Footlift: a new indication for injectable hyaluronic acid (HA)?

<p class="article-intro">At the Aesthetic &amp; Anti-ageing Medicine World Congress (AMWC), 6^th-8^th April 2017 in Monaco, Dr. Eric Essayagh&apos;s, who is a French aesthetic physician, demonstration of a foot cushioning on the 2^nd metatarsal head, was impressive. Dr. Christopher M. E. Rowland Payne, a leading dermatologist in London, at The London Clinic, reviews his own 15 years of experience in treating women with metatarsal pain with cross-linked HA. We got the chance to interview the expert about his opinion regarding this specific area. </p> <hr /> <p class="article-content"><p><em><strong>Dr. Rowland Payne, which hyaluronic acid do you use for the treatment of metatarsal pain? </strong></em><br /><em><strong>C. M. E. Rowland Payne:</strong></em> The filler I usually use is hyaluronic acid, to be specific, a standard denser hyaluronic acid, such as Restylane or Restylane Lyft (Perlane). <br /><em><strong>Where did you get the inspiration as to this procedure? </strong></em><br /><strong><em>C. M. E. Rowland Payne:</em></strong> The idea for this treatment came to me because a patient, whose face I had been treating with facial fillers, brought her mother to see me who, she explained, had sore feet. Examination of the mother&rsquo;s feet revealed metatarsalgia and I was struck by how thin the subcutaneous tissue was in this particular female patient who was aged about 70 years. It seemed logical to replace the lost subcutaneous tissue with HA filler. I proposed the treatment to the patient, she agreed and was very pleased with the result. She returned again one year or so later for a second treatment but did not need a third. <br />In metatarsalgia, palpation reveals that the periosteum of the head of the metatarsal is very near the deep aspect of the skin, the normal subcutaneous fat pat between bone and skin having become atrophic and attenuated consequent upon repeated ischemia due to repeated and prolonged unnatural weight bearing at this particular point. High heels are largely to blame, especially if the patient also has talipes equinovarus and/or fall&shy;en arches due to benign joint hyper-mobility syndrome. The subcutaneous fat cushion having been lost, it is logical to replace it with HA. <br /><em><strong>Is this an off-label use?</strong></em><br /><strong><em>C. M. E. Rowland Payne:</em></strong> This medical, rather than cosmetic, use of HA is indeed an off-label use of HA. <br /><em><strong>Is there any literature available? (Evidence based? Case reports?)</strong></em><br /><strong><em>C. M. E. Rowland Payne:</em> </strong>There is a small literature on fillers in the feet. <br /><strong><em>Does the molecular weight of the product matter? </em></strong><br /><strong><em>C. M. E. Rowland Payne:</em></strong> There would be some logic in using a denser type of HA but I have always had perfectly satisfactory results using standard molecular weight HA.</p> <p><img src="/custom/img/files/files_datafiles_data_Zeitungen_2017_Jatros_Ortho_1706_Weblinks_s57_1.jpg" alt="" width="684" height="915" /><br /><em><strong>How is it possible to reduce the metatarsal pressure points by injection of cross-linked HA?</strong></em><br /><em><strong>C. M. E. Rowland Payne: </strong></em>In metatarsalgia, there is pain superficial to the head of the metatarsal. The problem is that wearing high heels flattens the transverse forefoot arch and throws great weight onto the &ldquo;keystone&rdquo; of the arch, the head of the second metatarsal. The subcutaneous fatty cushion that lies between the periosteum and the skin is repeatedly and persistently compressed. As the fatty cushion is lost, the richly innervated periosteum of the underlying head of the metatarsal feels the pain. The rationale for treatment is to replace the lost cushion of fat with a cushion of HA filler. This deposit of HA, perhaps 0.3-0.5ml in volume, is introduced in the shape of a bun. The material is injected percutaneously using a cannula. The epicentre of the implant should be placed superficial to the point of maximum tenderness. Post-operatively the patient feels as if, for a couple of days, she is walking on a marshmallow. <br /><em><strong>What is the mean duration of the positive effect?</strong></em><br /><em><strong>C. M. E. Rowland Payne:</strong></em> The benefit lasts for many months or a year or more and, if the patient chooses no longer to wear high heels, the benefit can last indefinitely in some patients. <br /><strong><em>Are there any restrictions directly after the application of the HA?</em></strong><br /><strong><em>C. M. E. Rowland Payne:</em></strong> No, after the treatment, the patients can walk out of the room wearing their usual shoes. <br /><em><strong>What is the exact location for the injection? s.c.? Please describe.</strong></em><br /><em><strong>C. M. E. Rowland Payne:</strong></em> The plantar aspect of the forefoot is cleaned with alcohol, the point of maximum tenderness is identified by digital pressure, an entry point proximal to this is made using a 24g needle. Through the puncture point, a 25 or 27g cannula is ad&shy;vanced into the subcutaneous space to reach a position overlying the point of tenderness. An ovaloid implant of about 0.5ml of HA is introduced. As soon as the correct dose has been correctly placed, weight bearing is no longer painful. This is so even if a filler with&shy;out lidocaine is used. <br />It is better to use a cannula than a needle as a needle might cause an ecchymosis in the subcutaneous space, in a tendon sheath or subperiosteally. A subperiosteal haematoma may result in pain that may persist for months. These possibilities can be avoided by using a cannula. <br /><em><strong>Do you use local anesthetics? </strong></em><br /><em><strong>C. M. E. Rowland Payne:</strong></em> Local anes&shy;thetic is not needed (but prior use of a strong topical anesthetic agent helps, e.g. Pliaglis). HA with or without lidocaine may be used.</p> <p><img src="/custom/img/files/files_datafiles_data_Zeitungen_2017_Jatros_Ortho_1706_Weblinks_s57_2.jpg" alt="" width="930" height="581" /><br /><em><strong>Are there any foot pathologies which are contraindicated?</strong></em><br /><strong><em>C. M. E. Rowland Payne:</em></strong> The treatment would be contraindicated in the presence of bacterial cellulitis. <br /><em><strong>Is there any risk of tendon damage if the HA is injected in the direct region of a tendon?</strong></em><br /><em><strong>C. M. E. Rowland Payne: </strong></em>There is no risk of tendon damage as the injection is placed more superficially than the plantar aponeurosis which is itself superficial to the flexor tendons of the feet. Even if the HA were inject&shy;ed beside a tendon, it would not cause any damage; tendon sheath fluid is very similar in composition to HA. Moreover, if a cannula is used, the possibility of reaching a tendon is minimal. <br /><em><strong>How do you treat Morton&rsquo;s neuroma?</strong></em><br /><em><strong>C. M. E. Rowland Payne:</strong></em> Metatarsalgia needs to be differentiated from Morton&rsquo;s neuroma. Morton&rsquo;s neuroma is treated by intralesional corticosteroid injection. <br /><em><strong>Your experience in treating metatarsal pain of women who want to wear high heels goes back 15 years. Do clients come back on a regular basis?</strong></em><br /><em><strong>C. M. E. Rowland Payne:</strong></em> Yes, my experience of treating metatarsalgia dates back at least 15 years. Some pa&shy;tients return every year for treatment but most do not require repeated treatments because, once treated, if they choose no longer to wear the offending shoes, they will not develop the problem again. <br /><strong><em>What do orthopedic surgeons think about this procedure?</em></strong><br /><strong><em>C. M. E. Rowland Payne:</em></strong> I have not discussed it with them. What does your husband think? I know he is an orthopedic surgeon.</p></p>