A novel method to inject hyaluronic acid: the Fern Pattern Technique Journal of Drugs in Dermatology, August, 2007 by Tom

van Eijk, Martin Braun Abstract Nonanimal Stabilized Hyaluronic Acid (NASHA) has proven itself as one of the safest, most versatile dermal fillers with a high patient and physician satisfaction. The authors describe a novel technique to inject Restylane (NASHA) in the dermis for optimal correction of dynamic facial lines. Mobile facial folds represent a greater challenge for correction using standard injection techniques. The injection technique described is named the Fern Pattern Technique. The purpose of the Fern Pattern Technique is to use Restylane in such a way that it becomes a skin stiffening agent, rather than a simple filler in order to provide optimal correction for lines that deepen with expressive facial movements. The Fern Pattern Technique also uses less material to provide a correction that is not visible at rest or during dynamic movement for lines that deepen during a smile, as well as the dynamic lower nasolabial fold. Introduction Restylane, the dermal filler based on the Nonanimal Stabilized Hyaluronic Acid (NASHA) concept, has been used in over 6,000,000 treatments worldwide since it was originally introduced to market in 1996. Restylane has proven itself to be one of the safest, most versatile dermal fillers, with a high patient and physician satisfaction. (1,2) Four basic injection patterns have been described using dermal fillers in cosmetic dermatology: (3-7) 1. The linear threading technique: fill a fold with a singular "thread-like" shape after puncturing the epidermis once to provide linear volume (Figure 1). 2. The serial puncture technique: fill a fold with multiple injections of the epidermis placed in a row to provide linear volume (Figure 2). 3. The fanning technique: puncturing the epidermis once, "fanning" the needle in a fan pattern to provide volume in a triangular shape (Figure 3). 4. The cross-hatching technique: combines multiple injections of linear threading that crisscross at right angles to provide volume in a square shape (Figure 4). These injection techniques introduce hyaluronic acid (HA) into or underneath the skin, and provide the physician 4 ways to restore volume deficits. For example, areas of the face that are relatively immobile, such as the top half of the nasolabial fold or the tear trough can be filled with relative ease using one of these basic injection techniques. A good correction can usually be achieved. However, none of these 4 injection patterns are satisfactory for correcting the problem of dynamic folds, such as the lower half of the nasolabial fold, the corners of the mouth, and the smile lines found in the lower lateral cheeks. These folds are quite mobile with expressive facial movements, and they present a greater challenge in providing optimal correction. (8) [FIGURE 1 OMITTED]

[FIGURE 2 OMITTED] [FIGURE 3 OMITTED] [FIGURE 4 OMITTED] The Dynamic Nasolabial Fold The dynamic nasolabial fold is often filled using a linear threading technique. Unfortunately, during animation there remains a tendency of the nasolabial fold to shift alongside the filler if the correction used was only a linear threading technique, which can then be easily recognized by an observer. In order to solve this problem, it is necessary to produce a broad plane across the nasolabial fold to prevent it from reappearing lateral to the filler during a smile. Many injectors attempt to use the cross-hatching technique to provide more support next to the dynamic fold, which frequently gives the appearance of an area that is overfilled at rest. Among the most difficult wrinkles to adequately fill are the "smile lines," which appear on the lower lateral cheek while smiling (Figure 5). Linear threading is usually unsatisfactory, especially during animation, and cross-hatching often results in a "pad" of filler in patients who have thin skin. In addition, even linear threading can be visible in an individual with thin skin. [FIGURE 5 OMITTED] The Fern Pattern Technique To achieve correction that is undetectable at rest and during animation of a dynamic fold, we propose to use HA not as a filler, but rather as a skin stiffening agent to attempt to increase the stiffness of the skin on either side of the dynamic line. By using a novel injection technique developed by the lead author, we have observed increased stiffness of the skin on either side of the dynamic fold after injection and a decreased ability for movement of lines in the treated area. This technique has been named the Fern Pattern Technique. It is done by injecting along the fold, in a linear fashion using a series of punctures. However, unlike linear threading or serial puncture, the needle is inserted perpendicular to the fold and advanced a few millimeters away from the fold. HA is then injected in a retrograde fashion as the needle is withdrawn toward the fold. The maximum increase in dermal stiffness can be obtained by injecting small amounts of material in the mid dermis. The entire procedure is repeated along the length of the fold alternating between the left and right sides of the fold. This technique can be best described by visualizing a fern: the dynamic fold is the main stem of the fern and the leafy fronds are represented by the injections of HA at 90 degrees to the main stem. The Fern Pattern Technique is illustrated in Figure 6. A video of the procedure may also be viewed online at www.JDDonline.com. (9) Supporting the wrinkle by filling with injections at 90 degrees to this fold has also been called "bridging." Bridging, however, has one disturbing artifact; at the entry point of the needle tip, injecting while retracting the needle out of the skin, little nodules can be seen. This is due to the fact that a needle inserted at an oblique angle to the skin and slowly withdrawn will deposit more material superficially while withdrawing from the skin. The needle tip is not parallel to the epidermis. These nodules do not contribute to the overall aesthetic result of the treatment. By withdrawing the needle from the center of the fold, any HA material deposited more superficially

