Dermal fillers: an update

Using dermal filler to camouflage forehead osteoma: A case report

Objective

To review the technique and outcomes of using dermal filler to camouflage forehead osteoma, providing a minimally invasive alternative to surgical excision.

Background

Forehead osteoma, commonly known as a forehead bump or bone spur, can be a cosmetic concern. Surgical excision, while effective, carries risks of scarring and postoperative complications. An innovative approach using dermal filler offers a potential solution.

Methods

A hyaluronic acid‐based filler is injected into the deep subcutaneous plane over the bony prominence using a cannula. The fanning technique ensures even distribution of the filler. The procedure's safety, patient selection, and communication between the injector and patient are emphasized to achieve optimal results.

Results

The technique provides immediate aesthetic improvement with results that can last up to 12 months, depending on the filler used. While generally safe, potential complications include infections, swelling, asymmetry, and lumpiness. Proper technique, patient selection, and good communication between the injector and patient are critical to achieving optimal outcomes.

Conclusion

Using dermal filler to camouflage forehead osteoma is a minimally invasive alternative to surgical excision, offering immediate and long‐lasting results with minimal downtime and fewer risks. Further studies are needed to refine the technique and optimize outcomes.

A Cross-Sectional Survey on Pain Management in Dermal Filler Injections from Physicians' and Patients' Perspectives

BACKGROUND

Hyaluronic acid (HA) dermal fillers injection is a common procedure in patients with cosmetic needs. Concomitant pain is a major complaint among patients undergoing HA filler injections. Relevant research is limited and there is no consensus on pain management of dermal filler injection.

OBJECTIVES

To assist physicians in determining a more appropriate treatment approach, and to better provide treatment suggestions.

METHODS

A nationwide (China) cross-sectional survey was conducted using questionnaires designed for physicians and patients, respectively. A total of 62 semi-structured questionnaires were administered to aesthetic physicians via face-to-face interview, whereas 123 online-based questionnaires were collected from patients who have ever undergone HA treatment. The collected questionnaire information was analyzed using descriptive statistics and content analysis.

RESULTS

42 (67.74%) physicians observed that over 50% of their patients were concerned about pain during injection. 101 (82.11%) of patients were concerned about impending pain ≥5 points (a total score is 10) before injection. For preferred pain relief modalities, 48 (77.42%) physicians would choose a hyaluronic acid dermal filler with lidocaine, and 82 (66.67%) patients would choose anesthetic-containing products. 59 (95.16%) physicians who injected lidocaine-containing hyaluronic acid found patients had a comfortable treatment experience.

CONCLUSIONS

Pain management during hyaluronic acid dermal fillers injection is important from both perspectives of physicians and patients. This survey showed that compared with other analgesic methods, lidocaine-containing hyaluronic acid has offered a more satisfying experience. It also provides insights to physicians and patients in pain management.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A treatment algorithm for hyaluronic acid filler related complications of the face

BACKGROUND

Throughout the last decade, a notable increase in HA-filler-related complications have been observed, owing to the increase in demand for filler injections and availability of multiple products.

OBJECTIVES

The aim is to provide practical advice on the best way to prevent and treat HA-filler-related complications.

METHODS

Thirty patients who experienced visible and/or symptomatic complications localized within the facial area were treated according to our algorithm. Patients with inflammatory lesions underwent antibiotic and anti-inflammatory therapy, followed by hyaluronidase injections. Patients with abscesses were treated with antibiotics, incision, and drainage. Each patient completed the dermatology-specific quality of life questionnaire (DLQI) at the first and last examinations.

RESULTS

Among the 29 patients who received antibiotic therapy, 3 healed without further treatment. However, 18 received hyaluronidase injections, 9 underwent incision and drainage, and 5 presented with fistulas and developed retracted scars. Moreover, 80% of the patients were completely healed, 13% significantly improved, and 3% did not show any improvement. The DLQI scores analysis showed a notable impact of patients' diseases on their quality of life, mainly in the terms of personal relationships and symptoms, with minor impacts on intimate relationships, ability to work, and study. We demonstrated that our algorithm resulted in a significant improvement in the overall quality of life at the last follow-up (p < 0.001).

CONCLUSIONS

The use of filler injections requires caution and specific training because they can lead to serious complications. If these complications are recognized promptly, healing can be optimized. Our treatment algorithm demonstrated high rate of healing and significant improvement in the patients' quality of life.

Clinically Actionable Topical Strategies for Addressing the Hallmarks of Skin Aging: A Primer for Aesthetic Medicine Practitioners

In this narrative review, we sought to provide a comprehensive overview of the mechanisms underlying cutaneous senescence, framed by the twelve traditional hallmarks of aging. These include genomic instability, telomere attrition, epigenetic alterations, loss of proteostasis, impaired macroautophagy, deregulated nutrient sensing, mitochondrial dysfunction, cellular senescence, stem cell exhaustion, altered intercellular communication, chronic inflammation, and dysbiosis. We also examined how topical interventions targeting these hallmarks can be integrated with conventional aesthetic medicine techniques to enhance skin rejuvenation. The potential of combining targeted topical therapies against the aging hallmarks with minimally invasive procedures represents a significant advancement in aesthetic medicine, offering personalized and effective strategies to combat skin aging. The reviewed evidence paves the way for future advancements and underscores the transformative potential of integrating scientifically validated interventions targeted against aging hallmarks into traditional aesthetic practices.

Home-Use Hyaluronic Acid Jet Injectors: Unreliable and Unsafe

BACKGROUND

Needle-free hyaluronic acid (HA) jet injectors are gaining popularity for rejuvenation treatment. The devices are widely available online and are used for self-injection or in beauty salons by nonphysicians. However, little is known about their performance and safety.

OBJECTIVE

To explore the injection efficiency and cutaneous biodistribution patterns administered with home-use compared with medical jet injectors and to assess safety aspects.

