Each MD Code includes in[[f]]ormation regarding the target Keywords Aesthetics (cid:2) Dermal fillers (cid:2) Hyaluronic acid (cid:2)

depth o[[f]] injection, the proper delivery tool (needle or Rejuvenation (cid:2) Skin aging (cid:2) Skin wrinkling

selectedusingalgorithms[[f]]ocusedonlesseningunfavorable Patients who undergo facial aesthetic procedures may be

[[f]]acial attributes (a saggy, tired, sad, or angry look) and dissatisfied with treatment outcomes [1–3]. They often

enhancing positive attributes (an attractive, younger, more [[f]]ocus on particular areas with which they are unhappy,

contoured, or [[f]]eminine [soft] or masculine look). such as the periorbital area or jowls, and ask the clinician

Results Three case studies are presented to illustrate how providing treatment to speci[[f]]ically address those features

the MD Codes and their algorithms were used to address [4–8]. Even as patients believe that the objective o[[f]] treat-

Electronicsupplementarymaterial Theonlineversiono[[f]]this with treatmentbecausethey were expecting improvements

article(https://doi.org/10.1007/s00266-020-01762-7)containssup-

plementarymaterial,whichisavailabletoauthorizedusers. beyond the elimination o[[f]] isolated flaws. Patients com-

& Maur´ıciodeMaio

mauriciodemaio@uol.com.br

1 MDCodesInstitute,RuaSantaJustina,660-cjs121e124, Faces can convey a variety o[[f]] emotional cues or mes-

ViaOl´ımpia,SaoPaulo,SP,Brazil sages that o[[f]]ten do not reflect a patient’s true feelings. For

AesthPlastSurg

Table1 Keysourceso[[f]]

Variable Examples

variabilityinminimally

invasiveaesthetictreatment

Patient Age

outcomes

Ethnicity

Gender

Physiology

Bonestructure

Fatcontent

Muscleactivity

Skinquality

Product Typeo[[f]]filler(biodegradableandnonbiodegradable)

HAbrandtechnology

Concentration

Degreeo[[f]]cross-linking

Technique Injectiondetails

Location

Unit

Subunit

Layer

Mucosa,dermis,sub-dermis,subcutaneous,[[f]]atpads,muscle,bone

Volume

Injectiontool

Needletypeandgauge

Cannulatypeandgauge

Injectiondelivery

Micro-aliquot

Aliquot

Bolus

Linear

Fanning

Clinician Levelo[[f]]technicalskill

Yearso[[f]]experience

Deptho[[f]]knowledgeoffacialanatomy

Breadtho[[f]]experienceinthepatientpopulation(e.g.,byethnicity,gender)

example,apatient’s[[f]]acemaylooktiredwhenthepatientis experience, patient satisfaction with treatment is improved

not[[f]]eelingtiredormayconveysadnesswhenthepatientis when treatment focuses on reducing unfavorable facial

not [[f]]eeling sad [9–14]. Studies have demonstrated that messagesandonincreasingfavorableattributes,ratherthan

negative emotional messages are associated with speci[[f]]ic treating isolated areas. A number of emotional cues are

[[f]]acial deficiencies [9–11, 13, 15]; for example, an angry described in the literature, including anger, fear, fatigue,

appearancemaybecausedbyglabellarlinesoratiredlook sadness, and happiness [9–13, 15], In this paper, [[f]]acial

caused by eye bags [10, 11, 13, 15]. Changes that occur messages are grouped as [[f]]our unfavorable attributes

withagingintheskin,so[[f]]ttissue,andbonesofthefaceand (lookingtired,lookingsad,havingasaggyappearance,and

cause such de[[f]]iciencies may result in the accumulation of having an angry look) and four favorable or positive

these negative emotional messages [9, 11, 13]. However, attributes(lookingattractive,younger,morecontoured,and

treatmento[[f]]onlyoneisolatedarea(e.g.,theeyebags)may either feminine [soft] for women or masculine for men).

not lead to a success[[f]]ul aesthetic outcome. Addressing unfavorable facial attributes is challenging

Several authors have suggested that rather than treating given the many variables that in[[f]]luence treatment success,

individual [[f]]acial deficiencies, clinicians providing facial defined here as a reduction in negative attributes and

aesthetic treatment should address the emotional messages enhancement o[[f]] positive attributes (Table 1). Some vari-

ormiscueso[[f]]thepatient’sface[9,10,15].Inthisauthor’s ables,suchasapatient’sage,gender,andethnicity,arenot

AesthPlastSurg

Table2 Summaryo[[f]]thecomponentsoftheMDCodes

Number Thesubunitso[[f]]theanatomicalunit(e.g.,Ck1=zygomaticarch;Ck2=zygomaticeminence)

Numberlocation Thesideo[[f]]theface(e.g.,Ck1r=thezygomaticarchontherightside;Ck1l=thezygomaticarchontheleftside)

Superscript(Xn)re[[f]]erstoupperareas(e.g.,Lp1=vermilionbodyoftheupperlip)

Numberposition

Color Redcolordenotesalertareas,andadditionalcautionmustbetakeni[[f]]injectingatornearthesesites,forpatientsafety

Shape

Technicaldeliveryo[[f]]theproduct(e.g., =needle, =cannula, =fanning, =aliquots; =bolus)

within the clinician’scontrol.Each o[[f]]thosecharacteristics by the letters Ck, and subunits of the cheek are numbered:

in turn can independently a[[f]]fect fat content, muscle activ- Ck1 = zygomatic arch, Ck2 = zygomatic eminence,

ity, and skin quality and laxity, resulting in an in[[f]]inite Ck3 = anteromedial cheek–midcheek, and so on. The MD

variety o[[f]] faces. However, the technical aspects of treat- Codes numbers do not reflect the sequence in which the

ment, such as the product used and injection techniques injections should be administered, but instead provide a

applied, can be more precisely controlled. The MD checklist o[[f]] items that the clinician can mark when

