Received: 7 November 2016 | Revised: 19 December 2017 | Accepted: 27 June 2018

DOI: 10.1111/jocd.12774

ORIGINAL CONTRIBUTION

Rheology of hyaluronic acid and dynamic facial rejuvenation:

Topographical specificities

Thierry Michaud MD1

Private practice, Mulhouse, France

Abstract
Correspondence Sound knowledge of the rheology of hyaluronic acids is fundamental for facial reju-
Thierry Michaud, Private practice, Mulhouse,
France. venation procedures. Hyaluronic acid implants are subjected to complex mechanical
Email: cnem92@orange.fr forces within the facial tissues that vary depending on the anatomical region. Analy-
sis of these forces is important to establish the rheological specifications of hyaluro-
nic acid implants in each specific zone. This approach will optimize the correction of
age‐related loss of volume, since the filler will be chosen as a function of the
mechanics of the anatomical zone, with the objective to respect facial dynamics.

KEYWORDS
facial expressions, fillers, hyaluronic acid, rheology

1 | INTRODUCTION Many publications have analyzed the rheological properties of

Considerable advances have been made in facial rejuvenation with
improved knowledge of the physiology of facial aging. Nowadays,
facial dynamics, essential in interpersonal communication, can no
longer be neglected1 and have become the fourth dimension of aes-
thetic interventions. The concern expressed by many patients of an
unnatural result is mainly related to the fear of losing this essential
emotional language. Conversely, facial aging may induce negative
facial expressions due to the age‐related morphological and anatomi-
cal changes which are perceived by the patient and his entourage,
and may trigger a loss of self‐esteem and a poor quality of life. More
than the correction of aging signs, most patients wish to regain a
face connected with their inner self: to look good, fit, in great shape
rather than look ten years younger. The knowledge of facial dynam-
ics and of emotional expressions in relation with the age‐related
anatomical changes allows a natural correction through a tailored
treatment plan. The use of hyaluronic acids is nowadays essential in
all facial rejuvenation procedures.2 In this regard, understanding their
rheology is essential to select the right product, providing an accu-
rate and appropriate correction for each anatomical area, respecting
the emotional language of the face and its uniqueness, and thus
avoiding any “aesthetic cloning.” However, the face is a complex
anatomical structure, and implants are subjected to multiple resultant
intrinsic and extrinsic forces that vary according to the anatomical
zone treated.3,4
various hyaluronic acids,5–12 many of them oriented toward testing a
specific product. But to our knowledge, few put these properties in
perspective with the mechanical strains exerted in the different
areas of the face13 and even fewer with facial dynamics and expres-
sions. The aim of this article was to integrate the most recent knowl-
edge in these matters, to support the selection of the most
appropriate filler for each area by understanding the forces exerted
in the different regions of the face and the relevant rheological prop-
erties of the filler in each case. Practical illustration with clinical
cases is also displayed.
2 | MECHANICAL PROPERTIES OF
HYALURONIC ACID
Rheology is the study of flow and deformation of materials under
applied forces. Hyaluronic acid is a viscoelastic gel. It thus has a vis-
cous component that gives it the capacity to deform, during flow
through a needle or cannula for example, and an elastic component
that defines its capacity to return to its original, or close to original,
shape. During manufacturing, the elastic and viscous components of
hyaluronic acid are combined to obtain a gel with the desired prop-
erties. Several properties are essential both for the injection proce-
dure and for the clinical results: extrusion force, malleability, lifting
capacity, tissue mobilization during facial dynamics, ease of spread-
ing, and tissue integration.

736 | © 2018 Wiley Periodicals, Inc. wileyonlinelibrary.com/journal/jocd J Cosmet Dermatol. 2018;17:736–743.

