An Innovative Treatment Using Calcium Hydroxyapatite for Non-Surgical Facial Rejuvenation The Vectorial-Lift Technique

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<p>ORIGINAL ARTICLES FACIAL SURGERY</p><p>An Innovative Treatment Using Calcium Hydroxyapatite for</p><p>Non-Surgical Facial Rejuvenation: The Vectorial-Lift Technique</p><p>Virginia Marcia Amaral1 • Helena Hotz Arroyo Ramos2 • Fernanda Aquino Cavallieri3 •</p><p>Mariana Muniz4 • Guilherme Muzy5 • Ada Trindade de Almeida6</p><p>Received: 13 January 2024 / Accepted: 9 April 2024</p><p>� The Authors 2024, corrected publication 2024</p><p>Abstract</p><p>Background The facial aging process entails alterations in</p><p>the volume, shape, and texture of all skin layers over time.</p><p>Calcium hydroxyapatite (CaHA) is a well-established safe</p><p>skin filler with unique properties to resolve some skin</p><p>alterations by stimulating neocollagenesis. The vectoral-lift</p><p>(V-lift) technique targets the global repositioning of facial</p><p>structures by addressing distinct anatomical injection</p><p>planes. It includes deep facial augmentation with Radiesse</p><p>PlusTM to retain ligament restructuring and superficial</p><p>subcutaneous enhancement with diluted Radiesse DuoTM.</p><p>Herein, we present cases that illustrate the use of this</p><p>approach.</p><p>Methods This pilot study enrolled 36 participants (33</p><p>women and three men; ages 37–68 years) in a Brazilian</p><p>clinical setting, and all patients underwent a single treat-</p><p>ment. Photographs were taken at rest, in frontal and oblique</p><p>views, before injection, and 90 days after treatment.</p><p>Results Treatment resulted in elevation of the upper and</p><p>middle face, notable improvements in the infraorbital</p><p>hollow, and adjustment of the mean facial volume.</p><p>Conclusions The V-lift technique is a three-dimensional</p><p>pan-facial treatment that relies on ligament support and</p><p>face vectoring to obtain a lifting effect and facial contour</p><p>restoration. It encompasses deep facial augmentation</p><p>involving the use of Radiesse PlusTM for restructuring and</p><p>retaining ligaments and Radiesse DuoTM for superficial</p><p>subcutaneous enhancement. This approach targets a global</p><p>repositioning of the facial structures by addressing distinct</p><p>anatomical injection planes. It achieves a repositioning of</p><p>the overall facial anatomy without requiring a substantial</p><p>volumetric expansion.</p><p>Level of Evidence IV This journal requires that authors</p><p>assign a level of evidence to each article. For a full</p><p>description of these Evidence-Based Medicine ratings,</p><p>please refer to the Table of Contents or the online</p><p>Instructions to Authors www.springer.com/00266.</p><p>Keywords Skin aging � Collagen � Plastic surgery �</p><p>Dermatology � Aesthetics � Calcium hydroxyapatite �</p><p>Biostimulation</p><p>Introduction</p><p>Minimally invasive procedures have gained popularity</p><p>because of their shorter downtime, absence of visible scars,</p><p>and potential for corrective action if the outcomes deviate</p><p>from initial goals [1]. Consequently, procedural strategies</p><p>that account for facial shape, structure, proportions, and the</p><p>impact of aging on facial esthetics have become focal</p><p>points of esthetic medicine research [2]. Recent studies</p><p>have focused on refining the placement of soft tissue fillers</p><p>on the face, thereby augmenting both results and safety</p><p>while utilizing less volume of the product for superior and</p><p>natural final outcomes [3].