MATERIALS AND METHODS

The authors injected HA into ex vivo human skin with 4 home-use and 2 medical injectors. The intracutaneous dose of HA was calculated, and the cutaneous biodistribution of HA was assessed using a 3-dimensional Fluorescent Imaging Cryomicrotome System (3D-FICS). Safety aspects were evaluated based on the presence of a manual, CE (conformité européenne) mark, and sterility.

RESULTS

The intracutaneous dose delivered by the home-use injectors was markedly lower compared with the medical injectors. 3D imaging for home-use injectors showed superficial epidermal distribution with low distribution volumes. For medical injectors, volumes were substantially larger and mainly middermal. All evaluated safety aspects were lacking.

CONCLUSION

Results of this study suggest that the specific combinations of home-use injectors and HA used in this study are unreliable and unsafe, which casts doubts on the performance of these treatments in general.

A practical guide to selecting facial fillers

BACKGROUND

Dermal fillers have created a multi-billion-dollar industry. They are the second most popular form of injectable, as they primarily address volume loss, augmentation, and provide immediate results. The most popular form includes hyaluronic acid-based fillers, however, alternatives exist.

OBJECTIVE

To create clinical charts to help with filler selection, injection, and addressing common complications.

METHODS

The current literature and expert opinions form our two senior authors were used to create a numerical and color-coded chart based on G-prime for filler selection, as well as an anatomical table with current recommendations and pearls. We have also included a safety table with current clinical recommendation to deal with common filler-related complications.

CONCLUSION

Fillers are a safe and reliable method to achieve augmentation. Filler selection in various anatomical planes plays a significant role in achieving favorable results.

Long-term Safety and Effectiveness of Hyaluronic Acid Fillers Correcting Nasolabial Folds in Chinese Patients

Background

Soft-tissue fillers, specifically hyaluronic acid fillers, can reduce many signs of aging by treating the associated loss of subcutaneous fat and midfacial contour deficiencies. The objective of this study was to investigate whether the effectiveness and safety of Belotero Volume Lidocaine (BVL) compared with Restylane (RES, control) is noninferior in the treatment of severe nasolabial folds (NLFs) in Chinese patients.

Methods

This was a prospective, randomized, controlled, split-face clinical study. Overall, 220 Chinese patients of both sexes with symmetrical NLFs of severe intensity (grade 4) on the Wrinkle Severity Rating Scale (WSRS) were treated with both fillers. Treatment outcomes were assessed by the WSRS, and other scales, at multiple time points up to 18 months postinjection. The co-primary effectiveness outcomes were based on the blinded evaluator ratings of NLFs according to the WSRS scale after 6 and 12 months. Adverse events were assessed during the whole study and patients' pain sensation at three time points after injection.

Results

Noninferiority of BVL versus control based on the WSRS was demonstrated at month 6 and month 12. Response rates were slightly higher for BVL than control at all time points, and BVL had a sustained effect until month 18. Pain sensation scores were significantly lower for BVL compared with control. The incidence rates of treatment-related AEs were low and very similar for both treatments.

Conclusions

This study demonstrates that BVL is a safe, long-lasting, and effective treatment to correct severe NLFs in Chinese patients while being noninferior to the control device.

Adverse Reactions Associated with Dermal Fillers in the Oral and Maxillofacial Region: A Venezuelan Experience

BACKGROUND

Dermal facial fillers are increasingly popular. Published reports on the clinical and histopathologic characteristics related to adverse reactions to dermal fillers in the facial region have been relatively well documented. This study adds to the literature on adverse reactions to injected filler in the oral and maxillofacial region in a South American population.

METHODS

A retrospective, descriptive cross-sectional study (2019-2020) was performed. The study population was a dermatology service in Venezuela. Clinical and histopathologic features of patients with adverse effects were documented.

RESULTS

A total of 35 cases of adverse reactions associated with cosmetic filler procedures were diagnosed during the analyzed period; of these, six cases (17.1%) involved the oral and maxillofacial region. All cases occurred in women. The mean age at diagnosis was 59.3 years (58-73). In three cases, dermal fillers were used in different locations on the face, while three involved the lips. Five patients exhibited adverse reactions to lip filler. All six cases were histopathologically diagnosed as foreign body reactions to injected material. Four and two cases revealed microscopic features compatible with hyaluronic acid and polymethylmethacrylate, respectively.

CONCLUSION

Reflecting the dramatic increase in cosmetic procedures with soft tissue fillers, this study contributed by reporting six cases of foreign body reaction involving the oral and maxillofacial region, confirmed with biopsy and histopathology.

Polymethylmethacrylate-induced foreign body reaction presenting as bilateral parotid lesions: A case report of dermal filler adverse reaction diagnosed on fine needle aspiration

BACKGROUND

Dermal filler injections are being increasingly used as a non-surgical option for facial cosmetic procedures. However, their use has been implicated in multiple adverse events including immediate, early onset, and late onset complications.

AIM

We present a case of dermal filler-induced foreign body reaction presenting as bilateral parotid lesions and diagnosed using fine needle aspiration.

CONCLUSION

This case elucidate the risk of delayed adverse events in patients with dermal filler injections and stresses the importance of awareness by patients and providers for such events.