MICHAUD
Hyaluronic acid implants may be subjected to two fundamental
types of deformation, in varying combinations (Figure 1):
 Lateral shearing or torsion in one plane.
 Compression/stretching about an axis.
These forces determine the required characteristics of the hyaluronic
acid. The viscoelasticity is determined according to the lateral shear-
ing or torsion forces in the region, and cohesivity is determined by
the compression/stretch forces.
2.1 | Viscoelasticity
A hyaluronic acid must be viscoelastic: It must have the capacity to
deform sufficiently to be injected through a syringe (or cannula) and
to be modeled. Equally, it must be sufficiently elastic to provide dur-
able correction that is resistant to shearing forces. The degree of
resistance to shearing forces and/or torsion about an axis determines
the viscoelasticity. Four parameters have been defined using a
rheometer:
 Shear modulus G*: Total energy required to deform a material. It
is a global measure of viscoelastic properties and hardness of the
gel;
 Elastic modulus G′: The energy fraction of G* that is restored
after deformation. It is a measure of the elastic properties of the
gel particles and their ability to recover their shape after defor-
mation;
 Viscous modulus G″: The energy fraction of G* that is lost after
deformation. It reflects the inability of the gel to regain its initial
form completely after deformation. The viscous modulus is linked
to the injectability of the gel;
 Tan δ: The ratio G″/G′ indicates if a gel is more elastic or more
viscous.
Thus, for a 100% elastic gel, G′ tends toward G* and G″ tends
toward 0; for a 100% viscous gel (= a viscous liquid), G″ tends
toward G* and G′ tends toward 0. Fillers are viscoelastic gels lying
between these two extremes, defined by their tan δ. Moreover, G*
FIGURE 1 The different types of deformations to which the hyaluronic acids are subjected (from Kontis et al2)
| 737
and G′ tend to increase with higher levels of cross‐linking, while G″
tends to decrease. Clinically, the shearing forces are caused by slid-
ing movements between the different anatomical layers (skin, mus-
cle, fat, and bone). A gel with a high G* and G′ has particles with
greater resistance to such movements and thus particles retain their
shape better. However, a bolus of hyaluronic acid gel is not consti-
tuted of a single block/particle, but a blend of cross‐linked particles
that more or less adhere together. This introduces the notion of gel
cohesivity.
2.2 | Cohesivity
Cohesivity is defined as the internal adhesion forces that bind the
cross‐linked units of hyaluronic acid more or less together to within
the gel (Figure 2). Said otherwise, it defines the adhesion of the gel
to itself: The higher the cohesivity, the more the injected gel bolus
will keep its macroscopic shape versus face motions. For the same
G*/G′, a gel with lower cohesivity will provide less initial projection
per volume than a gel with higher cohesivity, due to the pressure of
surrounding tissues. This is more or less relevant depending on injec-
tion depth and the facial dynamics of the injected area.
Cohesivity can be measured as resistance to vertical compression
or stretching. It depends on the concentration of the hyaluronic acid
and some specific steps in the cross‐linking process. It is not corre-
lated with the level of cross‐linking. Clinically, cohesivity defines the
initial vertical projection of the injected bolus of hyaluronic acid gel,
before it is subjected to any shearing or compression stresses. More-
over, cohesivity strongly influences the modeling capacity of the gel
just after injection: The less cohesive the gel, the more malleable it
is. Cohesivity becomes less relevant over time as tissue integration
happens fast for most HA fillers, makes the implant less malleable,
and keeps it into place. The relationship between cohesivity and tis-
sue integration is difficult to characterize, as cohesivity is only one
among many factors involved in tissue integration:mechanical factors
(G′ and cohesivity), chemical (degradation at variable speed, local
stimulation of adjacent tissues depending on the filler's chemical
type and texture).
Another way to measure cohesivity has been proposed
recently,14 where the authors propose a semiquantitative method
738 | MICHAUD

FIGURE 2 Principles of cohesivity (from Kontis et al2)

