Radiance

The emerging role of biostimulators as an adjunct in facial rejuvenation: A systematic review

INTRODUCTION

Facial aging has long been an area of focus in esthetic surgery. It is the consequence of physiologic and environmental factors, with a trend toward non-surgical modalities. Although volume augmentation has long been a focus of non-surgical facial rejuvenation, there is emerging interest in the use of biostimulators to induce physiologic changes in the skin. This article aimed to provide an overview of this class of therapies.

METHODS

A systematic review regarding the clinical use of biostimulatory agents including platelet-rich plasma (PRP), platelet-rich fibrin (PRF), poly-L-lactic acid (PLLA) and calcium hydroxylapatite (CaHA) in facial rejuvenation was performed using PubMed databases. The protocol was developed following the preferred reporting for items for systematic reviews-protocols guidelines. Included studies matched predetermined criteria according to the employed intervention and outcomes.

RESULTS

The systematic review was performed in September 2023, with the primary search yielding 464 articles. Abstract review resulted in 73 articles of potential relevance. Comprehensive review of the articles and manual reference checks were performed, independently, by 2 authors. This yielded a total of 45 articles that met the inclusion criteria.

CONCLUSIONS

There is an increasing role for non-surgical modalities in facial rejuvenation. Biostimulatory agents may be used as an alternative, or act as an adjunct, to other non-surgical modalities. These agents induce physiologic changes that mitigate facial aging. There is limited, quantifiable data, which fully illustrate the effect in these products. Although these agents are known to illicit inflammatory changes, more controlled studies are needed to better elucidate the biostimulatory capacity of such non-surgical treatments.

Use of hyaluronic acid filler for enhancement of nipple projection following breast reconstruction: An easy and effective technique

Background

Breast reconstruction improves the psychological well-being of patients with breast cancer. Patients who complete nipple-areolar reconstruction are even more satisfied with their final reconstructive result. Nipple flattening is a common complication. We hypothesized that injectable soft-tissue filler can be used to augment nipple projection in patients who underwent breast reconstruction.

Methods

This is a retrospective study of patients who underwent breast reconstruction and desired an enhanced postoperative nipple projection. The patients underwent a single session of injection with a hyaluronic acid filler as an outpatient. The filler was injected intradermally at the base of the nipple until the desired nipple projection was obtained.

Results

Twelve patients and 22 breasts were included in this study. Enhanced nipple projection was observed in all cases, with an average increase of 3.0 mm in nipple height (range 2.5-4.5 mm). All injected nipples remained soft to the touch. All results were stable at a median of 7.5 months follow-up. No complications were observed.

Conclusions

The use of injectable fillers for enhanced nipple projection is a useful adjunct treatment in patients undergoing breast reconstruction. Advantages include the ability to obtain nipple projection in patients who opt to forgo nipple-areola reconstruction with local flaps, to augment reconstructed nipples in patients with thin mastectomy skin flaps especially following implant-based reconstruction, and to improve projection of the native nipple following nipple-sparing mastectomy. Another benefit of this adjunct treatment is that the injection is reversible. Filler injection is a safe and simple solution to the problem of insufficient nipple projection.

Filling Procedures for Lip and Perioral Rejuvenation: A Systematic Review

The ideal perioral and lip rejuvenation technique provides the longest period of efficacy, lowest complication rate, and best esthetic results. Genetics, intrinsic aging, sun exposure, and repetitive muscle twitching of the orbicularis oris produce angular, radial, and vertical lines of the perioral lines and, for this reason, the needs of patients in the treatment of this anatomical area can range from simple lip enhancement to a broader and more comprehensive treatment with simultaneous correction of perioral wrinkles. A myriad of materials have been described for rejuvenation of this area. At present, the most popular and commonly used lip enhancers are dermal fillers, but there is still no agreement on what the best material for filling soft tissue of the face and in particular of the perioral region is. This systematic review will focus on the various dermal fillers, of different materials approved by the US Food and Drug Administration (FDA) namely poly-L-lactic acid, calcium hydroxylapatite, and hyaluronic acid and also different grafts, for perioral rejuvenation, with the goal of determining the optimal approach. A systematic search for English studies involving perioral rejuvenation was performed using these databases: PubMed, Google Scholar, and Ovid, using a combined keyword search or medical subject headings. At the end of our study selection process, 17 relevant publications were included. For each study, year of publication, type of material used for filling, number of patients, subject of study assessment, and efficacy of the filler procedure for lip rejuvenation were analyzed.