Adverse Events Reported From Hyaluronic Acid Dermal Filler Injections to the Facial Region: A Systematic Review and Meta-Analysis

Dermal filler injections are one of the most popular cosmetic procedures in the United States. Of the many options available, hyaluronic acid (HA) dermal fillers like Juvederm or Restylane are often used. Despite their use and popularity, adverse events are known to occur from these procedures. Although most outcomes may be mild and resolve over time, rare instances of severe complications cannot be ignored, as these effects may be irreversible. Healthcare practitioners and patients must be aware of these risks, as these cosmetic procedures can affect the patient's quality of life. The aim of this study was to evaluate the incidence of adverse events (AEs) reported from the use of hyaluronic acid dermal fillers in the facial region. A systemized search of randomized controlled trials was conducted using Cochrane Central, Embase, Medical Literature Analysis and Retrieval System Online (MEDLINE), and the Web of Science databases. After screening for eligibility and conducting a critical appraisal of the articles, 19 studies were retained for the final review. The meta-analysis results included different side effects by facial location, i.e., nasolabial fold (NLF) vs. other (midface, perioral line, and lip region). The midface includes the anteromedial cheek region, the zygomaticomalar region, and the submalar region. The adverse events were swelling, pain, erythema, bruising, lumps and bumps, firmness, tenderness, itching, and skin discoloration. A significant difference was found in the proportion of individuals experiencing swelling, lumps or bumps, and firmness at the nasolabial fold site versus the midface, perioral line, and lip region. There was no significant difference in the proportion of individuals experiencing pain, erythema, bruising, tenderness, itching, or skin discoloration at the nasolabial fold site versus the other sites. The study highlights the prevalence of common AEs that can result from HA dermal fillers like Juvederm or Restylane, thus emphasizing the importance of healthcare professionals explaining the risk and benefits to patients.

Efficacy of a home-used high-intensity focused ultrasound device on wrinkle reduction

BACKGROUND

High-intensity focused ultrasound (HIFU) has been developed for the treatment of skin wrinkles on the face, neck, and body.

OBJECTIVES

This study aimed to evaluate the effects of a home-used HIFU device on wrinkles in mice based on the expression of fibrosis-related genes and proteins.

METHODS

The backs of 20-week-old mice were treated with a home-used HIFU using the following probes: 4 MHz, 1.5 mm focal depth. The treated mice were compared with young mice by histological examination, real-time polymerase chain reaction (PCR), and immunohistochemistry. Histological examination was performed by trichrome staining. Real-time PCR and immunohistochemistry were conducted to determine the expression of collagen types I and III, matrix metalloproteinase (MMP)-1, and tissue inhibitor of metalloproteinase (TIMP)-1.

RESULTS

Dermal thickness was increased after treatment with the home-used HIFU device at 30 and 60 s per day for 1 week or 30 and 60 s per day for 2 weeks on trichrome. Gene and protein expression of collagen types I and III and elastin were increased after treatment with HIFU at all options of 30 and 60 s per day for 1 week or 30 and 60 s per day for 2 weeks. Gene and protein expressions of MMP-1 and TIMP-1 were decreased after treatment with HIFU device at 30 and 60 s per day for 1 week or 30 and 60 s per day for 2 weeks.

CONCLUSION

The home-used HIFU device can be an effective therapeutic modality for skin tightening.

Efficacy and Safety of Polycaprolactone in Treating Nasolabial Folds: A Prospective, Multicenter, and Randomized Controlled Trial

Nasolabial folds (NLFs) are the most pronounced sign of facial aging. This study explored the efficacy and safety of polycaprolactone gel in treating Chinese patients with moderate-to-severe NLFs. Patients with moderate-to-severe NLF who wished to be treated by dermal fillers were recruited from three centers between July 2017 and September 2019. The randomizing ratio was 1:1 in the polycaprolactone group (polycaprolactone injection) or control group (sodium hyaluronate gel injection). The primary endpoint was the effectiveness rate of Wrinkle Severity Rating Score (WSRS) scores at 12 months after injection. The full-analysis set (FAS) and safety sets had 80 patients in the polycaprolactone group and control group, respectively. In the FAS, the effectiveness rate at 12 months in the polycaprolactone group was 88.8% compared with 23.8% in controls (P < 0.001). The improvement in WSRS sustained during 12 months in the polycaprolactone group, while gradually vanished in the control group since 3 months after surgery. The global aesthetic improvement scale (GAIS) by investigator assessments was improved, much improved, or very much improved in all patients during follow-up, while the proportion of patients with a "no change" assessment gradually increased during follow-up after 6 months in the control group. The rates of injection-related adverse event (AE) and serve injection-related AE were 8.8 versus 11.3% and 0 versus 1.3% in the polycaprolactone group and control groups, respectively. Polycaprolactone gel injection is effective and safe to treat moderate-to-severe NLFs in Chinese patients.

Patient Comfort, Safety, and Effectiveness of Resilient Hyaluronic Acid Fillers Formulated With Different Local Anesthetics

Supplemental Digital Content is Available in the Text.

Maximizing patient comfort during hyaluronic acid gel injection is a common concern that is usually addressed by selecting fillers with lidocaine.

Novel Hyaluronic Acid ethosomes based gel formulation for topical use with reduced toxicity, better skin permeation, deposition, and improved pharmacodynamics

Hyaluronic Acid (HA) has been applied as an anti-ageing molecule in the form of topical products. Current topical commercial formulations of HA face the limitations of very small and stagnant skin permeation, thereby demanding enduring administration of the formulation to sustain its action. In this study, Lipid-based nanocarriers in the form of ethosomes were formulated in a 1% w/w HA strength and were extensively evaluated in vitro, ex-vivo, and in vivo parameters along with a comparison to it's commercial counterpart. The optimised ethosomes-based HA gel formulation revealed required pH (6.9 ± 0.2), small globule size (1024 ± 9 nm), zeta potential of -6.39 ± 0.2 mV, and 98 ± 1.1% HA content. The ex vivo skin permeation and deposition potenwere conferred on synthetic membrane Strat-M, Human cadaver skin, mice skin, rat skin, and pig skin, and both parameters were found to be much higher in comparison to the commercial topical formulation. Skin deposition capacity of the optimised HA formulation was further confirmed by Scan Electron Microscopy (SEM) and Confocal Laser Scanning Microscopy (CLSM) and it was observed that the developed ethosomal gel formulation got deposited more on the treated skin. The in vivo anti-ageing effect of optimised ethosomal gel on rats was found to be greater when compared to commercial formulation of HA and the developed carrier-based system proved to deliver the HA molecule in very small amounts into the systemic circulation. The results endorse the ethosomal carrier-based formulation of HA as a attractive technique for better local bioavailability of HA.