involving: dying of the filler, extrusion of the colored gel into a bea- low, allows the clinical outcome to be verified immediately after
ker of water under constant stirring, observation of how much and injection.
how fast the gel strand disintegrates into particles. Then, they estab-  Texture (smooth or particular) plays a role in the Tyndall effect
lished five levels of cohesivity. While the results do seem to partially which is a purely physical effect due to the reflection of light on
correlate with resistance to compression, the act of dispersing gels HA generating a bluish coloration if the gel is placed too superfi-
into large amounts of water seems further away from the clinical sit- cially.
uation than compressing or stretching the gel between two plates.  Tissue integration pattern and how fast it occurs partly define
This methodology puts the gel under a complex stress (neither pure the visibility of the product and allow natural results to be
shear nor pure compression) but also brings unlimited amounts of obtained since facial dynamics are respected.
water to the gels, which can result in acute gel swelling which would  Durability over time.
not happen with such a magnitude in the facial tissues. Assuming  Tolerance of the filler: It would be helpful to determine a simple
that cohesivity is a function of noncovalent interactions between HA correlation between mechanical properties of the fillers and their
particles (hydrogen bonding, ionic bonding, and other weak types of adverse effects. Unfortunately, no such an association has been
interaction), water supply to the gel and subsequent gel swelling can described.
weaken these interactions well beyond the clinical setting.
This being said, gel cohesivity was defined similarly despite the
2.4 | Qualitative characteristics of hyaluronic acid
different methodology, so the clinical relevance of cohesivity can be
gel
discussed regardless.
The following schema resumes the essential properties of a hyaluro-
nic acid (Figure 3).
2.3 | Other fundamental properties of hyaluronic
It can be seen that the lift capacity of a hyaluronic acid depends
acid
essentially on its G′ and its cohesivity.
Aside from these fundamental mechanical properties, other factors These characteristics are supported by several essential
(which will not be detailed here) play an essential role in the clinical parameters15:
outcome:
 The type(s) of hyaluronic acid used, particularly the length of the
 Hydrophilia determines the risk of immediate edema (to be differ- chains implicated.
entiated from the edema due to the injection trauma, here only  The cross‐linking and formulation procedures.
the gel absorbing‐water properties are considered) and, when it is  The final concentration of hyaluronic acid.

G’ = elasticity

Resistance to deformation
Hydrophilia

Water absorbtion
Viscosity
Lifting ability
Injectability

Tissular integration

Cohesivity

Resistance to compression /
stretching

FIGURE 3 Essential properties of hyaluronic acid (in blue)

MICHAUD | 739

3 | FROM MECHANICAL PROPERTIES TO (A)

CLINICAL PRACTICE

3.1 | Mechanical stresses within the face

The face is a complex anatomical structure that is subjected to vari-
ous combinations of compression/stretching and lateral shearing.
These forces vary considerably depending on the region concerned.
The face is subjected to two types of forces:

 Intrinsic forces: The ensemble of tensions and motions between

the different facial tissues (bone, muscles, fat, and skin) both in
the static state and during facial dynamics.
 Extrinsic forces: Related to daily life and activities (sleep, physical
(B)
activity, nutrition, kissing, etc).

The mechanical forces in each anatomical zone vary in nature, inten-

sity, and frequency. For facial rejuvenation, it is therefore important
to use one or several hyaluronic acids with appropriate rheological
properties according to the specificities of the region.

3.2 | Rheological specifications of the upper third

of the face

3.2.1 | Dark circles

Under the eyes (Figure 4), there is little compression or shearing, as
this anatomical area is thin, with loose subcutaneous tissues devoid
of major compression forces.
Thus, the rheological specifications of the hyaluronic acid are lit-
tle resistance to compression, and high malleability. Equally, the hya-
luronic acid must have a low cohesivity and low‐to‐moderate
resistance to deformation (G′). Moreover, it must not induce edema
after injection; thus, it must have a low degree of hydrophilia. Lastly,
there must be no Tyndall effect (smooth gel), and the filler should be
invisible after injection. It should therefore be injected deeply, not in
excessive quantity, close to the bone, in the correct anatomical
layer.
3.2.2 | The frontal region
In this region, compressive forces are low to moderate and shearing
forces are moderate to strong. Indeed, in this area the skin is rather
thick, tightly stretched on the forehead, and the frontalis muscle is
rather strong, generating shear stress during its contraction.
The rheological specifications thus include a good lift, as well
as significant spreading capacity. The product must be nonde-
tectable statically as well as during dynamic mobilization of the
forehead. A hyaluronic acid with low‐to‐moderate cohesivity and
moderate‐to‐high resistance to deformity (G′) is therefore required.
If cohesivity or/and resistance to deformity are too high, the filler
may be noticeable at rest and/or during the frontalis muscle
contraction.
F I G U R E 4 Correction of dark circles using hyaluronic acid 15 mg/
mL (VYC‐15L). A, Before correction, B, After correction (Coll. Th.
Michaud)
3.2.3 | The temporal region
In the temporal region, mechanical forces are mostly compressive,
with low shearing forces. The skin is thick, stretched on the tempo-
ralis muscle, which has a large volume and is very strong. During its
contraction, the deeply injected filler is submitted to powerful
strains.
The rheological specifications depend on the technique used to
correct the loss of temporal volume (Figure 5):
For deep injections in the temporal fossa, a good lift capacity
and good resistance to compression are required; thus, the hyaluro-
nic acid must have a strong cohesivity and high resistance to defor-
mity (G′). If the filler is not elastic enough or not cohesive enough,
there will be no projection toward the surface because of fast flat-
tening of gel particles and gel bolus and the loss of volume will not
be appropriately corrected.
For injections in the superficial fatty compartment, the lift
capacity can be lower, but should be sufficient to obtain a good
result; the hyaluronic acid must also be malleable, with a good
spreading capacity to ensure that it is not noticeable with an
unsightly “wave” effect. The hyaluronic acid used should therefore
have a low‐to‐moderate cohesivity and mild‐to‐moderate resistance
to deformation (G′).
740 | MICHAUD

