BOLD LIFT A 7-POINT INJECTION STRATEGY

FOR WHOLE-FACE REJUVENATION

Jan 15, 2020 | Aesthetic Feature, Injectables | 0  |     

Yung-Hsueh Huang describes his Bold Lift strategy for long-lasting

results and reduced downtime when addressing deficient skeletal
support 

Yung-Hsueh HUANG, MD
20 Skin Clinic Taichung City, Xitun Taiwan

Facial ageing involves simultaneous changes to bones, subcutaneous

tissues, muscles, skin and retaining ligaments( 1) that cause skin atrophy,
sagging, wrinkles, skeletal resorption, and fat compartment
redistribution(1,2). During the ageing process, the skin, superficial and deep
subcutaneous tissue, superficial musculo-aponeurotic system (SMAS), deep
fascia, and bone(3), each adapt to decreasing strength, volume and
elasticity, causing tissue and pigmentation changes, hollowness and
laxity(4,5). However, facial fillers can correct ageing-related indications and
volume loss non-surgically(2,6), and can produce long-lasting, optimal results
with reduced invasiveness and downtime(7).
The author devised the Bold-Lift strategy for the pan-facial injection of
calcium hydroxyapatite fillers (CaHA, Radiesse®; Merz North America, NC,
USA). CaHA’s rheology facilitates its precise placement within resorbed
bony areas to resolve deficient skeletal support, exaggeration of contour
irregularities and sagging due to receding of the piriform fossa, cheekbone
flattening, and maxilla and mandible atrophy. 

CASE PRESENTATION 
Six patients without comorbidities, aged 30–40 years, self-presented with a
tired appearance, diagnoses of bone resorption and fat compartment
redistribution, and consented to receive CaHA injections for facial volume
loss using the Bold Lift technique. 
Figure 1 Bold Lift’s 7 Injection Points and improvements in key facial areas.
(A) Injection points and desired directional improvements.
(B) Patient is shown from frontal and oblique angles before treatment.
(C) 3 months after treatment. 

The patients had varying initial levels of aesthetic deficiency and were
assessed according to the validated Merz Aesthetic Scale (MAS) for Upper
Cheek8 and Brow Positioning9. For the treatment, CaHA was diluted 5:1 with
2%-lidocaine. Seven injection points were identified, one per eyebrow arch,
lateral eyebrow, lateral zygoma, piriform fossa and chin, and two in the
anteromedial cheek. Filler boluses were injected in the supraperiosteal
plane. For the eyebrow arch, 0.3mL of CaHA was injected using a 25 G
needle (25 mm). A 25 G needle (25 mm) was used to inject 0.2–0.3mL of
CaHA into the lateral eyebrow, lateral zygoma and anteromedial cheek. The
anteromedial cheek was palpated and the infraorbital foramen (IOF) was
injected. Finally, the piriform fossa and the chin each received 0.2–0.3 mL of
CaHA with a 25 G needle (23 mm). Chin fillers were injected below the
mentalis muscle. Ultimately, all patients received 3.6 mL of filler. 
“Patients were evaluated at rest as well as
before and after treatment, using the MAS
and the Global Aesthetic Improvement
Scale (GAIS).”