</p><p>& Virginia Marcia Amaral</p><p>dravirginiaamaral@gmail.com</p><p>1 IVA Medical Institute, Av. dos Bandeirantes 1518,</p><p>Belo Horizonte CEP: 30.315-032, Brazil</p><p>2 Vitória, Brazil</p><p>3 Rio de Janeiro, Brazil</p><p>4 São Paulo, Brazil</p><p>5 São Paulo, Brazil</p><p>6 Hospital do Servidor Público Municipal de São Paulo,</p><p>São Paulo, Brazil</p><p>123</p><p>Aesth Plast Surg</p><p>https://doi.org/10.1007/s00266-024-04071-5</p><p>http://orcid.org/0009-0004-7610-8015</p><p>http://www.springer.com/00266</p><p>http://crossmark.crossref.org/dialog/?doi=10.1007/s00266-024-04071-5&amp;domain=pdf</p><p>https://doi.org/10.1007/s00266-024-04071-5</p><p>It is speculated that the injection of collagen biostimu-</p><p>lators around the adhesion areas and retaining ligaments of</p><p>the face promotes contracture, causing a suspension effect</p><p>by acting as anchors and, as a result, elevating the tissues</p><p>and improving the lifting effect [4–6]. This occurs because</p><p>the facial retaining ligaments serve as pivotal anchoring</p><p>points for both the superficial musculoaponeurotic system</p><p>(SMAS) and the overlying dermis onto the deep fascia and</p><p>periosteum [7].</p><p>Moreover, there is a lack of studies that address the</p><p>physiology and mechanics of non-surgical repositioning of</p><p>the retaining ligaments of the face with collagen biostim-</p><p>ulators [4, 5, 8]. Calcium hydroxyapatite (CaHA) is a well-</p><p>established and safe dermal filler with unique properties</p><p>that enhance the mechanical properties of the skin. It</p><p>stimulates collagen and elastin production, angiogenesis,</p><p>and the proliferation of dermal cells [9]. However, there is</p><p>a lack of studies in the literature that address the physiol-</p><p>ogy and mechanics of non-surgical repositioning of</p><p>retaining ligaments of the face with CaHA injections.</p><p>In this study, we aim to introduce a technique that</p><p>employs CaHA-based dermal filler based on the principles</p><p>of periligamentar subMAS layer redensification and face</p><p>vectoring. The technique aims to attain lifting effect and</p><p>restore facial contours.</p><p>Materials and Methods</p><p>Study Design</p><p>This pilot study included 36 participants in a clinical set-</p><p>ting. The analysis involved thirty female participants and</p><p>three males, with an age range of 37–68 years. All patients</p><p>received a single treatment, and all procedures adhered to</p><p>the ethical guidelines outlined in the Declaration of Hel-</p><p>sinki, as revised in the year 2000.</p><p>Patient Selection and Documentation</p><p>For this study, women and men aged 35 years and older</p><p>were selected if they exhibited midface deflection. Indi-</p><p>viduals were excluded if they had received hyaluronic acid</p><p>(HA) fillers, neuromodulators, or biostimulators in the</p><p>previous 6 months, or if they planned to undergo any other</p><p>facial enhancement procedures such as fillers, chemical</p><p>lipolysis injections, energy-based devices, or surgeries in</p><p>the coming months. Extremely thin patients, those with</p><p>very heavy faces, or individuals with a surgical indication</p><p>were also excluded. All participants provided written</p><p>(signed) informed consent.</p><p>Photographs were taken at rest, in frontal and oblique</p><p>views before calcium hydroxylapatite (CaHA) injection</p><p>(Day 0) and 90 days after treatment (Day 90), using the</p><p>same camera (Canon EOS T5i with 50 mm f/1.8 STM</p><p>lens), lighting, and distance parameters..</p><p>Injection Techniques</p><p>To facilitate anatomical subdivision and delineation, the</p><p>treated regions were categorized as follows: temporal</p><p>(from the temporal line to the upper edge of the zygomatic</p><p>arch), zygomatic (covering the zygomatic arch region),</p><p>masseteric (extending from the lower edge of the zygo-</p><p>matic arch to the masseteric parotid region), orbital,</p><p>infraorbital, and mandibular regions (spanning from the</p><p>pre-jowl sulcus area to the angle of the mandible area).</p><p>Participants were clinically evaluated for skin laxity,</p><p>ptosis of subcutaneous fat, and shadow lines correlated</p><p>with ptosis of ligaments. Injection of different CaHA for-</p><p>mulations (Radiesse LidocaineTM and Radiesse DuoTM)</p><p>was carried out according to the need for facial restruc-</p><p>turing: Radiesse LidocaineTM was used in the subSMAS</p><p>layer, Radiesse DuoTM was administered to superficial</p><p>areas, while a combination of Radiesse LidocaineTM and</p><p>Radiesse DuoTM was used for restructuring of facial liga-</p><p>ments (Fig. 1).