Therapy concept using the example of hyaluron filler treatment

Also in aesthetic medicine an exact diagnosis is indispensable before treatment. Good standard operating procedures have a positive impact on outcomes and patient satisfaction. Absorbable hyaluronic fillers are very suitable for non-mimic wrinkles and volume defects and the safety profile is very good when used properly.

There is the famous saying “Beauty is in the eye of the beholder”, attributed to the Athenian strategist and outstanding ancient historian Thucydides (455-400 BC). This sentence has lost none of its validity to this day.

Treatment philosophy and objective

Of course, beauty is always dependent on time, society and culture. Nevertheless, there are also important constants that endure over time:

The beauty ideal of the Occident is clearly more than 2000 years old and thus far older than industrialization and general prosperity.
The occidental ideal of beauty has become globalized and flawless skin is strived for in all cultures.
Optimal proportions result in optimal function and optimal beauty as already impressively shown in the studies of the “Vitruvian Man” by Leonardo da Vinci (1452-1519) (Fig. 1).

Advantageous properties and the best possible function are therefore intrinsically linked. Beauty can therefore be objectified in spite of everything and finds its mathematical expression in the so-called “golden section” (Fig. 2).

We perceive people, animals, architecture and generally all objects that correspond to these proportions as beautiful. In non-mathematical terms, then, beauty has to do with harmony, symmetry, a pleasing appearance, and above all with the virtue of moderation, that is, the right measure. We are committed to this classic ideal of beauty in all clinics and centers of Pallas Kliniken AG. Thus, even in the presented case, it is more than just simple wrinkle treatment. We aim to treat aesthetic units on the face and also on the body non-invasively or minimally invasively [1]. Or in other words, to achieve big improvements in the overall appearance with small changes: Less is often more.

We want to understand our patients and their wishes first, so that we can offer them individual treatment options tailored to them, so that you look age-appropriate, fresh, natural and refreshed. They should literally feel comfortable in their own skin. We therefore do not want to attempt to make our patients look unnaturally or artificially altered 20 years pseudo-rejuvenated, which we would not succeed in doing convincingly either and would only lead to unsatisfactory or even grotesque results, as can unfortunately be seen with many a Hollywood star and starlets.

I would now like to illustrate our approach with an everyday case study using ^Belotero® products. Also in aesthetic medicine we strictly adhere to the proven sequence of:

Medical history
Findings
correct diagnosis
Therapy
Progress control

Case study

Medical history:

47-year-old female patient, healthy, no relevant medication, no known allergies, local anesthetics always well tolerated.
Have not had any aesthetic treatments so far.
No contraindication for treatment with lidocaine-containing hyaluronan fillers can be determined.

Findings: The patient is particularly bothered by the relatively pronounced nasolabial folds, the finer ventral cheek folds, the oral commissures, the lip wrinkles and would like to have a little more lip contour with minimal volume gain. The patient wishes to look as natural as possible (Natural Look) [2]. She explicitly does not want to have sprayed-on “inflatable boat lips” and would like a gentle touch-up of the areas described above without changing her facial characteristics. Incidentally, there is a relatively pronounced mimic glabella fold (frown line). Currently, however, there is still some resentment towards botulinum toxin, which would actually be the indicated treatment of choice here. Furthermore, there is a solar elastosis in the facial area, therefore we still recommended treatments with the fractional_{CO2 laser of} the entire face for the fall/winter in order to be able to still improve the skin quality and also especially the finest perioral wrinkles.

For both additional treatment options, the patient asked for more time to consider during the educational interview. In the first step, she would like to realize only the filler treatment at first. So the overall aesthetic diagnosis of the face is:

Non-mimic wrinkles: Nasloabial folds, ventral cheek wrinkles and oral commissures with a clear volume defect as well as superficial lip wrinkles, somewhat smudged lip contours and narrowed lip red with a slight volume reduction.
Mimic wrinkle: relatively pronounced forked wrinkle (frown line)

Solar elastosis with mild pigmentary incontinence

Material and method: Resorbable hyaluronic filler treatments [3] are among the most requested and performed facial aesthetic treatments worldwide. According to Statistica GmbH Hamburg, hyaluronic filler treatments ranked second among non-surgical treatments in 2017. This is also one of the most requested and performed minimally invasive procedures at Pallas Clinics Aesthetic.
Advantages of the treatment are:

