The H-Lift procedure
The patient is appropriately examined and informed of the details regarding the procedure prior to treatment. Complications of soft tissue fillers are discussed (Figure 1) and, if required, a period of reflection is advised. Having received patient consent for treatment and photographed the area for documentation, the face is thoroughly cleaned and disinfected from the zygomatic arch to the neck with an antiseptic solution (e.g. 2% chlorhexidine in 70% alcohol). The product used in this case is Radiesse 1.5ml, mixed with 0.1 ml 1% Lidocaine, however, practitioners could also use other products with a high-lifting capacity. Additional local anaesthetic may be used to infiltrate from skin entry points to the periosteum, with a further 0.1-0.2ml along the periosteum of the ramus and body supraperiosteally.
A dental syringe with a 27G is used to provide the anaesthetic and infiltration around the inferior dental nerve, and completes the anaesthesia of the area. The entry points are located at the angle of the mandible posteriorly and anterior-inferiorly at the mentum. We use a TSK Steriglide 25G x 50mm or 22G x 50mm which allows easy gliding in the soft tissue and accurate placement in the supraperiosteal plane. Having made an entry point, the cannula is ‘screwed’ to place the tip at the supra periosteal layer. The cannula is then steered along the inferior border of the mandible towards the area where the facial artery crosses the mandible. Although it is possible to steer the cannula behind the artery, we would recommend that until one is proficient in the use of cannulas, and has treated this area extensively, not to go beyond this area. Linear retrograde placement of the product is performed (0.4-0.6ml) and, from the same entry point, the cannula is introduced into the supraperiosteal layer along the ascending ramus. A bolus technique is used to place a right-angle triangle shape on the posterior border and recreate the 90/94 degree angle (0.4-0.6ml).
The anterior point is approached in a similar manner, the cannula is steered along the inferior border along to the area of the facial artery and no further. The linear threads are, therefore, away from the area of the facial artery and prevent compression of the vessels. A further 0.4-0.6ml can be placed in this plane. The cannula is then turned superiorly to place an additional bolus 0.2-0.3ml on the supraperosteal region of the protuberance of the mandible. If required, a further superior placement in line with the labiomental crease can be performed carefully, as this may be close to the oral sulcus in an elderly patient. The volumes stated are approximate amounts and are tailored to the patient’s requirements. If larger volumes are required, this is performed in a staged approach over a two-week period. Other ancillary procedures can also be performed with the anterior entry point, the marionette fold area can be revolumised in the supraperiosteal plane inferiorly, and then subcutaneously superiorly. Both entry points may be used to place threads to vector the soft tissue. Finally, in those patients who request an enhancement of the bigonial distance (masseter enhancement), the posterior entry point can be used to place the product as multiple threads around the masseter region in the subcutaneous region, and deep to the masseter to produce the ‘masculine’ jaw.
The injected areas are gently moulded and the patient is advised to avoid manipulating the area. Analgesia is advised as required and plans are made for a review of the patient after a period of two weeks. Further recontouring and top-ups may be performed at this review.
Figure 1
Potential complications include:1
- Injection site reactions
- Infection
- Erythema
- Oedema
- Pain/tenderness
- Bruising
- Itching
- Nodule
- Systemic responses to infection
- Granulomatous
inflammation
- Erythema varying from
- Disfiguring nodules
- Hypersensitivity
- Migration of filler
- Aseptic abscess
- Discoloration
- Redness
- Whiteness
- Hyperpigmentation
- Local tissue necrosis caused by vascular occlusion
- Potential blindness
subclinical
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Conclusion
The ‘H-Lift’ technique is based on the dynamic anatomical changes that are associated with ageing. The foundation of this rebuilds the bony tissue and then revolumises and repositions the soft tissues. This technique addresses the changes in the mandibular region and allows recontouring to be performed as an evidence- based technique in a safe plane, in order to reduce potential complications in a highly mobile area. The use of high volumising fillers produces the recontouring with low product volumes and results in a natural-looking appearance. The ‘H-Lift’ procedure is an advanced technique that requires specific anatomical knowledge and training to perform safely.
