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McCarthy AD, van Loghem J, Martinez KA, Aguilera SB, Funt D. A Structured Approach for Treating Calcium Hydroxylapatite Focal Accumulations. Aesthet Surg J 2024; 44:869-879. [PMID: 38366791 DOI: 10.1093/asj/sjae031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 01/23/2024] [Accepted: 01/30/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Radiesse, a widely utilized calcium hydroxylapatite (CaHA) dermal filler, has shown effectiveness in soft tissue augmentation and regeneration. As with all dermal fillers, the potential for nodules may arise. Understanding the pathogenesis of these nodules and exploring effective treatment methodologies are crucial for optimizing patient outcomes. OBJECTIVES A literature search was carried out to identify published literature documenting reversal of CaHA nodules. After identification, a consensus panel developed a structured approach, denoted by levels, for applying such reversal methods. METHODS This concise review presents an algorithmic approach to addressing CaHA focal accumulations (noninflammatory nodules) based on invasiveness, cost, and potential risks based on published literature. RESULTS Level 0 involves no intervention, relying on natural degradation for asymptomatic nodules. Level 1 interventions utilize mechanical dispersion techniques, including massage and in situ dispersion, which have demonstrated high success rates, cost effectiveness, and minimal invasiveness. Level 2 introduces alternative modalities such as pharmacological treatments with 5-fluorouracil and corticosteroids, lasers, and experimental approaches. Level 3 represents last-resort options, including calcium-chelating agents, manual removal, and surgical excision. CONCLUSIONS The article offers a structured approach to managing CaHA focal accumulations. LEVEL OF EVIDENCE: 4
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McCarthy AD, Berkowitz S, Chernoff WG. Successful Treatment of Noninflammatory CaHA Nodules Using Focused Mechanical Vibration. Aesthet Surg J Open Forum 2024; 6:ojae018. [PMID: 38650973 PMCID: PMC11033680 DOI: 10.1093/asjof/ojae018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024] Open
Abstract
Noninflammatory nodules arising from the injection of biostimulatory fillers persist as an unwanted complication. Pathologically, noninflammatory nodules may arise from superficial injection, accidental boluses, or incorrect concentration of microparticles contained within the filler. This case report introduces a method for reversing calcium hydroxylapatite (CaHA) using focused mechanical vibration. An in situ hyperdilution was created by injecting saline into the nodule core to prepare it for resuspension. Topical microneedling was subsequently applied to generate vibrations, aiming to disperse the accumulated CaHA particles. The outcome demonstrated a significant reduction in the size and visibility of the nodule. This combined saline-microneedling approach offers a potential noninvasive, nonpharmacologic solution for managing superficial CaHA nodules. Level of Evidence 5
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Affiliation(s)
- Alec D McCarthy
- Corresponding Author: Dr Alec D. McCarthy, 6501 Six Forks Rd, Raleigh, NC 27615, USA. E-mail:
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Cohen SR, Patton S, Wesson J, Tiryaki KT, Mora A. Radiesse Rescue: A Preliminary Study for a Simple and Effective Technique for the Removal of Calcium Hydroxyapatite-Based Fillers. Aesthet Surg J 2023; 43:365-369. [PMID: 36411258 DOI: 10.1093/asj/sjac299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 11/11/2022] [Accepted: 11/14/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Radiesse, or calcium hydroxyapatite (CaHA), is a semipermanent, biodegradable injectable filler that provides immediate aesthetic improvement, while also stimulating neocollagenesis for biological effects. The physical properties of CaHA make it difficult, if not impossible, to remove. Unlike some hyaluronic acid-based fillers, CaHA cannot be easily dissolved. OBJECTIVES The aim of this study was to present a simple and reliable technique for debulking and removing excess CaHA in the event of nodule formation, vascular compression, or overcorrection. METHODS An 18-gauge needle was used to make an incision near the filler excess. A 1-mm-diameter grater-type microliposuction cannula (Lipocube, Inc.; London, UK) was attached to a 5- to 10-mL syringe under negative pressure. The cannula under syringe suction was used in a back-and-forth reaming motion beginning in the base of the material and gradually moving toward the surface until the desired effect was achieved. Identification of the CaHA can be established and removal confirmed with ultrasound (Clarius, Inc.; Vancouver, BC, Canada) if available. RESULTS Although nodules, excess material and vascular compression secondary to CaHA are very rare occurrences, 4 patients were treated with excess material and/or nodules. In 1 patient, the prominent cheek filler was reduced and a 1-cm nodule that was palpable in the buccal region was eliminated. In the other 3 other patients, the palpable excess material was easily removed, in 2 at the time of injection and in the third, 6 months later. No patient required repeat treatment or replacement. CONCLUSIONS This removal technique has been shown to adequately remove excess CaHA filler but is not applicable to inadvertent intravascular injection.