</p><p>All participants of this study were administered a total</p><p>of two syringes each of Radiesse LidocaineTM and two</p><p>syringes each of Radiesse DuoTM, diluted with 0.5 mL of</p><p>2% lidocaine, by following the proposed 6-step technique</p><p>utilizing microcannulas.</p><p>The 6-Step Technique</p><p>Step 1: Markings and Delimitations of the Regions</p><p>for Treatment</p><p>We delimited the following areas of medial superior</p><p>injection: temporal region (temporal line to upper edge of</p><p>the zygomatic arch); zygomatic region (zygomatic arch);</p><p>masseteric parotid region (lower edge of the zygomatic</p><p>arch to a rectangular area of 2–3 cm in the masseteric</p><p>parotid region); and the ligament transition areas (infraor-</p><p>bital and zygomatic/malar areas).</p><p>We delimited the following lower injections areas: the</p><p>mandible angle region; the pre-jowl regions; and the planes</p><p>of injection (Fig. 2).</p><p>Step 2: Solution Preparation</p><p>The contents (1.5 mL) of a single Radiesse DuoTM syringe</p><p>were mixed with 0.5 mL of 2% lidocaine by employing a</p><p>direct connector or a female-to-female Luer-lock connec-</p><p>tor, resulting in a total volume of 2 mL per syringe.</p><p>123</p><p>Aesth Plast Surg</p><p>Step 3: Injection Technique for the First Syringe</p><p>of Radiesse DuoTM</p><p>The first access point was located immediately lateral to</p><p>the transition region, fixed face to mobile face, at the</p><p>zygomatic region for treatment of the temporal region, and</p><p>refinement in the infraorbital region.</p><p>To treat the temporal region, we injected 0.8 mL of the</p><p>solution per side using a 23G blunt cannula to cover the</p><p>entire area. Employing retrograde linear injection or ret-</p><p>rograde fanning techniques within the subcutaneous</p><p>superficial layer, we proceeded from the posterior bound-</p><p>ary to the orbital margin, targeting the temporal adhesion</p><p>ligament and the upper edge of the zygomatic arch.</p><p>For the treatment and enhancement of the ligament</p><p>adhesion regions (temporal ligament adhesion region and</p><p>from the lateral orbital adhesion to the lateral orbital</p><p>thickening), as well as the infraorbital area (orbicular</p><p>retaining ligament), we utilized the same entry point. We</p><p>injected 0.2 mL of the solution per side using a 23G blunt</p><p>cannula, employing multiple retrograde micro boluses</p><p>(Fig. 1). It is advisable to gently massage the treated area</p><p>immediately after the injection regimen to ensure uniform</p><p>CaHa distribution.</p><p>Step 4: Injection Technique for the First Syringe</p><p>of Radiesse LidocaineTM</p><p>For treating the zygomatic region, the same entry point was</p><p>employed as mentioned above. A volume of 0.45 mL of</p><p>Radiesse LidocaineTM per side was injected using a 23G</p><p>blunt cannula along the juxtaperiosteal plane (subSMAS),</p><p>encompassing the entire zygomatic area. Additionally,</p><p>0.3 mL per side was injected at the malar region, following</p><p>a juxtaperiosteal plane (around the zygomatic cutaneous</p><p>ligament), employing a retrograde linear injection</p><p>Fig. 1 Injection areas in the</p><p>subcutaneous and</p><p>supraperiosteal facial planes. 1:</p><p>Radiesse Duo injection areas in</p><p>the subcutaneous plane aim to</p><p>create a vector to lift the face. 2:</p><p>Radiesse Lidocaine injection</p><p>areas in the supraperiosteal</p><p>plane. 3: Radiesse Lidocaine</p><p>injection areas in the</p><p>subcutaneous plane</p><p>Fig. 2 Facial mapping for a series of injections. Top line: Markings and delimitations of the regions for treatment. Bottom line: The injection</p><p>sequence comprising Radiesse Duo (first syringe), Radiesse Lidocaine (second syringe), Radiesse Duo (third syringe), and Radiesse Lidocaine</p><p>(fourth syringe)</p><p>123</p><p>Aesth Plast Surg</p><p>technique with micro boluses in the deep layer (Fig. 1). A</p><p>gentle massage of the treated area immediately post-in-</p><p>jection is recommended to ensure a uniform CaHa</p><p>distribution.