Adverse reactions to dermal fillers: A review of European experiences

Management strategies for vascular complications in hyaluronic acid filler injections: A case series analysis

BACKGROUND

As hyaluronic acid (HA) filler injections have become increasingly popular in the esthetic field, so have their side effects. Vascular complications, which can lead to skin necrosis or permanent scarring, are a particularly dangerous complication and occur when the filler is injected directly into a blood vessel or when an adjacent blood vessel is compressed by the filler material.

OBJECTIVE

To assess the clinical prognosis based on post-procedural management and clinical findings of HA filler vascular complications.

METHODS

Herein, we present a case series of vascular complications due to HA filler and evaluate their clinical prognosis based on post-procedural management and clinical findings. Clinical assessments were performed using Doppler ultrasound, thermography, and laboratory tests.

RESULTS

Factors including white blood cell count, the time of treatment initiation, and time of hyaluronidase injection influenced the clinical outcomes. Early recognition and prompt hyaluronidase injection proved crucial in preventing further damage and improving prognosis.

CONCLUSION

This case series highlights the importance of early detection and appropriate management of HA filler complications. Physicians should be aware of the potential risks associated with fillers and promptly address any adverse effects to achieve optimal clinical outcomes. Further studies are warranted to confirm these findings and refine treatment strategies for the HA filler complications.

Multiple Cases of Facial Disfigurement From Filler Use and One Injector

PURPOSE

To present a case of facial disfigurement from an injectable permanent filler and describe the consequences to patients exposed to the same injector (common source outbreak).

METHODS

Case report and discussion of a common source outbreak after a group of persons developed complications years after permanent filler given by one injector.

RESULTS

A 39-year-old transgender model underwent polymethylmethacrylate (Artefill) facial filler injections to the lips, cheeks, and chin in 2018. A year later, the patient presented to the emergency room with severe facial swelling and difficulty breathing. Treatments have included 4 surgeries to remove filler and scar tissue and chronic low-dose oral steroid therapy. Upon questioning the patient, 6 additional people suffered from similar facial swelling years after injection by the same injector. The injector cannot be located.

CONCLUSIONS

Care must be taken in giving all facial fillers, particularly permanent ones. When one source patient is identified, questioning the patient's knowledge of others affected is critical to help manage an epidemic problem and to report a rogue injector. Physicians have a duty to investigate and report such cases.

TFOS Lifestyle: Impact of cosmetics on the ocular surface

In this report the use of eye cosmetic products and procedures and how this represents a lifestyle challenge that may exacerbate or promote the development of ocular surface and adnexal disease is discussed. Multiple aspects of eye cosmetics are addressed, including their history and market value, psychological and social impacts, possible problems associated with cosmetic ingredients, products, and procedures, and regulations for eye cosmetic use. In addition, a systematic review that critically appraises randomized controlled trial evidence concerning the ocular effects of eyelash growth products is included. The findings of this systematic review highlight the evidence gaps and indicate future directions for research to focus on ocular surface outcomes associated with eyelash growth products.

Increase in the incidence of acute inflammatory reactions to injectable fillers during COVID-19 era

Background

Acute inflammatory reactions (AIRs) are a rare complication following esthetic treatment with hyaluronic acid (HA) and/or human collagen fillers. However, a substantial increase in the frequency of AIRs was observed in the first author's clinic since May 2020.

Aims

To report AIR cases, we experienced and discuss potential underlying mechanisms.

Methods

This was a retrospective review of patients representing AIR symptoms following filler injection with HA or human collagen in our clinic.

Results

Although only one case of an AIR with an incidence rate of 0.01% was recorded following filler treatment between September 2008 and April 2020 in our clinic, we observed 14 AIR cases without anaphylaxis, with an incidence rate of 1.18% between May 2020 and June 2021, in line with the spreading of the new coronavirus pandemic. All cases were females aged 40–57 years, and the time of onset was within hours after filler injection. Three patients had been treated with HA fillers only, 2 with HA plus human collagen, and 9 with human collagen only. Most patients had been treated with these products in the past. Nine patients were treated with oral prednisolone. In all cases, symptoms resolved entirely within a week without sequelae.