CodesTM (or medical codes) is a system developed by the assessing each [[f]]acial unit. MD Codes in red denote alert

author to provide speci[[f]]ic injection guidelines giving the areas, where there are sensitive structures, such as neu-

precise location, layer, tool, delivery system, and product rovascular bundles in [[f]]acial danger zones [18]. These red

volume in[[f]]ormation to be used to achieve optimal results, codes (Fig. 1) remind the clinician to be cautious in these

regardless o[[f]] patient age, gender, or ethnicity. The areas when using needles and to consider the use of can-

achievement o[[f]] successful results, defined here as the nulas instead. The alert codes should never be used to

reduction in negative or un[[f]]avorable attributes and guide injection by novice clinicians. As discussed below,

enhancement o[[f]] positive attributes, will vary between treatmentofalertareas shouldonly bedeliveredbyhighly

clinicianso[[f]]differentskilllevelsandexperience;however, trained experts with extensive injection experience, thor-

the MD Codes guidelines can improve the per[[f]]ormance of ough knowledge of the anatomy and physiology of each

thenoviceclinician,whilealsotheoreticallyenhancingthe area, and the ability to manage severe complications,

successrateo[[f]]moreexperiencedclinicians.Theuseofthe should they occur.

MD Codes to address un[[f]]avorable emotional messages of Shapes associated with the codes for HAfillers indicate

the [[f]]ace has been presented online and in seminars injection delivery (e.g., bolus or linear injection; Table 3).

worldwide.WhilematerialsdescribingtheMDCodeshave For each MD Code, there is also an associated target

beenprovidedinconjunctionwiththoseseminars[16,17], injection depth (e.g., subcutaneous or supraperiosteal), a

this article provides the [[f]]irst peer-reviewed description of tool for product delivery (needle or cannula), and a mini-

the MD Codes system and its algorithms. Case studies are mal volume o[[f]] product to inject (active number). The use

presented to illustrate its use. o[[f]] needles is preferable for precise bolus injections at the

liplines).Theuseo[[f]]cannulasispreferredforsubcutaneous

The MD Codes are letters, numbers, shapes, and colors bundles is a concern.

understoodinanylanguageandthatserveasaplat[[f]]ormof MD Codes Equations

Injection sites are described using a combination o[[f]] letters A set of MD Codes that prescribes the treatment of a

and numbers; the letters signi[[f]]y anatomical units (e.g., the specific facial deficiency is grouped to form an equation

cheek, temple, or chin) and the numbers signi[[f]]y subunits, (Table 4).Forexample,theequationtotreattheteartrough

suchthateachcodeindicatesasingle,preciseinjectionsite area is Tt1 ? Tt2 ? Tt3, where each code denotes the

(Table 3;TableS1).Forexample,thecheekisrepresented [[f]]acial unit (Tt) and subunit (1, 2, or 3). However, direct

AesthPlastSurg

Fig.1 MDCodesanatomical

correlates(a)andinrelationto

thetopographicalanatomyo[[f]]

thecheek(b).Redcodesdenote

alertareas.Reprintedwith

permission[[f]]romAllerganplc,

Dublin,Ireland

treatment o[[f]] the tear trough area, or any deficiency, in areashouldbeplannedandcarriedoutinthecontextofthe

isolationisnotidealandmayleadtopatientdissatis[[f]]action unfavorable facial messages to which tear troughs con-

andadverseevents.Rather,thetreatmento[[f]]theteartrough tribute, including equations for each deficiency. Saggy

AesthPlastSurg

Table3 MDcodesandinjectionguidance[[f]]oranatomicalsitesusinghyaluronicacidfillers

Anatomical Injectionarea Targetdeptho[[f]] Injection Injection Alerts Activenumber

Foundation

Cheek(Ck)

eminence

Bewaryo[[f]]thezygomaticofacial

arteryd

cheek

Bewaryo[[f]]theinfraorbitalarteryd

pad

cheek/parotid

area Bewaryo[[f]]theparotidgland

area

Bewaryo[[f]]thebuccalnerve,facialvein

andartery

Contour

Upper[[f]]ace

Temple(T)

Bewaryo[[f]]thesuperficialfrontalartery

andthedeeptemporalarteriesd

Supraperiostealb

Bewaryo[[f]]thesuperficialfrontalartery

anddeeptemporalarteriesd

posteriortemple

Lower[[f]]ace

Chin(C)

midline)

Donotgotoolateralduetomental

arteryd

AesthPlastSurg

Table3 continued

Anatomical Injectionarea Targetdeptho[[f]] Injection Injection Alerts Activenumber

Jowls(Jw)

Bewaryo[[f]]parotidgland

Bewaryo[[f]]thesuperficialtemporal

arteryandtheparotidgland

chin

Re[[f]]inement

Periorbital

Forehead

(F)g,h

Injectionshouldbeavoidedinthe2-cm

regionabovetheorbit

Supraperiostealb

Bewaryo[[f]]thesupraorbitalartery

Bewaryo[[f]]thesuperficialtemporal

artery

Bewaryo[[f]]thesupratrochlearartery

Lateralorbital(O)

orbital

Avoidinjectingintothelowereyelid

orbital

Avoidinjectingintothelowereyelid

Supraperiostealb

orbital

Avoidinjectingintotheuppereyelid

Eyebrow(E)h

Injectlateralto

thesupraorbital[[f]]oramen

Injectlateralto

thesupratrochlear[[f]]oramen

AesthPlastSurg

Table3 continued

Anatomical Injectionarea Targetdeptho[[f]] Injection Injection Alerts Activenumber