(A) (B) (C)

F I G U R E 5 Correction of loss of temporal volume using hyaluronic acid 20 mg/mL (VYC‐20L). A, Before correction, B,C, After correction
(Coll. Th. Michaud)

3.3 | Rheological specifications of the middle third (A) (B)

of the face

3.3.1 | Deep volumization of the middle third

In the deep fatty compartment of the middle third of the face, lateral
shearing forces are low, but compression forces are moderate to
high. Actually, the deep fatty compartment is located deeply under
the orbicularis muscle and it is covered by the superficial fatty com-
partment and eventually by the skin: A rather high cohesivity is
needed to uplift the whole mass of covering tissues with elasticity
high enough that gel particles will not get flat too quickly.
For volume restoration, the hyaluronic acid must have a pro-
jection with maintenance of contours, and good resistance to
F I G U R E 6 Volume correction of the deep fatty compartment
compression/stretching. The filler must have high‐to‐moderate using hyaluronic acid 20 mg/mmol/L (VYC‐20L). A, Before correction,
cohesivity, with moderate‐to‐high resistance to deformity (G′). It B, after correction (Coll. Th. Michaud)
must not be visible or migrate: It must therefore be injected in
the correct position in the deep fatty compartment, close to the filler is too elastic or too cohesive, it will result in an unnatural and
bone (Figure 6). unsightly look such as a “lump” effect.
For a lifting effect, the hyaluronic acid must have greater elastic-
ity and cohesivity to lift all the adjacent tissues:muscle that provides
3.4 | Rheological specification of the lower third of
résistance during contraction, superficial fatty compartment, and
the face
skin.

