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DETAILS | PHOTOS COURTESY OF GARRY LEE, MD By Garry R. Lee, MD 22 MARCH 2014 | Med Esthetics Mid-Face Volume Replacement Injecting JUVÉDERM VOLUMA XC with a blunt-tipped microcannula for mid-face lifting. The quest for a longer-lasting hyaluronic acid (HA) cosmetic injectable wrinkle fi ller is over with the FDA's recent approval of JUVÉDERM VOLUMA XC (or simply, VOLUMA). The advantage of a long-lasting HA-based fi ller is that patients can be sculpted even months after injection—and if too much product is injected, it can be dissolved with hyaluronidase. VOLUMA is FDA-approved to add volume to the midface. Though it is only indicated for patients with signifi cant mid- face volume defi cits, lifting the cheeks with VOLUMA can help to diminish the nasolabial fold and tear trough areas. In fact, investigators in clinical trials found an impressive 32% improvement in the Nasolabial Fold (NLF) Severity Scale— even though there was no treatment at all in the NLF's. Another serendipitous fi nding was that 53% of subjects re- ported moderate or better improvement of the tear trough area—again without specifi c treatment. PATIENT SELECTION At my practice, I begin by screening patients for contraindi- cations such as multiple severe allergies, allergies to gram positive bacteria, and allergies to lidocaine—which is incorporated directly into VOLUMA. I then analyze the cheek to assess the Ogee Curve—the S-shaped curve from the cheekbone to the mid-cheek hollow. As we age, we lose this natural youthful curve. The midface fl attens, the skin sags, and bony landmarks and concavity become prominent. Next, I clean the skin and apply the topical anesthetic of choice for 10 or more minutes. Then, I wipe it off and use a surgical marker to draw in Hinderer's Lines to indicate the malar prominence and precisely mark the areas to place VOLUMA. Hinderer's Lines are two distinct lines which cross on the midface to delineate four areas: The fi rst line is from the lateral canthus to the oral commissure; the second is from the tragus of the ear to the upper alar lobule of the nose (see photo 1). This results in four distinct zones and four distinct injection sites per Allergan's VOLUMA protocol. Injection sites 1 and 2 are in the Zygomatic Arch above the periosteum. They lift the cheek laterally, setting an anchor point and establishing a fuller, rounder upper cheek. Injection site 3 is in the Anteromedial area, and injection site 4 is in the Submalar area. These injections sequentially add volume as needed. It is important to inject in sequence because less product will be needed medially and below if the structural frame- work laterally and above is fi rst established. To help pinpoint the precise injection sites, I like to apply traction just above the injection site and visually estimate the effect immediately below, a process I call Traction Estimation. INJECTION TECHNIQUE The injection process varies based on the type of needle used: traditional sharp needle or blunt-tipped microcannula. Whichever tool is used, the greater depth of injection to the BEFORE AFTER D e t a i l s M E D 3 1 4 . i n d d 2 2 Details MED314.indd 22 2 / 1 1 / 1 4 3 : 4 9 P M 2/11/14 3:49 PM