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Contents Introducing the MD Codes™...... 4 What are the MD Codes™?...... 5 Why use the MD Codes™?...... 6 The MD Codes™ and the VYCROSS® Collection...... 7
Treatment considerations...... 8 General aseptic precautions...... 9 Gender difference...... 9 Injection device...... 10 Injection delivery...... 11 Targeted structures ...... 12 Injection technique...... 12 Alert areas...... 13 The MD Codes™ have been developed by Dr Mauricio de Maio and all recommendations presented in this guide are based Using the MD Codes™ ...... 14 on his clinical experience. The injector is responsible for The 8-point lift...... 16 customising the MD Codes™ for each individual patient. The 3-point forehead reshape...... 22 Please refer to Instructions for Use before injecting. The 2-point temple reshape ...... 28 The 3-point eyebrow reshape...... 34 The 3-point lateral periorbital reshape...... 40 The 3-point tear trough reshape...... 46 The 5-point cheek reshape...... 52 The 3-point nasolabial reshape...... 58 The 8-point lip reshape ...... 64 The 3-point marionette lines reshape...... 74 The 6-point chin reshape ...... 80 The 5-point jawline reshape...... 86
Danger and alert zones ...... 92
References and mandatories...... 96
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What are the MD Codes™? Practical injection strategies
The MD Codes™ are a series of precise sites (or subunits) within each unit that are designed to guide injection . They are based on the principle that facial units have to be rebuilt, or treated, in an architectural mode . Each injection site is represented by a combination of letters and numbers . The letters represent the anatomical unit and the numbers indicate the sequence in which the injections may potentially be delivered . The most important injection site in a particular anatomical unit is represented by the number 1 and this should usually be the starting point . Injection site number 3 is typically an alert zone, and care should be taken in these areas . Every patient will have a specific sequence and may not need all of the MD Codes™ in the anatomical unit – each patient should be assessed and treated individually .
Each code is depicted with a combination of the following: Introducing the MD Codes™ Letters The anatomical unit (e .g . Ck=cheeks) Numbers The subunits of the anatomical unit (e .g . Ck1=zygomatic arch; Ck2=zygomatic eminence)
The side of the face (e .g . Ck1r is the zygomatic arch on the right hand side; Ck1l is the Number location zygomatic arch on the left hand side) Superscript (Xn) refers to upper areas (e .g . Lp1=vermilion body of the upper lip) Number position Subscript (Xn) refers to lower areas (e .g . Lp1=vermilion body of the lower lip)
Colours Alert areas denoted in red
Shapes Technical delivery of the product
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Why use the MD Codes™? The MD Codes™ and the VYCROSS® Collection A landmark in facial aesthetics Product selection
The MD Codes™ are a useful tool to help patients understand their treatment motivation . The VYCROSS® Collection, manufactured by Allergan, comprises of hyaluronic acid fillers designed to meet the specific anatomical needs of different facial regions . By presenting the MD Codes™ to the patient, they will point out the areas of concern so that the injector may discuss the appropriate codes for their individual treatment plan . The MD Codes™ can help the patient to understand why the improvement The VYCROSS® Collection of hyaluronic acid fillers includes: of a target area may be achieved by treating a neighbouring or distal area . JUVÉDERM® VOLUMA® Intended to restore volume of the face, for example, in temples, midface region, The MD Codes™ are treatment patterns that guide the spotting of injection points on the patient’s face, according to their with Lidocaine chin and jaw (≤2 ml per treatment area per session)1 individual treatment needs . They represent not only specific sequences of injection points but also act as a tool to facilitate the communication between patient and doctor . Treatment of deep skin depressions, face contouring and volume restoration to JUVÉDERM® VOLIFT® In addition, the MD Codes™ can be used to aid financial planning and patient follow up . correct facial structural defects such as asymmetry, contour deformities, volume loss with Lidocaine in the lips, cheeks, chin, lower face…etc 2.
Treatment of any fine lines and medium-sized skin depressions . Enhancement JUVÉDERM® VOLBELLA® and pouting of the lips to correct structural defects such as asymmetry, contour with Lidocaine The MD Codes™ are a landmark in facial aesthetics, it’s a FACT deformities, volume loss…etc 3.
Finance Patients come with a specific budget Unique crosslinking technology Assessment Accurate diagnosis must be made
VYCROSS® technology is a proprietary4 mix of low and high molecular weight hyaluronic acid, combined with a crosslinking Communication Clarify “Patient wants vs . Patient needs” process, which results in an efficiently and tightly crosslinked gel 5–9. This tight hyaluronic acid network results in: Technique Precise and safe injection can help achieve desired outcomes • Greater resistance to degradation, delivering long-lasting duration 5,7–9. • Minimal gel expansion due to low water uptake coupled with low hyaluronic acid concentration 5,9. This patented technology4 allows the customisation of gel hardness (G’) and cohesivity, resulting in products with optimised lift and mouldability 5–7,9.
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General aseptic precautions
The presence of active bacterial or viral infection should postpone treatment 1–3. Maintaining an appropriate aseptic environment will help reduce the risk of infection . Ensure the patient has removed any makeup and prepare the skin with antibacterial soap or alcohol 10. Wash your hands, wear appropriate clothing and use sterile or disposable gloves and equipment . Ensure you have everything you need before you start injecting .
Gender differences
Gender differences should be taken into account when individualising treatment .
