Ultrasound Morphology of Polycaprolactone Filler

Ultrasound in Aesthetics: Filler and Non-Filler Applications

Ultrasound in aesthetics presents multiple applications in several areas, including diagnosing fillers and non-fillers complications, the performance of ultrasound-guided injections in real-time, and identifying the most common types of cosmetic fillers. Furthermore, this application of ultrasound in aesthetics has become a must for managing aesthetic patients because, to date, this modality is the one that provides the higher resolution among imaging techniques, detailed anatomical information, and blood flow detection, besides showing worldwide availability. This paper aims to review the current applications of ultrasound in aesthetics based on publications from scientific literature and the authors' experience.

Complications of collagen biostimulators in Brazil: Description of products, treatments, and evolution of 55 cases

BACKGROUND

Complications of temporary and permanent fillers have been extensively studied. However, there is a lack of comparative data regarding poly-L-lactic acid (PLLA), calcium hydroxyapatite (CaHA), and polycaprolactone (PCL) known as collagen biostimulators.

AIMS

This study addressed the complications of collagen biostimulators concerning their diagnosis, type of product, treatment, and monitoring.

PATIENTS/METHODS

An electronic questionnaire was sent to Brazilian dermatologic ultrasound experts to identify complications related to biostimulators. The type of biostimulator, location of application, number of vials injected, application plan, time between injection treatment and complication, injector profile, treatment, and prognosis were assessed.

RESULTS

Fifty-five cases were identified, of which 49.1% were caused by PLLA-Elleva®, 23.6% by CaHA (alone or combined with hyaluronic acid), 20.0% by PLLA-Sculptra®, and 7.3% by PCL. The most affected area was the face (72.7%), with nodules being the most common clinical form (89.1%), generally occurring late (60.0%) (>1 month). Only one case was injected at an incorrect depth (musculoaponeurotic system-SMAS). Despite several treatments, including saline (45.5%), hyaluronidase (25.5%), diluted corticosteroids (23.6%), and energy-based devices (10.9%), only five cases showed complete resolution. Hyaluronidase was beneficial in complications related to fillers when there was an association of calcium hydroxyapatite with hyaluronic acid (p < 0.01).

CONCLUSIONS

Complications from collagen biostimulators were more common on the face, typically manifesting about 1 month after treatment. These issues seemed to be related more to the properties of the products rather than inadequate technique. Furthermore, hyaluronidase demonstrated efficacy only in cases where there was an association with HA.

Key Points to Select a Device for Dermatologic Ultrasound

What points to consider when selecting a device for practicing dermatologic ultrasound is an excellent question. After we met the requisites published in the guidelines for practicing dermatologic ultrasound, it is necessary to consider the main objective of the use because it is not the same to be focused mostly on the avoidance of the puncture of important facial vessels such as the case of injectors of cosmetic fillers in comparison to the use of operators that need to deal with the diagnosis and monitoring of a wide range of dermatologic pathologies. Currently, a broad variety of ultrasound devices meets the minimum requirements for practicing these examinations in the market. Thus, small, portable, and high-end devices may present advantages and limitations that must be balanced according to the primary purposes and the budget. Moreover, the shape and footprint of the probes can make difficult or facilitate a dermatologic procedure. Other points to consider are the type of storage and the need for technical service. In summary, there are key points that we need to consider when we select a dermatologic ultrasound device in dermatology or aesthetics.

The growing importance of ultrasonography in cosmetic dermatology: An update after the 23rd IMCAS Annual World Congress (2022)

BACKGROUND

Ultrasound (US) has been used for many years in the field of medicine. Many specialties have embraced US as a quick, painless, and relatively inexpensive tool to assist the clinician in determining anatomy, pathology, and aid in diagnostic or therapeutic procedures. US allows for precise mapping of cutaneous and subcutaneous structures in the face, in particular vascular structures. The use of US leads to reduced chances of complications and clinical failures, rendering more safety and high quality.

METHODS

US is considered the first-imaging technique for dealing with fillers and managing their potential complications. US can be deployed for vascular mapping, safe placement of fillers, and directed low-dose hyaluronidase reversal of vascular adverse events. It is a noninvasive imaging modality that provides a good definition for studying the skin, deeper layers, and blood flow in real time. In other words, we go from static to dynamic anatomy. In addition, US can guide with the application of botulinum toxin, in order to define the muscular planes. US may contribute to a more personalized procedure, better cosmetic results, and help to avoid complications. In general, physicians tend to use it for prevention. Last, for research purposes, US examination provides valuable information on the behavior, longevity, and interaction of the filler within the tissues.

