Effectiveness and Safety of Large Gel Particle Hyaluronic Acid With Lidocaine for Correction of Midface Volume Deficit or Contour Deficiency

Effectiveness of hyaluronic acid fillers for cheek augmentation using a treatment guide to choose between products

BACKGROUND

Patients can have different reasons for seeking cheek augmentation; while some are in need of volume augmentation, others may request projection and lifting. A treatment guide can be useful for treating clinicians in choosing the most suitable product.

AIMS

This 8-week, multicenter study was conducted to evaluate the effectiveness and safety of cheek augmentation using a treatment guide to choose between study products HACON and HALYF.

PATIENTS/METHODS

Female subjects intending to undergo cheek augmentation were treated according to primary need for treatment-HACON for contouring or HALYF for projection. Treatments were performed according to approved labels. Assessments included Global Aesthetic Improvement Scale (GAIS) evaluations, subject satisfaction, subject-perceived age (FACE-Q), naturalness of facial expressions, 3D imaging analysis, and safety assessments.

RESULTS

All subjects (n = 60) were assessed as aesthetically improved by the investigators 4 and 8 weeks after last injection. For all subjects, contouring or projection was achieved as planned with natural-looking results. Subject satisfaction was high in both study groups. Volume change of the cheek area was statistically significant from baseline to Week 4 (p < 0.001), in both treatment groups and on both sides of the face. Overall, treatments were well tolerated with mainly mild adverse events related to treatment.

CONCLUSIONS

The proposed guide for product selection of HACON or HALYF for treatment of the cheek area was useful to achieve the primary treatment goal for both products. Treatments were well tolerated and associated with improved aesthetic appearance of the cheeks as well as high subject satisfaction.

Restoring long-lasting midface volume in the Asian face with a hyaluronic acid filler: A randomized controlled multicenter study

BACKGROUND

Hyaluronic acid (HA) filler treatment is a minimally-invasive alternative to surgery to volumize the cheeks. HAVOL (Restylane® Volyme) is a flexible HA filler suited to contouring and volumizing the midface.

METHODS

This randomized, evaluator-blinded, no-treatment controlled study evaluated effectiveness and safety of HAVOL for correction of midface volume deficit and midface contour deficiency in Chinese subjects. In total 111 subjects were randomized to HAVOL and 37 to no treatment (control). The primary endpoint was response, on the blinded evaluator-assessed Medicis Midface Volume Scale (MMVS), at 6 months after last injection for the treatment group and 6 months after randomization for controls, where response was defined as ≥1-point improvement from baseline on both sides of the face.

RESULTS

HAVOL was superior to no treatment at 6 months, meeting the primary objective: 76% versus 8% MMVS responders, a difference of 68% (CI: 55.7%-79.4%, p < 0.0001). These effects were sustained in 51% at 12 months after last injection. A majority (≥96%) had improved aesthetic appearance of midface fullness at Month 1 (using the Global Aesthetic Improvement Scale [GAIS]), effects which remained in ≥80% up to 12 months. Volume change captured by 3D photography increased after 1 month to 3.6 mL (close to the total injected volume of 3.4 mL), and remained stable through 12 months. Over 97% reported satisfaction with results after treatment with HAVOL. Additionally, HAVOL was well tolerated, with no unanticipated related adverse events.

CONCLUSIONS

This study showed that HAVOL is effective and well tolerated for midface treatment in a Chinese population.

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.

Lifting the midface using a hyaluronic acid filler with lidocaine: A randomized multi-center study in a Chinese population

BACKGROUND

Soft-tissue augmentation of the midface is increasingly requested by patients, and hyaluronic acid (HA) fillers are frequently used in treatment.

AIMS

To evaluate the efficacy and safety of treatment of midface volume/contour deficit with a firm HA filler including lidocaine (HA_RL ).

PATIENTS/METHODS

This was a 12-month, randomized, evaluator-blinded, controlled study. Chinese adults with mild to substantial volume loss were randomly assigned in a 3:1 ratio to treatment or untreated control groups.

RESULTS

A total of 148 subjects were enrolled. The primary objective was met; results of the midface volume scale (MMVS) rated by a blinded evaluator were in favor of HA_RL at Month 6 (p < 0.0001 vs. the untreated control group). Similar to the MMVS improvement, improved midface fullness and aesthetic appearance was observed based on the Global Aesthetic Improvement Scale (GAIS) up to 12 months by both treating investigators and subjects (at least 96% at Week 4 and 65% at Month 12). Subject satisfaction was high, and the majority of subjects considered the results to look natural (>97%). The study product was well tolerated.