Teartrough(Tt)i

Supraperiostealb

Bewaryo[[f]]theinfraorbitalartery

branchesi

Bewaryo[[f]]theangulararteryandveini

Glabella(G)i

Bewaryo[[f]]theneurovasculatureinthe midline)

glabellarregion,inparticularthe

supratrochleararteries

Perioral

Nasolabial[[f]]old(NL)

Bonede[[f]]iciencyj

[[f]]old

Bewaryo[[f]]thefacialarteryandthe

branchestothenasal[[f]]lared,

Mild/moderatek

[[f]]old

Bewaryo[[f]]thefacialarteryandthe

branchestothenasal[[f]]lare

[[f]]old

Bewaryo[[f]]thefacialartery

Severek

[[f]]old

Bewaryo[[f]]thefacialarteryandthe

branchestothenasal[[f]]lare

[[f]]old

Bewaryo[[f]]thefacialartery

[[f]]old

Bewaryo[[f]]thefacialartery

Marionetteline(M)

line

line

line

AesthPlastSurg

Table3 continued

Anatomical Injectionarea Targetdepth Injection Injection Alerts Activenumber

Lip(Lp)

Lp1

Lp3

midline)

Bewaryo[[f]]thesuperiorlabialartery

Bewaryo[[f]]theinferiorlabialartery

Lp8

lines

lines

Other

Nose(N)h

angle)

0.3(only

midline)

midline)

midline)

AesthPlastSurg

Table3 continued

Anatomical Injectionarea Targetdeptho[[f]] Injection Injection Alerts Activenumber

unitMDcode injection device delivery perside(mL)a

Cartilageb Cannulam

ThevolumeshownintheActiveNumbercolumnistherecommendedvolume[[f]]orinjectioninonesideoftheface

ROOF,retro-orbicularisoculi[[f]]at;SMAS,superficialmuscularaponeuroticsystem;SOOF,suborbicularisoculifat;TML,top-modellook

aRecommended volumes were determined based on the author’s clinical experience with Juve´derm injectables with Vycross technology

includingVolumawithLidocaine(Juve´dermVolumaXC),Voli[[f]]twithLidocaine(Juve´dermVoliftXC),andVolbellawithLidocaine(Juve´derm

VolbellaXC;all,Allerganplc,Dublin,Ireland)

bDonotinjectintothecartilageorintothebone,butratheratthelevelo[[f]]thecartilageorthelevelofthebone

cCk1isthestartingpointo[[f]]everyinjectionwiththeMDCodes,anditsactivenumberis0.1?0.1?0.1mL.Thesethreeanchoringpointsare

injected downtothebone topromote SMASli[[f]]ting.Asingle bolusof0.3mLinonly onesiteisnotadvised here asitmaybulge andlook

unnatural

dAspirationishighlyrecommendedwheninjectingwithaneedleatthelevelo[[f]]thebone

eAlthoughtheactivenumber[[f]]orC1is0.5mL,whentreatmentofC1iscombinedwithC2,theactivenumberforC1becomes0.7mLsothatthe

totalvolume[[f]]orC1?C2=1.0mL(1syringe).ThesamehappenswhenCk1iscombinedwithT1orCk4

[[f]]Mainlyusedinmalepatients

gThisapproachis[[f]]orrestoringforeheadvolumeloss,foreheadadvancement,andforeheadreshape

hTreatment o[[f]] the forehead, eyebrow, glabella, and nose areas is very advanced and should only be delivered by highly trained experts with

extensiveinjectionexperienceandknowledgeonthemanagemento[[f]]severecomplications

iTeartroughandorbitalcodesarereserved[[f]]orspecialistsspecificallytrainedinthistechniqueandthosewhohaveasoundknowledgeofthe

anatomyandphysiology[[f]]orthisparticulararea

jThistreatmentapproachisdesignedtocorrectbonestructuralde[[f]]iciencies

kTheuseo[[f]]cannulasinthenasolabialfoldisadvisabletocorrectdynamicnasolabialfolds.Theuseofneedlesatthedeepdermallevelmaybe

used[[f]]orthecorrectionoffinelines

lLp8mayalsobetreatedusingmicro-aliquotinjectionswithneedlesatthesubdermallevel

mSmallandlownosesmaybebetteraddressedwithcannulas

=bolus,staticinjectiono[[f]]injectable(0.3mL); =linearinjection(anterogradeorretrograde;0.5mL); =fanning,definedasmultiple

linearinjectionsviaasingleentrysitecreatinga[[f]]an-likepatternwithcannulas(0.5mL); =micro-aliquotinjectionsofverysmalldropletsof

injectable(0.01–0.05mLperpoint); =aliquotinjections,de[[f]]inedasstaticinjectionsofasmallamountofinjectable(0.1–0.2mL)

cheeks, sunken temples, and eye bags may contribute to a and the lower [[f]]ace (chin and jawline). The final step is

tired appearance and, there[[f]]ore, the treatment of a tired refinement,whichinvolvestreatingteartroughsandlateral

look may require MD Codes equations [[f]]or each of those canthal lines (or crow’s feet lines) in the periorbital area,

de[[f]]iciencies. and deep nasolabial folds, the lips, and marionette lines in

Theorderinwhichtheserieso[[f]]MDcodesequationsare the perioral area. Thus, treating a tired look should be

addressedmaysigni[[f]]icantlyaffecttreatmentsuccess.Inthe addressed by first providing foundation to the midface

author’s experience, patient satis[[f]]action is improved when (e.g., saggy cheeks: Ck1 ? Ck2 ? Ck3 ? Ck4), then

planningandimplementationo[[f]]treatmentisconductedina contouringtheupperface(e.g.,sunkentemples:T1 ? T2),

speci[[f]]ic sequence, according to a principle of foundation, and,finally,refiningtheperiorbitalarea(e.g.,teartroughs:

contour,andre[[f]]inement.Thisapproachhasbeendescribed Tt1 ? Tt2 ? Tt3).

using the analogy o[[f]] the construction of a house [19];

laying a [[f]]oundation is always the first step, followed by Algorithms for Selecting MD Codes

contouring, or constructing the [[f]]raming, floors, and walls.