Patients were evaluated at rest as well as before and after treatment, using
the MAS and the Global Aesthetic Improvement Scale (GAIS). These ratings
were reinforced with standardised photos taken at rest, pre-injection,
immediately, 1- and 3-months post-injection, from the frontal angle, 45°
from the left and right oblique angles, and from the left and right profiles.
The level of improvements for brow positioning (at rest), as well as
physician (Table 1) and patient GAIS, were measured at follow-up. Patients
who achieved 1 point of improvement in the MAS for upper cheek fullness
(at rest) were analyzed for this report. All patients gave their informed
consent.
“In the author’s study, although pan-facial
improvement was the goal, only brow
positioning and upper cheek fullness were
graded because validated quantitation
scales for full-face assessments do not
exist. “
Patients rated ‘1’ to ‘2’ on the Upper Cheek scale had ‘ideal’ faces with
mild-to-moderate upper cheek hollowness, and required one treatment for
satisfactory-to-good results. Those rated ‘1’ to ‘3’ on the Brow Positioning
scale and ‘3’ to ‘4’ on the Upper Cheek scale had medium-to-flat eyebrow
arches and required two treatments with a 3-month interval. At 3-months
follow-up (Table 1) without touch-up, all patients had at least 1 MAS
improvement point in upper cheek fullness at rest, with mean scores at
baseline, immediately post-treatment, and 1-month and 3-months post-
treatment of 2.2, 0.8, 1.0, and 0.7, respectively. All patients also
demonstrated at least 1 MAS improvement point in brow-positioning from
the baseline at all timepoints, with mean scores at baseline, immediately
post-treatment, and at 1-month and 3-months post-treatment of 1.8, 0, 0.5
and 0.5, respectively. At all follow-up timepoints, improvements were
reported as ‘Much Improved’ or ‘Very Much Improved’. The cohort’s
treatment outcomes are demonstrated here in the results of one patient
(Figure 1). 
DISCUSSION
Minimally-invasive procedures produce multifactorial outcomes. First, a
more natural, refreshed and youthful appearance is created 10. Second, a
stratified approach selects for the most appropriate treatments through a
careful diagnosis of clinical changes in facial anatomy and dermatological
problems11. Third, blunt-tip cannulas are used to reduce tissue damage and
expedite recovery. Finally, they are cost-effective and give high levels of
patient satisfaction12. In devising the Bold-Lift injection technique, we
sought to include these outcomes within a single procedure for holistic,
whole-face improvements. CaHA’s rheological properties are due to its high
viscosity and G’, which impart a desirable elasticity and versatility. We
leveraged its high viscoelasticity to structurally replace bone resorbed
during physiological ageing and produce visible lifting. Its high viscosity
keeps it in place during injection, while a high G’ confers resistance to
deformation despite the shear forces inherent to natural physiological
activities, including muscular contraction. These characteristics make CaHA
fillers (Radiesse®) ideal for the technique devised in our Bold-Lift injection.
Moreover, CaHA, when hyperdiluted, also produces collagen and elastin,
leading to a skin-tightening effect(13).
“The Bold-Lift leveraged CaHA’s high
viscoelasticity to replace bone resorption
and increase and strengthen deficient
structural supports, resulting in a visible
and much-requested facial lifting effect.”

In the author’s study, although pan-facial improvement was the goal, only
brow positioning and upper cheek fullness were graded because validated
quantitation scales for full-face assessments do not exist. In the author’s
representative patient, placing fillers in the supraperiosteal plane of her
eyebrow arch lifted it. Fillers in her lateral eyebrow, lateral zygoma, and
anteromedial cheek lifted her eyebrow laterally, and also lifted her midface
and cheek while redefining the cheek apex. Fillers lifted the piriform fossa
and released her nasolabial fold, while chin fillers improved her mental
crease and supported her chin contour. The patient achieved a visible lift at
the outer eye corner, greater anterior anteromedial cheek projection and a
more prominent and smoother (less dimpled) chin. Immediately post-
injection, the eyebrow and lateral canthus angle lifted and the anteromedial
cheek area was more projected. Similar levels of improvements were
observed in all six patients (Table 1). Although no severe adverse events
were observed, all patients treated with this protocol experienced mild
swelling, ecchymosis, and erythema immediately post-injection that
resolved within two days without treatment. At 1- and 3-months post-
treatment, no long-term complications occurred. To the author’s
knowledge, there is only one other description of a similar treatment with
CaHA for face volumisation; however, a different set of injection points and
cannula or needle were used(14). The author adds to this knowledge by
demonstrating a further set of injection points and simplifying processes by
using just needles to achieve the  patient’s desired outcomes.  

CONCLUSIONS
The Bold-Lift technique is best used at treatment initiation to create the
framework for soft tissue augmentation and contouring. Although no severe
adverse events were observed, patients may experience post-injection
swelling, erythema and ecchymosis. The Bold-Lift leveraged CaHA’s high
viscoelasticity to replace bone resorption and increase and strengthen
deficient structural supports, resulting in a visible and much-requested
facial lifting effect.
   Declaration of interest The author declares no conflict of interest
  Acknowledgment The author expresses their appreciation to Merz Asia
Pacific Pte Ltd Taiwan Branch for funding the preparation of this
manuscript, and Shawna Tan, for manuscript writing and editorial
assistance
  Funding/Financial disclosures Yung-Hsueh Huang received an honorarium
from Merz to conduct the study. All authors had full access to the study
data and had final responsibility for the decision to publish. Editorial
assistance, funded by Merz Asia Pacific Pte. Ltd. (Taiwan Branch), was
provided by Shawna Tan.  The preparation of this manuscript was
sponsored by Merz Asia Pacific
 Figure 1   ©  Yung-Hsueh Huang

  Table 1   ©  Yung-Hsueh Huang

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