Novel Chitosan Dermal Filler with Enhanced Moldability and Elasticity

Currently, dermal fillers are largely based on commercialized cross-linked hyaluronic acid (HA) injections, which require a large injection force. Additionally, HA can be easily decomposed by enzymes, and HA-treated tissues present a risk of developing granuloma. In this study, a chitosan-based dermal filler is presented that operates on a liquid-to-gel transition and allows the injection force to be kept ≈4.7 times lower than that required for HA injections. Evaluation of the physical properties of the chitosan filler indicates high viscoelasticity and recovery rate after gelation at 37 °C. Furthermore, in an in vivo evaluation, the liquid injection-type chitosan filler transitions to a gel state within 5 min after injection into the body, and exhibits a compressive strength that is ≈2.4 times higher than that of cross-linked HA. The filler also exhibits higher moldability and maintains a constant volume in the skin for a longer time than the commercial HA filler. Therefore, it is expected that the chitosan filler will be clinically applicable as a novel material for dermal tissue restoration and supplementation.

Tear Trough Filler Techniques Utilizing Hyaluronic Acid: A Systematic Review

BACKGROUND

Hyaluronic acid soft-tissue augmentation fillers are commonly injected into multiple areas of the face, including the tear trough. Despite well-documented risks, there is no standardized, evidence-based approach to inject filler in this area, be it using a hypodermic needle or a microcannula. The authors, therefore, sought to establish a preference between the two methods to facilitate progression toward standardization and prevention of adverse events.

METHODS

This is a systematic review of articles discussing hyaluronic acid tear trough injection techniques performed in vivo and related outcomes. Searches were conducted across The Cochrane Library, PubMed, Scopus, Web of Science, and Embase to yield relevant articles published before February of 2020. All selected articles incorporated discrete patient cases and were analyzed by a variety of variables assessing evidence strength, outcomes, technique, and patient safety.

RESULTS

After appraisal, 42 articles met eligibility criteria: 20 using needles, 12 using cannulas, and 10 focusing on adverse events. Level III was the most commonly awarded evidence grade, corresponding to retrospective, nonexperimental descriptive studies. There were no statistically significant differences in reported aesthetic results, patient satisfaction, or incidence of adverse events across the needle-based and cannula-based articles. Some technique trends, such as targeted anatomical plane and needle position, emerged in subsequent articles.

CONCLUSION

Given that there were no statistically significant differences in patient safety or outcomes, an evidence-based preference for needle or cannula injection into the tear trough cannot be made at this time. Current inconsistencies make tear trough injection procedures difficult to replicate, making standardization based on avoidance of adverse events not feasible.

Facial Arterial Variations in Asians: A Study on Computed Tomographic Angiography

BACKGROUND

A consensus on facial artery anatomy has not been established due to the discrepancies in previous studies.

OBJECTIVES

The authors sought to assess the branches, course, and location of the facial artery in Asians by utilizing computed tomographic angiography.

METHODS

The computed tomographic angiography images of 300 facial arteries from 150 Asian patients were evaluated. The FA was classified as follows: type 1, facial artery terminates superior labial or inferior labial artery; type 2, facial artery terminates lateral nasal or inferior alar artery; type 3, facial artery terminates medial canthal artery; or type 4, facial artery is divided into duplex branches with dominant medial canthal artery laterally. The relationship between nasolabial fold and FA was evaluated, and the distances from anatomical landmarks to FA were measured to position the course.

RESULTS

Seventy (23.3%), 163 (54.3%), 49 (16.3%), and the other 18 arteries (6.0%) were classified as type 1, 2, 3, and 4, respectively. A total 72.3% of facial arteries were located medially to the nasolabial fold, and only 14.7% of arteries were lateral to the nasolabial fold. The vertical distance between the facial artery and the inner canthus or the midpoint of the inferior orbital rim decreased from type 1 to type 4 facial artery (P < 0.0001). The 4 types did not significantly differ in distance between the mandibular angle (P = 0.1226) or oral commissure (P = 0.1030) and the facial artery at inferior of mandible.

CONCLUSIONS

Detailed findings of the facial artery will provide a valuable reference for filler injection in cosmetic procedures and flap design in reconstructive surgery.

Design of an elastic porous injectable biomaterial for tissue regeneration and volume retention

Soft tissue reconstruction currently relies on two main approaches, one involving the implantation of external biomaterials and the second one exploiting surgical autologous tissue displacement. While both methods have different advantages and disadvantages, successful long-term solutions for soft tissue repair are still limited. Specifically, volume retention over time and local tissue regeneration are the main challenges in the field. In this study the performance of a recently developed elastic porous injectable (EPI) biomaterial based on crosslinked carboxymethylcellulose is analyzed. Nearly quantitative volumetric stability, with over 90% volume retention at 6 months, is observed, and the pore space of the material is effectively colonized with autologous fibrovascular tissue. A comparative analysis with hyaluronic acid and collagen-based clinical reference materials is also performed. Mechanical stability, evidenced by a low-strain elastic storage modulus (G') approaching 1kPa and a yield strain of several tens of percent, is required for volume retention in-vivo. Macroporosity, along with in-vivo persistence of at least several months, is instead needed for successful host tissue colonization. This study demonstrates the importance of understanding material design criteria and defines the biomaterial requirements for volume retention and tissue colonization in soft tissue regeneration. STATEMENT OF SIGNIFICANCE: We present the design of an elastic, porous, injectable (EPI) scaffold suspension capable of inducing a precisely defined, stable volume of autologous connective tissue in situ. It combines volume stability and vascularized tissue induction capacity known from bulk scaffolds with the ease of injection in shear yielding materials. By comparative study with a series of clinically established biomaterials including a wound healing matrix and dermal fillers, we establish design rules regarding rheological and compressive mechanical properties as well as degradation characteristics that rationally underpin the volume stability and tissue induction in a high-performance biomaterial. These design rules should allow to streamline the development of new colonizable injectables.