CONCLUSION

This new approach for US-guided treatments is a very practical and an effective method in cosmetic dermatology. As doctors, we owe it to our patients to do our best to prevent any harm. We feel that in near future, US will be an essential diagnostic tool in any dermatology or cosmetic doctor's office to both ensure safety and provide legal protection for the professional.

Dynamic ultrasound evaluation of body fillers and biostimulators in the buttocks of fresh-frozen specimen

BACKGROUND

Ultrasound imaging is a useful tool to study the injection of fillers and biostimulators in the body.

OBJECTIVE

Sonographically evaluate real-time injections of fillers and biostimulators and describe their behavior in the subcutaneous tissue of the buttocks of fresh-frozen specimen.

METHODS

injection of two brands of high-density hyaluronic acid (HA), one brand of calcium hydroxyapatite (CaHA), one brand of hybrid injectable (CaHa + HA), one brand of polycaprolactone (PCL) and three brands of poly-l-lactic acid (PLLA) were performed in the subcutaneous tissue of the gluteal region under ultrasonography visualization on a fresh-frozen specimen. Videos during injection and static images immediately after injection were obtained. The sonographic aspects of the substances and their dispersion and interaction with the surrounding tissues were described.

RESULTS

Real-time ultrasound showed different dispersion patterns of the two brands of HA, CaHA, hybrid injectable (CaHa + HA) and the three brands of PLLA. The sonographic aspects among the brands of PLLA were also different.

CONCLUSIONS

The dynamic ultrasound evaluation of the injection of HA, CaHA, hybrid injectable (CaHa + HA), PCL and PLLA in a fresh-frozen specimen shed some light on their aspects and dispersion pattern in the buttock. If these patterns are confirmed in further studies in vivo, there will be a positive impact on the selection and development of safer and more effective techniques to enhance buttock contour.

Ultrasonographic Subclinical Signs of Inflammation of the Lacrimal, Parotid, and Submandibular Glands in Users of Cosmetic Fillers

OBJECTIVES

To detect ultrasonographic inflammatory signs in the lacrimal, parotid, and submandibular glands in cosmetic fillers (CFs) users.

METHODS

A prospective and cross-sectional ultrasound study of the glands in cases with CFs was performed. The sample included users of hyaluronic acid, silicone oil, polymethylmethacrylate, polycaprolactone, calcium hydroxyapatite, and polyacrylamide. Abnormalities of the parenchyma and hypervascularity signs of the glands were compared with a control group (n = 10), evaluated by 2 observers, and correlated with the type, number, and location of the facial CFs. Cohen's kappa test and logistic regression models with odds ratios (OR) adjusted by age with 95% CI were performed.

RESULTS

Sixty-three patients with CFs met the criteria. Parotid and submandibular glands had the highest percentage of parenchymal involvement: 87.3 and 88.9%, respectively (p <.01). Abnormalities of the echostructure of the parenchyma and hypervascularity of the glands were detected with all kinds of fillers without significant differences per type. A significant substantial interrater kappa (0.61) with an agreement of 90% for all glands among observers was found.

CONCLUSION

Users of common types of CFs frequently present subclinical ultrasonographic signs of inflammation of the lacrimal, parotid, and submandibular glands. Further research on the topic seems necessary.

A Guide to Doppler Ultrasound Analysis of the Face in Cosmetic Medicine. Part 1: Standard Positions

Interest in Doppler ultrasound (DUS) analysis of the face has grown in cosmetic medicine, in particular for injectable fillers. When dealing with complications, DUS has the advantage of easily visualizing the filler and identifying the problem in relation to the patient's anatomy. When working with hyaluronic acid filler, ultrasound-guided injections with hyaluronidase can precisely target the problem. In addition, DUS can be used to study the anatomy of a patient, specifically to prevent intravascular injections. We predict that in a few years' time DUS will become standard equipment in the offices of cosmetic doctors. We discuss the basics of ultrasound imaging of different tissues with the concomitant terminology. With the use of 7 basic DUS probe positions, key anatomic reference points can be easily found. From these, all relevant anatomic structures in the face can be observed and analyzed. With some practice, physicians will ultimately be able to acquire a complete 3-dimensional mental image of a patient's face.