Re[[f]]inements, such as interior decor, are added last. When To handle the enormous variability among faces, the MD

treatingthe[[f]]ace,thefoundationislaidbycreatingstructure Codes algorithmswere developedtoguideselectionofthe

and reducing sagginess in the mid[[f]]ace. Treatment of the appropriate MD Codes for each individual. Not every

cheek area should always begin by addressing the lateral patientwillneedallo[[f]]thecodeswithineachequation.For

li[[f]]ting vectors, represented by Ck1 and Ck4. The contour example, the algorithm for saggy cheeks (Fig. 2a) guides

step is divided into the upper [[f]]ace (treating the temples) the selection of MD Codes based on the presence or

AesthPlastSurg

Table4 Checklisto[[f]]standardequationsfortreatingfacialdeficiencieswiththeMDcodes

Foundation,mid[[f]]ace Saggycheeks/cheek-volumeloss Ck1?Ck2?Ck3?Ck4?Ck5

Cliniciansshouldtailoreachequationtotheneedso[[f]]thepatient(seeTable1)

Cchin,Ckcheek,Eeyebrow,F[[f]]orehead,Jwjowl,Lplip,Mmarionette,Nnose,NLnasolabial,Oorbit,Ttemple,Ttteartrough

aFormalepatients

providemid[[f]]acefoundationby

(a)treatingsaggycheeks,to

contourtheupper[[f]]aceby

(b)treatingsunkentemples,and

toprovideperiorbitalre[[f]]inement

bytreating(c)theteartroughs

and(d)theeyebags.Ck1,

zygomaticarch;Ck2,zygomatic

eminence;Ck3,anteromedial

cheek–midcheek;Ck4,lateral

lowercheek/parotidarea;Ck5, Ck1 Ck1 + Ck4 Ck1 + Ck2 Ck1 + Ck3 Ck1 + Ck3 + Ck5

submalararea;T1,anterior

temple;T2,posteriortemple;

Tt1,centralin[[f]]raorbital;Tt2,

lateralin[[f]]raorbital;Tt3,medial

b

in[[f]]raorbital.Reprintedwith

Maio,MD,PhD

T1 +T2 (bone)

T1/T2 ([[f]]ascia)

AesthPlastSurg

Fig.2 continued c

Tear Trough

d

Eye Bags

Step 1

1. Correct:
2. Correct:

– Cheek sagginess

– Mid[[f]]ace volume loss

Step 2

Lateral eye corner

down?

eyelid position?

Avoid Tt

Tt1 + Tt2 + Tt3

injection

absence o[[f]] volume loss. When comparing a daughter, a treatment of all five cheek anatomical areas

mother,andagrandmother,thedaughtermayhave[[f]]ullness (Ck1 ? Ck2 ? Ck3 ? Ck4 ? Ck5).

in her cheek area and present with only a mild degree o[[f]] Someonewithatiredlookmayalsopresentwithsunken

sagginess. Thus, according to the saggy cheeks algorithm, temples.Thealgorithm[[f]]orsunkentemples(Fig. 2b)guides

she wouldbene[[f]]itfromtreatment ofonly Ck1.Themother clinicians on the selection of MD Codes based on the

may present with sagginess and volume loss concentrated severity o[[f]] volume loss in the temples. In the case of the

only in the medial aspect. She may bene[[f]]it from treatment daughter, the mother, and the grandmother, the daughter

o[[f]] Ck1, Ck3, and Ck4. The grandmother, due to a greater may not need any temple treatment as she may have no

severity o[[f]] volume loss and sagginess, may be eligible for deficiency there. The mother may present with mild to

AesthPlastSurg

Fig.3 Improvement in emotional attributes o[[f]] the face, with receiving4mLtotal,8mLtotal,andthefull17mLtreatment,within

increasing volume over successive treatment steps using the MD a single session. The patient received a total o[[f]] 17 syringes of

Codes.This53-year-oldAsianwomanpresentedwith[[f]]acialsignsof Juve´dermproducts(Allerganplc),administeredas13mLofVoluma,

sagginessinthemid[[f]]aceandlowerface,atiredlook,andasadlook 3mL of Volift, and 1mL of Volbella. Reprinted with permission

(le[[f]]t image). She is shown before treatment and immediately after fromMaur´ıciodeMaio,MD,PhD

only [[f]]rom treatment of T1. The grandmother, with a more Over the foundation, contour, and refinement steps, the

severetemplede[[f]]iciency,maybenefitfromtreatmentofT1 MD Codes approach can result in the progressive removal

and T2. o[[f]] the unfavorable attributes of tiredness, sadness, and

Thealgorithms[[f]]ortreatment oftheteartroughs andthe sagginess, and may enhance the positive attributes of

eyebagsareshowninFig. 2candd,respectively.Thevast looking younger and more [[f]]eminine. Figure 3 illustrates

majority o[[f]] people presenting with distracting tear troughs the change in appearance that may be observed as addi-

and eye bags also have saggy cheeks and/or volume loss tional MD Codes are used to add volume in successive

that would [[f]]irst require treatment of the cheeks (founda- treatment steps. Notice the improvement in the patient’s

tion) and the temples (contouring). Only a young patient cheek immediately a[[f]]ter providing midface foundation

whopresentswithnovolumelossorsagginessmaybene[[f]]it (Ck1 ? Ck2 ? Ck3 ? Ck4) and contouring of the upper