The Quality of Online Information on Cosmetic Injectable Fillers: Current Status

Web-based health information plays an increasingly vital role in spreading health information. Many patients interested in aesthetic surgery study the procedure on the Internet. This study aims to evaluate the quality of online health information on injectable fillers using the modified "Ensuring Quality Information for Patients" (EQIP) tool. Nine different search terms, including "fillers," "fuller cheeks," "wrinkle removal," and "antiwrinkle treatment" were identified and queried on Google. Unique links from the first three pages of each search term were identified and evaluated if the contents were in English language and were for general non-medical public use. A total of 172 websites were analyzed, with a median EQIP score of 20. In total 129 websites belonged to aesthetic practitioners, of which 81 were operated by medical doctors. Eighty-three percent of websites disclosed some forms of postoperative complications, most commonly edema (74%) and bruising (73%). Blindness and tissue necrosis were only mentioned by 12 and 10% of the websites, respectively. The current health information available on injectable fillers is of poor quality. While many do provide some information on risks, the majority of websites fail to disclose severe complications and quantifying risks. This poses a barrier against informed decision-making and may lead to unrealistic expectations. Patient satisfaction and expectations may be improved by developing better online education resources on fillers.

Clinical and radiographic features of facial cosmetic materials: A systematic review

Purpose

The aim of this study was to systematically screen the literature for studies reporting cosmetic material in the oral and maxillofacial complex to shed light on the types of cosmetic materials, their radiographic appearance, and possible complications.

Materials and Methods

Five electronic databases were reviewed for eligible studies. The general search terms were “cosmetic,” “filler,” “face,” and “radiograph.” Demographics, material types, clinical and radiographic presentation, and complications were recorded.

Results

Thirty-one studies with 53 cases met the inclusion criteria. The mean age was 52.6±15.4 years with a 4 : 3 female-to-male ratio. The most common material was calcium hydroxyapatite (CaHa) (n=14, 26.4%), found incidentally. The materials were generally located within the upper cheek and zygoma (n=35, 66.0%), radiographically well-defined (n=44, 83%), and had no effects on the surrounding structures (n=27, 50.9%). The internal structure was radiopaque (calcification, hyperdensity) for gold wires, CaHa, bone implants, and secondary calcification or ossification. Outdated cosmetic materials or non-conservative techniques were infiltrative, had effects on the surrounding structures, and presented with clinical signs, symptoms, or complications.

Conclusion

Conventional radiography, cone-beam computed tomography, and multi-detector computed tomography are useful to differentiate several cosmetic materials. Their magnetic resonance imaging appearance was highly variable. The infrequent inclusion of cosmetic materials in the differential diagnosis implies that medical and dental specialists may be unfamiliar with the radiographic appearance of these materials in the face.

Comparison of the efficacies of polycaprolactone filler and lidocaine-added filler on neocollagenesis in a rat model

BACKGROUND

Polycaprolactone (PCL) is a semi-permanent filler stimulating neocollagenesis. Lidocaine is frequently used to reduce the pain and, however, may have negative effects on collagen. It was aimed to compare the histological changes on rat skin and efficacies of PCL filler and lidocaine addition.

OBJECTIVE

In this study, results of PCL and PCL+Lidocaine application on rat skin were compared using hematoxylin-eosin (H&E) staining, Masson's trichrome (MT) staining, and electron microscope (EM).

METHODS

A total of 30 adult female rats were divided into three groups: the control group, the PCL group, and the PCL+Lidocaine group. The tissue samples taken at months 2 and 4 were examined using H&E, MT, and EM.

RESULTS

At month 2, dermis thickness, fibroblast count, and collagen fiber diameter increased similarly in the PCL and PCL+Lidocaine groups. Collagen fiber diameter was significantly higher in the PCL group than in the PCL+Lidocaine (p:0.016) and control groups (p:0.009). At month 4, no significant difference was detected between the PCL and PCL+Lidocaine groups in terms of fibroblast count, collagen fiber count, and collagen fiber diameter; dermis thickness was lower in the PCL+Lidocaine group at month 4 (p < 0.46). Dermis thickness, fibroblast count, collagen fiber count, and collagen fiber diameter were found to be significantly lower than in the PCL and PCL+Lidocaine groups.

CONCLUSIONS

Our study showed that lidocaine addition to PCL filler does not affect the efficacy of the filler and PCL filler stimulates neocollagenesis.

Otolaryngologists Trail Other Specialties in Industry Payments From Dermal Filler Companies

OBJECTIVES/HYPOTHESIS

Dermal filler (DF) is a widely used nonsurgical option for facial rejuvenation with a rapidly expanding market. Physician payments by DF industry leaders have yet to be characterized. We sought to investigate trends in physician-industry payments by DF companies over 6 years. Differences in payments based on physician specialty and time were characterized.

STUDY DESIGN

Database review.

METHODS

The Open Payments Database was queried from 2013 to 2018. Payments made by the three largest DF companies by market share to otolaryngologists, plastic surgeons, and dermatologists were analyzed. Total dollars paid, number of payments made, type of payments made, and total number of specialists paid were recorded. One-way ANOVA was used for statistical analysis.