</p><p>Step 5: Injection Technique for the Second Syringe</p><p>of Radiesse DuoTM</p><p>The second entry point was established just lateral to the</p><p>region of transition between the fixed and mobile aspects of</p><p>the face and was positioned approximately 3 cm beneath</p><p>the lower border of the zygomatic arch. This access point is</p><p>employed for treating the masseteric parotid region as well</p><p>as the ligament transition areas (infraorbital and the</p><p>zygomatic/malar region).</p><p>A second access point was utilized to treat the masse-</p><p>teric parotid region and involved the injection of 0.6 mL of</p><p>the solution per side using a 23G blunt cannula, employing</p><p>retrograde linear injection or retrograde fanning tech-</p><p>niques. A gentle massage of the treated area immediately</p><p>post-injection ensured a uniform CaHa distribution.</p><p>For the refinement of the ligament transition areas (in-</p><p>fraorbital and zygomatic/malar regions), the same access</p><p>point as above was employed, to administer 0.1 mL of the</p><p>solution per side with a 23G blunt cannula, utilizing mul-</p><p>tiple retrograde micro boluses. As before, a gentle massage</p><p>of the treated area immediately following the injection</p><p>regimen aids in an even CaHa distribution.</p><p>The third access point was positioned lateral to the</p><p>mandibular cutaneous ligaments to treat the pre-jowl</p><p>regions and mandibular angle regions.</p><p>For the treatment of the pre-jowl region within the mental</p><p>sulcus, the third access point is employed. This involves</p><p>injecting 0.3 mL of the solution per side using a 23G blunt</p><p>cannula, utilizing anterograde and/or retrograde linear injec-</p><p>tion, or anterograde and/or retrograde fanning techniques at the</p><p>subcutaneous layer. A gentle massaging of the treated area</p><p>immediately post-injection ensured an even CaHa distribution.</p><p>Step 6: The Injection Technique for the Second Syringe</p><p>of Radiesse LidocaineTM</p><p>For an improved outcome, the lower face can be treated with a</p><p>focus on repositioning the mandibular ligament through inter-</p><p>ventions in both the pre-jowl and lateral mandible regions.</p><p>To administer the mandible treatment, the same access</p><p>point as mentioned above was employed. We injected</p><p>0.45 mL of the solution per side at the lateral mandible</p><p>region and 0.3 mL per side at the pre-jowl region using a</p><p>23G blunt cannula. We employed anterograde and/or ret-</p><p>rograde linear injection or anterograde and/or retrograde</p><p>fanning techniques. Following the procedure, a gentle</p><p>massage of the treated area ensures even CaHa distribution.</p><p>Results</p><p>The 36 patients reported subjective improvement in skin</p><p>quality and repositioning of the midface at the 90-day</p><p>evaluation. Twenty-eight experienced swelling in the first</p><p>48 hours, and they were advised to enhance post-procedure</p><p>facial massage, leading to spontaneous symptom relief.</p><p>Four patients developed swelling after 48 hours and were</p><p>instructed to use prednisone 20 mg for 3 days, resulting in</p><p>symptom remission. Three patients complained of persis-</p><p>tent pain in the malar region for 20 days and were advised</p><p>to use analgesics for symptom control. Two patients</p><p>developed small nodules due to product accumulation,</p><p>which resolved after intranodular saline injection followed</p><p>by local massage. No infectious or vascular adverse effects</p><p>were observed.</p><p>Herein, we present cases that illustrate the use of this</p><p>approach.</p><p>The overall improvements in facial laxity and contour</p><p>90 days after the V-Lift procedure are presented in Figs. 3,</p><p>4, 5, 6, and 7.