Microscopic and ultrastructural evidences in human skin following calcium hydroxylapatite filler treatment

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.

Radiesse for Aesthetic Soft Tissue Augmentation

Introduction:

Calcium hydroxyapatite (CaHa; also spelled “hydroxylapatite”) is the main mineral component of bone, calcified cartilage, and teeth. It has been used since the 1970s in many specialties, including orthopedics, urology, otolaryngology, maxillofacial surgery, and radiology, as a bioactive implant that promotes chemical attachment of the soft tissue to its surface. In 2001, Radiance FN (now Radiesse) was introduced as a CaHa-based product and approved by the US Food and Drug Administration (FDA) as a radiographic tissue marker, for soft tissue vocal fold augmentation, and for implants in maxillofacial defects. Currently, it is also used outside the United States and off-label in the United States for facial soft tissue augmentation. Microspheres of CaHa are suspended in a mixture of water, glycerin, and carboxymethylcellulose gel that provides a scaffold for tissue infiltration. Once injected, the gel is degraded and the CaHa infiltrates the surrounding cells. CaHa is nonirritating, and the carrier gel components are classified as safe by the FDA. Although a great variety of fillers are currently on the market, CaHa (Radiesse) has demonstrated the longest duration in tissue without any reports of antigenicity, migration, or granuloma formation. In this study, we report our experience with CaHa (Radiesse) for aesthetic soft tissue augmentation.

Materials and Methods:

A total of 139 patients were treated over an 18-month period at 2 private offices in Argentina and the United States. Exclusion criteria included previous use of permanent tissue fillers in the treatment area. Patients with previous use of hyaluronic acid fillers in the treatment area (up to 1 year prior to the study) were allowed to participate in the study. Radiesse was injected from 1-mL prefilled syringes with 27½-gauge needles in different areas such as nasolabial folds, lips, marionettes lines, cheeks, and cellulite dimples. Patient satisfaction and adverse effects were assessed by both physicians and patients during the procedure and during follow-up visits up to 1 year later.

Results:

Minimal pain, erythema, edema, and bruising were noted during and immediately after the procedure. All of the patients treated were satisfied with their results after one visit. There were no long-term adverse effects during the study period or on follow-up visits. Evaluation of 75% of the patients 1 year after treatment revealed persistence of filling effects.

Discussion:

CaHa used for aesthetic soft tissue augmentation yields immediate clinical results with high patient satisfaction.

A novel injectable chitosan/polyglutamate polyelectrolyte complex hydrogel with hydroxyapatite for soft-tissue augmentation

This study demonstrated a chitosan (CS)/polyglutamate (PG) polyelectrolyte complex (PEC) hydrogel combined with spherical hydroxyapatite (HAp) particles as an injectable dermal filler for soft-tissue augmentation. The CS/PG PEC hydrogel with oppositely charged ionic cross-linking, a high gel content, and low degradation rate was introduced as a carrier to achieve high shape and volume stability. An MTT assay indicated that the CS/PG PEC had satisfactory cell biocompatibility. This PEC/HAp hydrogel showed good structural integrity in a PBS solution for up to 60 days. Clinical manageability was indexed by an injection force measurement through sterile 27-gauge needles using a texture analyzer. In an animal study, 0.2 mL of the PEC and PEC/hydroxyapatite (HAp) were implanted within the dorsal dermis of a swine ear. Injected tissue areas were biopsied 2 weeks, and 2 and 6 months after the injection. According to the histomorphometric results, the PEC and PEC/HAp groups showed percentages of retention of the maximum height of the cross-section of about 44% and 73% at 6 months. New collagen was observed in the central position indicating a possible collagenesis effect. These results suggest that this PEC/HAp system can be used as an alternative for soft-tissue augmentation.