Very good safety profile with few NW when used professionally and appropriately. Potential NW are, e.g., swelling, redness, small hematomas, rarely infections and granulomas. [4,5]
Good biodegradability [6].
Result immediately visible, no down time
Can be very well combined with other treatments, such as botulinum toxin, PRP, thread lift, fractional_{CO2 lasers}[7].
Good cost-benefit ratio or in other words good price-performance ratio
Problem-free repeatability with medium durability in tissue of 6-12 months [8].
We used 1 ml each of lidocaine-containing ^Belotero® Balance for smoothing and filling moderate wrinkles with a hyaluronic acid content of 22.5 mg/ml with pointed needle with 27G and ^Belotero® Intense for filling deep wrinkles with 25.5 mg/ml with pointed needle 30G

^Belotero® fillers are manufactured using a patented Dynamic Cross-Linking technology. This technology provides a special balance between cohesiveness, elasticity and plasticity [9,10]. Cohesive polydensified hyaluronic acid (^CPM® technology) supports optimal distribution in the tissue [11,12]. This allows for subtle results and soft transitions [13], which fit the natural features of the face. These characteristics support the physician in achieving predictable and harmonious outcomes that provide high patient satisfaction and confidence [14].

Our standardized consulting and treatment concept

A detailed consultation is always necessary and mandatory. For primary care patients, it is usually separate from the treatment appointment so as not to build up immediate pressure to make a decision.

Consulting content:

Evaluation patient request and patient presentation
Evaluation of findings (as in classical medicine, an exact diagnosis before treatment is crucial and absolutely essential for the therapeutic outcome and patient satisfaction)
Special anamnesis regarding previous diseases, previous treatments, medication contraindications etc.
Clarification about favored method and expected result
Education about alternative or additional methods
Detailed information about risks and NW of the treatment
Realistic idea of therapy of the patient and assessment of the required compliance
Determination of the treatment plan, prices and method of payment (cash or credit card immediately after the treatment).
Declaration and submission of the information sheet and contract

Treatment date:

Going through the signed clarification and the contract once again
Asking whether there have been any health-related changes in the meantime
Photo documentation before, possibly during and after treatment
Treatment room and treatment utensils have already been prepared by MPA according to exact procedure protocol (Standard Operation Procedere SOP)
Optimal positioning and preparation of the patient
Calm, relaxed, professional atmosphere that conveys safety to the patient

Literature:

Pavicic T, Gauglitz GG: Modern soft tissue augmentation- away from treating the single fold to volume replacement in the whole face. MMW Fortschr Med 2012; 154: 51-52, 54.
Merz Aesthetic Patient Survey, a globally conducted survey with 5,000 patients, July 2015.
Gauglitz GG: Panfacial aesthetic minimally invasive approaches. MMW Fortschr Med 2015; 157: 44-47.
Gauglitz GG: Complications associated with aesthetic procedures. MMW Fortschr Med 2015; 157: 47-50.
Funt D, Pavicic T: Dermal fillers in aesthetics: an overview of adverse and treatment approaches. Clin Cosmet Investig Dermatol 2013; 6: 295-316.
Heppt M, Hartmann D, Reinholz M, et al: Fillers and associated side effects. HNO 2015; 63: 472-480.
Wenz F, Rümmelein B: The versatile application possibilities of PRP. Skin Mag 1/2019, pp. 20-25.
Hartmann D, Heppt M, Gauglitz GG: Therapeutic concepts for the treatment of the “aging face”. Dermatologist 2015; 66: 764-771.
Gavard S, et al: Key importance of cmpression properties in the biophysical characteristic of hyaluronic acid soft-tissue fillers. Journal of the mechanical Behavior of Biomedical Materials 2016; 61: 29298.
Sundaram H, et al: Cohesivity of Hyaluronic Acid Fillers: Development and Clinical Implications of a Novel Assay, Pilot Validation with a Five-Point Grading Scale, and Evaluation of Six U.S. Food and Drug Administration-Approved Fillers. Plast Reconstr Surg 2015; 136(4): 678-686.
Pavicic T: Efficacy and Tolerability of a New Monophasic, Double-Crosslinked Hyaluronic Acid Filler for Correction of Deep Lines and Wrinkles. Journal of Drugs in Dermatology 2011; 10(2); 134-139.
Tran C, et al: In vivo Bio-Integration of Three Hyaluronic Acid Fillers in Human Skin: A Histological Study. Dermatology, DOI: 10.1159/000354384.
Fischer TC, Sattler G, Gauglitz GG: Hyaluron Filler Containing Lidocaine on a CPM Basis for Lip Augmentation: Reports from Practical Experience. Facial Plast Surg 2016; 32(3): 283-288.
Buntrock H, et al: Efficacy, safety, and patient satisfaction of a monophasic cohesive polydensified matrix versus a biphasic nonanimal stabilized hyaluronic acid filler after single injection in nasolabial folds. Dermatol Surg 2013; 39(7): 1097-1105.