Conclusions

The marked increase in AIRs coincided with the COVID‐19 pandemic. Possible explanations include immune system alterations caused by extensive changes in domestic and personal hygiene, prolonged and elevated stress levels, and subclinical COVID‐19 infection. Further studies may be warranted.

A Case of Orbital Granuloma Secondary to Dermal Filler Injection

A foreign body granulomatous reaction is a rare complication of the subcutaneous injection of fillers. We describe a 57-year-old female that presented with a six-month history of a non-painful, right lower eyelid mass. She had a dermal filler in the zygomatic region several months before the onset of her symptoms. Anterior orbitotomy and pathology revealed multinuclear giant cells consistent with a hyaluronic acid-based filler. This case describes the clinical presentation, histopathologic features, and treatment of an orbital granuloma secondary to dermal filler injection. Our case was uncommon because the zygomatic filler migrated across the orbital septum. Additionally, transconjunctival orbitotomy was used instead of a hyaluronidase injection due to the inferior location of the granuloma.

Filler Migration to the Orbit

BACKGROUND

Dermal filler injections continue to grow in popularity as a method of facial rejuvenation. This increase in the number of injections performed has resulted in an increasing number of types of filler-related complications.

OBJECTIVES

We report a series of cases where dermal filler injected in the face migrated to the orbit. Treatment methods and possible mechanisms of this newly reported complication are discussed.

METHODS

A retrospective, multicenter analysis was performed on patients with dermal filler migration to the orbit after facial filler injections.

RESULTS

Seven patients (6 females, 1 male; age range, 42-67 years) presented with orbital symptoms after filler injection and were subsequently found to have dermal filler in the orbit. Four out of 7 patients underwent orbitotomy surgery, 1 patient underwent lacrimal surgery, 1 patient had strabismus surgery, and 1 patient was treated with hyalurodinase injections. All patients have remained stable postoperatively.

CONCLUSIONS

Orbital complications secondary to migrated filler may occur long after the initial procedure. Because the site of the complication is distant from the injection site, patients and physicians may not immediately make the connection. Furthermore, this may lead to unnecessary examinations and a delay in diagnosis while looking for standard orbital masses. Dermal fillers should therefore be considered in the differential diagnosis of patients presenting with new-onset orbital masses.

LEVEL OF EVIDENCE: 4

Upper eyelid blepharoplasty following hyaluronic acid injection with improved facial aesthetics and eye symptoms: a case report

BACKGROUND

Dermatochalasis of the upper eyelids (blepharochalasis) is a typical age-related change in the upper third of the face and a major concern for facial aesthetics. Nowadays both surgical and nonsurgical interventions are available for patients complaining of upper eyelid dermatochalasis. Although nonsurgical treatments are often easier to perform, if they are not performed correctly, complications may ensue and worsen the condition.

CASE PRESENTATION

We describe the case of a Caucasian patient presenting with bilateral upper eyelid dermatochalasis, previously treated with multiple injections of hyaluronic acid filler. Following these procedures, the patient reported nonspecific eye symptoms (such as a sense of heaviness and asthenopia) and cosmetic concerns. We decided to perform an upper eyelid blepharoplasty. During the procedure we found a ribbon of hard, fibrous material, which was carefully removed. The patient reported resolution of functional eye symptoms owing to the reduction of upper lid heaviness, which also resulted in subjective improvement of the visual field. Patient satisfaction was assessed preoperatively and 3 months postoperatively using the Blepharoplasty Outcomes Evaluation (BOE), which showed an overall satisfaction rate of 95.8 %.

CONCLUSIONS

Blepharoplasty not only treated the patient's blepharochalasis but also allowed us to correct the previous nonsurgical intervention by removing the excessive amount of injected hyaluronic acid. Both aesthetic and functional results were successfully achieved.