RESULTS

Otolaryngologists, plastic surgeons, and dermatologists received average annual payments of $0.36 million, $6.3 million, and $6.6 million respectively (P < .001). An average of 330 otolaryngologists, 2,128 plastic surgeons, and 5,980 dermatologists were paid annually (P < .001). Accredited speaking arrangements, consulting fees, and royalty/licensing fees comprised the majority of dollars paid to physicians.

CONCLUSIONS

Average physician payment by DF companies exceeds $12 million annually, with otolaryngologists receiving significantly less compared to plastic surgeons and dermatologists.

LEVEL OF EVIDENCE

Not applicable Laryngoscope, 2021.

Model-Based Prediction to Evaluate Residence Time of Hyaluronic Acid Based Dermal Fillers

Dermal fillers are gel-type substances for nonsurgical medical-device use to achieve facial rejuvenation. Currently, the most widely used skin fillers are hyaluronic-acid-based dermal fillers. This study aimed to explain the change in the volume of injected dermal fillers by developing a mathematical kinetic model for various dermal fillers. The kinetics of the injected fillers were separated by a biphasic phenomenon. We attributed an increase in filler volume to the hydration of hyaluronic acid molecules and injection-site reaction and a decrease in volume to enzyme-mediated degradation. To explain these in vivo characteristics of dermal fillers, we proposed a two-compartment model, divided into a depot compartment (where the filler was injected) and a subcutaneous compartment (an observation compartment where the fillers swell and degrade), assuming that the swelling and degradation occurred in accordance with the swelling and degradation rate constants, respectively. The model was developed using five hyaluronic-acid-based dermal fillers and NONMEM. We determined that the rate-limiting step for the complete degradation of the dermal fillers in vivo was the swelling phase, as described by the swelling rate constant (K_swell). This study could enable scientists developing novel dermal fillers to predict the in vivo behavior of fillers.

Prospective Study on Clinical Efficacy and Safety of a Single Session of Microfocused Ultrasound With Visualization for Collagen Regeneration

BACKGROUND

Recent studies have shown that transcutaneous microfocused ultrasound with visualization is beneficial for noninvasive skin tightening, collagen regeneration, and lower face contour improvement.

OBJECTIVES

The primary study endpoint was the improvement of the laxity and ptosis face skin; the secondary endpoint was the improvement of wrinkles, texture, and hemoglobin content; and the third endpoint was the patient's responses to a patient satisfaction questionnaire.

METHODS

Patients with soft to moderate skin laxity and ptosis of the face and neck were enrolled and their sex, ethnicity, age, Fitzpatrick skin type, and smoking habit recorded. Patient assessment was made by digital macro-photographs, Vectra H2, and Antera 3D, and strict exclusion criteria were set up.

RESULTS

From November 2017 to November 2018, 47 women and 3 men with a mean age of 52.8 ± 7.43 years and Araco's Ptosis Scale System 2.7 ± 0.46, which fit the inclusion criteria, were enrolled in the study. All patients signed a consent form and received 1200 spot-lines (400 lines from each transducer) of microfocused ultrasound with visualization. No major side effects were reported during the study and all patients completed the follow-up after 6 months. Wrinkles, texture, Surgeon Assessment Scoring System scores, and patient satisfaction questionnaire scores improved significantly. Patients found the treatment tolerable according to the patient pain scale rate. No statistically significative differences were found among homogenous groups of smokers and nonsmokers.

CONCLUSIONS

The study proves that microfocused ultrasound with visualization in a single session of treatment in monotherapy is safe and effective for the treatment of face laxity and ptosis when a proper number of energy spot-lines is delivered in the correct tissue layer.

LEVEL OF EVIDENCE: 4

Liquid Platelet-Rich Fibrin and Heat-Coagulated Albumin Gel: Bioassays for TGF-β Activity

Liquid platelet-rich fibrin (PRF) can be prepared by high centrifugation forces separating the blood into a platelet-poor plasma (PPP) layer and a cell-rich buffy coat layer, termed concentrated PRF (C-PRF). Heating the liquid PPP was recently introduced to prepare an albumin gel (Alb-gel) that is later mixed back with the concentrated liquid C-PRF to generate Alb-PRF. PRF is a rich source of TGF-β activity; however, the overall TGF-β activity in the PPP and the impact of heating the upper plasma layer remains unknown. Here, we investigated for the first time the in vitro TGF-β activity of all fractions of Alb-PRF. We report that exposure of oral fibroblasts with lysates of PPP and the buffy coat layer, but not with heated PPP, provoked a robust increase in the TGF-β target genes interleukin 11 and NADPH oxidase 4 by RT-PCR, and for IL11 by immunoassay. Consistent with the activation of TGF-β signaling, expression changes were blocked in the presence of the TGF-β receptor type I kinase inhibitor SB431542. Immunofluorescence and Western blot further confirmed that lysates of PPP and the buffy coat layer, but not heated PPP, induced the nuclear translocation of Smad2/3 and increased phosphorylation of Smad3. The immunoassay further revealed that PPP and particularly BC are rich in active TGF-β compared to heated PPP. These results strengthen the evidence that not only the cell-rich C-PRF but also PPP comprise a TGF-β activity that is, however, heat sensitive. It thus seems relevant to mix the heated PPP with the buffy coat C-PRF layer to regain TGF-β activity, as proposed during the preparation of Alb-PRF.

Dermal Filler Presenting as Parotid Mass: A Case Report

Dermal filler injections are common cosmetic procedures and are growing in popularity. While frequently performed, dermal filler injections carry a risk of adverse events including vascular compromise and foreign body granulomas. Here, we discuss an unusual case of a patient with a history of dermal filler injections presenting with a parotid mass and an eyebrow mass requiring surgical resection. This case demonstrates the risk of delayed granuloma formation many years after dermal filler injection and highlights the importance of awareness and management of these potential long-term complications.