An evaluation of calcium hydroxylapatite (Radiesse) for cosmetic nasolabial fold correction: a meta-analysis and patient centric outcomes study

The use of calcium hydroxylapatite (Radiesse, BioForm Medical, San Mateo, California) for cosmetic soft tissue augmentation has increased significantly in recent years. Only a handful of authors have reported patient satisfaction data. A meta-analysis of published data was performed using a 5-point scale for patient satisfaction to allow data comparison across studies. A patient-centric outcomes study was also performed at our institution, using a blinded questionnaire. Five usable studies were identified for meta-analysis. Patient satisfaction was 4.16 of 5 in 324 patients at 3 to 6 months and 4.15 in 86 patients at 1 year. In our institutional patient-centric outcomes study, the early satisfaction rate was 3.7 of 5. At 1 year the rate was only 2.3 of 5. Calcium hydroxylapatite remains a viable option for augmentation of facial soft tissue structures. However, this report shows that further, accurate, large population outcomes assessments are absolutely required.

A five-patient satisfaction pilot study of calcium hydroxylapatite injection for treatment of aging hands

BACKGROUND

The process of skin aging is not limited to the face but involves every part of the body, including the hands. A common manifestation of aging of the hands is the loss of volume, which occurs as the skin loses its subcutaneous fat. Injectable dermal fillers have surfaced as a popular method to address such deficiencies.

OBJECTIVES

To report the use of calcium hydroxylapatite (CaHA) to address lost volume.

METHODS

Five female subjects with soft tissue deficiency of the dorsa of the hands were enrolled at Mount Sinai Medical Center. A solution of CaHA with 2% lidocaine in amounts of 0.3 to 1.0 mL was injected interdigitally at each of three to five insertion sites; the sites were massaged and molded up to three times to ensure an optimal cosmetic end point. Subjects were seen for a follow-up visit after 1, 4, 16, and 24 weeks.

RESULTS

With a single injection, all subjects reached their correction goals without requiring any touch-ups. At the 24-week visit, the subjects retained the filling effect, with no adverse events and high patient satisfaction.

CONCLUSION

CaHA, a new, easily injectable, safe dermal filler, has emerged as an excellent option for soft tissue augmentation in aging hands.

Use of calcium hydroxylapatite (Radiesse) for facial augmentation

Radiesse^® (Bioform Inc, USA) is a sterile, latex-free, non-pyrogenic, semi-solid, cohesive subdermal, injectable implant, whose principal component is synthetic calcium hydroxylapatite, a biocompatible material with over 20 years of use in medicine. The semi-solid nature of the product is created by suspending calcium hydroxylapatite microspheres of 25–45 microns diameter in a gel carrier of carboxymethylcellulose. The product has FDA approval for esthetic facial augmentation in the US. Such approval includes the long-lasting correction of moderate to severe facial wrinkles and folds and the treatment of facial fat loss due to immunodeficiency virus infection. Diverse facial regions can be injected in order to ameliorate or enhance some features: glabellar lines, subdermal support of the brows, malar and buccal fat pads, tear troughs, nasolabial folds, nose, lips, perioral region, marionette lines, oral commisures and chin among others, as well as saucerized acne scars. Other medical indications include nipple projection for nipple areolar reconstruction, urinary incontinence, vesicoureteral reflux, vocal cord augmentation, and use as a radiographic tissue marker. The average lasting result is from 12 to 18 months. Radiesse can be considered an effective soft-tissue filler for overall longevity, biocompatibility, and low rate of side effects.

Submucosal injection of micronized acellular dermal matrix: analysis of biocompatibility and durability

BACKGROUND

Posterior pharyngeal augmentation is a recognized treatment for velopharyngeal insufficiency in selected candidates. To date, however, the procedure has failed to gain widespread acceptance because of the absence of an implant material with sufficient safety, durability, and biocompatibility. In this study, the use of micronized acellular dermal matrix injection for augmentation of the posterior pharynx was investigated. Using a porcine animal model, the safety and durability of posterior pharyngeal augmentation by micronized decellularized dermis was evaluated.

METHODS

Twelve Yorkshire piglets were used in this study. Under general anesthesia, porcine-derived micronized acellular dermal matrix was injected into the submucosa of the right side of the pharynx. At 30 days, the animals were euthanized, and the implants and surrounding tissues were assessed grossly for degree of augmentation and histologically to determine the extent of host cell infiltration, vascularization, and matrix deposition and remodeling.