Penile girth augmentation by injectable fillers: a comprehensive review of imaging features and inflammatory complications

Despite the extensive controversy and debate of penile girth augmentation, high demands for such procedures are increasing. Penile inflammation is not common sequel after penile filler augmentation, but when it occurs, it has serious complications that sometimes necessitate emergency surgical intervention. Imaging with a variety of modalities, including ultrasonography, magnetic resonance imaging, and ascending urethrogrphy plays a paramount role in the detection and assessment of these conditions. Inflammatory conditions after penile girth augmentation using injectable fillers are ranging from local granuloma to penile abscess formation or diffuse cellulitis that may extend to the scrotum, perineum or deep pelvic organs. Rapid diagnosis and evaluation of extensions are important to avoid associated morbidity and permanent deformity. Our purpose is to provide a practical review of relevant penile anatomy, imaging appearance and injection technique of different types of subcutaneous fillers used in penile girth augmentation, and inflammatory complications that may occur after these procedures. Brief descriptions of patient clinical information and imaging features of inflammatory complications will be included and correlated in actual cases.

Granulomas and nongranulomatous nodules after filler injection: Different complications require different treatments

Dermal fillers are widely used for facial rejuvenation and reconstruction and present fewer risks than surgical approaches. Nevertheless, several complications may occur, including nodule formation. A nodule is a clinical sign corresponding to different etiologies, such as overcorrection, infection, allergic reaction, or granuloma. However, their treatment represents a diagnostic challenge. We present a retrospective review of 26 consecutive patients who underwent a biopsy for facial nodule formation more than 3 months after filler injections, to determine the diagnosis of the nodule and type of filler used. All patients were women (mean age, 57.8 years). Some patients suffered from different localizations: lip, 14 cases; nasolabial folds, 6; cheeks, 5; infraorbital region, 5; the glabella, 2; the temporal region, 1; and chin, 1 case. Only 5 (19.2%) patients knew the type of filler used, and in another 4 cases, the injector was able to provide some information. In 65.4% of cases, the filler type was unknown. Histopathological analysis revealed a "granulomatous" nodule in 30 sites and a "non-granulomatous" nodule in 4 cases. Concerning the type of filler, 5 different histopathological patterns were found. Our results demonstrate that a clinical history and histopathological analysis whether to confirm or not to confirm the diagnosis of granuloma and to identify the type of filler are essential tools to achieve an accurate diagnosis of the problem-oriented treatment of nodules after dermal filler injections. We propose an algorithm for the management of nodules after filler injection.

Periocular hyaluronic acid fillers: applications, implications, complications

PURPOSE OF REVIEW

The use of dermal filler in the periocular area is increasing - both for functional and aesthetic indications. Hyaluronic acid fillers dominate the market; these treatments offer an alternative to some surgical procedures with the advantage of instant results, minimal healing time and low complication rates. However, success depends on judicious selection of patients, products and procedures to achieve favourable outcomes. This article reviews current understanding of the principal complications in the periocular area and their management.

RECENT FINDINGS

Hyaluronic acid is a ubiquitous, biodegradable, nonspecies-specific molecular substrate with limited potential for immunogenic reactions. However, in the periocular area, such products can migrate and last significantly longer than the expected filler lifespan. Contamination or subsequent immune stimulation can trigger delayed-onset inflammatory reactions. Though minor vascular occlusions are not uncommon, cases of blindness secondary to facial filler injections are thought to be rare. Timely enzymatic degradation with injectable hyaluronidase can be effective in the treatment of some such complications. But recent studies demonstrate lack of penetration through arterial walls and optic nerve sheath, casting doubt on the role of retrobulbar hyaluronidase in the management of vision loss because of embolism with hyaluronic acid filler.

SUMMARY

Hyaluronic acid fillers represent an emerging and important addition to the armamentarium of the oculofacial plastic surgeon with their use in the aesthetic field also expected continue to rise. The oculoplastic facial surgeon, armed with a thorough knowledge of facial anatomy, safe injection planes and the means of minimizing and treating complications is in the best position to lead clinically in the use of this well tolerated and effective treatment modality.