Mechanism of Water Dynamics in Hyaluronic Dermal Fillers Revealed by Nuclear Magnetic Resonance Relaxometry

1 H spin-lattice nuclear magnetic resonance relaxation experiments were performed for five kinds of dermal fillers based on hyaluronic acid. The relaxation data were collected over a broad frequency range between 4 kHz and 40 MHz, at body temperature. Thanks to the frequency range encompassing four orders of magnitude, the dynamics of water confined in the polymeric matrix was revealed. It is demonstrated that translation diffusion of the confined water molecules exhibits a two-dimensional character and the diffusion process is slower than diffusion in bulk water by 3-4 orders of magnitude. As far as rotational dynamics of the confined water is concerned, it is shown that in all cases there is a water pool characterized by a rotational correlation time of about 4×10-9  s. In some of the dermal fillers a fraction of the confined water (about 10 %) forms a pool that exhibits considerably slower (by an order of magnitude) rotational dynamics. In addition, the water binding capacity of the dermal fillers was quantitatively compared.

Review of sterility of reused stored dermal filler

OBJECTIVE

This review is primarily focusing on the legitimate concern about bacterial contamination after reuse of stored filling syringes and its associated risk of infections.

METHODS

A comprehensive literature review was done through searching the PubMed, Medline, Google Scholar, and ResearchGate without setting a time limit. The following search terms were used soft tissue filler, hyaluronic acid, or calcium hydroxylapatite AND sterility, safety, retouch, touch up, or reuse.

RESULT

Immediate replacing needles used in injection with a sterile substitute before storage was associated with no growth in one study (Archives of Facial Plastic Surgery, 11, 2009, 271) and growth in another study (Dermatologic Surgery, 2017, 43, 967). There was no reported infection in the only patient-based study that examined the adverse events among patients injected with stored hyaluronic acid filler syringes.

CONCLUSION

All published research showed that stored fillers are safe and do not increase the risk of biofilm formation.

[Hyaluronic acid fillers in dermatology]

Hyaluronic acid based fillers (HA fillers) are the most frequently used soft-tissue fillers. They have a favorable benefit-risk ratio compared to other fillers and they can usually be dissolved using hyaluronidase. The anatomical area to be injected contributes to filler selection. In general, products with lower cross linking are suitable for fine wrinkles and more viscous products with a higher lift capacity for deeper wrinkles, but also for volume restoration, reestablishment of contours lost in the aging progress, and reshaping of anatomic facial regions. Profound knowledge of facial anatomy and its changes during aging processes, suitable patient selection, customized safe HA fillers and extensive experience with filler injection techniques are key prerequisites to perform this complex procedure. Comprehensive knowledge in the prevention and management of possible adverse events and complications are furthermore of paramount importance.

In Vitro Characterization of Hypoxia Preconditioned Serum (HPS)-Fibrin Hydrogels: Basis for an Injectable Biomimetic Tissue Regeneration Therapy

Blood-derived growth factor preparations have long been employed to improve perfusion and aid tissue repair. Among these, platelet-rich plasma (PRP)-based therapies have seen the widest application, albeit with mixed clinical results to date. Hypoxia-preconditioned blood products present an alternative to PRP, by comprising the complete wound healing factor-cascade, i.e., hypoxia-induced peripheral blood cell signaling, in addition to platelet-derived factors. This study set out to characterize the preparation of hypoxia preconditioned serum (HPS), and assess the utility of HPS–fibrin hydrogels as vehicles for controlled factor delivery. Our findings demonstrate the positive influence of hypoxic incubation on HPS angiogenic potential, and the individual variability of HPS angiogenic factor concentration. HPS–fibrin hydrogels can rapidly retain HPS factor proteins and gradually release them over time, while both functions appear to depend on the fibrin matrix mass. This offers a means of controlling factor retention/release, through adjustment of HPS fibrinogen concentration, thus allowing modulation of cellular angiogenic responses in a growth factor dose-dependent manner. This study provides the first evidence that HPS–fibrin hydrogels could constitute a new generation of autologous/bioactive injectable compositions that provide biochemical and biomaterial signals analogous to those mediating physiological wound healing. This therefore establishes a rational foundation for their application towards biomimetic tissue regeneration.

Hyaluronic acid dermal fillers in the management of recurrent angular cheilitis: A case report

OBJECTIVE

To report conservative treatment based on the use of dermal fillers for a case of recurrent angular cheilitis.

CASE REPORT

An 80-year-old patient with a history of recurrent angular cheilitis that was not resolved with a conventional approach sought treatment. Complete remission of the pathology was achieved with the injection of hyaluronic acid fillers.

CONCLUSION

This case illustrates the potential of nonsurgical facial aesthetics (NSFA) for treating this common pathology among elderly people. This case report shows that, aside from achieving aesthetic goals, NSFA approaches can also help treat some oral pathology.

An innovative method to quantitate tissue integration of hyaluronic acid-based dermal fillers

BACKGROUND/PURPOSE

Following intradermal injection, hyaluronic acid (HA)-based fillers tend to spread within the reticular dermis and to distribute between the dermal fibers. This biointegration is commonly measured qualitatively using histological methods. We developed a "toolbox" consisting of a visual scoring and a semi-automatic image analysis method using internal developed algorithm to quantitate the biointegration of Restylane® in histological sections.

METHODS

Restylane^® was injected intradermally in the abdominal skin of 10 healthy human subjects scheduled for abdominoplasty. The injections were performed either in vivo before surgery or ex vivo on samples taken post-surgery at different time points. The samples were processed for histology by visual scoring and image analysis using algorithms developed in Definiens to assess biointegration.

RESULTS

The image analysis segmentation was accurate with <5% manual changes. Furthermore, the results calculated with the semi-automatic method were consistent with the visual scores obtained on injected human skin samples by means of a 5-grade photographic scale. A modified hematoxylin-eosin staining was found adequate to visualize both, the filler and the general morphology, on the same section. An excellent correlation was observed between the integration results obtained with PAS/Alcian Blue and HE-stained slides, allowing for a single staining in future studies.

