve location, the next in the zygomatic area, and the last in the medial nasal-jugal sulcus area. Typically one or more full syringes are emptied into the first area. After a critical amount of material has been injected in the midline, there is a sudden lift of the tear trough which is ablated or softened.
Discussion
Midface aging is characterized by several features, notably soft tissue ptsosis, loss of cheek projection, mid-cheek crease, tear trough formation, deepening of the nasal labial lines, and lower eyelid bags. Most normal-weight individuals will have some visible degree of these changes present by the age of forty.
The explanation for the durability of HA when placed as a bolus in the subcutaneous fat is unknown. The material is intentionally injected to keep it concentrated as a nodule, and not dispersed. With this technique there may be less surface area available for degradation by enzymes when compared to the feathering technique. Alternatively, the body may try to wall off a large inert mass in contrast to small microdrops or cylinders.
The important factors for success depend on the correct placement; viscosity and type of HA; control of flow and migration; and the correct volume. The technique of three specific injection sites, slow injection, and large volume is the key to success and duration.
Dr Wayne Carey pioneered the technique of long lasting volume filling of the cheek using Hyaluronic acid injections called the Tri Site Bolus technique which is a patented in Canada and the USA. He has demonstrated his technique internationally at numerous workshops around the world. The technique involves strategic points of injection and volume of material using Hyaluronic acid. He uses exclusively Teosyal ultra deep for his technique because of its lifting ability and duration. During the lecture and workshop this year he will illustrate the fundamentals of the technique and also demonstrate how he chooses the ideal patients for this technique. His goal is to correct the volume loss creating a natural pleasing look without having an exaggerated or abnormal projection. Dr. Carey is presently the Director of the Dermatological fellowship program at McGill University in Montreal and also the former Chief of Dermatology. He presently practices in a private clinic in Montreal.
References
1. Ramirez OM. Buccal fat pad pedicle flap for midface augmentation. Ann Plast Surg 1999;43:109-18.
2. Freeman SM. Rejuvenation of the midface. Facial Plastic Surg 2003;19:223-236.
3. Flowers RS. Tear trough implants for correction of tear trough deformity. Clinics in Plastic Surgery 1993;20:403-415.
4. Camirand A, Doucet J, Harris J. Eyelid Aging: The historical evolution of its management. Aesthetic Plastic Surgery 2005;29:65-73.
5. Coleman SR. Structural fat grafts. The ideal filler? Clinics Plast Surg 2001;28:111-119.
6. Verpaele A, Stran A. Restylane Sub-Q, a non-animal stabilized hyaluronic acid gel for soft tissue augumentation of the mid and lower face. Aesthetic Surgery J 2006;S10-S17.
7. Goldberg RA, McCann JD, Fiaschetti D et al. What causes eyelid bags? Analysis of 114 consecutive patients. Plast Reconstr Surg 2005;115:1395-1402.
8. Mendelson BC. Herniated fat and the orbital septum of the lower lid. Clinics in Plastic Surgery 1993;20:323-330.
9. Carruthers A, Carey WD, De Lorenzi C et al. Randomized, double-blind comparison of the efficacy of two hyaluronic acid derivatives, Restylane, Perlane and Hylaform, in the treatment of nasolabial folds. Dermatol Surg 2005;31:1591-1598.
10. Ascher B, Cerceau M, Badspeyras M et al. Soft tissue filling with hyaluronic acid. Annales de Chirurgie Plastique Esthetique 2004;49:465-485.
11. Soparkar SC, Patinely JR, Tschen J. Erasing Restylane. Ophthal Plast Reconstr Surg 2004;20:317-318.
12. Klein AW. Soft tissue augumentation 2006: Filler fantasy. Dermatologic Therapy 2006;19:129-133.
13. Furnas DW. Festoons, mounds, and bags of the eyelids and cheek. Clinics in Plastic Surgery 1993;20:367-385.
14. Farrior RT, Kassir RR. Management of malar folds in blepharoplasty. Laryngoscope 1998;108:1659-1663.
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