Extreme makeover filler edition: Non-surgical correction for facial deformities post-trauma

In conclusion, HA filler emerges as a reliable non-surgical option for facial deformities. It offers versatility in addressing aesthetic con - cerns with lower risks and quicker recovery times than traditional sur - gery. Additionally, its non-permanent nature allows for personalized results without committing to irreversible interventions, highlighting its promising role supported by sustained responses over time.


L E T T E R T O T H E E D I T O R Extreme makeover filler edition: Non-surgical correction for facial deformities post-trauma 1 | INTRODUC TI ON
To the editor, facial deformities can result from traumatic events, surgical interventions, or congenital conditions.They have a significant impact on patients, affecting various aspects of daily life and social interactions.The treatment of these conditions has undergone significant evolution over the years, employing increasingly advanced and personalized techniques.Despite the progress in current craniofacial plastic surgery methods, aesthetic imperfections can persist.
To achieve facial harmony, it is crucial to consider the application of minimally invasive techniques in addition to surgery or as an alternative approach. 12][3] In this report, we describe a successful correction of facial deformity achieved exclusively with HA injections, with a long-lasting response.

| C A S E PR E S E NTATI O N
We present the case of a 40-year-old man who, following a road accident in 2008, experienced a traumatic brain injury with infarction of the optic chiasm and subsequent total blindness, followed by stabilization of the cranial vault with a titanium plate.After 15 years from the event, he referred to our dermatology ambulatory.Clinical examination revealed a loss of structure in the superolateral area of the left orbit and in the frontal region, leading to challenges in using eyeglasses and noticeable deformity (Figure 1A,C).The patient underwent treatment using Vycross® HA filler with a density of 20 mg/ mL of HA (VYC-20) following the MD CodesTM system 4 (Figure 2).
In T1 and T2, two injections of HA filler, each of 1 mL, were administered into the supraperiosteal plane using a 27-gauge needle (12 mm length) with the bolus technique.Additionally, needle injections of three boli of 0.2 mL each were performed into the supraperiosteal plane along the zygomatic arch (Ck1), and another of 0.4 mL in Ck2.
In Ck3, one bolus of 1 mL was performed into the supraperiosteal plane with needle and two injection of 1 mL each were administrated into the deep malar fat pad and suborbicularis oculi fat levels, with a 22-gauge cannula (70 mm length).Lastly, a 1 mL needle injection of HA filler was conducted at the inner canthus in the supraorbital region of the left eye and 2 mL was administered in the left frontal region using a fanning technique with cannula.These last two areas were treated without following the MD CodesTM system.There were no reported adverse effects, and the volumes were almost fully restored allowing the patient to wear hat and sunglasses.After 4 months from the treatment, an additional HA filler injection of 2 mL with cannula was performed in the frontal region (Figure 1B,D).The result was extremely pleasing and remained stable at the 8 month follow up visit.

| DISCUSS ION
The use of HA fillers has experienced rapid diffusion in the last few decades quickly becoming the standard intradermal injection material for facial recontouring and rejuvenation. 2Despite its primary application in aesthetic procedures, in recent years, there has been an opportunity to propose HA injections as an alternative approach or in conjunction with surgery, in patients with facial deformities. 1,3,5en though fat injections have demonstrated efficacy in patients experiencing significant volume loss, the primary hurdle in structural fat grafting lies in preserving its viability.Moreover, fat may not be reabsorbed uniformly and could lead to asymmetries, requiring a reintervention. 1,3On the other hand, HA fillers have the advantage of a low incidence of adverse events, attributed to the availability of an antidote, hyaluronidase, making its action reversible. 1,5The fluidity of HA fillers ensures precision during injection and the ability to perform the procedure both in superficial and deep levels.The use of fillers featuring a medium density, as presented in our case, allows for good versatility and adaptability to the characteristics of the treated area.Furthermore, the development of cross-linking technology, like Vycross®, has allowed enhancing his durability and longevity. 1,6,7Several cases of patients with facial deformities treated with surgery in conjunction with fat or HA fillers are reported in literature. 1,5Our study stands out as a distinctive example of exclusive HA injection treatment in the reconstruction of facial deformities.
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.© 2024 The Authors.Journal of Cosmetic Dermatology published by Wiley Periodicals LLC.Ilaria Proietti and Francesca Svara equal study contribution.

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CON CLUS ION In conclusion, HA filler emerges as a reliable non-surgical option for facial deformities.It offers versatility in addressing aesthetic concerns with lower risks and quicker recovery times than traditional surgery.Additionally, its non-permanent nature allows for personalized results without committing to irreversible interventions, highlighting its promising role supported by sustained responses over time.K E Y WO R DS facial volume, filler, Hyaluronic acid AUTH O R CO NTR I B UTI O N S All authors were responsible for the concept and design of the study, collection and collation of data, analysis, and interpretation of data, write an article, reviewing this article, final reviewing this article and graphics performance.

F I G U R E 1
Three quarter view of the patient before treatment (A); three quarter view after 4 months (B); upside view before treatment (C); upside view after 4 months (D).

F I G U R E 2
Treatment plan withVycross* hyaluronic acid (HA) filler in reference to the treated areas according to MD CodesTM system and those treated without adhering to them.