Where ligament injection came from — de Maio’s MD Codes and Restylane’s HIT
When I explain ligament support injection, I am often asked, “Isn’t that MD Codes?” Yes — the roots connect. Filler companies have built injection systems for training doctors, and much of the thinking behind this treatment grew from them. Here is that story.
The short answer
The idea of ‘placing small amounts in the deep layer near the ligaments to support from above’ was formalised in injection systems such as the MD Codes of Brazilian plastic surgeon Maurício de Maio, a training system on the Juvederm side, and HIT from Galderma, the maker of Restylane. MD Codes divides the face into injection units (codes), sets the depth, tool and minimum volume for each, and addresses impressions such as ‘looking tired or sagging’ first. However, the full-face MD Codes study used an average of 14 syringes and was not a controlled trial. Miso Clinic in Daegu (4F Bombom Building, 125 Dongdeok-ro, Jung-gu, +82-53-428-2700) borrows this thinking but uses about 2 cc for the whole face, only at the anchor points that need support.
What is MD Codes?
It is a filler injection system created by Brazilian plastic surgeon Maurício de Maio. It became widely known as a doctor training course using Juvederm products.
There are two core ideas. First, it divides the face into small anatomical units and gives each one a code stating “at what depth, needle or cannula, by what technique, and at least how much”. The aim is to reduce how much results vary from injector to injector.
Second, it does not start from erasing a single line. It first looks at the impression a face gives — “looks tired · looks saggy · looks sad · looks angry” — and then finds the areas that create that impression. I think this second idea is the bigger contribution. Very often the line a patient points to and the place actually causing it are different.
Where is the ‘support’ in MD Codes?
In MD Codes-family writing, the midface — the cheekbones and upper cheeks — is called the ‘foundation’. The 7-point · 9-point Shape approach described in 2022 explains that laying a foundation in the cheeks and giving contour to the chin and jawline indirectly improves lower-face concerns such as nasolabial folds and jowls.
This is where it meets the thinking of ligament injection: rather than solving a lower concern from below, support near the anchor points above to change the lines below.
There are differences too. MD Codes is a broad framework for redesigning the shape and proportions of the whole face. The treatment called ligament injection is closer to taking just the ‘support near anchor points’ part of it and using it in small amounts.
What does the Restylane side do?
Galderma, the maker of Restylane, introduced an approach called HIT (Holistic Individualized Treatment). It is a framework that looks at the face in the order assess · anatomy · range · treat, and combines Restylane products to suit each area. A separate midface lifting method was introduced within it.
In the public material I checked, I could not find a sentence that explicitly calls HIT ‘ligament support’. But the direction — “look at the whole face first, then support the midface to lift the lines” — is the same as MD Codes. Different companies, same anatomy as the starting point, so that is to be expected.
So is MD Codes well supported by evidence?
This needs pointing out. A sophisticated system and one verified by controlled trials are different matters.
| Study | What was done | What to look for when reading |
|---|---|---|
| Methodology paper 2020 | Description of the code system, 3 cases | An explanation of method, not an outcome study |
| Full-face retrospective study 2020 (250 people) | Mean 14 ± 4 syringes + botulinum toxin; appearance-distress score 54.3 → 36.1 | No control group. Bruising 35.2% |
| Facial impression case study 2023 (12 people) | 12 mL per person; all rated “natural” at 9 months | Retrospective, no control group |
What stands out is the volume. These studies used around 12–14 mL per person. Redesigning the whole face can take that much. And without a control group, “it improved because of MD Codes” cannot be separated from “it changed because that much was injected”.
Why does Miso Clinic use 2 cc?
What I borrowed from these systems is ‘the order of thinking’: look at the impression first, and support above to change below. I did not borrow the volumes.
We support only near the anchor points, with about 2 cc for the whole face and about 0.1 cc per point. There are three reasons. For the same result, injecting less looks less puffy, leaves room to add other treatments later, and is easier to reverse if you are not happy with it.
In return, the range of what 2 cc can do is clear. Filling a markedly hollow face or changing face shape cannot be done with this amount. If that is the case, I say so from the start. The evidence for ligament support itself is set out in Ligament injection in Daegu is really about placing a support.
Can I ask for ‘MD Codes, please’ at the consultation?
You can. But asking these questions is more useful than the name.
- Which anchor points on my face need support
- How many cc for the whole face, and how much per point
- Which product it is, and whether it is hyaluronic acid that can be dissolved
- Needle or cannula, and at what depth
Whether MD Codes or HIT, the name of the system does not decide the result. In the end, the points and volumes chosen for that face decide the result.
Frequently asked questions about MD Codes and ligament injection
What is MD Codes?
A filler injection system created by Brazilian plastic surgeon Maurício de Maio. It divides the face into injection units (codes) and sets a depth, tool, technique and minimum volume for each. It addresses impressions such as ‘looking tired or sagging’ before lines.
Are MD Codes and ligament injection the same thing?
Not the same, but the thinking connects. MD Codes is a broad framework for redesigning the whole face; ligament injection is closer to taking out the part that places small supports near the anchor points.
What is Restylane HIT?
An injection approach from Galderma, the maker of Restylane (Holistic Individualized Treatment). It looks at the face in the order assess, anatomy, range, treat and uses products to suit each area. I could not find a sentence in public material that explicitly mentions ligament support.
Is there evidence for MD Codes treatment?
There is a methodology paper and retrospective studies without control groups. A 250-person study used an average of 14 syringes and appearance-distress scores fell, but without a control group the effect of the system cannot be separated from the effect of the volume injected.