[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.

Practical Approach and Safety of Hyaluronic Acid Fillers

Supplemental Digital Content is available in the text.

Soft-tissue filler use has grown considerably related to the increasing popularity of minimally invasive cosmetic procedures. Hyaluronic acid products are currently the most utilized soft-tissue fillers. Proper working knowledge of individual products, limitations to use, and anatomic principles can improve outcomes. Prevention is key to minimize complications; however, when present, complications must be managed methodically. Complications are categorized based on the timing of presentation and include early, late, and delayed. Vascular compromise and tissue necrosis are among the most devastating complications seen with filler use. Nodules can be related to an inflammatory or infectious etiology but should be distinguished as treatment varies. Hyaluronidase is mandatory to have available as a reversal agent for hyaluronic acid products and can be used in treatment for many complications and untoward sequela.

Autoimmune/inflammatory syndrome induced by adjuvants-ASIA-related to biomaterials: analysis of 45 cases and comprehensive review of the literature

Systemic autoimmune or granulomatous disorders related to biomaterials of human use have rarely been described. The aim of this study was to report cases of autoimmune/inflammatory syndrome induced by adjuvants (ASIA) related to biomaterial injections and prostheses, mainly silicone, hyaluronic acid, acrylamides and methacrylate compounds in a Spanish patient cohort. This study is a retrospective analysis of clinical, laboratory, histopathological and follow-up data of 45 cases of patients suffering from late-onset, non-infectious inflammatory/autoimmune disorders related to bioimplants. Late onset was defined as 3 months or more post injection. Data were obtained through a further non-systematic but comprehensive review of the literature. Forty-five cases of late-onset adverse reactions related to biomaterial injections or prostheses were reviewed. All cases had systemic complaints that could be categorised as ASIA. In all but four patients, inflammatory features at the implantation site preceded distant or systemic manifestations. Abnormal blood tests were common. Localised inflammatory nodules and panniculitis in 40/45 (88.88%) evolved into a variety of disorders, viz., primary biliary cirrhosis, Sjögren's syndrome, sarcoidosis, human adjuvant disease, vasculitis, inflammatory bowel syndrome and inflammatory polyradiculopathy. Five (11.11%) cases presented primarily with systemic autoimmune disorders. Biomaterials and prostheses can provoke late-onset systemic autoimmune disorders fulfilling ASIA criteria, or present primarily local/regional inflammatory reactions that may eventually evolve into systemic autoimmune and/or granulomatous disorders which fall under ASIA.

Full-face augmentation using Tissuefill mixed with platelet-rich plasma: "Q.O.Fill"

BACKGROUND

Hyaluronic acid fillers have become popular soft tissue filler augmentation agents over the past several years. Q.O.Fill (JW Pharmaceutical Co., Ltd., Seoul, Korea) is a newly developed soft tissue augmentation agent using Tissuefill (hyaluronic acid derivatives) mixed with platelet-rich plasma (PRP). The purposes of this study were to describe the Q.O.Fill method and evaluate the outcome of face augmentation.

METHODS

A retrospective chart review was performed over a 2-year period. Seventy-five Asian participants with a mean age of 43.5 years were enrolled in the study. Mean total injection volume (baseline and touch-up) per participant was 8.9 mL. All participants underwent injection of Tissuefill mixed with PRP, Q.O.Fill. The results were evaluated using photographs and according to patients' satisfaction.

RESULTS

Six months after the last injection, 100% of participants had improvement. At month 6, 97.3% of participants remained least improved over the baseline, and 90.7% felt much better or a little better until 2 years after the injection. The incidence of complications was low.

CONCLUSIONS

The study showed that Q.O.Fill injection resulted in a very good aesthetic outcome and few adverse events. We believe that a facial augmentation with Tissuefill mixed with PRP is a safe and effective treatment method.