</p><p>Case 1 (Fig. 3) involved a woman with complaints of</p><p>facial laxity and loss of facial contour. Ninety days after</p><p>the 6-step V-lift injection regimen, it was possible to note</p><p>restoration of the global positioning of the facial tissues</p><p>with better positioning of the eyebrow, enhancement of the</p><p>zygomatic malar layers redensification points and attenu-</p><p>ation of the nasolabial, mental and labiomental folds with</p><p>significant elevation of the lip commissure.</p><p>In Case 2 (Fig. 4), we present a lady with a ‘‘heavy’’</p><p>face, with a saggy appearance of the whole face and deep</p><p>markings at the malar region. Ninety days after the V-lift</p><p>injections, it was possible to discern attenuation of the</p><p>grooves and amelioration of global face complaints.</p><p>In Case 3 (Fig. 5), we present a woman with skin laxity,</p><p>loss of facial contour and a ‘‘sad mouth’’ appearance.</p><p>Ninety days after the V-lift procedure, a restoration of the</p><p>global positioning of the face with better positioning of the</p><p>eyebrows was observed, as well as an enhancement of the</p><p>zygomatic malar layers redensification points, attenuation</p><p>of the nasolabial, mental, and labiomental folds, and a</p><p>significant elevation of the lip commissure.</p><p>Discussion</p><p>The depletion of anatomical tissues is a consequence of the</p><p>aging process observed throughout the layers of facial soft</p><p>tissue (Fig. 6), and in addition to skeletal changes</p><p>[2, 10–14].</p><p>The role of the retaining ligaments in the process of</p><p>facial</p><p>aging is not well defined [10]. Some authors believe</p><p>123</p><p>Aesth Plast Surg</p><p>Fig. 3 Timeline of treatment</p><p>comprising Day 0 (D0; day of</p><p>treatment) and Day 90 (D90; 90</p><p>days after treatment) time-</p><p>points for a patient who</p><p>underwent the V-lift technique.</p><p>A generalized improvement of</p><p>the shadows of the face,</p><p>restoration of the zygomatic</p><p>arch and malar region,</p><p>attenuation of nasolabial lines,</p><p>and elevation of the angle of the</p><p>mouth can be observed 90 days</p><p>after completion of the V-lift</p><p>technique</p><p>Fig. 4 Timeline of treatment</p><p>comprising Day 0 (D0; day of</p><p>treatment) and Day 90 (D90; 90</p><p>days after treatment) time-</p><p>points for a patient who</p><p>underwent the V-lift technique.</p><p>A generalized improvement of</p><p>face shadows, restoration of the</p><p>zygomatic arch, attenuation of</p><p>the malar mound with</p><p>restoration of the malar region,</p><p>attenuation of nasolabial lines,</p><p>and elevation of the pre-jowl</p><p>area can be observed 90 days</p><p>after completion of the V-lift</p><p>technique</p><p>123</p><p>Aesth Plast Surg</p><p>that the loosening of the retaining ligaments results in the</p><p>descent of the soft tissue that they normally support</p><p>[12, 15, 16]. Other groups postulate that ligaments retain</p><p>their relative strength, while the surrounding tissues</p><p>experience a loss of support and subsequently descend over</p><p>these ligaments that remain relatively stable in their posi-</p><p>tion, leading to the formation of grooves [7, 17, 18].</p><p>In any case, age-related alterations in facial bone and</p><p>skin are widely recognized. The ongoing and lifelong</p><p>remodeling of the bony framework, coupled with the</p><p>loosening of the skin, leads to the distortion of ligament</p><p>attachment points and their adhesions to the skin. This, in</p><p>turn, impacts the neighboring structures supported by these</p><p>ligaments, as the changed position and trajectory of the</p><p>ligaments create a ripple effect [19, 20].</p><p>For these reasons, approaches that focus exclusively on</p><p>facial volume restoration often yield esthetically unsatis-</p><p>factory outcomes because they require larger additional</p><p>volumes to achieve noticeable results in the superficial</p><p>layer [21]. Cong et al. [5] described a method that differs</p><p>Fig. 5 Timeline of treatment</p><p>comprising Day 0 (D0; day of</p><p>treatment) and Day 90 (D90; 90</p><p>days after treatment) time-</p><p>points for a patient who</p><p>underwent a V-lift technique.