Treatment considerations Recommended for men Injection point for a more masculine outcome
Recommended for women Injection point for a more feminine outcome
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Injection device Injection delivery
The choice of injection device should be based on individual experience and preference .
Micro-aliquot Very small droplet of filler (0 .01–0 .05 ml per point) • May minimise risk of intravascular injury and bruising Cannula • Recommended for use in alert zone areas
Aliquot Static injection of a small amount of filler (0 .1 or 0 .2 ml) • May be preferred for fine, controlled injections Needle • Ideal for bolus at the supraperiosteal level
Small bolus Static injection of filler (<0 .3 ml)
• Injection of JUVÉDERM® VOLUMA® with Lidocaine with the supplied 27G 1/2” sterile needle is recommended .1 Use of a cannula where mentioned is the recommendation of Dr de Maio .* Linear Antegrade or retrograde • Injection of JUVÉDERM® VOLBELLA® with Lidocaine with the supplied 30G 1/2” sterile needle is recommended . It is possible to use a 30G sterile cannula 2. • Injection of JUVÉDERM® VOLIFT® with Lidocaine with the supplied 30G 1/2” sterile needle is recommended . It is possible to use a 25G, 27G or 30G sterile cannula 3. Fanning Multiple linear injections via a single entry site creating a fan-like pattern
*Use of cannula with JUVÉDERM® VOLUMA® with Lidocaine has not been validated by Allergan.
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Targeted structures Alert areas
1. To minimise the risk of injury to blood vessels and nerves, standard precautionary measures should be taken in all areas Dermal Mucosa of the face . These include injecting slowly and frequently checking for signs of pain and skin colour changes . 2. Alert areas are highlighted with a caution sign, where needle aspiration is highly recommended or the use of cannulas should be considered . 3. Standard injection technique should include reflux/aspiration of the syringe plunger to check if blood is drawn into the chamber . If blood is detected, withdraw the needle, compress and choose a different site . It is important to prime Subcutaneous / fat pads Supraperiosteal before injecting .
• High-risk areas where additional caution must be taken if injecting at or near these sites Injection technique Alert area • Alert areas may be highly vascular, highly innervated or adjacent to critical structures or organs 1. Aspiration is highly recommended during deep injections close to the bone . 2. Avoid scratching the periosteum during injection, it can lead to pain and bleeding . The technique and depth of the injection vary depending on the area to be treated . Do not inject • Areas to avoid injecting with dermal fillers 3. Massage gently following injection to ensure tissue integration and even distribution of the product . A more robust massage may be needed in deeper planes with a higher volume . 4. When creating structure, remember that indirect changes may happen in neighbouring or distal areas . 5. Younger patients with mild-to-moderate deficiencies may require smaller volumes than older or more complex patients . 6. Do not inject more than 2 ml of JUVÉDERM® VOLUMA® with Lidocaine per treatment area in a single session .
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Using the MD Codes™
The treatment codes provided in this book include guidance on product, choice of injection device, technique and a suggested volume range . These recommendations are based on the clinical experience of Dr de Maio and may be adapted based on the experience of the injector and the patient’s facial features .
The MD Codes™
L The 8-point lift Ck The 5-point cheek reshape
F The 3-point forehead reshape NL The 3-point nasolabial reshape Using the MD Codes™ T The 2-point temple reshape Lp The 8-point lip reshape
E The 2-point eyebrow reshape M The 3-point marionette lines reshape
C The 6-point chin reshape O The 3-point lateral periorbital reshape
Jw The 5-point jawline reshape Tt The 3-point tear trough reshape
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The 8-point lift: The 8-point lift: Surface anatomy Injection areas and effects
Code Injection area Effect of injection Structures affected
L1 Lifts the cheek Bone structure and Zygomatic arch (Ck1) Gives support to eyebrow and lower eyelid lateral SOOF
L2 Provides projection of the cheek and Bone structure and Zygomatic eminence (Ck2) shortening of palpebral-malar sulcus lateral SOOF
L3 Improves the medial lid-cheek junction and Bone structure; deep malar Anteromedial cheek (Ck3) softens the tear trough fat pad; medial SOOF
L1 L4 Reduces the prominence of the Subdermal support Nasolabial fold L2 (NL) nasolabial folds to nasolabial fold
L3 Strengthens and lifts the mucosa of the L5 Subdermal support Marionette line oral commissure and improves the (M) to marionette lines appearance of marionette lines L4 L8 L6 Reduces the prominence of the Bone structure and/or Prejowl sulcus (C6, Jw4) prejowl sulcus subcutaneous
Bone structure; L7 Mandible angle Reshapes and lifts the jawline L5 L7 subcutaneous
Addresses the sunken area and improves L8 Parotid and submalar area submalar and preauricular volume loss; Subcutaneous (Ck4, Ck5) L6 and lifts the jawline
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The 8-point lift: The 8-point lift: Topographical anatomy for deep injection Topographical anatomy for superficial injection
Be wary of the angular and facial arteries L1 L2 L3 L8 L4 Deep injection with needles at the infraorbital L7 foramen is L5 L1 prohibited L2 L6 L3
L3 alert: Be wary of the infraorbital artery L8 alert: Be wary of the parotid gland, buccal nerve, L4 alert: Be wary of the facial artery facial vein and artery L7
L6 L2 L3
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The 8-point lift: Notes Product and volume recommendations
Volume Injection Injection Targeted Code Product Notes range (ml) technique device structure
L1 0 .1–0 .3 (Ck1) JUVÉDERM® VOLUMA® with L2 Lidocaine 0 .2–0 4*. (Ck2) Zygomatico- facial artery† JUVÉDERM® VOLUMA® with Infraorbital artery† L3 Lidocaine 0 .1–0 .3 or or (Ck3) JUVÉDERM® VOLIFT® with Lidocaine
L4 0 .1–0 5. (NL) JUVÉDERM® VOLIFT® Facial artery; or with Lidocaine inject slightly medial L5 to the nasolabial 0 .1–0 .5 (M) crease
L6 0 .1–0 .5* or or or (C6, Jw4) JUVÉDERM® VOLUMA® with Lidocaine L7 0 .1–0 .5* or
JUVÉDERM® VOLUMA®
L8 with Lidocaine 0 .2–1 .0 or Parotid gland; buccal (Ck4, Ck5) JUVÉDERM® VOLIFT® nerve; facial vein and with Lidocaine artery†
* The total volume should be delivered in small boluses (<0.3 ml) † Aspiration is highly recommended These recommendations are provided by Dr Mauricio de Maio and are based on his clinical experience. Some of these recommendations (e.g. volume, injection device, targeted structure) may not be aligned with the Instructions for Use and other products from the VYCROSS® Collection may be used to treat this area. Please consult the Instructions for Use document for each product.