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Affiliation(s)
| | - Sarah Patton
- Medical student at University of Louisville, Louisville, KY, USA
| | - Jordan Wesson
- Research assistant at a private plastic surgery practice, San Diego, CA, USA
| | | | - Alexandra Mora
- Facial plastic surgeon in private practice, Bogota, Colombia
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Haneke E. Adverse effects of fillers. Dermatol Ther 2018; 32:e12676. [PMID: 30187592 DOI: 10.1111/dth.12676] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 06/27/2018] [Accepted: 07/10/2018] [Indexed: 11/28/2022]
Abstract
Filler injections belong to the most frequently performed noninvasive beautifying procedures. When done correctly they are generally well tolerated. However, a number of factors, such as poor filler quality, and particularly host as well as user dependent filler reactions may lead to unwanted effects. These may be early, late, or delayed events with characteristics for each of them. Temporary fillers almost invariably cause temporary side effects whereas those of permanent fillers may last forever. Some fillers are notorious for their poor safety profile; for example, silicone is banned in the European Union and the United States but nevertheless used by many practitioners and beauticians. Many fillers can be identified in histopathologic sections allowing specific measures to be instituted.
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Affiliation(s)
- Eckart Haneke
- Dermatology Practice Dermaticum, Freiburg, Germany.,Department of Dermatology, Inselspital, Universitätsspital Bern, Bern, Switzerland.,Centro Dermatol Epidermis, Instituto CUF, Porto, Portugal.,Department of Dermatology, University Hospital, Ghent, Belgium
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Zerbinati N, D'Este E, Parodi PC, Calligaro A. Microscopic and ultrastructural evidences in human skin following calcium hydroxylapatite filler treatment. Arch Dermatol Res 2017; 309:389-396. [PMID: 28324170 PMCID: PMC5486564 DOI: 10.1007/s00403-017-1734-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 02/21/2017] [Accepted: 03/08/2017] [Indexed: 11/23/2022]
Abstract
This study uses light and electron microscopes to gain a better knowledge of the interactions of calcium hydroxylapatite filler with the connective tissue of the skin and the modifications of the human deep dermis, after 2 months of treatment. Some morphological evidences of this observational study of filler treated tissue support-specific mechanism involved in the structural modifications of both filler microspherules and cells of the connective tissue. They demonstrate the absence of any immunological reaction and show that the used filler is modified very slowly over time by the action of cells of the connective tissue closely related to the filler without any activity of phagocytosis. Furthermore, associated with the modifications of the filler, evidences of stimulatory effects on dermal fibroblasts are reported.
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Affiliation(s)
- Nicola Zerbinati
- Department of Surgical and Morphological Sciences, University of Insubria, Varese, Italy.
| | - Edoardo D'Este
- Dermatology Department Centro Medico Polispecialistico, Pavia, Italy
| | - Pier Camillo Parodi
- Department of Medical, Experimental and Clinical Sciences, University of Udine, Udine, Italy
| | - Alberto Calligaro
- Department of Public Health, Experimental and Forensic Medicine, Histology and Embryology Unit, University of Pavia, Pavia, Italy
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Abstract
BACKGROUND The ever-expanding range of dermal filler products for aesthetic soft tissue augmentation is of benefit for patients and physicians, but as indications and the number of procedures performed increase, the number of complications will likely also increase. OBJECTIVE To describe potential adverse events associated with dermal fillers and to provide structured and clear guidance on their treatment and avoidance. METHODS Reports of dermal filler complications in the medical literature were reviewed and, based on the publications retrieved and the authors' extensive experience, recommendations for avoiding and managing complications are provided. RESULTS Different dermal fillers have widely varying properties, associated risks, and injection requirements. All dermal fillers have the potential to cause complications. Most are related to volume and technique, though some are associated with the material itself. The majority of adverse reactions are mild and transient, such as bruising and trauma-related edema. Serious adverse events are rare, and most are avoidable with proper planning and technique. CONCLUSION For optimum outcomes, aesthetic physicians should have a detailed understanding of facial anatomy; the individual characteristics of available fillers; their indications, contraindications, benefits, and drawbacks; and ways to prevent and avoid potential complications.