RESULTS

No animal perioperative or postoperative morbidity resulted from the operations. When the animals were euthanized and the tissue was harvested at 30 days, there existed no evidence of gross augmentation on the experimental side of the pharynx in any of the specimens. Histologic analysis demonstrated trace amounts of residual implant, with extensive host lymphocytic infiltration of the material.

CONCLUSIONS

Although micronized acellular dermal matrix is a safe material when injected into the pharyngeal wall, this study demonstrated that it is not a durable implant at this site. The authors do not recommend its use for long-term soft-tissue augmentation of the posterior pharyngeal wall in patients with velopharyngeal insufficiency.

Technique for calcium hydroxylapatite injection for correction of nasolabial fold depressions

BACKGROUND

Injectable calcium hydroxylapatite is a soft-tissue augmentation material that is used off-label for facial augmentation, including repletion of depressed nasolabial folds.

OBJECTIVE

We sought to assess the safety of calcium hydroxylapatite injection for correction of nasolabial fold depressions. Specifically, we sought to obtain a quantitative assessment of injection-related adverse events using a reproducible placement technique with long-term follow-up.

METHODS

We conducted an open-label, single-center prospective study using reproducible technique with 1- to 1.5-year follow-up. All patients were treated with infraorbital nerve blocks. Then, parallel linear threading technique using 27-gauge/1.25-in needles was used to place 1 to 2 mL of injectant at the dermal subcutaneous junction into each pair of depressed folds. A triangular array of injectant was deposited under the melonasal junction. At follow-up at 2 to 3 weeks and at 1 to 1.5 years, respectively, patients were asked to report and characterize injection-related redness, swelling, bruising, nodule or granuloma formation, asymmetric correction, textural change, hypersensitivity reactions, degree of correction remaining, and overall satisfaction. In addition, patients who had received other injectable soft-tissue materials were asked to compare these with calcium hydroxylapatite in terms of risk profile and longevity of effect.

RESULTS

In all, 22 patients were treated and complete follow-up data were obtained from 18. Of the 18 patients, all reported at least mild postinjection redness and swelling, which abated within 1 to 5 days. Bruising was reported by fewer than half, and resolved within 4 to 10 days. Palpable but not visible nodules were reported by 2 of 18 patients; these resolved within 3 months of injection. Asymmetric correction, textural change, granulomas, and hypersensitivity reactions were not reported. In all, 14 of 18 patients reported that cosmetically significant correction lasted longer than 1 year. Two thirds of injected patients who had received other fillers for nasolabial fold correction preferred calcium hydroxylapatite, with the primary reason being increased longevity of effect.

LIMITATIONS

There was a lack of objective outcomes measures.

CONCLUSIONS

When a consistent, defined injection technique is used, injectable calcium hydroxylapatite appears to be a well-tolerated soft-tissue augmentation material for correction of nasolabial fold depressions. A long duration of effect may make this material particularly desirable for some patients.

Calcium Hydroxylapatite: Radiesse

Among the array of choices for aesthetic soft tissue fillers, Radiesse occupies a unique niche as a safe, easily administered, "semi-permanent" material. Composed of calcium hydroxylapatite in a gel matrix, it has a proven safety profile and has been approved by the US Food and Drug Administration for use in the nasolabial folds and for HIV lipoatrophy. Radiesse have evolved quickly into a effective filler for moderately deep facial folds with high patient and physician approval.

Nasal grafts and implants in revision rhinoplasty

Problems associated with primary rhinoplasty are often due to overresection of the nasal skeleton. One of the primary goals in revision rhinoplasty is to restore nasal architecture. To do so, the facial plastic surgeon can choose from numerous grafting materials. A key understanding of the benefits and limitations of each implant or graft and implants commonly used in revision rhinoplasty surgery.

Acne scar correction using calcium hydroxylapatite in a carrier-based gel

OBJECTIVES

This study sought to determine the efficacy and safety profile of calcium hydroxylapatite filler in the treatment of acne scars.

METHODS

Ten subjects with a variety of acne scars were treated with calcium hydroxylapatite filler.