[[f]]rom direct treatment of the tear troughs (Tt1 ? Tt2 ? face (T1) with a total 4 mL of HA filler. The patient’s

Tt3), but this rarely occurs in clinical practice. jawline was improved a[[f]]ter contouring of the lower face

Combining the MD Codes identi[[f]]ied using the three with an additional 4 mL of HA filler (C1 ? C2 ? Jw4 ?

algorithmstotreatatiredlookmayresultin,[[f]]orexample,a Jw5). Improvement in her double chin was also achieved

total o[[f]] seven MD Codes for the mother ([Ck1 ? Ck3 ? by addressing the cheek first, then contouring the chin and

Ck4] ? [T1] ? [Tt1 ? Tt2 ? Tt3]), and 10 codes [[f]]or the anterior jawline. Foundation and contour were reinforced

grandmother ([Ck1 ? Ck2 ? Ck3 ? Ck4 ? Ck5] ? [T1 ? with additional codes (Ck3 ? C6), re[[f]]inement of the peri-

T2] ? [Tt1 ? Tt2 ? Tt3]).Thus,thedi[[f]]ferencebetweenthe orbital area improved the tear troughs (Tt1 ? Tt2 ? Tt3),

treatmentplans[[f]]orthemotherandthegrandmotherisinthe and perioral refinement addressed the lips and nasolabial

number o[[f]] codes, based on degree of severity; the grand- folds (Lp ? Lp2 ? Lp3 ? Lp ? Lp5 ? Lp6 ? NL1)

1 3

mother does not necessarily receive more volume usinga[[f]]inal9 mLoffiller.TheimageontherightinFig. 3

per code, which could lead to unnatural results and shows the patient immediately a[[f]]ter the total injection

adverse events. Once the MD Codes are selected [[f]]or the volume of 17 mL. Increasing the number of MD Codes

individualpatient,atiredlookisaddressedstepbystep,[[f]]irst overthesemultipletreatmentstepsyieldedmoreimpactful

providing [[f]]oundation in the midface, then contouring at the results. Thispatientreceivedalltreatmentstepsinasingle

temples, and, [[f]]inally, directly addressing the tear troughs or session; however, the author suggests planning treatment

eyebagsasre[[f]]inement.AdditionalMDCodesalgorithmsare such that 4 mLis injected per session. To achieve the best

provided in Figure S1 in the Supplemental Materials. Clini- possible results, more volume may be provided by using

cians must explain to patients who [[f]]ocus only on the additional codes in successive sessions to reinforce facial

re[[f]]inement step that the foundation and contour should be restructuring in the midface, cheek, and jawline.

addressed [[f]]irst, as represented in these algorithms.

AesthPlastSurg

0.3mL

One o[[f]] the biggest challenges clinicians may encounter T1 0.7mL =

product required [[f]]or treatment. Often a clinician may dis- Ck2 0.2mL =

not adequate. When [[f]]illers were first introduced to the Ck3 0.3mL =

market, it was common [[f]]or clinicians to treat only naso- 0.3mL

0.5mL

resultsandpatientdissatis[[f]]action.Clinicaljudgmentshould

2.0mL

beusedtodeterminetheappropriatetotalvolumebasedon

individual patient needs; however, a recommended injec- [[f]]ace(292.0mL) 4.0mL

volumes should be determined by the clinician [[f]]or each same session, the active number for T1 is increased from

patient.

The analogy o[[f]] building a house is again useful for Forthisspecifictreatment,theclinicianwillneedatotalof

amount o[[f]] material to be used in each stage of construc- whose treatment plans include the same MD Codes will

advance,inordertocreatea[[f]]inancialplanandensurethat way, the MD Codes approach reduces variability in out-

know be[[f]]orehand how many syringes they will need for differences in age, gender, and ethnicity in the faces that

costin[[f]]ormationtothepatientandtoachieveoptimaland

established progressively by the author based on clinical The MD Codes were designed to provide guidelines [[f]]or

e[[f]]fectiveplacementofHAfillers;futurelarge-scalestudies

period. Clinicians may [[f]]ollow a simple rule: bolus injec- with MD Codes are needed to verify the rate of adverse

same compartment, to avoid disturbing muscle move- general. Most commonly reported complications with

injecting the temple (T1 ? T2) and the mandible angle such as swelling, bruising, redness, and pain [20–23].

speci[[f]]ic area with a cannula, no less than 0.5 mL should systematic review of 22 studies of HA fillers; rates of

be used. swelling, bruising, and lumps or bumps ranged [[f]]rom less

Toestimatetheproductvolumeneededduringtreatment than 10%tomorethan 90%across trials [23].Fewstudies

planning, clinicians should [[f]]irst determine the MD Codes reported the severity of adverse events, but in those that

required[[f]]ortheirpatient,usingthealgorithmsasdescribed did, most events were mild (71–88%) or moderate

above.Theactivenumbers[[f]]oreachcodearethensummed (11–16%)[23].Moreseriouscomplicationsarerarebutdo

to estimate the minimum total volume required. For occur. Delayed in[[f]]lammatory reactions, examined in an

example, treating a tired look may require the [[f]]ollowing analysisof35studies,werefoundtooccuratarateof1.1%

