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

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.