Development of Poly(HEMA-Am) Polymer Hydrogel Filler for Soft Tissue Reconstruction by Facile Polymerization

The number of breast reconstruction surgeries has been increasing due to the increase in mastectomies. Surgical implants (the standard polydimethylsiloxane (PDMS) implants) are widely used to reconstruct breast tissues, however, it can cause problems such as adverse immune reactions, fibrosis, rupture, and additional surgery. Hence, polymeric fillers have recently garnered increasing attention as strong alternatives for breast reconstruction materials. Polymeric fillers offer noninvasive methods of reconstruction, thereby reducing the possible adverse effects and simplifying the treatment. In this study, we synthesized a 2-hydroxylethylmethacrylate (HEMA) and acrylamide (Am) copolymer (Poly(HEMA-Am)) by redox polymerization to be used as a biocompatible filler material for breast reconstruction. The synthesized hydrogel swelled in phosphate buffered saline (PBS) shows an average modulus of 50 Pa, which is a characteristic similar to that of the standard dermal acrylamide filler. To investigate the biocompatibility and cytotoxicity of the Poly(HEMA-Am) hydrogel, we evaluated an in vitro cytotoxicity assay on human fibroblasts (hFBs) and human adipose-derived stem cells (hADSCs) with the hydrogel eluate, and confirmed a cell viability of over 80% of the cell viability with the Poly(HEMA-Am) hydrogel. These results suggest our polymeric hydrogel is a promising filler material in soft tissue augmentation including breast reconstruction.

Soft tissue fillers for adipose tissue regeneration: From hydrogel development toward clinical applications

There is a clear and urgent clinical need to develop soft tissue fillers that outperform the materials currently used for adipose tissue reconstruction. Recently, extensive research has been performed within this field of adipose tissue engineering as the commercially available products and the currently existing techniques are concomitant with several disadvantages. Commercial products are highly expensive and associated with an imposing need for repeated injections. Lipofilling or free fat transfer has an unpredictable outcome with respect to cell survival and potential resorption of the fat grafts. Therefore, researchers are predominantly investigating two challenging adipose tissue engineering strategies: in situ injectable materials and porous 3D printed scaffolds. The present work provides an overview of current research encompassing synthetic, biopolymer-based and extracellular matrix-derived materials with a clear focus on emerging fabrication technologies and developments realized throughout the last decade. Moreover, clinical relevance of the most promising materials will be discussed, together with potential concerns associated with their application in the clinic.

Injectable facial fillers: imaging features, complications, and diagnostic pitfalls at MRI and PET CT

Injectable fillers are widely used for facial rejuvenation, correction of disabling volumetric fat loss in HIV-associated facial lipoatrophy, Romberg disease, and post-traumatic facial disfiguring. The purpose of this article is to acquaint the reader with the anatomy of facial fat compartments, as well as with the properties and key imaging features of commonly used facial fillers, filler-related complications, interpretation pitfalls, and dermatologic conditions mimicking filler-related complications. The distribution of facial fillers is characteristic and depends on the anatomy of the superficial fat compartments. Silicone has signature MRI features, calcium hydroxyapatite has characteristic calcifications, whereas other injectable fillers have overlapping imaging features. Most fillers (hyaluronic acid, collagen, and polyalkylimide-polyacrylamide hydrogels) have signal intensity patterns compatible with high water content. On PET-CT, most fillers show physiologic high FDG uptake, which should not be confounded with pathology. Abscess, cellulitis, non-inflammatory nodules, and foreign body granulomas are the most common filler-related complications, and imaging can help in the differential diagnosis. Diffusion weighted imaging helps in detecting a malignant lesion masked by injected facial fillers. Awareness of imaging features of facial fillers and their complications helps to avoid misinterpretation of MRI, and PET-CT scans and facilitates therapeutic decisions in unclear clinical cases.

KEY POINTS

• Facial fillers are common incidental findings on MRI and PET-CT scans. • They have a characteristic appearance and typical anatomic distribution • Although considered as safe, facial filler injections are associated with several complications • As they may mask malignancy, knowledge of typical imaging features is mandatory. • MRI is a problem-solving tool for unclear cases.