MD Codes: per year based on patient month at risk [24]. A review o[[f]]

AesthPlastSurg

severe complications in the literature reported 22 articles then provided to the upper [[f]]ace by addressing the volume

describing necrosis or impending necrosis in patients de[[f]]icit in the temple (T1), which indirectly improved the

treated with HA [[f]]illers, most commonly following injec- appearance of her eye bags. Next, the lower face was con-

tions in the nose, nasolabial [[f]]olds, or glabella [25]. Vision touredbyinjectingC1toimprovethelabiomentalangle,C2

loss or blindness may also occur on rare occasions, likely toincreasetheverticalheighto[[f]]thechin,andJw4andJw5

due to blockade o[[f]] ophthalmic circulation via the oph- to advance the mandible and to improve the prejowl area.

thalmic artery by [[f]]iller emboli; 44 cases of partial or Midface foundation was reinforced by injecting Ck3 with

completeblindnessa[[f]]terHAfillerinjectionweredescribed twodifferent approaches,first the deep malar fatpad, then

in a review o[[f]] vision loss associated with HA filler treat- the suborbicularis oculi fat (SOOF). The lateral aspects of

ment [26]. Vision loss most commonly resulted [[f]]rom thechinandprejowlareaswerealsoaddressedbyinjecting

injectionsin the area o[[f]]the nose butfollowed treatment at C6.Finally,periorbitalrefinementwasprovidedinthetear

a range o[[f]] upper and midface sites. trough area (Tt1 ? Tt2 ? Tt3). Refinement in the perioral

In the author’s practice, no serious complications, such area was provided by addressing the nasolabial [[f]]olds

as arterial embolic accident or necrosis, have occurred. (NL1 ? NL2) and lip volume (Lp1 ? Lp ? Lp6). Lastly,

Among 387 treated patients (in which the average number Jw1 was injected toreshape the mandible angle.

o[[f]] syringes injected was 14), the most frequent adverse Images taken immediately after treatment illustrate

event was mild or moderate localized edema(28 patients), improvementsinthepatient’smid[[f]]ace,jawline,periorbital,

occurring within the [[f]]irst 2 months after the procedure in and perioral areas (Fig. 4a–c). The reshape of the jawline

the majority o[[f]] those patients reporting this event; delayed apparent in the oblique view (Fig. 4b) was accomplished

edema occurred in [[f]]ew cases. Most patients received a bycontouringwithinjectionsinC1,C2,Jw4,Jw5,C6,and

corticosteroid and an antihistamine prior to treatment, Jw1.Intheobliqueview,improvemento[[f]]theeyebagswas

which may have contributed to low rates o[[f]] injection site observedafterinjectionofCk1,T1,Ck2,Ck3andTt1,Tt2,

reactions. Edema generally subsided within 2 h, without Tt3. The periorbital lines improved a[[f]]ter addressing peri-

additional treatment. When needed, antihistamines were orbital de[[f]]lation. In the photographs taken immediately

used as a [[f]]irst medication therapy and, if unresolved, after treatment, you can see that using the MD Codes

prednisolone (40 mg/day [[f]]or 5 days) was prescribed. algorithm to select codes and focusing treatment on foun-

Delayed edema was usually associated with a trigger [[f]]ac- dation, contour, and refinement resulted in the elimination

tor, such as sinusitis, a cold, or [[f]]atigue; patients with of the unfavorable tired, saggy, and sad attributes of the

multiple allergies were also at higher risk. Rarely, hyalur- [[f]]ace and enhancement of the positive attributes of looking

onidase was needed to dissolve the product. younger, more [[f]]eminine, and attractive. This patient (and

Although the MD Codes denote alert areas, they are the [[f]]ollowing 2 cases) received all injections in a single

designed only to remind clinicians o[[f]] areas where extreme session, for educational purposes. However, in clinical

caution is required and do not eliminate the risk o[[f]] com- practice, this treatment could be provided in multiple ses-

plications when those areas are addressed. Clinicians must sions, with [[f]]our syringes of HA filler injected during each

consider the risk–bene[[f]]it ratio in providing facial aesthetic session.

treatment,andonlyhighlytrainedexpertswhohaveadeep

understanding o[[f]] the anatomy and physiology of an alert Case Study 2

area should attempt treatment o[[f]] a hazardous area.

A 44-year-old woman (Fig. 5) presented with [[f]]acial signs

o[[f]] sagginess, tiredness, and sadness, represented by the

Case Presentations presence o[[f]] saggy cheeks, eye bags, and marionette lines.

Be[[f]]ore treatment, indentation was apparent on the anterior

Case Study 1 right cheek when she smiled (Fig. 5c). The [[f]]irst treatment

step [[f]]ocused on providing foundation in the midface

A 43-year-old Caucasian woman (Fig. 4) presented with (Ck1 ? Ck4) and contouring the upper [[f]]ace (T1). The

signs o[[f]] sagginess in the midface and lower face, looking second step addressed the lower face by treating the chin

tired around the eyes and looking sad around the eyes and (C1 ? C2) and anterior jawline (Jw4 ? Jw5). In step 3,

mouth. The [[f]]irst step of treatment provided foundation in due to the degree of severity and to further improve the

the mid[[f]]ace by addressing the cheek codes. The algorithm jawline, Jw4 and Jw5 were reinjected. In the same step,

[[f]]or saggy cheeks was used to select the MD Codes for Ck3wasinjectedtocompensateforthedeepmalarfatpad

injection and, as mentioned previously, always starts with andthentheSOOF.The[[f]]inalstepincludedperiorbitaland

thelateralli[[f]]tingcheekvectors(Ck1 ? Ck4)andproceeds perioral refinement through injections in the tear trough

totheanterior(Ck2)andmedial(Ck3)cheek.Contourwas area(Tt1 ? Tt2 ? Tt3),thenasolabial[[f]]olds(NL1 ? NL2),