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The 3-point forehead reshape: The 3-point forehead reshape: Surface anatomy Injection areas and effects
Code Injection area Effect of injection Structures affected
F1 Medial forehead
Reshapes the forehead and improves the appearance F2 Lateral forehead Deep support F2 F1 F3 of forehead lines
F3 Central forehead
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The 3-point forehead reshape: The 3-point forehead reshape: Topographical anatomy Product and volume recommendations
Volume Injection Injection Targeted Code Product Notes range (ml) technique device structure
F1 0 1–0. .3 Supraorbital artery F2 F1 F3 F2 F1 F3 JUVÉDERM® VOLIFT® F2 0 2–0. .5* or or with Lidocaine 2 cm
F3 0 1–0. .2 Supratrochlear artery * The total volume should be delivered in small boluses (<0.3 ml)
When direct approach to the lines is needed, use JUVÉDERM® VOLBELLA® with Lidocaine
Volume Injection Injection Targeted Code Product Notes range (ml) technique device structure F1 alert: Be wary of the supraorbital artery F3 alert: Be wary of the supratrochlear artery
F1 0 1–0. 3. Supraorbital Injection should be avoided in the 2 cm region above the orbit artery
JUVÉDERM® VOLBELLA® F2 0 1–0. 3. with Lidocaine
F3 0 1–0. 3. Supratrochlear artery
These recommendations are provided by Dr Mauricio de Maio and are based on his clinical experience. Some of these recommendations (e.g. volume, injection device, targeted structure) may not be aligned with the Instructions for Use, please consult these documents before using these products.
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Notes Notes
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The 2-point temple reshape: The 2-point temple reshape: Surface anatomy Injection areas and effects
Code Injection area Effect of injection Structures affected
T1 Anterior temple Reshapes the temple Deep support T2 Posterior temple
T2 T1
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The 2-point temple reshape: The 2-point temple reshape: Topographical anatomy Product and volume recommendations
Volume Injection Injection Targeted Code Product Notes range (ml) technique device structure
T1 0 .2–0 .5* Aspiration is highly JUVÉDERM® VOLUMA® recommended with Lidocaine Avoid deep T2 0 .3–0 .5* temporal arteries
* The total volume should be delivered in small boluses (<0.3 ml)
T2 The volume range may vary according to the degree of severity: • Mild deficiencies up to 0 .5 ml per side per session . T1 • Moderate deficiencies up to 1 ml per side per session . • Severe deficiencies up to 2 ml per side per session . A total of 2–4 boluses may be required .
These recommendations are provided by Dr Mauricio de Maio and are based on his clinical experience. Other products from the VYCROSS® Collection may be used to treat this area, please consult the Instructions for Use document for each product.
T2 T1
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Notes Notes
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The 3-point eyebrow reshape: The 3-point eyebrow reshape: Surface anatomy Injection areas and effect
Code Injection area Effect of injection Structures affected
E1 Eyebrow tail
E2 Eyebrow centre Lifts and projects the eyebrow Fat pads (ROOF)
E3 Eyebrow head
ROOF=Retro-orbicularis oculi fat
E3 E2 E1
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The 3-point eyebrow reshape: The 3-point eyebrow reshape: Topographical anatomy Product and volume recommendations
Volume Injection Injection Targeted Code Product Notes range (ml) technique device structure
E2 E3 E1 E1
E2 alert: Inject lateral E1 0 .1–0 .2 or or to the supraorbital foramen Inject slowly E3 alert: Inject lateral JUVÉDERM® VOLIFT® and protect to the supratrochlear with Lidocaine the upper eyelid foramen with your finger E2 0 .1–0 .2
or
E3 0 .1–0 .2
These recommendations are provided by Dr Mauricio de Maio and are based on his clinical experience. Some of these recommendations (e.g. volume, injection device, targeted structure) may not be aligned with the Instructions for Use; please consult these documents before using these products. NOTE: JUVÉDERM® VOLBELLA® with Lidocaine can also be used to treat fine lines in this area .