CONCLUSIONS

Midfacial treatment using HA_RL was effective, well tolerated, and led to high levels of satisfaction in a Chinese population for up to 12 months.

CLINICALTRIALS

GOV IDENTIFIER

NCT03097783.

Efficacy evaluation of True Lift®, a nonsurgical facial ligament retightening injection technique: Two case reports

BACKGROUND

With aging, four major facial retaining ligaments become elongated, leading to facial sagging and wrinkling. Even though synthetic fillers are popular, however, it cannot address the problems of soft tissue descent alone, and injection of these fillers requires knowledge of the injection technique including the selection of injection sites, the amount of filler, and the dosage used per injection site.

CASE SUMMARY

This report aimed to assess the safety and efficacy of a nonsurgical retightening technique to lift and tighten the true ligaments of the face, to improve age-related skin sagging and wrinkling. We objectively quantified the aesthetic lifting effect of a nonsurgical facial retightening procedure that strategically injected high G’ fillers into the base of the true retaining ligaments of the face in two female patients. Facial images were recorded with a three-dimensional facial imaging system for comparison of the clinical outcome. The primary efficacy outcome was the change in facial anthropometric measurements obtained prior to and after injection. The patients were followed for 6 mo after the procedure. Skin retightening was observed, with an evident lift in the orbital, zygomatic, and mandibular regions, and the lifting effect was still observable at the 6-mo follow-up. Few mild adverse events, such as mild-to-moderate pain, tenderness, and itching, occurred during the 1st week after the procedure. No adverse events were reported 1 mo post-procedure.

CONCLUSION

The results of this study demonstrated that our nonsurgical retightening procedure with strategically placed high G’ fillers achieved quantifiable aesthetic improvements in the orbital, zygomatic, and mandibular regions of two patients. Future research with a larger sample could provide a more in-depth evaluation and validation of the aesthetic improvements observed in this study.

Individualized Treatment Algorithm Using Hyaluronic Acid Fillers for Lifting, Contouring and Volumizing the Midface

Purpose

Patients seeking treatment for the midface are individuals with different objectives and characteristics of skin and soft tissue. In this study, patients were treated in the midface with one of three products with different properties; HA_RV, HA_RD, or HA_RL, using a treatment algorithm based on primary need for treatment (volumizing, lifting or contouring) and tissue coverage (thin or thick tissue). The aim was to optimize the treatment outcome and to provide an individualized treatment approach that distinguishes different types of patients seeking midfacial treatment.

Materials and Methods

Subjects were treated in the midface at baseline to achieve optimal aesthetic results (≤2 mL per side of the face), and touch-up was allowed after 4 weeks (≤1 mL per side of the face). Study visits were scheduled at Weeks 8, 16 and 24. Assessments included aesthetic improvement of the midface, evaluation of midface fullness, and subject satisfaction. Safety evaluations included local tolerability symptoms collected at 4 weeks after treatment and adverse events.

Results

A total of 90 subjects were included in the study, mean age was 45 years (range 29–55) and 82% of subjects were female. Mean total injected volume for the products was 4.4 mL (HA_RV and HA_RL) and 4.2 mL (HA_RD). At least 92% of subjects were assessed as aesthetically improved throughout the study. Assessment of midface fullness showed ≥90% of subjects being responders until Week 24. In addition, subject satisfaction was high throughout the study. Tenderness, bruising and swelling were the most reported local tolerability symptom for all study products, and no adverse events related to study product/treatment were reported.

Conclusion

Midface treatment with either HA_RV, HA_RD, or HA_RL using a treatment algorithm to guide the choice of product to individual subject needs was effective and safe for up to 24 weeks after treatment.

Injection Guidelines for Treating Midface Volume Deficiency With Hyaluronic Acid Fillers: The ATP Approach (Anatomy, Techniques, Products)

Midface rejuvenation is among the most valuable indications of hyaluronic acid dermal fillers, because malar projection and full upper cheeks significantly contribute to a youthful appearance. Hyaluronic acid fillers have evolved over the past 2 decades to meet specific clinical needs such as strong projection capacity and adaptability to facial dynamism. As a result, they now represent the treatment of choice for midface rejuvenation throughout age ranges by offering the potential for noninvasive treatment, immediate results, and minimal downtime. Because the 5-layered structure of the midface plays a central role in the human face, injecting the midface area may also indirectly improve other aesthetic concerns such as infraorbital hollowing and nasolabial folds. Nonetheless, midface rejuvenation requires a tailored treatment approach and a thorough knowledge of anatomy to minimize procedural risks and achieve natural-looking results. This article provides an extensive anatomical description of the midface and of the usual course and depth of vascular structures circulating nearby to delineate a treatment area and minimize procedural risks. Furthermore, considering the differential mobility and mechanical constraints of each layer of the midface, a multilayer treatment algorithm is proposed for adapting the treatment strategy to patient specificities (including age, gender, skin type, and morphology). Emphasis is also placed on desirable filler properties to create deep structural support on the one hand and accompany facial movement on the other hand.