</p><p>Note the global repositioning of</p><p>tissues with the resulting softer</p><p>facial expression</p><p>Fig. 6 A comparison of a young and aging face showing the three-dimensional aging process. Left: A schematic representation of the face of a</p><p>young woman with well positioned anatomical layers. Right: A schematic representation of an aging face with changes in the positioning of</p><p>ligaments due to the gravitational weight of anatomical compartments determined by aging</p><p>123</p><p>Aesth Plast Surg</p><p>from the augmentation of facial fat compartments in that it</p><p>was not intended to restore the volume of the deflated fat</p><p>compartments, but to achieve a vertical tissue displace-</p><p>ment, that is, a lifting effect. Our technique is based on the</p><p>concept that injecting CaHa around the regions of adhesion</p><p>and retaining ligaments of the face triggers the reposi-</p><p>tioning of the cutaneous ligaments, resulting in a suspen-</p><p>sion effect. These ligaments effectively serve as anchoring</p><p>points for the SMAS and the dermis, overlying the deep</p><p>fascia and periosteum (Fig. 8) [8]. The role of CaHa in</p><p>improving the mechanical characteristics of the skin has</p><p>been broadly reported, as it stimulates collagen and elastin</p><p>production, angiogenesis, and dermal cell proliferation [8]</p><p>that could be an advantage of the present technique, as it</p><p>could offer layers redensification.</p><p>The facial retaining ligaments are robust, deep, and</p><p>fibrous connections that stem from the periosteum or the</p><p>deep facial fascia. These ligaments traverse facial layers</p><p>perpendicularly, anchoring into the dermis. Attenuation of</p><p>the retaining ligaments at all levels reduces the quality of</p><p>fixation of the layers (5). Hence, three-dimensional facial</p><p>repositioning interventions encompass the vertical adjust-</p><p>ment of these ligaments. This approach directly counteracts</p><p>the detrimental impact of negative weight vectors gener-</p><p>ated by the aging process on the face [22]. This concept can</p><p>be elucidated through the ‘‘torch’’ theory, where the</p><p>robustness of CaHA collagen biostimulator enables the</p><p>elevation of facial structures (Fig. 9). Movement/Moment/</p><p>Torque is a mathematical variable that scales the direction</p><p>of movement based on the balance of forces. Conditioned</p><p>by the vectors that depress or elevate the face, the liga-</p><p>ments must be evaluated as lever arms that have a fixed</p><p>origin (bone) and a mobile insertion point (skin). It is</p><p>necessary to consider the ligament as a lever arm, its</p><p>position being directly influenced by deep repositioning</p><p>(subMAS layer redensification—without distension/en-</p><p>largement of the compartment) and superficial reposition-</p><p>ing (vectoring with gain in skin quality) through the</p><p>superficial suspension force of the SMAS, considering the</p><p>zygomatic arch as the bone support point. Thus, the posi-</p><p>tive (counterclockwise) direction of the torque was directly</p><p>influenced by the vector force and the angle related to the</p><p>origin or axial point of rotation (Fig. 9).</p><p>The objective of the technique is to address the liga-</p><p>mentous origin through the redensification of underlying</p><p>tissues by injecting calcium hydroxylapatite (CaHa) in the</p><p>justaperiosteal plane (subSMAS). In the subdermal plane,</p><p>the goal is the potential stretching of superficial ligamen-</p><p>tous fibers through the supposed vectorization implemented</p><p>by neocollagenesis. Therefore, the focus is not on the</p><p>ligament itself as a specific target, but rather on its terri-</p><p>tory. While the study did not include imaging examinations</p><p>for all patients, we had the opportunity to assess the</p><p>injection planes in a patient who underwent a CT scan for</p><p>another reason (Fig. 10), 21 days after CaHa injection in</p><p>the midface and bilateral temples. Since CaHa is radio-</p><p>paque, the injection plane of the product could be visual-</p><p>ized according to the described technique.