06. Volumetric revitalisation by means of Macrolane VRF 20 and VRF 30
KEYWORDS: volumetric revitalisation, Macrolane suspension, volumetric correction of the face, treating stretch marks
Revitalisation of the skin and subcutaneous tissues is carried out by means of cross-linked hyaluronic acid. As non-cross-linked hyaluronic acid spreads very easily, it does not exert a local revitalising effect, but disperses very rapidly in the organism.You can write your auto collapsible text here.
For volumetric revitalisation, we use Macrolane VRF 20 and VRF 30 (Q-Med AB, Uppsala, Sweden), a biodegradable, biocompatible, stabilised gel of non-animal origin.
The material needed in order to carry out suspension for volumetric revitalisation is what you can see: two 20 ml syringes, Macrolane VRF 20 and VRF 30, 10% glycerol, lactate Ringer solution or physiological solution, a 1 ml syringe, 4 mm-long 27 G needles and 2% lidocaine.
A connecting tube is also needed in order to transfer the material utilized from one syringe to the other.
1.5 ml of Macrolane 20 is placed in one of the 20 ml syringes; 0.5 ml of Macrolane 30 is then added to the same syringe.
The other 20 ml syringe is then used to aspirate 6 ml of 10% glycerol. The contents of both syringes are then mixed by using the connecting tube, so as to create a suspension of particles of cross-linked hyaluronic acid. Now the lactate Ringer or physiological solution is added in order to reach a quantity of 18 ml. The mixture is passed from one syringe to the other several times by means of the connecting tube, in order to create a uniform suspension. Finally, 2 ml of 2% lidocaine is added to make up a volume of 20 ml.
The suspension is mixed by means of the connecting tube. The 1 ml syringe which will be used to carry out volumetric revitalisation is filled; the suspension will be injected by means of a 4 mm-long 27 G needle.
The suspension is made up of particles of cross-linked hyaluronic acid of two different sizes: smaller particles of Macrolane VRF 20 and larger particles of Macrolane VRF 30. For about three months, these particles will release molecules of hyaluronic acid locally; this will exert a revitalising effect. At the same time, the particles will correct the volumetric configuration of the face, enhance the volume where necessary, improve facial symmetry, reduce roughness and wrinkles, promote the elimination of stretch marks, correct small blemishes left on the skin immediately after elastic face lifting, etc.
In this patient, volumetric revitalisation is being carried out in the zygomatic region. The facial volumes are increased and the molecules of hyaluronic acid will exert a trophic action on the skin.
The short 27 G needle follows a brief pathway; this means that if the needle pierces a dermal capillary or a venule, the blood can easily escape, thus avoiding haematomas and ecchymoses . A 1 ml syringe must be used for injection, as the pressure exerted with this syringe is very high. In order to pass through the 27 G needle, the particles of Macrolane VRF 30 will have to be deformed; this is why they have to be subjected to high pressure. In a few cases, the needle may become blocked, and only prolonged constant pressure on plunger of the syringe will enable injection of the suspension to be continued. Using a 1 ml syringe facilitates the injection procedure and prevents the needle from detaching from the syringe owing to the high pressure exerted on the plunger.
Volumetric revitalising suspension can be applied to the entire face. Here, the procedure is being used to restore the volumes of the temporal fossa; in order to avoid the veins in the region, a green light close to the infrared range is being used
Volumetric revitalising suspension can be performed before Adipofilling of the face, in order to evaluate the effect of the permanent filling that results from the grafting of adipose and stromal cells. If the tissues are poorly hydrated and asphyctic, the amount of Macrolane VRF 20 can be increased to 2 ml.
It is not advisable to increase the amount of Macrolane VRF 30, as this would make superficial injection with thin needles more difficult. Volumetric revitalising suspension is also used to correct small imperfections of the skin after elastic MACS lifting, until such time as the areas of skin no longer subjected to gravity retract and the elastic thread is transformed into a “natural” ligament. When enriched with sodium glutathione, volumetric revitalising suspension is particularly efficacious in the treatment of wrinkles of the neck and face. In such cases, injection is intradermal along the line of the wrinkle. When treating stretch marks, the lactate Ringer or physiological solution can be replaced by the patient’s autologous serum obtained by centrifuging the patient’s blood at high velocity for 30 minutes. Mixing the cross-linked hyaluronic acid with the factors present in the serum exerts a permanent trophic and angiogenic action.
