Treatment of the facial wrinkles with Hyaluronic Acid

The treatment of facial wrinkles has been one of the most wanted medical treatments in these past few years. Among all the molecules in disposal, the most used and safest is obviously the hyaluronic acid.

What is hyaluronic acid?

It is a natural mucopolysaccharide of the body composed of Glucuronic Acid and N-acetylglucosamine. The connective of skin is composed of water (63%), collagen (32%) and hyaluronic acid (1%).
The hyaluronic acid is represented in different ways in the body: for example, it is well concentrated in the vitreous humor, in the umbilical cord and in the articulations, where it allows a great mobility of bones.
It is an amorphous substance, soluble in water, and it has among its most important functions, the one to keep water, giving plasticity and turgidity to the cutaneous tissue, so typical in young creatures: let us think about babies’ skin!
Beside, in the derma, it regulates the hydration and turgidity, establishing a tridimensional structure.
The hyaluronic acid is used, beside the aesthetic medicine, in orthopedics for the intra-articular injections, to recover the viscoelasticity of articular liquid (due to its antiphlogistic and analgesic action), in dermatology, in the treatment of some dermatitis, in urology for the treatment of interstitial cysts.

How can we fill the wrinkles?

The operation is based on injecting a gel under the wrinkle, or where the volume is missing: for example, to reshape the cheekbones, or give the volume back to too thin lips, or consumed by the time.
The injection is done with a very thin needle in the derma. During this step, experience is fundamental, but especially the wisdom of the operator.
Exaggerated lips or too defined or faked cheekbones are often much in demand by some patients, but sometimes, on the contrary, at the end of the treatment we have the same results without the consent or the awareness of the patient.

I personally prefer not to treat patients who want exaggerated results and I have to admit that I often had to let some patient go and I now see them after bad injections.
Both the operator and the patient have to have some artistic sense to obtain good results.

Is the treatment painful?

The patient has to come to the surgery al least half an hour before the treatment: an anesthetic lotion made of lidocaine or prolocaine that take all the pain away, is applied on the patient.
In some spots, this anesthesia is almost total, while in some others, as lips, can not be totally sufficient.
Beside, the efficiency of anesthesia depends on the person and how much pain he can stand.
In some patient the anesthesia is not needed.
It is possible on more sensitive area, as lips, to have a truncal anesthesia which allows not to feel the pain.

Different types of Hyaluronic Acid:

Filling Acids, fillers:

Beside important hyaluronic acids imported from outside Europe, as countries from the Far East which I personally think they are not safe, the most used are the American hyaluronic acid, Hylaform, produced from the crest of cocks, and the Sweden hyaluronic acid, Restylane, produced in laboratory.
Then, there are different concentrations for each of them:

• the fine line used for very thin wrinkles (200.000 particles per ml)
• the normal type used for every kind of needs (100.000 particles per ml)
• a third type with big particles (10.000 particles per ml), used for the volumes of cheekbones, lips and cheeks.

Nowadays there are fillers that can be reticular so that they can last more. Besides having the addition of the biointeractive hyaluronic acid, the injectibility improved a lot and it is possible to use very thin needles.

The duration lasts according to the substance and quantity injected, which means approximately from 3-4 month for the fine line to the 8 months for the big particles.
The injective technique can be with microponfi, one close to the other, or tunnelized, depositing the material while the needle comes out.
In particular, the reticulum technique is very useful on cheeks because it gives support to the skin besides filling up the poor tissue.
Lately on the market there are new products, more lasting which allow two different actions:

• a regenerative one, which allows the formation of new collagen with a curative function.
• a filling one.

This double action allows to obtain more lasting results in a year, sometimes more.

Beside, we still have on the market fillers made of cross-linked hyaluronic acid with the addition of hydroxy-propyl-methyl-cellulose, cross-linked dextan and lactic acid.
Next on the Italian market based on biotechnology (we are still waiting for the prices to lower a little bit so that every patient can have the same possibility) a new product (Isolagen), which allows to obtain growings of fibroblasts, and from these, new autologous collagen from the same person.
A piece of skin is taken from the back of the ear, it is sent to a specific laboratory (American or English). Here the fibroblasts are isolated, cultivated, multiplied and reintroduced in a syringe. Through this syringe, pre-filled with patient’s fibroblasts, some implants on poor area are performed: these will produce collagen giving the filling effect.
It is used for lips or nasogenian furrow, but also for acne where seems to give some good results.
Clinical trials are now advanced and we think we will be able to propose it to our patients soon.

All these substances are very expensive, and this is the reason why often prices appear too exaggerated. We need to consider that safety is important and it is not possible to think about saving, buying less cheap acids, but from an uncertain origin.
I believe that it is better to spend a little bit more, but be sure that what you are injecting is safe.