E3 E2 E1 E1
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Notes Notes
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The 3-point lateral periorbital reshape: The 3-point lateral periorbital reshape: Surface anatomy Injection areas and effects
Code Injection area Effect of injection Structures affected
O1 Central periorbital
Improves the appearance O2 Lower periorbital of static lines and volume loss Subdermal in the lateral periorbital area
O3 Upper periorbital
O3
O1
O2
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The 3-point lateral periorbital reshape: The 3-point lateral periorbital reshape: Topographical anatomy Product and volume recommendations
Volume Injection Injection Targeted Code Product Notes range (ml) technique device structure
O1
JUVÉDERM® VOLBELLA® O2 0 .2– 0 .5 with Lidocaine
O3 Upper eyelid
These recommendations are provided by Dr Mauricio de Maio and are based on his clinical experience.
O3
O1
O2
O3 alert: Avoid injecting into the upper eyelid
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Notes Notes
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The 3-point tear trough reshape: The 3-point tear trough reshape: Surface anatomy Injection areas and effects
Code Injection area Effect of injection Structures affected
Tt1 Central infraorbital
Lid-cheek junction; Tt2 Lateral infraorbital Improves infraorbital area palpebral-malar sulcus; nasojugal sulcus
Tt3 Medial infraorbital
Tt3 Tt2 Tt1
This treatment is reserved for specialists specifically trained in this technique and having a sound knowledge of the anatomy and physiology in this particular area .
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The 3-point tear trough reshape: The 3-point tear trough reshape: Topographical anatomy Product and volume recommendations
Volume Injection Injection Targeted Code Product Notes range (ml) technique device structure
Tt1 0 .1– 0 .3 The tear trough Infraorbital should be JUVÉDERM® foramen Tt3 treated by Tt2 VOLBELLA® 0 .1–0 .3 or specialists Tt3 Tt2 Tt2 with Lidocaine specifically Tt1 Tt1 trained in this technique
Tt3 0 .1–0 .3 Infraorbital foramen; angular artery
These recommendations are provided by Dr Mauricio de Maio and are based on his clinical experience.
Tt1 alert: Be wary of the infraorbital artery branches Tt3 alert: Be wary of the angular artery and vein
Injection with needles at the infraorbital foramen should be avoided
This treatment is reserved for specialists specifically trained in this technique and having a sound knowledge of the anatomy and physiology in this particular area .
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Notes Notes
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The 5-point cheek reshape: The 5-point cheek reshape: Surface anatomy Injection areas and effects
Code Injection area Effect of injection Structures affected
Lifts the cheek Ck1 Zygomatic arch Gives support to eyebrow Bone structure and lateral SOOF (L1) and lower eyelid
Provides projection of the Ck2 Zygomatic eminence cheek and shortening of Bone structure and lateral SOOF (L2) palpebral-malar sulcus Ck1 Ck1
Improves the medial Ck3 Bone structure; deep malar fat Ck2 Ck2 Anteromedial cheek lid-cheek junction and softens (L3) pad; medial SOOF the tear trough Ck3 Ck3 Ck4 Addresses the sunken area Lateral lower cheek/ at the parotid level and Ck4 Subcutaneous Ck5 Ck5 parotid area preauricular volume loss; lifts the jawline
Addresses the sunken area Ck5 Submalar and improves volume loss in the Subcutaneous submalar area
SOOF=suborbicularis oculi fat
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The 5-point cheek reshape: The 5-point cheek reshape: Topographical anatomy Product and volume recommendations
Volume Injection Injection Targeted Code Product Notes range (ml) technique device structure
Ck1 Aspiration is highly 0 1–. 0 .3 (L1) recommended JUVÉDERM® VOLUMA® with Lidocaine Ck2 Zygomaticofacial 0 2–. 0 .4* Ck1 Ck1 (L2) artery Ck2 Ck2 Ck3 Ck3 JUVÉDERM® VOLUMA® with Lidocaine Infraorbital artery Ck4 Ck3 Ck5 0 1–. 0 .3 or (L3)
JUVÉDERM® VOLIFT® with Lidocaine
or
JUVÉDERM® VOLUMA® In large areas with Lidocaine prefer cannula† Ck4 0 2–1. .0
Ck2 JUVÉDERM® VOLIFT® with Lidocaine Parotid gland Ck3 JUVÉDERM® VOLUMA® with Lidocaine Buccal nerve; Ck5 0 2–. 0 .5* or facial vein JUVÉDERM® VOLIFT® Ck3 alert: and artery Be wary of the with Lidocaine infraorbital foramen
Ck5 alert: † Be wary of the * The total volume should be delivered in small boluses (<0.3 ml) Use of cannula with facial artery JUVÉDERM® VOLUMA® with Lidocaine has not been validated by Allergan These recommendations are provided by Dr Mauricio de Maio and are based on his clinical experience. Some of these recommendations (e.g. volume, injection device, targeted structure) may not be aligned with the Instructions for Use; please consult these documents before using these products.
NOTE: JUVÉDERM® VOLBELLA® with Lidocaine can also be used to treat fine lines in this area .
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Notes Notes
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The 3-point nasolabial reshape: The 3-point nasolabial reshape: Surface anatomy Injection areas and effects
Code Injection area Effect of injection Structures affected
NL1 Upper nasolabial fold
Reduces prominence Subdermal support to NL2 Central nasolabial fold of the nasolabial folds nasolabial fold
NL1 NL3 Lower nasolabial fold
NL2 Consider treating the cheek first .
