A Four-Step Strategy for the Treatment of Facial Rhytids: A Focus on Upper Facial Wrinkles.

Abstract

Facial wrinkles, characterizing cutaneous aging, involve multifactorial mechanisms such as dermal collagen fragmentation, elastin degeneration, and volume loss, which are often inadequately addressed by single-modality treatments. This study aims to assess the efficacy and safety of a four-step injection strategy combining subcutaneous hyaluronic acid (HA) volume restoration, intradermal microdroplet HA, and selective botulinum toxin type A (BoNTA) for treating facial wrinkles. In this retrospective study, 53 subjects with moderate-to-severe upper facial wrinkles (including glabellar lines, forehead lines, and crow's feet) received a standardized protocol: (1) cannulabased subcutaneous HA restoration; (2) intradermal microdroplet injection of diluted HA; (3) microdroplet diluted BoNTA along persistent rhytids; and (4) conventional BoNTA for dynamic wrinkles. Outcomes were evaluated via blinded physician assessments and patient questionnaires immediately, at 1 month, and at 12 months. All subjects completed follow-up. Physician ratings showed significant wrinkle improvement at 1 and 12 months (P<0.01). Patients reported high satisfaction and improved quality of life. No serious adverse events occurred; minor transient bruising resolved within two weeks, while all observed erythema resolved within one week. This four-step strategy, by concurrently targeting anatomical and kinetic causes of rhytids, offers a safe, effective, and durable approach to upper facial rejuvenation with high patient satisfaction.