Repeated Full-Face Aesthetic Combination Treatment With AbobotulinumtoxinA, Hyaluronic Acid Filler, and Skin-Boosting Hyaluronic Acid After Monotherapy With AbobotulinumtoxinA or Hyaluronic Acid Filler

BACKGROUND

Full-face aesthetic treatment involving several treatment modalities may improve facial aesthetic outcome.

OBJECTIVE

To evaluate clinical outcomes and patient perceptions of monotherapy with either abobotulinumtoxinA (ABO) or hyaluronic acid (HA) filler followed by full-face combination treatments of ABO, HA filler, and skin-boosting HA (RSB).

MATERIALS AND METHODS

Subjects aged 35 to 50 years were randomized to monotherapy with 50 s.U ABO in the glabella or ≤1 mL HA filler in the nasolabial folds (NLFs)/cheeks. At Month 6 and Month 12, all subjects received combination treatment with ≤50 s.U ABO in the glabella, ≤2 mL HA filler in the NLFs/cheeks (and other facial areas as applicable), and ≤1 mL RSB (additional RSB treatment at Month 7). Assessments included global facial aesthetic appearance and improvement, first impression, perceived age, wrinkle severity, satisfaction questionnaires, and adverse events.

RESULTS

Repeated full-face combination treatment with ABO, HA filler, and RSB was associated with considerably higher levels of aesthetic improvement and subject satisfaction than monotherapy with ABO or HA filler. Improvement rate of glabellar lines was increasing with each treatment.

CONCLUSION

Repeated combination treatment achieved greater change in global facial aesthetic appearance than monotherapy. Aesthetic improvement and subject satisfaction was high and increased with each treatment. All treatments were well tolerated.

A randomized, split-face, double-blind, comparative study of the safety and efficacy of small- and large-particle hyaluronic acid fillers for the treatment of nasolabial folds

BACKGROUND

Injections of hyaluronic acid (HA) for tissue augmentation are one of the most common aesthetic treatments performed worldwide. However, few studies have compared the safety and efficacy of small- and large-particle HA (SP-HA; LP-HA).

AIM

To assess and compare the safety and efficacy of SP-HA and LP-HA for the correction of nasolabial folds (NLFs).

METHODS

A prospective, split-face, triple-blind study design was used. Ten female subjects were recruited. Patients underwent treatment at baseline, an optional touch up at Week 2, and a follow-up visit at Week 4. At weeks 2 and 4, a blinded reviewer assessed the patients using the Global Aesthetic Improvement Scale (GAIS) and Wrinkle Severity Rating Scale (WSRS); and subjects completed the Patient Satisfaction Questionnaire (PSQ). At all visits, 3-dimensional imagery and ultrasonography of patients' NLFs were captured. Adverse events (AEs) were evaluated by the Investigator and recorded by subjects in diaries.

RESULTS

The GAIS response rate, defined as ≥ "improved" from baseline, was between 90 (2 weeks) and 100% (1 month) for SP-HA and was 100% for LP-HA, at both visits. Paired-samples t tests revealed significant differences in the change in WSRS scores between groups, at both visits (P < .01). Differences in the clinical effect and lifting capacity of both products were observed in 3-dimensional imagery and ultrasonography. Treatment volumes varied, with 61.32% more SP-HA being required than LP-HA for achieving a ≥ one-grade WSRS improvement. There were no severe AEs throughout the trial, nor AEs related to the investigational device.

CONCLUSIONS

LP-HA demonstrates better efficacy for correcting bony resorption in the nasal pyriform region.

The Role of Clinical Examination in Midface Volume Correction Using Hyaluronic Acid Fillers: Should Patients Be Stratified by Skin Thickness?

Background

Aesthetic physicians have several hundred injectable products to select from. Due to differences in their manufacturing technology, these products display varying biophysical qualities, such as their cohesivity and lift capacity. Currently, there is no guidance to objectively selecting the best product for a particular patient. Therefore, an algorithmic approach is required to take specific skin characteristics into consideration.