NL3
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The 3-point nasolabial reshape: The 3-point nasolabial reshape: Topographical anatomy Product and volume recommendations
Volume Injection Injection Targeted Code Product Notes range (ml) technique device structure
NL1 0 .1–0 .4 Facial artery
JUVÉDERM® VOLIFT® NL2 0 .2–0 .4 or NL1 with Lidocaine Inject slightly medial to the nasolabial crease NL3 0 .1–0 .2 NL2 NL1 alert: Be wary of the facial artery and the branches to the nasal flare . NL3 In Asian patients the These recommendations are provided by Dr Mauricio de Maio and are based on his clinical experience. Other products from the VYCROSS® Collection may be used to treat facial artery may lie this area; please consult the Instructions for Use document for each product. in the nasolabial fold
NL1
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Notes Notes
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The 8-point lip reshape: The 8-point lip reshape: Surface anatomy Injection areas and effects
Lp1, Lp2 and Lp3 Code Injection area Effect of injection
Lp1 Vermilion body Promotes lip augmentation
Lp2 Cupid’s bow Gives structure to cupid’s bow area
Gives structure to the white line/lip border . Lp3 Lip border Indirectly decreases perioral lines
Lp2 3 Lp Lp1 Lp1
Lp1 Lp1
Lp 3
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The 8-point lip reshape: The 8-point lip reshape: Surface anatomy Injection areas and effects
Lp1, Lp2, Lp3, Lp4 and Lp5 Code Injection area Effect of injection
Lp1 Vermilion body Promotes lip augmentation
Lp2 Cupid’s bow Gives structure to cupid’s bow area
Gives structure to the white line/lip border . Lp3 Lip border Indirectly decreases perioral lines
Lp4 Medial tubercle Provides projection or fullness of the medial tubercle of the upper lip Lp2 3 Lp Lp5 Lateral tubercles Provides projection or fullness of the lateral tubercles of the lower lip Lp1 Lp4 Lp1
Lp1 Lp5 Lp5 Lp1
Lp 3
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The 8-point lip reshape: The 8-point lip reshape: Surface anatomy Injection areas and effects
All codes Code Injection area Effect of injection
Lp1 Vermilion body Promotes lip augmentation
Lp2 Cupid’s bow Gives structure to cupid’s bow area
Gives structure to the white line/lip border . Lp3 Lip border Indirectly decreases perioral lines
Lp7
Lp8 Lp4 Medial tubercle Provides projection or fullness of the medial tubercle of the upper lip Lp2 3 Lp Lp5 Lateral tubercles Provides projection or fullness of the lateral tubercles of the lower lip Lp1 Lp4 Lp1 Lp6 Lp6 Oral commissure Lifts and corrects the downturn of the corner of the mouth Lp1 Lp5 Lp5 Lp1
Lp 3 Lp7 Philtrum column Gives structure and defines philtrum columns
Lp8 Perioral lines Corrects the perioral lines
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The 8-point lip reshape: The 8-point lip reshape: Topographical anatomy Product and volume recommendations
All codes Volume Injection Injection Code Product Structure range (ml) technique device
Lp1 0 .05– 0 .1 or
Lp2 0 .05– 0 .1
Juvéderm® VOLBELLA® Lp3 with Lidocaine 0 .05– 0 .1 Lp7 or Lp8 JUVÉDERM®Juvéderm® VOLIFT® VOLIFT® Lp2 with Lidocaine 3 Lp4 or 0 .05– 0 .1 Lp JUVÉDERM ULTRA® XC or Lp1 Lp4 Lp1 or JUVÉDERM ULTRA Lp6 Lp5 0 .05– 0 .1 PLUS® XC
Lp1 Lp5 Lp5 Lp1 Lp6 0 .05– 0 .1 or Lp 3
Lp7 0 .05– 0 .1
Lp8 0 .1– 0 .2
These recommendations are provided by Dr Mauricio de Maio and are based on his clinical experience. Inject at the level of the mucosa Inject at the intradermal layer
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Notes Notes
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The 3-point marionette lines reshape: The 3-point marionette lines reshape: Surface anatomy Injection areas and effects
Code Injection area Effect of injection Structures affected
M1 Upper marionette line
Improves the appearance Subdermal and subcutaneous M2 Central marionette line of the marionette lines support to marionette lines
M3 Lower marionette line
M1
M2
M3
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The 3-point marionette lines reshape: The 3-point marionette lines reshape: Topographical anatomy Product and volume recommendations
Volume Injection Injection Targeted Code Product Notes range (ml) technique device structure
M1 0 .1–0 .2 M1
Inject medially to JUVÉDERM® VOLIFT® M2 M2 0 .2–0 .4 or the labial-mental with Lidocaine crease
M3 M3 0 .2–0 .4
These recommendations are provided by Dr Mauricio de Maio and are based on his clinical experience. Some of these recommendations (e.g. volume, injection device, targeted structure) may not be aligned with the Instructions for Use and other products from the VYCROSS® Collection may be used to treat this area. Please consult the Instructions for Use document for each product.