</p><p>For this reason, we consider the Radiesse line to be a</p><p>valuable treatment instrument for the profile of patients</p><p>who aim for three-dimensional face repositioning and</p><p>Fig. 7 A schematic representation of the repositioning of the</p><p>cutaneous ligaments leading to a suspension effect</p><p>Fig. 8 Biomechanical subMAS layer redensification mechanisms and vectorization of the facial ligaments implement the global repositioning of</p><p>the face as a mechanism of pulleys interconnected by the superficial musculoaponeurotic system (SMAS) and superficial temporal fascia</p><p>123</p><p>Aesth Plast Surg</p><p>progressive results without subsequent volumetric gains, as</p><p>there is less hydrophilic effect compared to hyaluronic</p><p>acid; thus, a stable overall esthetic outcome is attained.</p><p>Only a small volume is needed for this ligament injection</p><p>technique, and the 23G blunt cannula was chosen due to</p><p>the possibility of accessing the desired layers (suprape-</p><p>riosteal and subdermic).</p><p>Site 1 was placed in the temporal ligamentous adhesion</p><p>region to lift the tail of the eyebrow, and site 2 was placed</p><p>in the region of the lateral orbital thickening to reduce</p><p>ptosis of the lateral canthus. Injections at the two sites had</p><p>a lifting effect on the periorbital region, as early ptosis of</p><p>the eyebrows and lateral canthi could be partly reversed in</p><p>a subtle manner, restoring a youthful appearance. As for</p><p>the midface, site 3 and site 4 targeted the zygomatic</p><p>retaining ligament and zygomatic cutaneous ligament,</p><p>respectively, to augment the midfacial soft tissue. The apex</p><p>of the cheekbone intensely reflected light, and the length of</p><p>the lower eyelid seemed to decrease due to the interplay of</p><p>light and shadow, contributing to a visual lifting effect.</p><p>CaHa injections at these two sites would also affect the soft</p><p>tissue of the anteromedial midface, so that the nasolabial</p><p>fold would be simultaneously effaced. In the lower face,</p><p>the nasolabial fold and the pre-jowl sulcus were also</p><p>reduced by the injections at sites 5 and 6, corresponding to</p><p>the regions of the maxillary and mandibular ligaments,</p><p>respectively. Therefore, injecting at the sites corresponding</p><p>to the actual ligament areas could effectively enhance the</p><p>redensification effect of the subSMAS layer, simultane-</p><p>ously reducing facial grooves and alleviating the signs of</p><p>aging. Upon completion of the treatment, which involves</p><p>lifting the upper and middle face, significant enhancements</p><p>were noted in the infraorbital hollow and the repositioning</p><p>of the overall facial volume. Moreover, this treatment has</p><p>the ability to restore volume, tissue resilience, and harmony</p><p>within the modiolus region, marionette zone, and pre-jowl</p><p>Fig. 9 A schematic</p><p>representation of the planes of</p><p>injection, vectors and direction</p><p>of injection of different types of</p><p>CaHA, according to study</p><p>objectives and definition of</p><p>facial planes</p><p>Fig. 10 Face CT scan showing</p><p>CaHa injection in the zygomatic</p><p>arch in the subSMAS plane</p><p>(justaperiosteal) and in the</p><p>temporal region in the</p><p>subcutaneous plane</p><p>123</p><p>Aesth Plast Surg</p><p>sulcus. The main point of this technique involves attaining</p><p>natural outcomes following facial procedures by using less</p><p>volume and shortened distances. These natural-looking</p><p>results play a pivotal role in enhancing patient satisfaction</p><p>and bolstering self-assurance as natural outcomes have the</p><p>potential to alleviate the stigma often associated with</p><p>cosmetic procedures [22–24].