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Abstract
A large list of foreign substances may penetrate the skin and induce a foreign body granulomatous reaction. These particles can enter the skin by voluntary reasons or be caused by accidental inclusion of external substances secondary to cutaneous trauma. In these cases, foreign body granulomas are formed around such disparate substances as starch, cactus bristles, wood splinters, suture material, pencil lead, artificial hair, or insect mouthparts. The purpose of this article is to update dermatologists, pathologists, and other physicians on the most recent etiopathogenesis, clinical presentations, systemic associations, evaluation, and evidence-based management concerning foreign body granulomatous reactions of skin.
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Affiliation(s)
- Ana M Molina-Ruiz
- Department of Dermatology, Fundación Jiménez Díaz, Universidad Autónoma, Avda. Reyes Católicos 2, Madrid 28040, Spain.
| | - Luis Requena
- Department of Dermatology, Fundación Jiménez Díaz, Universidad Autónoma, Avda. Reyes Católicos 2, Madrid 28040, Spain
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Abstract
Fillers belong to the most frequently used beautifying products. They are generally well tolerated, but any one of them may occasionally produce adverse side effects. Adverse effects usually last as long as the filler is in the skin, which means that short-lived fillers have short-term side effects and permanent fillers may induce life-long adverse effects. The main goal is to prevent them, however, this is not always possible. Utmost care has to be given to the prevention of infections and the injection technique has to be perfect. Treatment of adverse effects is often with hyaluronidase or steroid injections and in some cases together with 5-fluorouracil plus allopurinol orally. Histological examination of biopsy specimens often helps to identify the responsible filler allowing a specific treatment to be adapted.
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Affiliation(s)
- Eckart Haneke
- Department of Dermatology, Inselspital, University of Bern, Bern, Switzerland, Europe; Department of Dermatology, Clinic Dermaticum, Freiburg, Germany, Europe; Centro de Dermatología Epidermis, Inst CUF, Porto, Portugal, Europe; Department of Dermatology, Ghent University Hospital, Gent, Belgium, Europe
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9
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Choi WY, Cho HW, Lee DW. Complications of Injectable Soft Tissue Filler. ARCHIVES OF AESTHETIC PLASTIC SURGERY 2015. [DOI: 10.14730/aaps.2015.21.1.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Woo Young Choi
- Department of Plastic and Reconstructive Surgery, Yonsei University Health System, Severance Hospital, Seoul, Korea
| | | | - Dong Won Lee
- Department of Plastic and Reconstructive Surgery, Yonsei University Health System, Severance Hospital, Seoul, Korea
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Cuerda-Galindo E, Palomar-Gallego MA, Linares-Garcíavaldecasas R. Are combined same-day treatments the future for photorejuvenation? J COSMET LASER THER 2014; 17:49-54. [DOI: 10.3109/14764172.2014.968578] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Maier T, Flaig M, Ruzicka T, Berking C, Pavicic T. High-definition optical coherence tomography and reflectance confocal microscopy in the in vivo
visualization of a reaction to permanent make-up. J Eur Acad Dermatol Venereol 2014; 29:602-6. [DOI: 10.1111/jdv.12402] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 11/05/2013] [Indexed: 11/30/2022]
Affiliation(s)
- T. Maier
- Department of Dermatology and Allergology; Ludwig-Maximilian University of Munich; Munich Germany
| | - M.J. Flaig
- Department of Dermatology and Allergology; Ludwig-Maximilian University of Munich; Munich Germany
| | - T. Ruzicka
- Department of Dermatology and Allergology; Ludwig-Maximilian University of Munich; Munich Germany
| | - C. Berking
- Department of Dermatology and Allergology; Ludwig-Maximilian University of Munich; Munich Germany
| | - T. Pavicic
- Department of Dermatology and Allergology; Ludwig-Maximilian University of Munich; Munich Germany