M1
M2
M3
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Notes Notes
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The 6-point chin reshape: The 6-point chin reshape: Surface anatomy Surface anatomy
C1 C1 C6 C6
C3 C3 C3
C5 C5 C2 C2 C4 C4 C5 C6
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The 6-point chin reshape: The 6-point chin reshape: Injection areas and effects Topographical anatomy
Code Injection area Effect of injection Structures affected
Reduces the protrusion of Mental crease/ the lower lip, gives support to C1 Subcutaneous; muscle Labial-mental angle the oral commissure and elongates the chin
C2 Improves vertical dimension/ Chin apex Bone structure (Jw5) chin height C1 C6 C6 C6 C3 C3 C6 Anterior chin/ Improves anterior projection C3 Bone structure; subcutaneous C5 C5 Soft tissue pogonion of the chin C2
Enhancer of C2 and C3 – further Submental/ improves vertical dimension C4 Subcutaneous; muscle Soft tissue menton and anterior projection . It also rotates the chin upwards
Widens the chin and gives lateral C5 Lateral lower chin support, producing a more Bone structure square chin . Ideal for men
C6 Reduces the prominence Bone structure and/or Prejowl sulcus (L6, Jw4) of the prejowl sulcus subcutaneous C3 C2 C2 C4 C4
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The 6-point chin reshape: Notes Product and volume recommendations
Volume Injection Injection Targeted Code Product Notes range (ml) technique device structure JUVÉDERM® VOLUMA® with Lidocaine C1 0 .5–1 .0 or or JUVÉDERM® VOLIFT® with Lidocaine
C2 0 .2–0 .4* (Jw5)
C3 0 .2–0 .4* or Don’t go too lateral due to mental artery
C4 0 .2–0 .4*
JUVÉDERM® VOLUMA® with Lidocaine
C5 0 .2–0 .4* Recommended for men
C6 0 .1–0 .5* or or or (L6, Jw4)
* The total volume should be delivered in small boluses (<0.3 ml) These recommendations are provided by Dr Mauricio de Maio and are based on his clinical experience. Some of these recommendations (e.g. volume, injection device, targeted structure) may not be aligned with the Instructions for Use; please consult these documents before using these products. NOTE: JUVÉDERM® VOLBELLA® with Lidocaine can also be used to treat fine lines in this area.
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The 5-point jawline reshape: The 5-point jawline reshape: Surface anatomy Injection areas and effects
Code Injection area Effect of injection Structures affected
Widens the face Bone structure (for masculine-looking results) Jw1 Mandible angle Lifts and defines the Subcutaneous mandible angle
Lifts the skin and reduces Jw2 Pre-auricular area Subcutaneous jawline sagginess
Improves definition Jw3 Mandible body Subcutaneous of the jawline Jw2
Jw4 Reduces the prominence of the Bone structure and/or Prejowl sulcus (L6, C6) prejowl sulcus subcutaneous
Jw5 Improves vertical dimension/ Chin apex Bone structure (C2) chin height Jw1
Jw3
Jw4 Jw5
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The 5-point jawline reshape: The 5-point jawline reshape: Topographical anatomy Product and volume recommendations
Volume Injection Injection Targeted Code Product Notes range (ml) technique device structure
Jw2 0 2–0. .5* Recommended JUVÉDERM® VOLUMA® for men Jw1 with Lidocaine Jw1 0 2. Jw1 Recommended for women Jw3 JUVÉDERM® VOLUMA® with Lidocaine Jw2 0 5–1. 0. or Be wary of JUVÉDERM® VOLIFT® parotid gland Jw5 Jw4 with Lidocaine
Jw3 0 2–0. .5 or Be wary of facial artery
Jw3 alert: Don’t touch the bone with the needle . Jw4 JUVÉDERM® VOLUMA® 0 1–0. .5* Be wary of the facial artery (L6, C6) with Lidocaine or or or
Jw5 0 2–0. .5* (C2)
Jw5 * The total volume should be delivered in small boluses (<0.3 ml) These recommendations are provided by Dr Mauricio de Maio and are based on his clinical experience. Some of these recommendations (e.g. volume, injection device, targeted structure) may not be aligned with the Instructions for Use; please consult these documents before using these products. NOTE: JUVÉDERM® VOLBELLA® with Lidocaine can also be used to treat fine lines in this area.
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Notes Notes
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G2 E3
G1
Tt3 Danger and alert zones Whenever injecting into a danger or alert zone, knowledge of topographic anatomy is essential. For safety reasons, L3 Tt1 Ck3 some of these areas should be treated using a blunt cannula. When injecting close to the bone or in an alert zone with needles, aspiration is highly recommended.