Polycaprolactone-based dermal filler complications: A retrospective study of 1111 treatments

Background

Aging signs can be corrected through volume restoration in multiple soft tissue layers and in the supraperiosteal plane using hyaluronic acid (HA) or nonhyaluronic acid (non‐HA) fillers. The non‐HA bioresorbable polycaprolactone (PCL)‐based filler with collagen‐stimulating properties has a proven safety profile, but rare potential complications such as nodules and granuloma can occur. Furthermore, PCL‐based fillers cannot be immediately removed by injection of an enzyme. These potential drawbacks have yet to be described in the literature.

Aims

The author performed 1111 treatments between 2015 and 2018. This study aims to review and analyze these treatments to ascertain the complication rates of the PCL‐based filler. Suggestions for complication prevention and management are also discussed.

Methods

780 patients treated with the PCL‐based filler were reviewed by the physician between April 2015 and May 2018. During this period, 5595 syringes were used in 1111 treatments. All complication data were acquired by phone interviews, reports by patients, or observation at follow‐up visits. Complications were subdivided into early‐onset (occurring up to 2 weeks after treatment) and late‐onset events (occurring more than 2 weeks to years after treatment).

Results

Among the 1111 treatments, there were 50 cases (4.5%) of edema that lasted longer than 2 weeks, 30 cases (2.7%) of bruising, 8 cases (0.72%) of malar edema, 5 cases (0.45%) of temporarily palpable lumps and 2 cases (0.18%) of discoloration. There were no cases of intravascular injection, nodules/granulomas, or infection.

Conclusion

The complication rate of the PCL‐based filler was found to be low, and there were no cases of intravascular injection, nodules, and/or granulomas during the 3‐year observation. Longer‐lasting edema was associated with a higher injection volume and malar edema was related to lymphatic compression.

Polycaprolactone: How a Well-Known and Futuristic Polymer Has Become an Innovative Collagen-Stimulator in Esthetics

Compared to other domains, tissue engineering and esthetics have dramatically expanded in recent years, leading to both major biomedical advances and futuristic perspectives. The two share a common approach based on biomaterials, especially polymers. This paper illustrates this with the example of polycaprolactone (PCL), a polymer synthesized in the early 1930s, and one of its most recent applications, a PCL-based collagen stimulator, a filler used in esthetics. PCL is biocompatible and biodegradable. Its specific physicochemical and mechanical properties, viscoelasticity and ease of shaping led to the production of PCL-based products with various shapes and durations dependent on its biodegradation kinetics. PCL has been safely used in the biomedical field for more than 70 years, from sutures to tissue and organ replacement by 3D printing. The PCL-based collagen stimulator is composed of PCL microspheres suspended in a carboxymethyl-cellulose gel carrier providing immediate and sustained volumizing effects when injected; the morphology, the biocompatibility of the PCL microspheres embedded with the collagen fibers produced all contribute to the creation of a unique 3D scaffold for a sustained effect. Its safety has been investigated in clinical studies and vigilance surveys. Recently published experts' recommendations on injection modalities and techniques should help further optimize treatment outcome and safety. This paper also integrates reviews and recommendations on the prevention and management of adverse events related to dermal and subdermal fillers including the PCL-based collagen stimulator. In addition, in terms of efficacy and safety, this product benefits from its daily clinical use in esthetics worldwide and continuous extensive fundamental and clinical research, both on it and the PCL polymer. Forthcoming data from further investigations will reinforce knowledge of the product and procedures in the field.

Nomenclature proposal for the sonographic description and reporting of soft tissue fillers

BACKGROUND

There is a steady increase in publications about the use of ultrasound and filler treatments, written by physicians from different specialties. The terminology used to describe the ultrasound images of fillers is not uniform, making the different articles difficult to compare. Standardization of the descriptions based on their basic sonographic parameters is recommendable.

AIMS

The purpose of this study is to propose a nomenclature for the sonographic description and reporting of cosmetic fillers.

METHODS

An assessment of articles indexed for MEDLINE/PubMed and Embed electronic database was conducted; in total of 39 articles could be included.

RESULTS

All articles were investigated for their sonographic descriptions of soft tissue fillers. Ten parameters used for describing and monitoring soft tissue fillers were distinguished.

CONCLUSION

The proposed sonographic descriptions for cosmetic fillers may contribute to a better standardization and understanding fillers ultrasound images in the reports or literature.