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Funt D, Pavicic T. Dermal fillers in aesthetics: an overview of adverse events and treatment approaches. Clin Cosmet Investig Dermatol 2013; 6:295-316. [PMID: 24363560 PMCID: PMC3865975 DOI: 10.2147/ccid.s50546] [Citation(s) in RCA: 112] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background The ever-expanding range of dermal filler products for aesthetic soft tissue augmentation is of benefit for patients and physicians, but as indications and the number of procedures performed increase, the number of complications will likely also increase. Objective To describe potential adverse events associated with dermal fillers and to provide structured and clear guidance on their treatment and avoidance. Methods Reports of dermal filler complications in the medical literature were reviewed and, based on the publications retrieved and the authors’ extensive experience, recommendations for avoiding and managing complications are provided. Results Different dermal fillers have widely varying properties, associated risks, and injection requirements. All dermal fillers have the potential to cause complications. Most are related to volume and technique, though some are associated with the material itself. The majority of adverse reactions are mild and transient, such as bruising and trauma-related edema. Serious adverse events are rare, and most are avoidable with proper planning and technique. Conclusion For optimum outcomes, aesthetic physicians should have a detailed understanding of facial anatomy; the individual characteristics of available fillers; their indications, contraindications, benefits, and drawbacks; and ways to prevent and avoid potential complications.
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Affiliation(s)
- David Funt
- Mount Sinai Hospital, Department of Plastic Surgery, New York, NY, USA
| | - Tatjana Pavicic
- Department of Dermatology and Allergy, Ludwig-Maximilian University of Munich, Munich, Germany
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Hélou J, Maatouk I, Moutran R, Obeid G, Stephan F. Efficacy and Safety of 10,600-nm Carbon Dioxide Fractional Laser on Facial Skin with Previous Volume Injections. J Cutan Aesthet Surg 2013; 6:30-2. [PMID: 23723602 PMCID: PMC3663173 DOI: 10.4103/0974-2077.110094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: Fractionated carbon dioxide (CO2) lasers are a new treatment modality for skin resurfacing. The cosmetic rejuvenation market abounds with various injectable devices (poly-L-lactic acid, polymethyl-methacrylate, collagens, hyaluronic acids, silicone). The objective of this study is to examine the efficacy and safety of 10,600-nm CO2 fractional laser on facial skin with previous volume injections. Materials and Methods: This is a retrospective study including 14 patients treated with fractional CO2 laser and who have had previous facial volume restoration. The indication for the laser therapy, the age of the patients, previous facial volume restoration, and side effects were all recorded from their medical files. Objective assessments were made through clinical physician global assessment records and improvement scores records. Patients’ satisfaction rates were also recorded. Results: Review of medical records of the 14 patients show that five patients had polylactic acid injection prior to the laser session. Eight patients had hyaluronic acid injection prior to the laser session. Two patients had fat injection, two had silicone injection and one patient had facial thread lift. Side effects included pain during the laser treatment, post-treatment scaling, post-treatment erythema, hyperpigmentation which spontaneously resolved within a month. Concerning the previous facial volume restoration, no granulomatous reactions were noted, no facial shape deformation and no asymmetry were encountered whatever the facial volume product was. Conclusion: CO2 fractional laser treatments do not seem to affect facial skin which had previous facial volume restoration with polylactic acid for more than 6 years, hyaluronic acid for more than 0.5 year, silicone for more than 6 years, or fat for more than 1.4 year. Prospective larger studies focusing on many other variables (skin phototype, injected device type) are required to achieve better conclusions.
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Affiliation(s)
- Josiane Hélou
- Department of Dermatology, Hôtel-Dieu de France Hospital, Faculty of medicine, Saint Joseph University, Beirut, Lebanon
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