NL1
Jw3 L8 Ck5
Be careful when injecting close to the highlighted areas
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Notes Notes
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JUVÉDERM® VOLIFT® is a sterile, pyrogen-free gel implant presented in a graduated, pre-filled, disposable syringe, containing 17.5 mg/mL cross-linked hyaluronic acid with lidocaine 3 mg/mL. PBS Information: JUVÉDERM range of products are not listed on the PBS JUVÉDERM® VOLBELLA® is a sterile, pyrogen-free gel implant presented in a graduated, pre-filled, disposable syringe, containing 15 mg/mL cross-linked hyaluronic acid with lidocaine 3 mg/mL. Indications: JUVÉDERM® VOLIFT® with lidocaine is intended for the treatment of deep skin depressions, face contouring and volume restoration via deep dermis or lip mucosa injection. JUVÉDERM® VOLBELLA® with lidocaine is intended for the treatment of any fine lines and medium sized skin depressions as well as for enhancement and pouting of lips via superficial, mid-dermis or lip mucosa injection. The presence of lidocaine is meant to reduce the patient’s pain during the treatment. Contraindications: Common to both: Injection into the blood vessels (intravascular); overcorrection; patients with untreated epilepsy, those who tend to develop hypertrophic scarring or suffer from porphyria; hypersensitivity to hyaluronic acid, lidocaine, amide-type local anaesthetics and/or gram- BEFORE PRESCRIBING, PLEASE REVIEW APPROVED INSTRUCTIONS FOR USE (IFU’S) AVAILABLE ON positive bacterial proteins; in areas with inflammation or infection; children; pregnant or breast-feeding women; simultaneous administration with laser therapy, chemical peeling or dermabrasion. JUVÉDERM® VOLIFT® should not be injected in the periorbital area (eyelids, bags under the eyes, crow’s feet) and glabellar region. JUVÉDERM® VOLBELLA® should not be injected in the eyelids. REQUEST FROM ALLERGAN BY PHONING 1800 252 224 OR FROM www.allergan.com.au/products Precautions/Warnings: Standard precautions associated with injectable materials should be followed. Caution for use with another non-Allergan dermal filler; patients with autoimmune disease, history of severe and/or multiple allergies, streptococcal disease or anaphylactic shock, on anti-coagulation medication or using substances that can prolong bleeding including herbal supplements; Minimum Instructions for Use areas with inflammation or infection; Avoid makeup for 12 hours and avoid prolonged exposure to sunlight/UV light/extreme temperatures for at least 2 weeks post-treatment. Incompatible with JUVÉDERM ULTRA® XC and ULTRA PLUS® XC are sterile pyrogen-free gel implants presented in a graduated prefilled, disposable syringe, containing 24 mg/mL cross-linked hyaluronic acid with quaternary ammonium salts, e.g. benzalkonium chloride, and therefore filler must not be placed in contact with objects treated with these substances. Due to presence of lidocaine, caution is to be lidocaine 3 mg/mL. Indications: JUVÉDERM ULTRA® XC is for filling medium-sized depressions of the skin via mid-dermis injection, as well as for lip definition and pouting of lips. JUVÉDERM used when filler is used in combination with drugs that reduce or inhibit hepatic metabolism and in patients with symptoms of cardiac conduction disorders. It is recommended not to inject into a site ULTRA PLUS® XC is for filling mid and/or deep depressions of the skin via mid and/or deep dermis injection, as well as for lip definition and enhancement. The presence of lidocaine is meant to which has been treated with a permanent implant. Not intended for use in breast augmentation/reconstruction. Adverse Reactions: Injection site inflammatory reactions (redness, oedema, erythema) reduce the patient’s pain during treatment. Contraindications: Common to both: Injection into the blood vessels (intravascular); overcorrection; patients with untreated epilepsy, those who tend to which may be associated with itching and/or pain on pressure and/or paraesthesia; haematomas; induration or nodules; discolouration; weak filling effect; abscesses; granuloma and hypersensitivity. develop hypertrophic scarring or suffer from porphyria; hypersensitivity to hyaluronic acid, lidocaine, amidetype local anaesthetics and/or gram-positive bacterial proteins; in areas with inflammation Rare but serious adverse events associated with intravascular injection of dermal fillers in the face and tissue compression have been reported and include temporary or permanent vision impairment, or infection; children; pregnant or breast-feeding women; simultaneous administration with laser therapy, chemical peeling or dermabrasion. JUVÉDERM ULTRA® XC should not be injected into blindness, cerebral ischaemia or cerebral haemorrhage, leading to stroke, skin necrosis and damage to underlying structures. Dose/Administration: Injected into dermis or the mucous membrane of eyelids. JUVÉDERM ULTRA PLUS® XC should not be used in the crow’s feet or glabellar region. Precautions/Warnings: Standard precautions associated with injectable materials should be the lips by a medical practitioner trained in injection technique for filling. Inject slowly. After needle insertion and before injection, it is recommended to withdraw slightly the plunger to aspirate and verify followed. Caution for use with another non-Allergan dermal filler; patients with autoimmune disease, history of severe and/or multiple allergies, streptococcal disease or anaphylactic shock, on anti- the needle is not intravascular. The quantity injected will depend on the areas to be corrected. Massage the areas treated after the injection for uniform distribution. If immediate blanching occurs at any coagulation medication or using substances that can prolong bleeding including herbal supplements; areas with inflammation or infection; Avoid makeup for 12 hours and avoid prolonged exposure time during the injection, the injection should be stopped and appropriate action taken such as massaging the area until its return to a normal colour. (24Nov2016) to sunlight/UV light/extreme temperatures for at least 2 weeks post-treatment. Incompatible with quaternary ammonium salts, e.g. benzalkonium chloride, and therefore filler must not be placed in References: 1. JUVÉDERM® VOLUMA® with Lidocaine IFU. 2. JUVÉDERM® VOLIFT® with Lidocaine IFU. 3. JUVÉDERM® VOLBELLA® with Lidocaine IFU. 4. WO2004/092222A2 patent. 