Consensus statement on prevention and management of adverse effects following rejuvenation procedures with hyaluronic acid-based fillers

Facial fillers play an important role in the correction of facial changes associated with ageing. They offer quick treatments in the outpatient setting with minimal subsequent downtime that provide predictable, natural-looking, long-lasting results. Adverse reactions after hyaluronic acid injections tend to be mild or moderate and rather temporary. However, as with all injected or implanted biomaterials, severe adverse events can occur and patients must be fully informed of potential risks prior to undergoing treatment. A panel of experts from Germany (D), Austria (A) and Switzerland (CH) developed recommendations, and this study provides the 'DACH Consensus Recommendations' from this group specifically on the use of hyaluronic acid fillers. The aim is to help clinicians recognize potential risks and to provide guidance on how best to treat adverse events if they arise. Contraindications to hyaluronic acid fillers are also detailed, and ways to prevent adverse events occurring are discussed. Hyaluronic acid-based products are claimed to be very close to an ideal tissue augmentation agent; nevertheless, profound medical, anatomical and product knowledge are of paramount importance to minimize the occurrence of adverse reactions.

Nasal Reshaping with Hyaluronic Acid: An Alternative or Complement to Surgery

BACKGROUND

Rhinoplasty has traditionally been preferred for correction of nasal defects. Long-term clinical experience with hyaluronic acid (HA) injection as an alternative or complement to rhinoplasty is presented.

METHODS

A retrospective review of the author's clinical experience with HA gel for nasal reshaping from 1997 to 2012 was conducted, with treatments performed during 1998, 2005, and 2012 selected for detailed review.

RESULTS

More than 250 patients were treated for nasal reshaping with HA since 1997. In addition to being a complement to surgery, HA injection successfully addressed nasal defects that would have been difficult to correct surgically. The effect persisted for >1 year in most patients (>5 y in some patients), with individual variations. No serious complications occurred. When comparing the 3 years reviewed in detail, new indications for nasal reshaping with HA gel became evident over time, which was also reflected by the increase in number of patients treated (1998: n = 2; 2005: n = 22; 2012: n = 51). Of these patients, 55 (73%) received HA injection instead of rhinoplasty, 20 (27%) received HA injection after rhinoplasty, and 5 (7%) underwent rhinoplasty after HA injection. The mean injection volume was 0.4 mL HA gel/treatment. All patients were satisfied with the primary outcome of treatment. Retreatment was performed in 32 patients (43%).

CONCLUSIONS

Injection of HA gel is a valuable tool for nasal reshaping. It can also be used for correction of minor postrhinoplasty defects in appropriate patients.

Glans Penis Augmentation Using Hyaluronic Acid Gel as an Injectable Filler

Glans penis augmentation (GPA) has received little attention from experts despite the existence of a subset of patients who may be dissatisfied with a small glans or poor tumescence of the glans during erection. Recently, GPA using an injectable filler or implantation of a graft or filler has been developed. Despite a demanding injection technique and inevitable uneven undulation of the glandular surface, GPA using injectable hyaluronic acid (HA) gel is a novel and useful therapy and an effective and safe procedure for soft tissue enhancement. For long-term presence of implants, timed supplementation can be used similar to that for fascial plasty. In complications such as mucosal necrosis of the glans penis, most cases occur from the use of non-HA gel or an unpurified form and misunderstanding of the management protocol for immediate side effects. Currently, GPA using injectable HA gel is not recommended in the International Society for Sexual Medicine guideline due to possible sensory loss. In a 5-year long-term follow-up of GPA by subcutaneous injection of HA gel, the residual volume of implants decreased by 15% of the maximal glandular circumference, but was still effective for alleviating the hypersensitivity of the glans penis in premature ejaculation patients. For efficacy in premature ejaculation, selection of appropriate candidates is the most important factor for success. GPA does not harm erectile function and is less invasive and irreversible compared to dorsal neurectomy. To refine the procedure, more interest and well-designed studies are required for the establishment of the procedure.