will enhance the correction of the fold, because the needle was originally inserted into the base (and deepest point) of the fold. [FIGURE 6 OMITTED] In order to use these artifacts to our benefit, we chose to place all injection entry points in the middle of the fold, alternating the injection direction toward both sides, thus creating a fern pattern. Hence, the name Fern Pattern Technique. Next to the improved aesthetic result, another interesting observation that we have made with the Fern Pattern Technique is that one uses much less filler to achieve an optimal dynamic fold correction compared to the other traditional techniques. This is especially true when using the Fern Pattern Technique to fill the "marionette lines," which form during the aging process with loss of volume and skin firmness of the lateral commissure of the lip and form a fold that descends toward the prejowel sulcus. This entire area has earned the nickname "the abyss," due to the large amounts of filler material frequently necessary to achieve any correction at all. Using the Fern Pattern Technique provides a greater correction of the marionette line with less material than used during linear threading or the fanning technique. Crosshatching in this area often leads to material deposited into the modeolos, slightly superior and lateral to the marionette line. [FIGURE 7 OMITTED] [FIGURE 8 OMITTED] [FIGURE 9 OMITTED] [FIGURE 10 OMITTED] Figures 7 and 8 demonstrate a patient immediately after receiving 0.2 ml of Restylane into the smile line using the Fern Pattern Technique. Figures 9 and 10 demonstrate the patient 2 weeks later at rest and smiling. The correction is undetectable at rest and dynamic movement skin firmness has been restored. Summary The Fern Pattern Technique is a novel injection method for providing optimal correction using HA for dynamic facial lines. Dynamic facial lines are particularly challenging to fill using one of the 4 classical injection techniques, and will respond better to the Fern Pattern Technique with the added benefit of requiring less material. In our opinion, it is the method of choice to correct dynamic facial lines. Disclosures The authors have received honoraria from Medicis and Q-Med. The paper was devised and funded by the authors. References

1. Matarasso SL, Carruther JD, Jewell ML, and the Restylane Consensus Group. Consensus recommendations for soft-tissue augmentation with nonanimal stabilized hyaluronic acid (Restylane). Plast Reconstr Surg. 2006;117(suppl):3s-34s. 2. Born T. Hyaluronic acids. Clin Plast Surg. 2006;33:525-538. 3. Biesman B. Soft tissue augmentation using Restylane. Facial Plast Surg. 2004;20:171-177; discussion 178-79. 4. McCracken MS. Khan JA, Wulc AE, et al. Hyaluronic acid gel (Restylane) filler for facial rhytids; lessons learned from American Society of Opthalmic Plastic and Reconstructive Surgery member treatment of 286 patients. Opthal Plast Reconstr Surg. 2006;22:188-191. 5. Carruthers JD, Carruthers A. Facial sculpting and tissue augmentation. Dermatol Surg. 2005;31(11 Pt 2):1604-1612. 6. Klein AW. Techniques for soft tissue augmentation: an 'a to z.' Am J Clin Dermatol. 2006;7:107-120. 7. Narins RD, Bowman PH. Injectable skin fillers. Clin Plast Surg. 2005;32:151-162. 8. Carruthers J, Klein AW, Carruthers A, et al. Safety and efficacy of nonanimal stabilized hyaluronic acid for improvement of mouth corners. Dermatol Surg. 2005;31:276-280. 9. van Eijk T, Braun M. A demonstration of the Fern Pattern Technique, a novel method for injecting hyaluronic acid. Available at: www.JDDonline.com. Accessed July 1, 2007. ADDRESS FOR CORRESPONDENCE Martin Braun MD Medical Director Vancouver Laser and Skin Care Center 309-750 W. Broadway Vancouver, BC Canada V5Z 1H2 e-mail: info@vancouverlaser.com Tom van Eijk MD, (a) Martin Braun MD (b) a. Jacob Marisstraat, Amsterdam, The Netherlands b. Vancouver Laser and Skin Care Center, Vancouver, BC, Canada

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