Capurro S. (2013) Volumetric revitalisation with Macrolane VRF 20 and VRF 30. CRPUB Medical Video Journal. Other techniques section. http://www.crpub.org
How long does the volumetric increase achieved through revitalisation with Macrolane last?
About three months. However, the improved trophism of the cutaneous and subcutaneous tissues remains.
What are the main indications for volumetric revitalisation?
Correction of facial symmetry, volume enhancement of the face and body, and the correction of small irregularities of the skin after elastic MACS lifting. Elastic lifting of the temporal regions and eyebrows can also be levelled by means of volumetric suspension, until such time as the skin retracts. It should be borne in mind that this procedure is extremely efficacious, but may require:
A) correction of the temporal fossa if it is too hollow; this is done before volumetric revitalisation with Macrolane, followed by Adipofilling (grafting of adipose and stromal cells);
B) redistribution of the skin in the temporal region, which is achieved by implanting a second elastic thread in a position superior to the previous one. The other indications for volumetric revitalisation are roughness of the skin of the face and body, neck wrinkles, etc. Many patients undergo volumetric revitalisation before going on holiday, in order to appear younger and fresher. Men may also have this treatment in order to correct a hollow face. After a few sessions of revitalisation, the result is permanent; this is indicative of an increase in the subcutaneous tissue.
How much glutathione should be added to the 20 ml of the preparation in order to reduce neck wrinkles?
Normally, a 600 mg vial is added. The preparation must be injected into the deep dermis; if it is too superficial, the particles of Macrolane VRF 30 may remain visible. For greater safety, in patients with thin skin, volumetric revitalisation of neck wrinkles may be carried out by means of Macrolane VRF 20 alone. The results are highly satisfactory.
Is there any risk that skin imperfections may remain after the injection of the volumetric suspension of Macrolane?
As already mentioned, if the skin is thin, it is not advisable to inject Macrolane VRF 30 into the superficial dermis. In the subcutaneous tissue or deep dermis, the suspension behaves exactly like a physiological solution. The small irregularities that can be seen after injection disappear within a few minutes. The operator only needs to smooth the treated area and to accompany the volumetric increase in such a way as to obtain a pleasing result.
Volumetric revitalization is revealing itself to be a highly efficacious and versatile technique for increasing volumes, correcting asymmetry, eliminating superficial roughness and treating deeper wrinkles. Volumetric revitalization is able to make the forehead more convex by eliminating all irregularities, to fill the temporal fossae, to enhance the volume of the upper eyelids, to eliminate bags under the eyes, to flesh out the malar and zygomatic region, to fill depressions in the cheeks, nasolabial folds and “puppet” wrinkles, to increase the thickness of the lips, to modify the volumes of the jaw and chin, and to reduce neck wrinkles (Venus’ necklace). The suspension is injected through 27G needles. Deep injections, for example to treat bags under the eyes, or the malar and zygomatic regions, also contain a small amount of Macrolane VRF 30; more superficial injections, immediately beneath the dermis (injections a in a web-like pattern), or intradermal injections (in wrinkles) contain only Macrolane VRF 20. Injections repeated every three months stimulate the volumetric enhancement of the patient’s tissues. Volumetric revitalization is often also used after procedures of elastic lifting of the face or body (gluteoplasty) in order to accompany temporary alterations of the skin surface until they disappear naturally. The volume increase determined by the injection of the suspension of Macrolane is due to the water retained by the molecules of hyaluronic acid that detach from the small cross-linked fragments. This enables slight over-correction and avoids any alteration of the surface of the skin. In this suspension, we have replaced lidocaine with procaine (one 2 ml vial of 2% procaine for every 10 ml of suspension) on account of its greater trophic effects.