Foreign body granulomas after the use of dermal fillers: pathophysiology, clinical appearance, histologic features, and treatment

A foreign body granuloma is a non-allergic chronic inflammatory reaction that is mainly composed of multinucleated giant cells. Foreign body granulomas may occur after the administration of any dermal filler. Factors such as the volume of the injection, impurities present in the fillers, and the physical properties of fillers affect granuloma formation. The formation of granulomas involves five phases: protein adsorption, macrophage adhesion, macrophage fusion, and crosstalk. The clinical and pathologic features of granulomas vary depending on the type of filler that causes them. Foreign body granulomas can be treated effectively with intralesional corticosteroid injections. Surgical excisions of granulomas tend to be incomplete because granulomas have ill-defined borders and moreover, surgical excisions may leave scars and deformities.

Complications of injected vitamin E as a filler for lip augmentation: case series and therapeutic approach

The strive for proficient cosmetic facial appearance is growing in the past decades. Fillers for tissue augmentation are gaining wide popularity. Uncertified products based on oleic solutions are applied by untrained staff, thus growing the risk for certain complications such as infections, allergic and irritant contact dermatitis, and lipogranuloma formation. We present a series of three cases lipogranuloma after liquid vitamin E injection for lip augmentation. In all cases, painful edema at the injected area followed the procedure. The patients were presented with erythema, firm indurations of the lips and the perioral skin, and tenderness. Histological examination of skin biopsies showed round-ovoid cavities of varying sizes, resulting in a Swiss cheese-like appearance, consistent with a lipogranuloma. In this paper, we propose a protocol for treatment of this specific complication with systemic corticosteroids and a broad spectrum antibiotics.

Classification of the Aging Lips: A Foundation for an Integrated Approach to Perioral Rejuvenation

BACKGROUND

Although perioral aging is highly individual with several distinct processes taking part simultaneously, there is scarce systematic information which helps to indicate the right rejuvenation approach among the multitude of proposed procedures. Existing data about perioral aging has not yet been transformed into a consistent therapeutic concept. The intention of this study was to provide a simple, yet reproducible classification and to offer appropriate rejuvenation approaches.

METHODS

To identify reliable and constant landmarks of the ongoing process of perioral aging, 462 perioral photo documentations were morphometrically analyzed. Based upon the identified landmarks a two-dimensional classification was developed. The classification was validated by three plastic surgeons. Inter- and intra-rater reliability was calculated using Cohen's kappa coefficient.

RESULTS

Perioral aging can be broken down into changes of the lip shape and changes of the lip surface. Both processes can be classified into three stages each: Lip shape according to the shape in profile view, the lip length in relation to the frontal incisors, and the degree of vermilion inversion. Lip surface according to the presence and degree of radial wrinkles and the visibility of the structural elements Cupid's bow, philtrum, and white roll. Inter-observer reliability was rated very good (kappa values between 0.819 and 0.963) and perfect for intra-observer reliability (1.0).

CONCLUSION

A better understanding of perioral aging leads to a simple classification for the aging lips. Using the classification helps to tailor an appropriate treatment to the individual patient and aids to achieve a natural rejuvenation result.

Efficacy and safety of porcine collagen filler for nasolabial fold correction in Asians: a prospective multicenter, 12 months follow-up study

Recently, injectable dermal fillers have become important alternatives to surgical procedures for the correction of facial wrinkles. Bovine collagen is the first approved material for filler injection, and several studies have shown its efficacy. However, the risk of developing an allergic reaction and xenogenic transmission of bovine spongiform encephalopathy remain among its disadvantages. In this randomized, double-blinded, split-face study, we compared the efficacy and safety of a porcine collagen filler (TheraFill®) with that of a bovine collagen filler (KOKEN®) for nasolabial fold correction. A total of sixty one patients with mild to severe nasolabial fold were randomized to receive TheraFill® and KOKEN® on contralateral sides of the face. During the 12-month follow-up period, improvement in the Wrinkle-Severity Rating Scale score was slightly higher in TheraFill® group than KOKEN® group, although the difference was not statistically significant. No serious adverse reactions were observed and both materials were tolerable in most cases. In conclusion, the long-term effect of TheraFill® on nasolabial fold correction was comparable to that of KOKEN®, and it may be a good alternative to bovine collagen filler.