Does Miso Clinic inject as much as MD Codes?
No. Miso Clinic supports only near the anchor points, with about 2 cc for the whole face and about 0.1 cc per point. We borrow the system’s thinking but use less volume.
Where can I get a ligament injection consultation in Daegu?
Miso Clinic is at 4F Bombom Building, 125 Dongdeok-ro, Jung-gu, Daegu, in front of Exit 1 of Kyungpook National University Hospital Station. +82-53-428-2700. Weekdays 11:00–19:00, Saturday 10:00–16:00, closed Sundays and public holidays.
Read next
- Ligament injection in Daegu — it does not make ligaments ‘stronger’, it places a support beneath them
- Ligament injection and thread lifts lift in different ways
- Ligament injection: what to watch even in small doses
- Retaining ligament filler — how far does the evidence actually go
- Fillers in Daegu: the site decides the plane, and the plane decides the product
Product pages
Related reading: Needle or cannula? · What crosslinked hyaluronic acid means
Who wrote this
Written and reviewed by Lee Chi-Hak, MD, director of Miso Clinic, Daegu. The treatment standards and injection design set out here are the ones we use in practice.
| Medical director | Lee Chi-Hak, MD |
|---|---|
| Address | 4F Bombom Building, 125 Dongdeok-ro, Jung-gu, Daegu, South Korea · Exit 1, Kyungpook National University Hospital Station |
| Phone | +82-53-428-2700 |
| Hours | Weekdays 11:00–19:00 (lunch 13:00–14:00) / Saturday 10:00–16:00 (no lunch break) / Closed Sundays and public holidays |
| Columns | All clinical columns |
| Reference library | All booster and device references |
References
- MD Codes methodology — de Maio M, Aesthetic Plast Surg 2021;45(2):690–709 (online 2020), PMID 32445044, DOI 10.1007/s00266-020-01762-7. A system that divides the face into anatomical units (codes) and assigns each code a depth, tool, injection technique and minimum recommended volume. It addresses impressions such as looking tired, sagging or sad before individual lines. 3 cases.
- 7-point · 9-point Shape — de Maio M, Facial Plast Surg 2022;38(2):102–110, PMID 35114709, DOI 10.1055/s-0041-1741499. An MD Codes-family approach that gives the midface (cheeks) a foundation and the lower face (chin and jawline) contour, aiming to improve lines and jowls indirectly.
- Retrospective full-face MD Codes study — Bertossi D et al. (co-authored by de Maio), J Cosmet Dermatol 2020;19(9):2219–2228, PMID 32623790, DOI 10.1111/jocd.13596. 250 people, mean 14 ± 4 syringes (4–25), with botulinum toxin. FACE-Q appearance-related distress score 54.3 → 36.1 (3 months). Bruising 35.2%, transient swelling 14.0%, persistent swelling around the eyes 3.6%. No control group.
- MD Codes case study of facial impressions — de Maio M et al., Clin Cosmet Investig Dermatol 2023;16:3441–3453, PMID 38050477, DOI 10.2147/CCID.S430747. 12 people, 12 mL of HA per person. At 6 and 9 months all patients rated the result natural; 49 external observers. Retrospective, no control group.
- Galderma HIT — Aesthetics Journal report “Galderma unveils new HIT approach at CCR” (CCR London, around 2022). Holistic Individualized Treatment, an Assess · Anatomy · Range · Treat (AART) framework, introducing “Shape Up”, a midface lifting method using the Restylane range. I could not find any description of ligament support in this report. Related trial registration NCT05819502 (Profile HIT).
- Randomised trial, ligament technique vs conventional technique — Feng G et al., Aesthetic Plast Surg 2023;47(4):1550–1559, PMID 36810835, DOI 10.1007/s00266-023-03278-2, ChiCTR2100041702. 2 centres in China, 40 people with moderate to severe nasolabial folds, split-face randomised and double-blind. Blinded WSRS improvement at 24 weeks: ligament technique 0.73 ± 0.61 vs conventional 0.89 ± 0.61 (p>0.05); GAIS 1.32 vs 1.41 (p>0.05). The authors concluded “similar efficacy, better improvement of midface deficiency and fewer adverse events”, but I could not confirm those figures in the abstract. Funded by the product company.
- Split-face study injecting outside the ligament line first — Casabona G et al., J Cosmet Dermatol 2019;18(5):1237–1243, PMID 31402563, DOI 10.1111/jocd.13089. 12 people. The side where points outside the ligament line were injected first used less total volume, 1.26 ± 0.64 cc vs 1.88 ± 0.57 cc (p=.02), with no left-right difference in assessment scores (p=1.00).
- Korean Medical Service Act — Article 56(2) prohibits treatment-experience testimonials, comparisons with other clinics and superlatives in medical advertising. This is why the column carries no reviews, before-and-after photos or prices.
- Miso Clinic treatment criteria — Support injections at ligament points use small divided doses: about 2 cc in total for the whole face and about 0.1 cc per point (confirmed by the director); thread lifts use dissolvable threads only, planned conservatively for people aged 50 and over; for hollow cheeks, dissolvable hyaluronic acid filler comes first. Source of the sentences written as “I” or “we”.
Everything in this column is general information and does not replace medical diagnosis or treatment. Effects and side effects vary with individual skin condition, age and underlying illness, and the same result is not guaranteed for everyone. Any decision to proceed should be made in an in-person consultation with a physician.