RESULTS

Saucerized acne scars responded to treatment; ice-pick scars did not. Results lasted, at least to some degree, for 12 months after treatment. No significant treatment complications were noted.

CONCLUSIONS

Calcium hydroxylapatite is a safe and effective long-term filler for the treatment of saucerized acne scars.

Dermal filler agents: a practical review

PURPOSE OF REVIEW

Facial aging results from multiple microscopic (histopathologic) and macroscopic (anatomic) changes. Whereas skin care and traditional surgery have much to offer patients desiring cosmetic improvement, they can fail to adequately address certain signs of facial aging. Soft-tissue augmentation with dermal fillers can successfully address these signs of aging by filling soft-tissue defects caused by age, scar formation, or disease. All dermal fillers aim to achieve the same goal: long-lasting soft-tissue augmentation without side effects. Each dermal filler preparation available for patient use has unique compositions and characteristics that impact its proper handling, therapeutic results, potential complications, and, ultimately, its ideal use. This review surveys the currently available preparations for soft-tissue augmentation.

RECENT FINDINGS

A review of the medical literature and manufacturers' information are included for dermal fillers currently approved for use by the US Food and Drug Administration. The composition, use, and potential limitation of each available preparation are reviewed.

SUMMARY

Dermal filling agents offer an excellent option for management of certain facial cosmetic changes. Since a wide range of products with significantly different characteristics is available, the treating physician should have sound knowledge of them all.

Calcium Hydroxylapatite Facial Filler (Radiesse™): Indications, Technique, and Results

This article discusses the use of Radiesse; a semisolid, cohesive subdermal injectable implant. Through direct and invaluable experience gained over time, plastic surgeons will decide which areas of the face may best be suited for Radiesse and which may be appropriate for other fillers.

Calcium Hydroxylapatite for Facial Rejuvenation

Porous calcium hydroxylapatite has been used in otolaryngology, dentistry and radiology for many years. Currently, calcium hydroxylapatite is gaining popularity for facial esthetics in the form of the product Radiesse (San Mateo, CA). Although Radiesse is not yet approved in the United States for cosmetic use, it is being used off-label by an increasing number of dermatologists and plastic surgeons for facial soft-tissue augmentation. Preliminary clinical and histologic studies have shown safety, efficacy and durability in various esthetic applications including the nasolabial folds and HIV lipoatrophy.

Prospective, Open-Label, 18-Month Trial of Calcium Hydroxylapatite (Radiesse) for Facial Soft-Tissue Augmentation in Patients with Human Immunodeficiency Virus-Associated Lipoatrophy: One-Year Durability

BACKGROUND

The objective was to evaluate the safety and effectiveness of soft-tissue augmentation of calcium hydroxylapatite (Radiesse) in patients with facial lipoatrophy secondary to human immunodeficiency virus disease.

METHODS

This 18-month, prospective, open-label, multicenter clinical trial of calcium hydroxylapatite for soft-tissue augmentation of patients with facial lipoatrophy enrolled 100 subjects (94 men and six women).

RESULTS

Correction of facial lipoatrophy was evaluated by comparing changes from baseline using the Global Aesthetic Improvement Scale, with confirmation using standardized photography. All 100 patients were determined to be improved or better at 3 months. Secondary effectiveness endpoints-improvement at 6 months on the scale and skin thickness measurements at 3 and 6 months-were also met. Twelve-month data and 18-month scale scores were also available. One hundred percent of assessable patients were rated as improved or better on the scale at every time point through 12 months; 91 percent were improved or better at 18 months. "Yes" responses to all patient satisfaction questions ranged from 97 percent to 100 percent at every evaluation through 12 months. In addition, skin thickness measurements at 12 months remained statistically better than those at baseline. Eighteen-month patient satisfaction and skin thickness measurements were not available at the time of submission. Adverse events reported through 12 months were generally mild (ecchymosis, edema, erythema, pain, and pruritus), not unexpected, and generally short in duration. Eighteen-month safety data were not available at the time of submission.

CONCLUSIONS

Radiesse is an appropriate and well-tolerated treatment for patients with facial lipoatrophy. It demonstrates an excellent safety profile, causes immediate augmentation of the soft tissues, and appears to provide relatively long-lasting improvement in appearance, with very high patient satisfaction.