Myomodulation with Injectable Fillers: An Update
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EDITORIAL
Myomodulation with Injectable Fillers: An Update Maurı´cio de Maio1
Ó The Author(s) 2020
Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. ‘‘Myomodulation with Injectable Fillers: An Innovative Approach to Addressing Facial Muscle Movement’’ [1] was presented as a theoretical discussion of the concept of using injectable hyaluronic acid (HA) fillers to modulate the action of mimetic muscles to improve facial appearance. Traditionally, excessive muscle contraction has been addressed using neurotoxins (chemical myomodulation), with HA fillers used in conjunction to add volume and fill folds and wrinkles [2, 3]. However, extensive experience using HA fillers to treat patients with facial palsy, structural deficits, and bone and/or soft tissue loss associated with aging has shown that filler treatment can alter interactions between facial structure and muscle movement and balance action within muscle groups to modify appearance on both animation and at rest. Chemical myomodulation is used to reduce muscle contraction, whereas HA fillers can act via mechanical myomodulation to either increase or reduce muscle action (Fig. 1a). As discussed in the original paper, filler treatment can be used to correct structural deficiency, facilitate muscle action, and create an obstacle to extreme muscle excursion and depressor contraction. Where contraction is weakened due to congenital structural deficiency or volume loss with aging, mechanical myomodulation can facilitate action by & Maurı´cio de Maio [email protected] 1
MD CodesTM Institute, Rua Santa Justina, 660 - cjs 121 e 124, Vila Olı´mpia, Sa˜o Paulo, SP 04545-042, Brazil
providing support under the muscle between its origin or insertion (creating a fulcrum or pulley effect), or improve tensile strength by increasing distance between the origin and insertion, thereby reducing slack. Where muscle action is excessive, it can be reduced by adding tissue resistance above the muscle or injecting directly into or beneath the muscle near its origin or insertion to create a mechanical block. As a theoretical paper, the discussion of these concepts was limited by a lack of experimental evidence for proposed mechanisms underlying observed effects, and the effectiveness of treatment based on myomodulation has not yet been assessed in clinical studies [4]. However, although the posited mechanisms remain to be tested, the ideas presented in the paper can be of value to clinicians practicing facial aesthetics and rehabilitation, challenging them to reconsider how they plan and carry out HA filler and neurotoxin treatments. The current focus of my work has grown directly out of this understanding of the value of myomodulation with HA fillers. In forthcoming publications, clinical tools developed for employing mechanical myomodulation in practice will be des
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