5. Callan P contact with objects treated with these substances. Due to presence of lidocaine, caution is to be used when filler is used in combination with drugs that reduce or inhibit hepatic metabolism and in et al. Clin Cosmet Investig Dermatol. 2013;6:81–89. 6. Borrell M et al. J Cosmet Laser Ther. 2011;13:21–7. 7. Muhn C et al. Clin Cosmet Investig Dermatol. 2012;5:147–158. 8. Raspaldo H. J Cosmet patients with symptoms of cardiac conduction disorders. It is recommended not to inject into a site which has been treated with a permanent implant. Not intended for use in breast augmentation/ Laser Ther. 2008;10:134–142. 9. Eccleston D, Murphy DK. Clin Cosmet Investig Dermatol. 2012;5:167–172. 10. Sherman, R. Clinics in Dermatology. 2009;27:S23–S32. ™® Trademark(s) and reconstruction. Adverse Reactions: Injection site inflammatory reactions (redness, oedema, erythema) which may be associated with itching and/or pain on pressure and/or paraesthesia; Registered trademark(s) of Allergan, Inc. Allergan Australia Pty Ltd. 810 Pacific Highway, Gordon NSW 2072. ABN 85 000 612 831. Allergan New Zealand Limited, Auckland. © 2017 Allergan. All haematomas; induration or nodules; discolouration; weak filling effect; abscesses; granuloma and hypersensitivity. Rare but serious adverse events associated with intravascular injection of dermal rights reserved. ANZ/0153/2016. DA1731CB. ALMD12507W. Date of preparation: June 2017. Ward6. fillers in the face and tissue compression have been reported and include temporary or permanent vision impairment, blindness, cerebral ischaemia or cerebral haemorrhage, leading to stroke, skin necrosis and damage to underlying structures. Dose/Administration: Injected into dermis or the mucous membrane of the lips by a medical practitioner trained in injection technique for filling. Inject slowly. After needle insertion and before injection, it is recommended to withdraw slightly the plunger to aspirate and verify the needle is not intravascular. The quantity injected will depend on the areas to be corrected. Massage the areas treated after the injection for uniform distribution. If immediate blanching occurs at any time during the injection, the injection should be stopped and appropriate action taken such as massaging the area until its return to a normal colour.
JUVÉDERM® VOLUMA® with Lidocaine is a sterile, pyrogen-free gel implant containing 20 mg/mL cross-linked hyaluronic acid with lidocaine 3 mg/mL. Indications: JUVÉDERM® VOLUMA® with Lidocaine is intended to restore volume of the face. The presence of lidocaine is meant to reduce the patient’s pain during the treatment. Contraindications: Injection in the periorbital area (eyelids, bags under the eyes, crow’s feet), glabellar region or in the lips; injection into the blood vessels (intravascular); overcorrection; patients with untreated epilepsy, those who tend to develop hypertrophic scarring or suffer from porphyria; hypersensitivity to hyaluronic acid, lidocaine, amide-type local anaesthetics and/or gram-positive bacterial proteins; in areas with inflammation or infection; children; pregnant or breast-feeding women; simultaneous administration with laser therapy, chemical peeling or dermabrasion. Precautions/Warnings: JUVÉDERM® VOLUMA® with Lidocaine is not indicated for injections other than subcutaneous, upper-periostea, or into the deep dermis. Standard precautions associated with injectable materials should be followed. Caution for use with another non-Allergan dermal filler; patients with autoimmune disease, history of severe and/or multiple allergies, streptococcal disease or anaphylactic shock, on anti-coagulation medication or using substances that can prolong bleeding including herbal supplements; areas with inflammation or infection; Avoid makeup for 12 hours and avoid prolonged exposure to sunlight/ UV light/extreme temperatures for at least 2 weeks post-treatment. Incompatible with quaternary ammonium salts, e.g. benzalkonium chloride, and therefore filler must not be placed in contact with objects treated with these substances. Due to presence of lidocaine, caution is to be used when filler is used in combination with drugs that reduce or inhibit hepatic metabolism and in patients with symptoms of cardiac conduction disorders. It is recommended not to inject into a site which has been treated with a permanent implant. Not intended for use in breast augmentation/reconstruction. JUVÉDERM® VOLUMA® with lidocaine is not recommended for intramuscular injections. There is no available clinical data regarding the efficiency and tolerance of JUVÉDERM® VOLUMA® with Lidocaine injection into the non-midline areas of the nose, nasal tip and the post-surgical/traumatic nose. Medical practitioner should be aware of the increased risk of vascular compromise/injury in the nasal tip due to the limited space available to accommodate injected product and in the post-surgical/traumatic nose due to scar and/or anatomic disruption. Adverse Reactions: Injection site inflammatory reactions (redness, oedema, erythema) which may be associated with itching and/or pain on pressure and/or paraesthesia; haematomas; induration or nodules; discolouration; weak filling effect; abscesses; granuloma and hypersensitivity. Rare but serious adverse events associated with intravascular injection of dermal fillers in the face and tissue compression have been reported and include temporary or permanent vision impairment, blindness, cerebral ischaemia or cerebral haemorrhage, leading to stroke, skin necrosis and damage to underlying structures. Dose/ Administration: Injected into deep dermis, subcutaneously or in the upper periostea by a medical practitioner trained in injection technique for filling. Inject slowly. After needle insertion and before injection, it is recommended to withdraw slightly the plunger to aspirate and verify the needle is not intravascular. The quantity injected will depend on the areas to be corrected. Massage the areas treated after the injection for uniform distribution. If immediate blanching occurs at any time during the injection, the injection should be stopped and appropriate action taken such as massaging the area until its return to a normal colour.
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