Revitalizing Acids:

There are some products, the so called revitalizing, that are useful as filling, but they also have the aim to revitalize the tissues. They are used by themselves and in association with some other substances and locally injected in face, neck, décolleté and hands, the zones that are more exposed to aging.
It is a hyaluronic acid, equal to the one present in the tissues that, once it is in the skin, helps to recreate an ideal physiological environment, to stimulate the cellular functionality, and recreate the same conditions when we were young.
These hyaluronic acids are more useful for instance in the treatment of neck and décolleté, but they are also well efficient even in the treatment of knees and arms.
Then there are numerous associations of hyaluronic acid with non reabsorbable product that I use.

Which are the risks of an infiltration with hyaluronic acid?

Saying that there are not completely safe substances and that even the sterile water, if injected with low dosage, can provoke some reactions, the hyaluronic acid remains a very safe and reliable substance.
The cases of reactions are 1% and for the majority of cases they go away after few hours or at most after few days.
There are not allergic proof to do, it is not required by law and even the pharmaceutical firms do not need to have it done because, in many years, allergic reactions never occurred.
It is normal to see sometimes a swelling in the area injected, rarely impressive, especially on lips. It is due to hydration and it goes away after few hours.
Infections are possible.
Ecchymosis are possible. Very rare the ematomas.
In conclusion, it has to be underlined that every reaction goes away with the reabsorption of the used substance that for what regards the hyaluronic acid is always completed.
For this reason, the non reabsorbable materials are more dangerous.

Tab. 1: advantages and disadvantages

What can we treat with hyaluronic acid?

Hyaluronic acid is very useful in the filling of volume, so in all those cases where we need to fill a particular district or in the direct filling of wrinkles:

Wrinkles of the forehead, glabella and crow’s feet:

Even thought these wrinkles are mimic, and so they better respond to treatment as botulinum toxin that reduces the muscular movement, it is however possible to fill them with the hyaluronic acid. In this case it is better to use not too coarse acids, but the “fine line” ones are in general the best.

Cheekbones:

This is a very important area in the aesthetic of face. In fact the cheekbone zone tends to drop down in the middle, accentuating the wrinkle of the nasogenian furrow.
Filling the cheekbone area naturally, the nasogenian furrow improves a lot. Obviously it is very important not to exaggerate, doing faked cheekbones…
The injection is very easy, without pain and it has to be done deeply, using the hyaluronic acid with big particles and very reticular so that it lasts as much as it can.

Peribuccal area: code bar wrinkles:

This is the most interesting area and it has always been done with hyaluronic acid.
It is used associated to a technique with microponfi.

The result, if the indication is correct, is always good.

Another good material for these wrinkles is the collagen of human derivation. It has no longer the allergic problem it used to have and it is very malleable, more than the hyaluronic acid.
The only faults it has are: being very expensive and it does not last too much!

Nasogenian furrows:

Even these are treated often and with very good results. The results are visible for 6-8 months, but the quantity of filler needed has to be adequate and very abundant (even 2-3 phials).

Lip: paris lip.

Lips are an area that is practically treated with hyaluronic acid. We can give back the volume, or give volume to a smaller lip. We can also give more projection to a lip already perfect, but that wants to be more defined.

New areas: jaw profile.

The jaw profile with the wrinkles of the marionette tend to become irregular because the tissues tend to drop down in the middle.
With the hyaluronic acid, we can reduce this defect a lot, even thought the best result can be obtained with a surgical operation (lifting).
In this area the botulinum toxin can give great results, and as I always underline, we can obtain great results with integrated techniques.
We have not found yet, the technique that solves every problem!

New areas: the superior orbital profile.

Even the orbital bone tends to become rarefied with the time and this is associated with a drop of tissues.
With the hyaluronic acid it is possible to give the volume back to the orbital profile right under the eyebrow, in particular in its lateral side, with the total dump of the superior eyelid which will improve a lot and with a better projection of the zone.
Even the eyebrow will appear higher, almost lifted up.

New areas: medical rhinoplasty

Through the combined use of the hyaluronic acid and the botulinum toxin, it is possible to treat many cases of nose irregularities, from Dante’s nose to a not very accentuated gibbus, to all those minor defects that the surgeon does not treat.

The operation with the hyaluronic acid is immediately visible, you just need few minutes and no problems occur. It is as genial as simple it is.
In the picture above, you see the result just after few minutes after the injections!

In conclusion, the characteristics of hyaluronic acid are: the great handiness and the immediate results with a very acceptable incidence of collateral effects.

Dr Redaelli Alessio

Update on 07.04.2007

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