AesthPlastSurg

Fig.4 Case1:A43-year-old

womanwithasaggyappearance

inthemid[[f]]aceandlowerface,

tirednessaroundtheeyes,and

sadnessintheperiorbitaland

perioralareas.Imagesshowthe

patientbe[[f]]oretreatmentand

immediatelya[[f]]terthelast

treatmentstep[[f]]rom(a)the

[[f]]rontalviewandfromthe

obliqueview,with(b)neutral

and(c)animated[[f]]acial

expressions.TheMDCodes,

volumes,andproductsinjected

aresummarizedinpaneld.The

patientreceivedJuve´derm

productsadministeredas12mL

o[[f]]Voluma,3mLofVolift,and

1mLo[[f]]Volbella,withatotalof

16syringesinjected.aThe

patientneededadditional

treatmento[[f]]C6andJw1during

thethirdand[[f]]ourthstepsto

provideadditionalcontourto

thelower[[f]]ace.Reprintedwith

permission[[f]]romMaur´ıciode

Maio,MD,PhD

AesthPlastSurg

AesthPlastSurg

bFig.5 Case2:A44-year-oldwomenwith[[f]]acialsignsofsagginess, and Jw5, to improve chin shape and address the double

tiredness, and sadness represented by the presence o[[f]] saggy cheeks, chin. When the patient smiles, a reduction in his double

eye bags, and marionette lines. Images show the patient be[[f]]ore

chinandsmilelinescanbeseen(Fig. 6b).Hissmilelooks

treatment and immediately a[[f]]ter the last treatment step from (a) the

[[f]]rontal view and from the oblique view, with (b) neutral and moreconfidentduetoimprovementsinthelateralstructure

(c) animated [[f]]acial expressions. The MD Codes, volumes, and of the face (Ck1 ? T1 ? Ck4) and support of the deep

products injected are summarized in panel (d). The patient received malar [[f]]at pads (Ck3). Injection of C1 also lifted the lower

11mLo[[f]]Voluma,3mLofVolift,and1mLofVolbella,withatotal

lip and lessened showing o[[f]] his lower teeth when smiling.

o[[f]]15syringesinjected.ReprintedwithpermissionfromMaur´ıciode

Maio,MD,PhD The oblique view (Fig. 6c) shows improved de[[f]]inition of

thezygomaticarchresulting[[f]]romCk1(TML),abetterjaw

angle due to treatment o[[f]] Jw1, a more square chin shape

duetotreatmento[[f]]C1,C2,C5,andC6,andamoredefined

and lip (Lp1 ? Lp ? Lp6). Images taken immediately

1 jawline due to treatment o[[f]] Jw3. When the patient looked

a[[f]]ter the last treatment step illustrate the changes in facial

down, the improvement o[[f]] facial shape and increased sta-

shape, including increased volume in the cheeks, and the

bility in the lower lip helped to create a more con[[f]]ident

more triangular appearance o[[f]] the chin (Fig. 5a). After the

appearance (Fig. 6d).

lip treatment, an upturn o[[f]] the oral commissures was

observed. In the oblique view, the improvement o[[f]] saggy

cheeks, eye bags, and the jawline resulted in a less tired,

Discussion

less saggy, and less sad appearance than be[[f]]ore treatment

(Fig. 5b). Injection o[[f]] CK1 and Ck4 improved cheek sag-

Theapproachtotreatmentwith[[f]]acialfillershashistorically

giness and reduced the indentation o[[f]] the woman’s right

[[f]]ocused on improving the appearance of lines and folds

cheek,makinghersmileappearmoreattractiveandnatural

[[f]]ound distracting by the patient. The MD Codes approach

(Fig. 5c).

wasnotdesignedtotreatindividualde[[f]]iciencieswithinthe

patient’s [[f]]ace, but to focus instead on the emotional attri-

Case Study 3

butes that the entire [[f]]ace presents. By addressing the

messages o[[f]] the face and sequencing treatment using the

A 42-year-old Caucasian man (Fig. 6) presented with a

principle o[[f]] foundation, contour, and refinement, the clin-

narrow [[f]]ace, saggy cheeks, apoorlydefined jawline,anda

ician can deliver improvement beyond the elimination o[[f]]

double chin. The [[f]]irst treatment step focused on the same

isolated de[[f]]iciencies tomeetpatients’trueexpectationsfor

lateral li[[f]]ting vectors as in case 2 (Ck1 ? T1 ? Ck4) to

a more global trans[[f]]ormation.

build mid[[f]]ace foundation and to contour the upper face.

The MD Codes speci[[f]]y the injection location, depth,

Step2[[f]]ocusedonimprovingchinprojectionbytreatingthe

volume, and device, allowing clinicians to reduce vari-

chin (C1 ? C2) and jawline (Jw4 ? Jw5) in the same

ability in those technical aspects that can be precisely

mannerthattreatmentwasdelivered[[f]]orcases1and2.For

controlled. However, there will always be variability in

this patient, repeat treatment was required in a subsequent

patient outcomes because each person’s [[f]]ace presents a

session due to the degree o[[f]] severity. The lateral chin area

di[[f]]ferentstartingpoint.UsingthesameMDCodeswillnot

and prejowl sulcus (C6), the lateral lower chin (C5), and

cause all patients to look the same a[[f]]ter treatment, as

the chin apex (C2) were then addressed. In addition, Ck1

illustrated in the presented case studies. Two o[[f]] these

was injected [[f]]or the top-model look (TML; Ck1), which

patientsreceivedtreatmentusingthesameMDCodes,and

re[[f]]ers to the injection of Ck1 with a cannula to create a

each achieved improvement in the un[[f]]avorable messages

linear appearance o[[f]] the zygomatic arch. Ck3 was injected

their [[f]]aces conveyed. Further, results will likely vary with

to address the deep malar [[f]]at pad. Injection of Ck1 (TML)

