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12/4/2013
Midface Rejuvenation
with bolus injection technique:
Impact on Tear Through & NLF
My experience with Allergan portfolio innovations based
on VYCROSS technology.
Koenraad De Boulle MD
Sharm El Sheikh, November 27th 2013
The importance of using a whole
face approach
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1973
2013
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Vycross Technology
Voluma
Volbella
Volift
Volbella
Volift
Voluma
Primary usage
Fine lines
Medium-sized skin depressions
Enhancement of the lip area
Deep skin depressions
Face contouring
Restore volume of the face
Implantation depth
Superficial to Mid-dermis
Lip mucosa
Deep dermis
Lip mucosa
Subcutaneous
Upper-periosteal
Deep dermis
HA concentration
15 mg/mL
17.5 mg/mL
20 mg/mL
Gel Hardness [1](G’ @ 5Hz)
 200Pa
 250Pa
 320 Pa
Compression[1]
17 gmf
23 gmf
39 gmf
Duration
Up to 12 months[2]
Up to 12 months[4]
Up to 18 months[3]
Needle size
30 G ½”
30 G ½”
23 G 1” (2mL syringe)
27G ½” (1mL syringe)
Duration
Lift capacity
[1] TR896 and TR897 reports, Internal data.
[2] Eccleston D, Murphy DK, Clinical, Cosmetic & Investig Dermatol 2012, 5, 167-172.
[3] Raspaldo H, J Cosmet Laser Therapy 2008, 10(3), 134-142.
[4] Technical Report RE1210037, Internal data.
Implantation depth
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Midface Revolumizing
• Considerations about
– Revolumizing
– Bolus technique
– Versatility in use of Voluma
– Impact on other features
– Before and afters
What are we talking about?
• “Re-volumizing”
– Increasing (sub)cutaneous volume by injecting a
biocompatible substance aiming to restore the
fullness of young and attractive facial features
De Boulle K
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What are we talking about ??
• “Bolus technique”
– Single injection with needle
– Deposition of substance in one specific location
– Substance: Vycross technology in Voluma®
Versatility
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Mid face
Cheekbone
Temple
Eyebrow
Pre jowl sulcus
Chin
Nose
Earlobe
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Addressed issues
• Mid face
contouring, volumizing and rejuvenation:
– most popular
– techniques
• possibilities of injections
– Needle or cannula
– Bolus technique
Addressed issues
• Mid face
contouring, volumizing and rejuvenation:
– most popular
– techniques
• possibilities of injections
– Needle or cannula
– Bolus technique
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Why mid face with bolus?
• Proficient method of restoring malar contour
and convexity
• Creates a support and anchor point for lower
third of face
• Global, 3-dimensional approach to natural rejuvenation: recommendations
for volume restoration
Raspaldo, Gassia, Niforos J Cosmet Dermatol. 2012 Dec;11:279-89
• Lifting vector for the lower face
• Injectable Fillers for Volume Replacement in the Aging Face
Greco, Antunes, Yellin Facial Plast Surg 2012;28:8–20.
Why bolus?
• Standardized technique easy to replicate
– 1-2-3 injection points
– A Prospective, Observational Study of the Volumizing Effect of Open-Label Aesthetic
Use of Juvéderm® VOLUMA® with Lidocaine in Mid-Face Area Philipp-Dormston,
Eccleston, De Boulle J Cosm Laser Therapy Accepted for Publ Oct2013
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Limited trauma
Limited areas for mistakes
Immediate result and gratification
Immediate resuming of daily activities
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Where bolus?
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1. lateral zygomatic region
2. zygomaticomalar region
3. anteromedial cheek
Explaining the technique
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Technique
Before and after: overview
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Before and after: detail
Explaining the technique
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A typical female patient
What’s bothering her?
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Assess from different angles
HA with bolus approach
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Mid face revolumizing:
Mid face revolumizing:
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Tear trough softening
Tear trough softening
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Stab quickly
Inject slowly
Tear Through Softening
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Tear Through Softening
A typical male patient
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Assess from different angles
Mid face revolumizing : bolus
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Mid face revolumizing
Extra benefits of zygomatico-malar
enhancement
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Lifting effect in adjacent areas
Improvement of ogee curve
Softening of tear through
Softening of nasolabial folds
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Midface revolumizing
T. Fisher
1 cc/malar side bolus
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Cheek enhancement
De Boulle, Aalst Belgium
Cheek enhancement
De Boulle, Aalst Belgium
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Cheek enhancement
De Boulle, Aalst Belgium
Voluma/Volift for dermal/fat atrophy
in end stage dermatomyositis
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Patient satisfaction
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Philip-Dormston W, Eccleston D, De Boulle K, Hilton S, van
den Elzen H, Nathan M
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Prospective, open label, multi-centre, study
N= 115
single treatment with Juvéderm® VOLUMA® with Lidocaine 2ml
or 1ml or a combination of both
Accepted for publication Oct 2013 J Cosmet Dermatol
Patient satisfaction
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
Philip-Dormston W, Eccleston D, De Boulle K, Hilton S, van
den Elzen H, Nathan M
Objectives:
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subject / physician reported satisfaction (immediat after – D 21)
• 5 point Subject Satisfaction Questionnaire (SSQ)
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improvement in volume loss (Mid-Face Volume Deficit Scale)
perceived smoothness of result of injections
assessment of pain
ease of use and overall satisfaction with the outcome
• through an Injector Satisfaction Questionnaire (ISQ)
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Subject’s overall satisfaction
95.6% (n=110 out of 115) of subjects were delighted/happy with the overall experience
immediately after treatment, 93.7% at 21 days post treatment (n=105 out of 112).
Subject’s perceived
smoothness of result
96.5% considered the immediate results smooth to extremely smooth
95.6% considered the results at day 21 smooth to extremely smooth
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Study Subject
Safety
Procedure and product well tolerated
 No device-related AEs reported
 In total, 5 procedural-related AEs were reported
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oedema/swelling n=3 (1 patient reported both)
hematoma
n=1
pain on injection n=1
considered not or probably not related to the product.
none were considered life-threatening.
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Chin – pre jowl sulcus
Chin – pre jowl sulcus
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Lifting the lateral brow: Volift®
Lifting the lateral brow: Volift®
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Lifting the lateral brow: Volift®
Volift® treatment examples
Supra orbital hollow with remaining
horizontal frown lines : cannula
 Marionette lines : needle
 Accordion pleads on the cheeks: cannula
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How to do this? part 1
How to do this? part 2
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How to do this? part 3
Final Case Study
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Conclusions
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Midface rejuvenation with bolus technique
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Need for careful assessment and realistic objectives
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Easy procedure
Predictable outcome and duration of effect
Favorable safety profile
Extremely rewarding for patients and practitioners
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