Objectives

To evaluate (1) whether subjects seeking injectable treatments for midfacial volume loss and/or contour deficiency can be stratified based on specific skin characteristics (eg, thickness, fat quantity, bony structure) and (2) whether particular hyaluronic acid fillers perform best when used in such particular strata.

Methods

This was a prospective, Phase IV, open-label, single-center clinical trial. Thirty female patients with midface/cheek volume loss and/or contour deficiency were recruited (mean age, 53.5 years; SD, 12.57; range, 35–75 years). Subjects were treated with either Restylane Lyft (HA_L) or Restylane Volyme (HA_V) and followed for 4 months post-injection. Treatment allocation was based on the treating physician’s clinical evaluation and compared with ultrasound evaluation. Ultrasound images were used to confirm stratification. Safety and efficacy assessments were performed at each study visit: baseline, week 2, week 4, week 8, and week 16. Subgroup analyses evaluated whether particular strata performed best when treated with specific products.

Results

The 2 investigative products varied in their efficacy, depending on the characteristics of the subject.

Conclusions

The use of a treatment algorithm may improve outcomes for patients seeking injectable treatments for midfacial volume loss and contour deficiencies.

Level of Evidence: 2

A Prospective, Multicenter, Randomized, Evaluator-Blinded, Split-Hand Study to Evaluate the Effectiveness and Safety of Large-Gel-Particle Hyaluronic Acid with Lidocaine for the Correction of Volume Deficits in the Dorsal Hand

BACKGROUND

Hand rejuvenation has become increasingly popular, but there are few reports published on the use of hyaluronic acid gels for correction of volume deficits in the dorsal hand.

METHODS

This study evaluated the efficacy and safety of large-gel-particle hyaluronic acid with lidocaine, a 20-mg/ml hyaluronic acid gel with 0.3% lidocaine, compared to no treatment for the correction of volume deficits in the dorsal hand. This was a prospective, multicenter, split-hand study in 90 subjects who received treatment with product in one hand. The primary efficacy endpoint was based on a 1 point of improvement with treatment versus no treatment according to the Merz Hand Grading Scale at week 12. Other assessments included Central Independent Photographic Reviewers evaluations of hand photographs, Global Aesthetic Improvement Scale, subject satisfaction, and safety.

RESULTS

The mean injection volume was 2.1 ml at the first treatment. Subjects demonstrated significantly higher response rates with treatment compared to no treatment at week 12 (85.9 percent versus 21.2 percent) and at weeks 16, 20, and 24 (p < 0.0001). Photographic Reviewers assessments showed consistently greater improvements in the treated hands compared with the untreated hands from week 12 to week 24. Most subjects and investigators (≥92.8 percent) reported improvements in Global Aesthetic Improvement Scale score across all time points with treatment. Treatment-related adverse events were reported in seven subjects (7.9 percent). Most of these were mild, and none were serious.

CONCLUSION

Hyaluronic acid with lidocaine is safe, effective, and well tolerated for the correction of volume deficits in the dorsal hand.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Microcannula Injection of Large Gel Particle Hyaluronic Acid for Cheek Augmentation and the Correction of Age-Related Midface Contour Deficiencies

BACKGROUND

There is a growing trend toward the use of blunt-tip microcannulas for the treatment of midface volume loss with injectable hyaluronic acid.

OBJECTIVE

To evaluate the safety and efficacy of large gel particle hyaluronic acid with lidocaine, injected with a blunt-tip microcannula, for cheek augmentation and the correction of age-related midface contour deficiency.

MATERIALS AND METHODS

Sixty subjects with mild to substantial loss of midface fullness were treated to optimal correction. Adverse events (AEs) were obtained during each examination visit. Efficacy was evaluated using the Global Aesthetic Improvement Scale, the Medicis Midface Volume Scale (MMVS), and the FACE-Q subject satisfaction questionnaire through 16 weeks.

RESULTS

Five AEs were reported, with only one being considered injection procedure-related (mild presyncope). No serious AEs were reported. Global aesthetic improvements were reported for the majority of subjects (≥98.3% for investigator-assessed and ≥91.5% for subject-assessed) for up to 16 weeks. At 8 weeks, the MMVS responder rate was 100% and subject satisfaction scores (5/6 questions) in the FACE-Q were ≥91.5%.

CONCLUSION

Hyaluronic acid with lidocaine, injected with a blunt-tip microcannula, has a favorable safety profile and is effective up to 16 weeks for cheek augmentation and the correction of age-related midface contour deficiencies (NCT03160716).