the level o[[f]] a clinicians’ expertise. The clear and stan-

was repeated in a later session to [[f]]urther reinforce the

dardized instruction o[[f]] the MD Codes on how HA fillers

zygomatic width, and Jw3 was injected to sharpen the

should be injected may help novice clinicians reduce

jawline. Immediately a[[f]]ter treatment, changes in facial

variability in their results to achieve success[[f]]ul outcomes

shape could be observed, with improvements in the

and patient satis[[f]]action, and may optimize success rates in

bitemporal, bizygomatic, and bigonial widths due to the

experienced clinicians.

injections o[[f]] T1, Ck1, and Jw1, respectively (Fig. 6a).

Patient education during the treatment planning stage,

Indirectimprovementstotheteartroughareacouldalsobe

establishing with each patient the larger goals o[[f]]treatment

observed [[f]]ollowing the injectionof Ck1, T1, and Ck3. The

and the process by which they can be achieved, is also

chinpresentedwithamoresquareshape,andtherewasless

critical [[f]]or successful outcomes. Patients tend to focus on

indentationo[[f]]the labiomentalsulcus andthe prejowl area.

the re[[f]]inement step. The clinician can educate the patient

NotethatC1,C2,C5,andC6wereinjected,aswellasJw4

ontheimportanceo[[f]]providingfoundationandcontourfirst

AesthPlastSurg

AesthPlastSurg

bFig.6

Case 3: A 42-year-old man with saggy cheeks, a poorly assessing the practical utility o[[f]] this clinical tool, but

de[[f]]inedjawline,andadoublechin.Beforeandafterimagesareshown comparative studies should be developed to assess the

relativesa[[f]]etyandefficacyoftreatmentadministeredusing

[[f]]rom(c)theobliqueview,andfrom(d)thefrontalviewwiththehead

tilteddownward.TheMDCodes,volumes,andproductsinjectedare

Thereisaneedto[[f]]ocustheapproachtoinjectableHAfiller

usingthehousebuildinganalogy.WiththeMDCodesand treatments worldwide on delivering more natural-looking

resultsandoptimalpatientsatis[[f]]action.TheMDCodesare

understand the components o[[f]] their treatment plan and to a set of shapes, colors, and numbers that provide a uni-

versallanguage[[f]]orclearandobjectiveguidelines.Theyare

Theactivenumbersallowclinicianstoestimateinadvance designed to reduce treatment variability, increase clinician

successrates,and[[f]]acilitatefinancialplanning.Whileyears

accordingtotheiremotionalattributes.Theyprovideatool o[[f]] experience with HA filler treatments and thorough

[[f]]orfinancialplanningandmayhelptoensurethattheentire

knowledgeo[[f]]facialanatomymayhavethegreatestimpact

contents o[[f]] a syringe will be used, minimizing waste and on treatment outcomes, the MD Codes may optimize the

The MD Codes may also help to eliminate language cess o[[f]] clinicians with more experience. To improve

treatments.Theyareeasytolearn,donotrequiretheability nation o[[f]] isolated lines and folds to define success as a

tospeakorreadaspeci[[f]]iclanguage,andreducetheamount reduction in negative attributes and enhancement of posi-

o[[f]] text required for planning and implementing treatment. tive attributes. By sequencing treatment with MD Codes

The MD Codes can thus [[f]]acilitate clear communication according to the principle of foundation first, contour

between clinicians and help newer clinicians to achieve second, and re[[f]]inement last, clinicians may deliver next-

quality, reproducible results. The components o[[f]] the MD level HA filler treatment focused on the emotional mes-

the [[f]]uture, the MD Codes may prove useful for reducing Acknowledgements The authors thank Michael Silberberg, MD,

variability across clinicians within clinical studies to more MBA, o[[f]] Allergan plc for his support during the preparation of this

treatment.

PelotonAdvantage,LLC,anOPENHealthcompany,andwas[[f]]unded

Although the ideas within this paper represent the byAllerganplc,Dublin,Ireland.

developed based on extensive experience treating patients Funding ThisstudywassponsoredbyAllerganplc,Dublin,Ireland.

Medicalwritingandeditorialassistancewereprovidedtotheauthors

worldwide;cliniciansaroundtheworldhave[[f]]oundtheMD

Codesandalgorithmstobee[[f]]fectiveandareusingthemin

clinicalpracticeandeducationalsettings[27,28].TheMD [[f]]ormsofpaymentweremadeforauthorship.

CompliancewithEthicalStandards

with a worldwide patient population, are intended as a speakingeventsandmedicaleducation[[f]]orAllerganplc.Someofthe

starting point [[f]]or the treatment plan, to be tailored to each conceptsincludedinthispaperhavebeenpresentedbytheauthorin

seminarsasaparto[[f]]anAllerganMedicalInstituteeducationalseries,

andimagesusedinFig.1havebeenincludedinAllergan’smedical

educationmaterials.

mentinclinicalpractice,andthereare,asyet,noobjective

measures to support this approach [[f]]or optimizing out- Ethical Approval This article does not contain any studies with

humanparticipantsoranimalsper[[f]]ormedbytheauthor.

areavailable.CommonadverseeventsassociatedwithHA

AesthPlastSurg

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