</p><p>This study has certain limitations. It is based on sub-</p><p>jective observations made by the authors, a factor that</p><p>warrants consideration when interpreting the presented</p><p>data. Future investigations should explore the histological</p><p>and mechanical characteristics of the ligaments following</p><p>treatment with collagen biostimulators. This could be</p><p>achieved by incorporating a control group, employing</p><p>randomized selection, and utilizing objective outcome</p><p>measures. Furthermore, studies encompassing a broader</p><p>participant pool and a prolonged postoperative timeline are</p><p>imperative for a more comprehensive understanding. A</p><p>prospective study is warranted to quantify the improvement</p><p>in facial aging achieved through the Radiesse V-Lift</p><p>technique. This study should incorporate control groups,</p><p>implement blinding methodologies, and employ objective</p><p>outcome measures.</p><p>Conclusion</p><p>We present the preliminary results of a three-dimensional</p><p>injection technique known as the V-lift technique, which</p><p>utilizes calcium hydroxylapatite (CaHA) collagen bios-</p><p>timulators to address the signs of aging. The V-lift tech-</p><p>nique was well-tolerated, yielding enduring subjective</p><p>results attributed to the stimulation of collagen and elastic</p><p>fiber deposition (collagenesis). However, more robust</p><p>studies are needed to substantiate these concepts.</p><p>Funding Medical writing support was provided by Merz Brazil, in</p><p>accordance with Good Publication Practice guidelines.</p><p>Declarations</p><p>Conflict of interest A.R.T. de Almeida has been a consultant to</p><p>Allergan Inc. and Merz and has participated in clinical trials for</p><p>Allergan and Galderma. Mariana Muniz is a medical consultant and</p><p>speaker for Merz Aesthetics. The authors declare no potential con-</p><p>flicts of interest with respect to the research, authorship, or publica-</p><p>tion of this article.</p><p>Human and Animal Rights This article does not contain any studies</p><p>with human participants or animals performed by any of the authors.</p><p>Open Access This article is licensed under a Creative Commons</p><p>Attribution 4.0 International License, which permits use, sharing,</p><p>adaptation, distribution and reproduction in any medium or format, as</p><p>long as you give appropriate credit to the original author(s) and the</p><p>source, provide a link to the Creative Commons licence, and indicate</p><p>if changes were made. The images or other third party material in this</p><p>article are included in the article’s Creative Commons licence, unless</p><p>indicated otherwise in a credit line to the material. 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J Drugs Dermatol 15:1536–1542</p><p>Publisher’s Note Springer Nature remains neutral with regard to</p><p>jurisdictional claims in published maps and institutional affiliations.</p><p>123</p><p>Aesth Plast Surg</p><p>An Innovative Treatment Using Calcium Hydroxyapatite for Non-Surgical Facial Rejuvenation: The Vectorial-Lift Technique</p><p>Abstract</p><p>Background</p><p>Methods</p><p>Results</p><p>Conclusions</p><p>Level of Evidence IV</p><p>Introduction</p><p>Materials and Methods</p><p>Study Design</p><p>Patient Selection and Documentation</p><p>Injection Techniques</p><p>The 6-Step Technique</p><p>Step 1: Markings and Delimitations of the Regions for Treatment</p><p>Step 2: Solution Preparation</p><p>Step 3: Injection Technique for the First Syringe of Radiesse DuoTM</p><p>Step 4: Injection Technique for the First Syringe of Radiesse LidocaineTM</p><p>Step 5: Injection Technique for the Second Syringe of Radiesse DuoTM</p><p>Step 6: The Injection Technique for the Second Syringe of Radiesse LidocaineTM</p><p>Results</p><p>Discussion</p><p>Conclusion</p><p>Open Access</p><p>References</p>