Dermal fillers: facts and controversies

Dermal fillers have been used for decades in soft tissue augmentation. Currently, filler implementation is among the most common minimally invasive procedures for rejuvenation and body sculpturing. There is a broad variety of filler materials and products. Despite immense experience, a number of controversies in this topic exist. Some of these controversies are addressed in this review, for example, who should perform filler injections, the difference between permanent and nonpermanent fillers, the off-label use of liquid silicone, and the role of pain reduction. Implementation of guidelines and restriction of filler use by trained physicians can improve safety for patients.

Late-onset inflammatory adverse reactions related to soft tissue filler injections

An ever-increasing number of persons seek medical solutions to improve the appearance of their aging skin or for aesthetic and cosmetic indications in diverse pathological conditions, such as malformations, trauma, cancer, and orthopedic, urological, or ophthalmological conditions. Currently, physicians have many different types of dermal and subdermal fillers, such as non-permanent, permanent, reversible, or non-reversible materials. Despite the claims of manufacturers and different authors that fillers are non-toxic and non-immunogenic or that complications are very uncommon, unwanted side effects do occur with all compounds used. Implanted, injected, and blood-contact biomaterials trigger a wide variety of adverse reactions, including inflammation, thrombosis, and excessive fibrosis. Usually, these adverse reactions are associated with the accumulation of large numbers of mononuclear cells. The adverse reactions related to fillers comprise a broad range of manifestations, which may appear early or late and range from local to systemic. Clinicians should be aware of them since the patient often denies the antecedent of injection or is unaware of the material employed. Most of these adverse effects seem to have an immunological basis, the fillers acting more as adjuvants than as direct T-cell activators, on a background of genetic predisposition. Their treatment has not been the subject of well-designed studies; management of both acute and systemic reactions is often difficult, and requires anti-inflammatory and occasionally immunosuppressive therapy. The clinical, pathological, and therapeutic aspects of inflammatory and immune-mediated late-onset adverse reactions related to soft tissue filler injections are thoroughly reviewed herein.

The utility of soft tissue fillers in clinical dermatology: treatment of fine wrinkles and skin defects

This review discusses treatment strategies for wrinkles and skin defects through an in-depth overview of current soft tissue fillers utilized within the fields of dermatology and plastic surgery. From the review, it is evident that the utilization of different materials for various skin abnormalities is extremely wide in scope. Many clinicians have adopted their own preferences based on not only the knowledge provided by their experience but also the respective profiles of each individual filler, including their efficacy, practicality and safety. With the ongoing emergence of commercially available products designed for soft tissue augmentation, the market will continue to present new and improved treatment options. Although the search for the perfect or most ideal filler is far from over, this review demonstrates that there are a number of commercially available products that are more than acceptable to both patients and clinicians in the treatment of wrinkles and other skin defects.

Inflammatory nodules following soft tissue filler use: a review of causative agents, pathology and treatment options

Nodule development is a common complication following the use of fillers for soft tissue augmentation and is commonly categorized as inflammatory or non-inflammatory in nature. Inflammatory nodules may appear anywhere from days to years after treatment, whereas non-inflammatory nodules are typically seen immediately following implantation and are usually secondary to improper placement of the filler. Although inflammatory nodules are more common with permanent fillers such as silicone, inflammatory nodule development following administration of temporary fillers such as hyaluronic acid and collagen has also been reported. Treated many times with corticosteroids due to their anti-inflammatory properties, inflammatory nodules may be secondary to infection or biofilm formation, warranting the use of alternative agents. Appropriate and prompt diagnosis is important in avoiding delay of treatment or long-term complications for the patient. This paper addresses the etiology, development, and studied treatment options available for inflammatory nodules secondary to each of the major classes of fillers. With this knowledge, practitioners may expeditiously recognize and manage this common side effect and thus maximize functional and aesthetic benefit.