CONCLUSION

We developed a modified HE staining histological method and a new histomorphometric image analysis tool to quantitate biointegration of HA-based fillers in human skin. The results obtained in this study confirmed the known intermediate biointegration properties of Restylane®, thus validating these innovative methods.

Hyperbaric Oxygen for Ischemia due to Injection of Cosmetic Fillers: Case Report and Issues

Natural and synthetic fillers have revolutionized aesthetic facial rejuvenation and soft-tissue augmentation. We present a case highlighting the dangers of filler self-injection. A 37-year-old woman self-injected a dermal filler around both temples. She immediately experienced left--side hearing loss, blanching over the left face, and pain. Prompt treatment with hyaluronidase, topical nitro paste, and warm compresses ensued. An emergency computed tomography angiogram showed occlusion of a superficial temporal artery branch. We treated her with enoxaparin, aspirin, dexamethasone, piperacillin-tazobactam, and intradermal lidocaine. After 6 hyperbaric oxygen therapy (HBO2) treatments in 3 days, the patient showed improvement in appearance with markedly decreased ischemic discoloration and her hearing returned to baseline. Algorithms for treating such injuries generally neglect HBO2. HBO2 is thought to be efficacious in these situations by a variety of mechanisms: oxygenation of ischemic tissues, reduction of edema, amelioration of ischemic/reperfusion injury, promotion of angiogenesis and collagen maturation. Her resolved hearing highlights the utility of HBO2 in sudden hearing loss as well. Injectors should have guidelines for using product, not only on patients but staff as well. Filler courses should include handling complications and include HBO2 in their guidelines. Clinicians should remind patients to seek treatment from qualified clinicians. The goal of a bargain price using self-injection may quickly become expensive and disfiguring.

Use of polymethylmethacrylate (PMMA) microspheres collagen to treat atrophic acne scars

Acne scarring is a common and persistent sequela affecting many individuals worldwide, with significant physical and long-lasting psychological effects. Currently, the treatment options available for acne scars are mostly invasive and have several side effects. This paper explores the possibility of using polymethylmethacrylate (PMMA) collagen microspheres, a relatively underexplored technique hitherto, to treat common atrophic scars. PMMA-collagen is more popularly used in injectable wrinkle fillers. Preliminary research has shown that PMMA-collagen has a beneficial effect on atrophic scars while having the added advantage of being safe, tolerable and minimally invasive as well.

Prevention and management of vision loss relating to facial filler injections

INTRODUCTION

With the increased use of filler and fat injections for aesthetic purposes, there has been a corresponding increase in the incidence of complications. Vision loss as an uncommon but devastating vascular side effect of filler injections was the focus of this paper.

METHODS

A review committee, consisting of plastic surgeons, aesthetic medical practitioners, ophthalmologists and dermatologists from Singapore, was convened by the Society of Aesthetic Medicine (Singapore) to review and recommend methods for the prevention and management of vision loss secondary to filler injections.

RESULTS

The committee agreed that prevention through proper understanding of facial anatomy and good injection techniques was of foremost importance. The committee acknowledged that there is currently no standard management for these cases. Based on existing knowledge, injectors may follow a proposed course of action, which can be divided into immediate, definitive and supportive. The goals were to reduce intraocular pressure, dislodge the embolus to a more peripheral location, remove or reverse central ischaemia, preserve residual retinal function, and prevent the deterioration of vision. Dissolving a hyaluronic acid embolus remains a controversial option. It is proposed that injectors must be trained to recognise symptoms, institute immediate actions and refer patients without delay to dedicated specialists for definitive and supportive management.

CONCLUSIONS

Steps to prevent and manage vision loss based on current evidence and best clinical practices are outlined in this paper. Empirical referral to any emergency department or untrained doctors may lead to inordinate delays and poor outcomes for the affected eye.

Literature Review of Cosmetic Procedures in Men: Approaches and Techniques are Gender Specific

The proportion of men receiving non-surgical cosmetic procedures has risen substantially in recent years. Various physiologic, anatomic, and motivational considerations differentiate the treatments for male and female patients. Nevertheless, research regarding approaches to the male cosmetic patient is scarce. We sought to provide an overview and sex-specific discussion of the most popular cosmetic dermatologic procedures pursued by men by conducting a comprehensive literature review pertaining to non-surgical cosmetic procedures in male patients. The most common and rapidly expanding non-surgical interventions in men include botulinum toxin, filler injection, chemical peels, microdermabrasion, laser resurfacing, laser hair removal, hair transplantation, and minimally invasive techniques for adipose tissue reduction. Important sex-specific factors associated with each of these procedures should be considered to best serve the male cosmetic patient.

Overview of Facial Plastic Surgery and Current Developments

Facial plastic surgery is a multidisciplinary specialty largely driven by otolaryngology but includes oral maxillary surgery, dermatology, ophthalmology, and plastic surgery. It encompasses both reconstructive and cosmetic components. The scope of practice for facial plastic surgeons in the United States may include rhinoplasty, browlifts, blepharoplasty, facelifts, microvascular reconstruction of the head and neck, craniomaxillofacial trauma reconstruction, and correction of defects in the face after skin cancer resection. Facial plastic surgery also encompasses the use of injectable fillers, neural modulators (e.g., BOTOX Cosmetic, Allergan Pharmaceuticals, Westport, Ireland), lasers, and other devices aimed at rejuvenating skin. Facial plastic surgery is a constantly evolving field with continuing innovative advances in surgical techniques and cosmetic adjunctive technologies. This article aims to give an overview of the various procedures that encompass the field of facial plastic surgery and to highlight the recent advances and trends in procedures and surgical techniques.