3.3.2 | Correction of the superficial fatty
compartment
With only skin above, compressive forces in the superficial fatty
compartments are lower, and shearing forces are low to moderate
(Figure 7). Little projection is required, with good malleability and
good tissue integration to ensure that the product is nonpalpable
and invisible statically and during movement. The product should
have a low‐to‐moderate cohesivity and moderate resistance to
deformation (G′). Indeed, opposite to the deep fatty compartment
which is fixed and static, the superficial fatty compartment is mobile
during facial dynamics, especially during smile, which uplifts it: If the
3.4.1 | Lips
The red and white lips should be differentiated.
Red lips: The mechanical stresses in this zone are complex, with
high compressive/stretching forces associated with low shearing
forces. The orbicularis muscle contraction generates notable stretch
in the dynamics (especially when smiling); conversely, the resting tis-
sues are loose.
The rheological specifications include good projection and
respect of the natural static, with a nondetectable product that has
excellent mobility during facial movement. Good tissue integration is
also important. Good cohesivity with a mild resistance to deforma-
tion (G′) is thus required.
MICHAUD
F I G U R E 7 Anatomy of the superficial fatty compartments of the
middle third (Coll. Th. Michaud)
White lips: In this zone, there are little compression and little
shearing. Treatment involves the superficial correction of helioderm
wrinkles and/or expression wrinkles from contraction of the orbicu-
laris ori muscle.
The rheological specifications include excellent malleability and
good spreading. The filler should be undetectable both statically and
dynamically. The hyaluronic acid should have a low cohesivity and
low resistance to deformation (G′; Figure 8). Too much cohesivity
and resistance will produce a bad dynamic result, without respect of
(A) (B)
(C) (D)
F I G U R E 8 Labial correction using hyaluronic acid 15 mg/mL
(VYC‐15L). A,B Before correction, C,D after correction (Coll. Th.
Michaud)
| 741
the natural lips design:big lips at rest, with anterior projection very
unnatural and unsightly (“bee sting” lips).
3.4.2 | Perioral zone
The mechanical stresses in this zone are complex, with low‐to‐mod-
erate compression/stretching forces and low‐to‐moderate shearing
forces. The tissues are rather loose, and mobilization forces (mainly
the zygomaticus major) produce only a moderate motion.
The filler must have good malleability and be undetectable stati-
cally and dynamically. It should therefore have low‐to‐moderate
cohesivity and moderate resistance to shear (G′). Too much cohesiv-
ity and resistance induce an unsightly look in statics and in dynamics
with a “lump” effect. In the case of deep furrows, a hyaluronic acid
with a very high cohesivity may be necessary. However, it will be
more difficult to shape and will be more easily detected, particularly
during movement (Figure 9).
3.4.3 | Chin
There are very high compressive forces with relatively little shearing
in this region. The thick skin lies flat on the bone which projects the
tissues forward.
The rheological specifications include good projection with a pro-
duct which should not migrate under any circumstances. The hya-
luronic acid should therefore have a high cohesively and high
resistance to deformity (G′).
A lack of cohesivity and/or elasticity would result in a poor result
per injected volume.
3.4.4 | The nose
Compressive forces are moderate, and there is no shearing. This area
has little tissues: The skin is lying flat on the bone and cartilage, and
there are little or no subcutaneous tissues.
(A) (B)
F I G U R E 9 Correction of the perioral region using hyaluronic acid
17.5 mg/mL (VYC‐17.5L). A, Before correction, B, after correction
(Coll. Th. Michaud)
742 | MICHAUD
(A) (B)
F I G U R E 1 0 Correction of “trumpet” nose following rhinoplasty
using hyaluronic acid 17.5 mg/mL (VYC‐17.5L). A, Before correction,
B, After correction (Coll. Th. Michaud)
The filler should have a good projection capacity, good mal-
leability, must not migrate, and must remain undetectable. The hya-
luronic acid should therefore have a low to moderate cohesively
and a moderate G′ for a subtle approach: A filler with too much
elasticity and/or cohesivity would induce a deformation of the nose
shape (Figure 10). If the patient wants a very sharp look on dorsum
and bridge, high cohesivity will be preferred to prevent product
migration.
3.4.5 | The oval of the face
Compression/stretching forces are moderate, and shearing forces are
low to moderate. The rheological specifications differ depending on
the depth of the zone to correct:
Deep periosteal correction to restore the contour of the face
requires a filler with a good projection that does not migrate. The
hyaluronic acid should have a high cohesivity and resistance to
deformity (G′). Insufficient elasticity and chiefly insufficient cohesiv-
ity may result in a lack of aesthetical result, providing that this area
is submitted to frequent extrinsic strains.
Superficial correction requires a filler that is easily modeled and
undetectable statically and dynamically. The cohesivity of the hya-
luronic acid should be rather low, with a moderate resistance to
deformation (G′). Excessive cohesivity and resistance to deformity
would make the filler noticeable and make the contour heavier.
Hence, lower cheek line (accordion lines) correction implies shear
resistance but relatively low cohesivity to cover large areas with
more malleable filler.
4 | CONCLUSION
Facial rejuvenation must take facial dynamics into account. For a
good outcome, it is essential to understand the rheological proper-
ties of the hyaluronic acids injected. Each hyaluronic acid can be
defined by its rheological characteristics: viscoelasticity
cohesivity. These depend on different parameters, including the con-
centration of hyaluronic acid, the length of the hyaluronic chains,
and the cross‐linking and formulation technology. Each region of the
face is subjected to specific mechanical forces. These forces must be
taken into account in the choice of hyaluronic acid to correct age‐
related loss of volume: Rheological characteristics for hyaluronic
acids can be defined for each region of the face. An approach to
correction of age‐related loss of volume based on these rheological
specifications ensures a natural outcome and respect of facial
dynamics with preservation of the emotional language of the face
while correcting negative, age‐related expressions.
Thus, the rheological qualities of the filler can be selected as a
function of the mechanical characteristics of the anatomical region
to be corrected. If the right agent is placed in the right zone, the
results will be optimal, both statically and, importantly, during move-
ment. For patients, it is essential to respect the “referent face”
(David Le Breton) in order to fulfill their expectations.
ORCID
Thierry Michaud http://orcid.org/0000-0003-3894-2223
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