Assessment of Long-term Outcomes of Soft-Tissue Augmentation by Injecting Fibroblasts Suspended in Hyaluronic Acid Filler

Importance

In previous studies, this group has reported that cultured human fibroblasts suspended in hyaluronic acid (HA) filler might have potential use as a long-lasting injectable soft-tissue filler. However, the data were insufficient to determine the long-term outcomes.

Objective

To evaluate the long-term outcomes of cultured human fibroblasts suspended in HA filler used for soft-tissue augmentation.

Design, Setting, and Participants

A long-term case series study was performed. Between January 2010 and December 2013, a total of 38 patients were treated with fibroblast-HA filler mixture to augment nasal dorsa, nasolabial folds, and cheek depressions. Of these 38 patients, patients with follow-up period of greater than 3 years were included in this study. A total of 22 patients met the inclusion criteria.

Main Outcomes and Measures

Subjective assessment was performed to evaluate degree and time of resorption, improvement, satisfaction, softness of injection sites, and willingness to recommend this treatment to others. Objective assessment was carried out with patients' photographs. Safety and tolerability were also evaluated for this treatment.

Results

Of the 22 patients included in this study, 19 were women; mean (SD) patient age was 43 (15) years. All 22 patients experienced improvement following the treatment. Twenty (91%) patients were satisfied with the treatment. Nineteen patients (86%) considered that the injection site was as soft as it was before treatment. Patients' mean (SD) grading of improvement, satisfaction, and softness were 4.50 (0.51) (95% CI, 4.27-4.73), 4.14 (0.71) (95% CI, 3.82-4.45), and 4.82 (0.50) (95% CI, 4.59-5.00) at the last visit, respectively. Objective assessment demonstrated postoperative improvement in all patients: a rating of "much improved" was given to 7 patients (32%) by investigator 1; 8 patients (36%) by investigator 2; and 12 patients (55%) the injecting physician. This treatment was well tolerated; no adverse event was recorded for any patient.

Conclusions and Relevance

Injection of cultured human fibroblasts suspended in HA filler might be successful for long-term soft-tissue augmentation. To our knowledge, this study represents the longest follow-up study of soft-tissue augmentation with a fibroblast-HA filler mixture to date.

Level of Evidence

4.

Hyaluronic acid, a promising skin rejuvenating biomedicine: A review of recent updates and pre-clinical and clinical investigations on cosmetic and nutricosmetic effects

Hyaluronic acid (HA) plays multifaceted role in regulating the various biological processes such as skin repairmen, diagnosis of cancer, wound healing, tissue regeneration, anti-inflammatory, and immunomodulation. Owing to its remarkable biomedical and tissue regeneration potential, HA has been numerously employed as one of the imperative components of the cosmetic and nutricosmetic products. The present review aims to summarize and critically appraise recent developments and clinical investigations on cosmetic and nutricosmetic efficacy of HA for skin rejuvenation. A thorough analysis of the literature revealed that HA based formulations (i.e., gels, creams, intra-dermal filler injections, dermal fillers, facial fillers, autologous fat gels, lotion, serum, and implants, etc.) exhibit remarkable anti-wrinkle, anti-nasolabial fold, anti-aging, space-filling, and face rejuvenating properties. This has been achieved via soft tissue augmentation, improved skin hydration, collagen and elastin stimulation, and face volume restoration. HA, alone or in combination with lidocaine and other co-agents, showed promising efficacy in skin tightness and elasticity, face rejuvenation, improving aesthetic scores, reducing the wrinkle scars, longevity, and tear trough rejuvenation. Our critical analysis evidenced that application/administration of HA exhibits outstanding nutricosmetic efficacy and thus is warranted to be used as a prime component of cosmetic products.

A Novel and More Aesthetic Injection Pattern for Malar Cheek Volume Restoration

The loss of superior midface contour and projection can be corrected with the use of injectable hyaluronic acid (HA) dermal fillers, however, the most frequently used injection pattern employs a technique which was originally designed for malar implant surgery. Here we describe a novel injection pattern for restoring facial contours with a HA dermal filler inspired by traditional make-up artistry, which includes greater superolateral positioning of injection sites. Importantly, this technique helps injectors avoid creating an excess of volume in the anterior portion of the malar complex. Contributing authors/injectors, who now use this technique exclusively, have found that it has so far provided optimal aesthetic results for hundreds of patients with no observables complications. The malar cheek contributes much to the aesthetic curvature of the face and deserves a thoughtful update for injectable HA, as the traditional technique has never actually been aligned with its medium. In the experience of the contributing authors, this technique helps achieve a greater aesthetic outcome in the correction of midface contour deficiencies and has consistently resulted in high patient satisfaction. Level of Evidence IV 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .