Effective Rejuvenation with Hyaluronic Acid Fillers: Current Advanced Concepts

The gold protocol: A combined treatment approach for neck rejuvenation with calcium hydroxyapatite, botulinum toxin, and hyaluronic acid in the same session

BACKGROUND

The signs of aging seem to be more visible on the neck compared to other locations, especially if a patient has already gone through facial rejuvenation procedures. Treatment of the aging neck imposes a challenge to the clinician, since one single approach is usually not enough to achieve the desired result, requiring multiple injections and sessions, which apart from being painful for the patients, is time-consuming for the clinician.

AIM

To describe the use of calcium hydroxyapatite, incobotulinum toxin type A and Cohesive poly-densified matrix hyaluronic acid diluted in the same syringe and injected in the same session for neck rejuvenation.

PATIENTS AND METHODS

Fifteen women, older than 18 years, with cervical skin flaccidity grade 1-4 in a previously validated 5-point rating scale (Dermatologic Surg, 2016; 42, S94), who sought neck rejuvenation were injected in this pilot study with a single session with a combined hybrid mixture of calcium hydroxyapatite, incobotulinum toxin type A, and Cohesive poly-densified matrix hyaluronic acid and followed up for 90-180 days.

RESULTS

At the 4-month post injection evaluation, 93.3% of the patients presented at least 1-grade improvement in the 5-point scale as evaluated by the investigator. No serious adverse events were reported, being most mild and transient in nature.

CONCLUSION

CaHA, incoBonTA, and CPM-HA have complementary mechanisms of action and may be injected from the same syringe in the same session, boosting the final outcome, with high patient satisfaction, and ease of process for both patients and clinicians.

An Innovative Treatment Using Calcium Hydroxyapatite for Non-Surgical Facial Rejuvenation: The Vectorial-Lift Technique

BACKGROUND

The facial aging process entails alterations in the volume, shape, and texture of all skin layers over time. Calcium hydroxyapatite (CaHA) is a well-established safe skin filler with unique properties to resolve some skin alterations by stimulating neocollagenesis. The vectoral-lift (V-lift) technique targets the global repositioning of facial structures by addressing distinct anatomical injection planes. It includes deep facial augmentation with Radiesse PlusTM to retain ligament restructuring and superficial subcutaneous enhancement with diluted Radiesse DuoTM. Herein, we present cases that illustrate the use of this approach.

METHODS

This pilot study enrolled 36 participants (33 women and three men; ages 37-68 years) in a Brazilian clinical setting, and all patients underwent a single treatment. Photographs were taken at rest, in frontal and oblique views, before injection, and 90 days after treatment.

RESULTS

Treatment resulted in elevation of the upper and middle face, notable improvements in the infraorbital hollow, and adjustment of the mean facial volume.

CONCLUSIONS

The V-lift technique is a three-dimensional pan-facial treatment that relies on ligament support and face vectoring to obtain a lifting effect and facial contour restoration. It encompasses deep facial augmentation involving the use of Radiesse PlusTM for restructuring and retaining ligaments and Radiesse DuoTM for superficial subcutaneous enhancement. This approach targets a global repositioning of the facial structures by addressing distinct anatomical injection planes. It achieves a repositioning of the overall facial anatomy without requiring a substantial volumetric expansion.

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 .

The Anatomical Layering Assessment: The Construction of Beauty

Restructuring an aging face from bone structure to the surface of the skin can be metaphorically compared to building and renovating a house. While each anatomical layer of the face undergoes an aging process of its own, there is also an interdependency of superficial structures on deeper layers, so that a change in one layer may lead to changes to the adjacent layers. This interaction among the structures deep into the skin, along with the skin's ability to envelope them is what determine the aspect of the aging face. Thus, a careful assessment of all the layers is imperative and we describe herein a step-by-step facial layering assessment and facial restructuring approach from bone structure to the surface of the skin to implement a treatment plan able to deliver a harmonious rejuvenating outcome.

Comparison of 2 Fillers for Lip Injection-A Randomized-Controlled Clinical Trial Assessed by 3D Imaging

Background

Lip aging is a concern for many, and hyaluronic acid (HA) injections are a popular solution.

Objectives

This study compared 2 different HA gel technologies (OBT and NASHA) for lip augmentation in 20 volunteers.

Methods

Both groups received treatment from the same injector using the same method. Lip volume was measured with a 3D stereophotogrammetry device before, immediately after, and 30 days posttreatment. Patient satisfaction and adverse events were assessed through FACE-Q scales analysis.

Results

The NASHA group showed an immediate volume increase (P = .01), which decreased after 30 days. The OBT group did not show a significant immediate growth (P = .535) but did exhibit a significant increase after 30 days (P = .014). After 30 days, there were no significant volume differences between the groups (P = .802 and P = .999). FACE-Q analysis revealed no significant differences among groups after 30 days.

Conclusions

This study highlights that less cohesive gels may modify faster in dynamic lip areas, emphasizing the importance of selecting products based on their physicochemical and rheological properties. In the context of lip augmentation with HA, it is important not to consider immediate aesthetic changes as definitive results, as volume changes may persist and develop over time after the treatment.

Level of Evidence 2

Long-term Performance and Safety of Princess VOLUME PLUS Lidocaine for Midface Augmentation: The PRIMAvera Clinical Study

BACKGROUND

Hyaluronic acid-based dermal fillers are the most applied medical devices for midface augmentation.

OBJECTIVES

This postmarket investigation evaluated the long-term performance and safety of and patient satisfaction with Princess VOLUME PLUS Lidocaine (PVPL; now Saypha VOLUME PLUS Lidocaine) for the correction of midface volume deficit (MVD).

METHODS

This was an open-label, prospective, interventional, multicenter, noncomparative, postapproval study of 91 patients with moderate or severe MVD (grade 2 or 3 on the 5-point Midface Volume Deficit Severity Scale, or MVDSS). At Day 0 (Visit 1), patients were treated with PVPL; they returned for follow-up assessments at weeks 2, 4, 12, 24, 36, and 52 and had long-term follow-up until 36 months. A touch-up treatment could be done at week 2. The performance was assessed with the MVDSS, Global Aesthetic Improvement Scale (GAIS), and a subject satisfaction scale. Adverse events were collected to assess safety throughout the study.

RESULTS

Four weeks after treatment, 100% of injected patients improved by ≥1 grade on the MVDSS compared to baseline, with improvements still visible in 77% of patients 52 weeks after treatment. Based on the GAIS and post hoc survival analysis, the treatment effect was maintained for a median of 386 days, and in severe cases the effect lasted longer, which seemed to be independent of the volume injected at baseline. No serious side effects were reported. Results were substantiated by high patient satisfaction.

CONCLUSIONS

Princess VOLUME PLUS Lidocaine was perceived as safe and effective by patients and investigators, with long-term aesthetic improvement in moderate and severe cases.

LEVEL OF EVIDENCE: 3

A green-based approach for noninvasive skin rejuvenation: Potential application of hyaluronic acid

Gradually, loss of skin elasticity and elastic properties occurs after 30 years of age and will be associated with several changes, including creating wrinkles, skin laxity (sagging skin), and skin blemishes. In general, people all over the world are looking for ways to keep their facial skin young over time. There are several strategies to skin rejuvenate, including invasive and non-invasive methods. However, invasive methods have less popularity than non-invasive methods due to their need for specialist physicians (medical expertise), localized neuropathic pains for patients, the prevalence and incidence of skin infections, and high-cost clinical services. In the meantime, skin hydration is one of the simplest non-invasive methods for skin rejuvenation, and HA, with anti-aging and skin collagen-stimulating properties, has been introduced as a natural skin moisturizing agent. Therefore, since this composition maintains facial skin moisture and radiance, and improves its elasticity, it has always been considered by experts and specialist physicians. On the other hand, due to its lipophilic properties, hydrophilic macromolecules containing HA cannot pass through the stratum corneum. However, they have temporary and superficial softening effects on the skin. Hence, some nanocarriers have been suggested to overcome this problem and develop the properties and positive influences of HA on skin rejuvenation. Therefore, the present study aimed to introduce some new non-invasive approaches in facial skin rejuvenation, including applying liposomes, niosomes, ethosomes, and ionic liquids, to transport HA into the inner and deeper layers of the skin, including Dermis. In this review article, we examine non-invasive methods using nanoparticles to deliver HA to the epidermis and dermis of the skin for skin rejuvenation.

Connections between cohesion and properties that related to safety and effectiveness of the hyaluronic acid dermal fillers: A comparative study of the cohesive and non-cohesive gels

BACKGROUND

Although the importance of the cohesion of a hyaluronic acid (HA) filler has been recognized, the relationship between the cohesion and the other performance that related to safety and effectiveness, as well as the underlying mechanism is barely studied. Much efforts need to be made on this subject to provide guidance for clinical practice.

MATERIALS AND METHODS

Two types of the HA fillers (cohesive and particulate gels) were selected for the comparison of the cohesion and the other key physicochemical properties.

RESULTS

Hyalumatrix, with significantly higher cohesion, was homogeneously smooth and showed a linearly oriented morphology, whereas Matrifill and Restylane were particulate and showed obvious boundaries between particles. The high cohesion of Hyalumatrix is beneficial to the properties that related to safety and effectiveness, including recovery under shear stress, injectability, tissue integration and in vitro resistance to enzymolysis. The underlying reason was that the strong internal interactions of the cohesive gel protect the network structure from collapse and keep the gel as an intact whole when the gel was subjected to the stress. The homogeneously smooth morphology further improved the tissue compliance and injectability. The G' of Hyalumatrix is in the middle level of the commercially available HA fillers.

CONCLUSION

Hyalumatrix is a rare HA filler product to possess good cohesion and intermediate G' simultaneously. More clinical practice is needed to verify the connection between the cohesion of Hyalumatrix and the clinical performance.

Dizziness and Pain After Temporal Augmentation With Hyaluronic Acid

Hyaluronic acid is a commonly used soft tissue filler. However, it has been associated with numerous complications including skin necrosis, loss of vision, and cerebral infarction. In this article, the authors have reported the case of a 25-year-old woman who presented with significant dizziness and pain in the temporal and intrahairline region after undergoing hyaluronic acid augmentation of the temple and inner temporal hairline regions. Subsequently, the patient received 4 doses of a hyaluronidase injection to dissolve the emboli. She demonstrated improvement in clinical symptoms after emboli dissolution. During the 10-month posttreatment follow-up, the patient experienced gradual relief from pain and dizziness. The use of hyaluronic acid fillers should be limited in the intrahairline region as the resulting complications can be difficult to manage.

An Experimental Model Exhibiting Anterograde and Retrograde Vascular Occlusion of Facial Fillers to Avoid Vision Loss

Background

Facial filler injection techniques that help decrease the risk of vascular occlusion are an important growing area of study. This study demonstrates a model of injecting fillers into a simulated bifurcated arterial system, using different sized needle gauges at a constant injection pressure.

Methods

Three facial fillers were injected into a bifurcated intravenous tubing with continuous irrigation at a constant pressure to simulate a vascular system. Videography was used to observe for retrograde flow through the simulated supratrochlear artery to the bifurcation point, where the filler was redirected by anterograde flow into the branch representing the ophthalmic artery.

Results

Filler injection with retrograde flow to the bifurcation occurred with all the 27G needle trials. In comparison, the 30G needle trials were only able to reach the bifurcation point in three of the nine trials. The average time to the bifurcation point with subsequent ophthalmic artery anterograde flow with the 27G and 30G needles were 8.44 (95% confidence interval ±2.06) and 33.33 (95% confidence interval ±16.56) seconds, respectively.

Conclusions

Larger 27G needles consistently reached retrograde flow and the bifurcation point faster than 30G needles. This study suggests thinner needles may be less likely to cause retrograde occlusion.

Gender Facial Affirmation Surgery: Cheek Augmentation

Cheek augmentation is frequently used in facial feminization surgery. Options for augmentation include both surgical and nonsurgical techniques, such as autologous and non-autologous injections, implants, and osteotomies. Cheek augmentation can be combined with other facial procedures. Complications of cheek augmentation include malposition, resorption, asymmetry, and unfavorable cosmetic results. Cheek augmentation should be considered as part of an overall facial feminizing plan.

Enhanced Transdermal Absorption of Hyaluronic Acid via Fusion with Pep-1 and a Hyaluronic Acid Binding Peptide

It is always big challenges for hyaluronic acid (HA) in transmembrane absorbing and efficient delivering to the skin. Pep-1, as one of the cell-penetrating peptides, has been documented to permeate various substances across cellular membranes without covalent binding. Here, a novel hyaluronic acid binding peptide (named HaBP) is designed, and then combined with Pep-1 to enhance the cell-penetrating efficiency of HA. The results of ELISA and immunofluorescence assay show that HaBP could bind with HA very well, and a combination of Pep-1 and HaBP could efficiently improve the transmembrane ability of HA. Furthermore, HA gradually enters the dermis from the surface of the skin in mice when it is administrated with both HaBP and Pep-1, while there are no obvious allergies or other adverse reactions during this process. This study finds a new method to promote the efficient transmembrane and transdermal absorption of HA, and throws some light on further research on the development of hyaluronic acid and its related cosmetics or drugs.

Nasolabial Sulcus Rejuvenation: Paranasal Augmentation Using a Folded Dermal Graft

BACKGROUND

Nasolabial sulcus rejuvenation is steadily gaining popularity among Asians. Though many treatment options using synthetic grafts and autografts have been introduced, none of them has yet been accepted as an ideal technique. This study describes the operative procedure and evidence-based clinical outcomes of paranasal augmentation using dermal grafts.

METHODS

From March 2015 to August 2019, 56 patients underwent paranasal augmentation. The dermal graft, harvested from the buttock, was folded into 4 to 6 layers and inserted into the supraperiosteal pocket through a gingivobuccal incision. Ultrasonographic evaluation was performed at postoperative months 1, 6, 12, and 18 to appraise the change in the thickness of the graft.

RESULTS

No major complications, including foreign body sensation and graft extrusion, occurred. The average dermal thickness was 10.31 mm at postoperative month 1 and 6.30 mm, 5.21 mm, and 5.17 mm at postoperative months 6, 12 and 18, respectively. The average absorption rates were 38.72%, 49.36%, and 49.92% at postoperative months 6, 12, and 18, respectively.

CONCLUSIONS

Paranasal augmentation using a folded dermal graft serves as a useful method to rejuvenate the midface with durable and aesthetically satisfactory outcomes. By virtue of biocompatibility, complications occurred rarely compared with the artificial implants.

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.

Anatomical Basis for Malar Augmentation Injection With the Zygomatic Ligamentous System

BACKGROUND

The malar augmentation injection has gained popularity in recent years, but the exact location of each injection site has not been clearly identified.

OBJECTIVE

To discover ideal injection sites by comprehensively considering the distributions of ligaments, muscles, and vessels.

MATERIALS AND METHODS

Eighteen cadaver heads were dissected to investigate the zygomatic ligamentous system and to measure the position of muscles. Sixty-six cadaver heads were subjected to computed tomographic scanning and three-dimensional vessel reconstruction. Radiological evaluation of the fillers was performed before and after experimental injection in one hemiface and dissected to confirm safe delivery. Five patients were enrolled in a prospective clinical study. 2D and 3D photographs were taken before and after the injections for comparison.

RESULTS

Site 1 was defined along the zygomatic arch, except the first 1/4 length and the midline of the arch. Site 2 was on the body of the zygoma, superior to the level of the infraorbital foramen and medial to the jugale. Site 3 was defined in the anteromedial midface approximately 30 mm below the lateral canthus.

CONCLUSION

Injections at these 3 sites can be performed within the range of the ligaments to achieve effective lifting effects and minimize potential complications.

Current Practices in Hyaluronic Acid Dermal Filler Treatment in Asia Pacific and Practical Approaches to Achieving Safe and Natural-Looking Results

Complications such as delayed inflammatory reactions (DIRs) and unnatural outcomes can sometimes arise from hyaluronic acid (HA) dermal filler treatments and can be challenging to address. Given the popularity of HA dermal fillers for aesthetic procedures, there is a need for preventive strategies to minimize these complications. Two hundred practitioners from 10 regions in Asia Pacific who administer HA fillers completed a survey on prevention of DIRs and unnatural outcomes. Thirteen global experts convened to evaluate the current practices and propose practical approaches for safe and appropriate use of HA dermal fillers. From the survey, the top three measures used to reduce the risk of DIRs included choosing an appropriate HA filler, aseptic technique, and patient selection. Key strategies employed to achieve natural-looking outcomes were treatment customization, understanding the rheological properties and behavior of different HA fillers, and being conservative in treatment approach. The panel developed a concise reference guide aimed at minimizing the risk of DIRs while achieving natural aesthetic outcomes. Five practical considerations were recommended: patient assessment and individualization of treatment plan, choice of an appropriate HA filler, adequate knowledge of facial anatomy, strict adherence to aseptic methods, and proper injection technique. The panel highlighted the need for education efforts to increase awareness of differential immunogenicity between HA fillers and to improve understanding on the importance of preserving aesthetic individuality for optimal results. These practical insights from the global experts support practitioners in optimizing safety and quality of aesthetic treatment with HA fillers.

Non Surgical Facelift - by PDO Threads and Dermal Fillers: A Case Report

BACKGROUND

Non-surgical, minimally invasive techniques are an effective way to bring a facelift with long lasting results; and minimal downtime and side effects. Due to an increased awareness and growing social acceptability, a large number of patients have been seeking these treatments to maintain a youthful appearance.

OBJECTIVE

To assess the efficacy of combined use of PDO threads and hyaluronic acid fillers for non-surgical facelift in a male patient.

METHOD

A 39-year-old male patient underwent a non-surgical facelift using a combination of PDO threads and hyaluronic acid dermal fillers. Treatment was done in two sessions at an interval of one week using 4 pair mint PDO cog threads in the first session followed by injection of 5ml of hyaluronic acid dermal filler (4 ml JuvedermVoluma and 1 ml Juvederm Ultra Plus).

RESULTS

Combined use of PDO threads and dermal fillers is an effective technique for face lift and to correct sagging. Significant improvement is seen within a week of procedure which ensures high degree of patient satisfaction.

CONCLUSION

Facial rejuvenation and lifting using PDO cog threads and hyaluronic acid dermal fillers are effective in providing immediate, long lasting results with minimal downtime.

Application of Nonsurgical Modalities in Improving Facial Aging

Objective. This review aims to summarize different kinds of applications of minimally invasive surgery in improving facial aging to provide a comprehensive and accurate introduction on the issue of esthetic treatment of facial skin. Overview. In the twentieth century, facial rejuvenation has become a new beauty trend. Facial cosmetology has entered a period of antiaging and rejuvenation therapies and microplastic surgery. The pursuit of beauty has promoted the development of minimally invasive plastic surgery. This review introduces the possible causes of facial aging and its related topics with a focus on facial injectable drugs, such as botulinum toxin, main filler materials (hyaluronic acid, calcium hydroxyapatite, poly L-lactic acid, collagen, autologous fat, and polymethyl methacrylate), and some current antiwrinkle technologies, such as thread lift and radiofrequency rhytidectomy. Conclusions. Despite the difference in mechanisms of action, each technique can address facial aging involving the loss of collagen, displacement and enlargement of fat, and muscle relaxation. Combinations of these treatments can provide patients with reasonable, comprehensive, and personalized treatment plans.

Efficacy and safety of two hyaluronic acid fillers with different injection depths for the correction of moderate-to-severe nasolabial folds: A 52-week, prospective, randomized, double-blinded study in a Chinese population

BACKGROUND

Hyaluronic acid (HA) fillers are known to be effective for the correction of facial wrinkles and folds, but there is no clinical study that compares the efficacy of small-to-medium-particle HA fillers and large-particle HA fillers for the correction of nasolabial folds (NLFs). Moreover, injection depth also plays an important role in the correction of NLFs as well as improvement of facial aesthetics.

OBJECTIVES

To assess the efficacy, safety, and durability of a small-to-medium-particle HA filler, Restylane, and a large-particle HA filler, Yishumei, as well as the effect of injection depth in the correction of moderate-to-severe NLFs and facial aesthetics in a Chinese population.

METHODS

This 52-week, prospective, randomized, double-blind study enrolled 100 participants with moderate-to-severe NLFs. The participants were randomized to receive either Restylane (Group A) or Yishumei (Group B). Group A and Group B were further randomly divided into a superficial injection group (Group A1 & B1) and a deep injection group (Group A2&B2) according to injection depth. Improvement in the Wrinkle Severity Rating Scale (WSRS) score and Global Aesthetic Improvement Scale (GAIS) and participants' satisfaction were evaluated as endpoints. All adverse events were monitored throughout the study.

RESULTS

The treatments were well tolerated by all the participants. All four groups showed a reduction in their mean WSRS scores and GAIS scores by week 12. At week 24, the WSRS and GAIS scores did not change in Group A1 and A2, while participants in Group B1 and Group B2 had higher WSRS and GAIS scores than those in the previous weeks. By week 52, the WSRS scores in all the groups returned to almost baseline levels. The mean FACE-Q scores increased compared with the baseline scores in all groups through week 24. Most participants were satisfied with their treatment, and no meaningful differences were found between the fillers in terms of participant satisfaction. The most common adverse events were swelling, redness, and tenderness at the injection site, but they resolved spontaneously without treatment.

CONCLUSION

The two HA fillers had good therapeutic effect on NLFs in the early stage of treatment, but Restylane had a more prolonged effect. Moreover, compared with the superficial injection, the deep injection provided slight midface lifting and improved facial aesthetics.

A Prospective, Observational Registry Study to Evaluate Effectiveness and Safety of Hyaluronic Acid-Based Dermal Fillers in Routine Practice: Interim Analysis Results with One Year of Subject Follow-Up

Background

Monitoring the effectiveness, safety and emerging uses of hyaluronic acid (HA) fillers in their wide range of indications requires a holistic approach.

Purpose

To propose an observational study design aiming to gather real-world evidence (RWE) and continuously evaluate the performance and safety of marketed devices in routine practice.

Materials and Methods

A prospective, observational registry was initiated at six European sites. Investigators enrolled any subject receiving at least one injection with a target study device (TEOSYAL Deep Lines [HA_DL] and/or Global Action [HA_GA]). They followed their routine practice regarding injection technique, volume, and subject follow-up. Effectiveness was evaluated at 3 months using the global aesthetic improvement scale (GAIS). Safety was assessed based on common treatment reactions (CTR) and adverse events (AE).

Results

High quantity of RWE was collected following the initiation of this registry. In the first 158 subjects enrolled, 1220 injections were performed in more than 25 indications, including 679 with the target devices and 271 with devices of the same filler line. The primary objective was achieved, with 93.9% of treatments providing improvement at Month 3 according to the PI and subject. Post-injection CTR were mild to moderate and short-lived, and there was no clinically significant AE. More than 76% of treatments still provided some visible effect at month 12.

Conclusion

Based on RWE, HA_DL and HA_GL are effective and safe in their respective indications mostly distributed in the midface, perioral region, and lower face. Observational registries are a valuable asset in the context of post-market clinical follow-up.

Injectable Filler Technique for Face Lifting Based on Dissection of True Facial Ligaments

BACKGROUND

Strengthening weakened ligament tissues with injectable fillers to improve their supportive effect may achieve the aesthetic goal of face lifting.

OBJECTIVES

The aim of the study was to design an injectable technique for enhancing the true facial ligaments and dissect the ligaments to provide anatomical guidance for effective injection.

METHODS

Six true facial ligaments were chosen as target anatomical sites for injection. Specimens were dissected, and 3-dimensional (3D) images were reconstructed to confirm the exact location of each injection site and to confirm that the proposed injection routes will not cause dangerous vascular damage. A total of 5 patients received the injections; 3D images were taken before and after the injections for comparison and clinical outcome assessments.

RESULTS

The injection technique was designed to target 6 true facial ligaments, as follows. Site 1 targeted the temporal ligamentous adhesion region to lift the lateral ends of the eyebrows. Site 2 targeted the region of the lateral orbital thickening to lift the lateral canthus. Site 3 and site 4 targeted the zygomatic retaining ligaments and zygomatic cutaneous ligaments, respectively, to augment the soft tissues of the midface. Site 5 targeted the region of the maxillary ligament to lessen the nasolabial folds, and site 6 targeted the mandibular ligament to reduce the marionette line.

CONCLUSIONS

This site-specific injection technique targeting the true ligaments may lead to increased efficiency and accuracy of face rejuvenation and exert a lifting effect.

LEVEL OF EVIDENCE: 4

Radiographic Features of Facial Cosmetic Material: Report of Two Cases

Recently, the use of noninvasive facial cosmetic procedures has been widely disseminated. In the face, cosmetic fillers, threads, and implants are used to reduce or delay the effects of aging or adjust facial defects caused by trauma or disease. The dentist or dental specialist may encounter these materials in the radiographic images of their patients. There are few reports in the dental literature describing the radiographic appearance of some materials along with the diseases they mimic. As the procedures and materials advance and evolve, dentists and dental specialists must be aware of their radiographic appearance to avoid errors in diagnosis. This is a report of two cases that include panoramic radiography and CBCT scan. Among these cases, there is an unusual appearance of a cosmetic filler due to a subperiosteal injection method. Moreover, it will discuss common types of cosmetic materials used in the face and their imaginological appearance. This is the key to dentists and dental specialists due to increasing use of facial cosmetic materials and a parallel increase in the use of cone beam CT and chances to encounter such findings.

Transvascular Hydrolysis of Hyaluronic Acid Filler With Hyaluronidase: An Ex Vivo Study

BACKGROUND

Despite the favorable safety profile of hyaluronic acid (HA) dermal fillers, side effects can occur. Skin necrosis is one of the most severe early-occurring complications resulting from accidental vascular impairment. Hyaluronidase (HYAL) is commonly used to degrade HA chains, allowing the degraded product to pass through vessels, and thus relieving the vascular obstruction.

OBJECTIVE

The purpose of this study is to evaluate, in an ex vivo setting, the capability of HYAL to degrade crosslinked HA that was injected into human vessels.

MATERIALS AND METHODS

During a neck dissection, a portion of the anterior jugular vein and facial artery was harvested. The vein and artery specimens were filled with 25 mg/mL of crosslinked HA filler. Each specimen was soaked in 0.5 mL of HYAL (300 IU/mL), in its own test tube, for 4 hours, after which the remaining HA was quantified.

RESULTS

The remaining HA volume was found to be 0.02 mL in the vein segment and 0.002 mL in the artery segment.

CONCLUSION

A single administration of HYAL may not be adequate to restore blood flow in the event of embolism, and relatively high doses of this enzyme must be injected hourly into the affected tissue until resolution is complete.

Surgical Lip Remodeling Following Permanent Filler Injection: A Scoping Review

ABSTRACT

Over the years, several techniques have been introduced to obtain permanent lip enhancement, such as the use of silicone lip implants or the off-label use of permanent fillers. Although some reports indicate that permanent lip filler is safe, many others describe early- and late-onset complications. The main issue with permanent lip fillers is the lack of a standard technique to correct undesirable results. The aim of this scoping review was to list and evaluate the surgical pathways described in literature to correct lip deformity resulted from the injection of permanent fillers. The methods and the inclusion criteria of this work were specified in advance and documented in a protocol, according to the PRISMA 2009 checklist. The research was carried out on electronic databases PubMed, Cochrane Library, and Scopus databases identifying articles from March 1991 to December 2020 and conducted up to December 23rd, 2020. Articles language was limited to English. The selection process identified 3 retrospective studies eligible for inclusion. 73 patients and a total of 111 lips (72 upper and 39 lower) were considered. Two early complications were identified, 1 suture dehiscence and 1 total lip mucosa necrosis. Surgical lip remodeling following permanent filler injection seems to be an effective approach although the surgical pathway needs to be customized per each patient. Complication rate seems to be coherent to lip surgery performed with reconstructive purposes. To confirm these data case-control studies with much wider cohorts are needed to reach statistical significance.

Male lip filler-Aesthetic enhancement is not just limited to females: A case report

BACKGROUND

Lips play an important role in facial aesthetics. Hyaluronic acid fillers have been widely used for lip augmentation in females but very few men seek this treatment due to the fear of feminization of lips. However, there are very few case reports published for correction of lips using fillers in men.

AIM

To assess the effectiveness of hyaluronic acid dermal fillers for enhancement of lips in males.

METHOD

A 52-year-old male underwent two sessions of treatment for inturned lips. In the first session, 2 ml hyaluronic acid dermal filler (Juvederm Ultra Plus-JUP) with 27G × 8 mm needle via bolus and retrograde linear thread technique was used. Assessment of lips was done after one week. Second session of treatment was done after 30 months of first treatment with 1 ml of filler.

RESULTS

Injection of filler not only led to a significant improvement in vermillion show, but also improved the overall facial appearance. The results of this treatment were long lasting and even after 30 months from the first treatment the patients' vermillion body still showed ten per cent improvement from the original.

CONCLUSION

Dermal lip filler treatment in men can be a very satisfying and rewarding procedure. Its awareness should be spread afar to increase its acceptability.

Use of Hyaluronic acid fillers in treatment of periorbital melanosis induced by tear trough deformity: Anatomical considerations, patient satisfaction, and management of complications

BACKGROUND

Periocular melanosis (POM) due to shadow effect of tear trough deformity (TT) does not respond to the conventional treatment modalities. Hyaluronic acid (HA) fillers are a favurable treatment modality. This area is a high risk for injectables due to its unique anatomy.

AIMS

To find role of HA fillers in treatment POM due to TT deformity with special emphasis on practical anatomy, patient satisfaction rate, and management of complications. A correlation of the grade of TT, age of the patient, and patient satisfaction was done. A follow-up at 1 year was done to assess longevity of results.

METHODS

Retrospective study of 60 cases of clinically diagnosed POM (120 TT) due to TT deformity was performed. Each patient was injected with 1 ml, cross-linked HA 22.5 mg/ml in under-eye area using 30 G needle or a 25 G cannula. Follow-up was done at 2 weeks, 4 weeks, and 1 year.

RESULTS

Mean age of patients was 36.4 years. Majority of patients, that is, 31 (52%) were in the age group of 30-40. As per Hirmand's classification, 46.6% (28/60) had grade 2 TT which was most common. We graded results in the form of VAS and 80% patients had VAS > 7. There were no major side effects.

CONCLUSION

Hyaluronic acid fillers are promising treatment modality without any major side effects. Both needle and cannula can be used effectively. Patient satisfaction is higher in younger patients with low grade of TT and results persisted in all cases for a minimum of 1 year.

1540-nm fractional erbium: Glass laser is a safe and effective modality for nonablative facial rejuvenation

BACKGROUND

Laser treatments for facial rejuvenation are common, with ablative modalities being of more common use for this indication. Efficient nonablative modalities are of rising demand.

AIM

Our aim was to determine the safety and efficacy of high-fluence, nonablative 1540-nm fractional Erbium:glass laser for facial rejuvenation.

PATIENTS AND METHODS

A retrospective study of patients treated with 3-4 treatments using the 1540-nm fractional Erbium:glass laser for facial rejuvenation, using 2500-3000 mJ/stacked pulses (51-61 mJ per pixel). Patients were followed-up for 3 months following their last treatment. Before and after photos were independently blindly evaluated by 2 dermatologists, who graded them using a scale from 0 (exacerbation) to 4 (76%-100% improvement) for 2 different facial regions (frontal face region and lateral canthal region). Pain perception and adverse effects as well as patient satisfaction were documented throughout the study.

RESULTS

Sixteen patients completed both treatment and follow-up period. At the 3-months posttreatment follow-up visit, moderate-to-significant improvement in rhytids appearance (mean grade of improvement: 2.93 for frontal face and 3 for lateral canthal region) was observed. Patients' satisfaction was high (4.25). Patients reported mild and transient erythema posttreatment with no other adverse effects.

CONCLUSION

The high-fluence 1540-nm fractional Erbium:glass laser is a safe and effective nonablative modality for facial rejuvenation.

The Impact of Dermal Fillers on Perceived Personality Traits and Attractiveness

BACKGROUND

Dermal fillers are increasingly popular for facial rejuvenation and enhancement, including effacement of nasolabial folds (NLFs) and marionette lines and lip augmentation. This study aimed to evaluate casual observer perception of physical and interpersonal traits of subjects who receive filler treatment.

METHODS

An anonymous survey of 8 before/after treatment photographical sets was administered in Likert scale format (1-7) using online crowdsourcing. Three sets of photographs were before/after NLF/ marionette line treatment, three of lip augmentation, and two internal controls. Respondents were surveyed on personal demographics, as well as perceptions of subject photographs across nine domains (facial symmetry, confidence, likeability, youthfulness, trustworthiness, attractiveness, intelligence, approachability, happiness).

RESULTS

In total, 260 respondents completed the survey. The majority were male (63.1%), Caucasian (58.1%), 18-34 years old (58.1%), and college graduates (66.2%). Respondents rated photographs with line filler treatment and lip filler treatment as significantly improved compared to the pre-treatment photographs across all nine trait domains [p < 0.001, for all]. No differences were found between the control photosets [p > 0.05, for all]. Middle-aged respondents (35-55 years) were more likely to perceive treated filler photographs as more youthful than younger respondents (18-34 years) [p < 0.006] Additionally, respondents with lower educational attainment (high-school graduate or less) were more likely to perceive treated patients as less intelligent compared to higher-educated respondents (college/postgraduates) [p < 0.05, for both].

CONCLUSION

The use of dermal fillers for treatment of NLF/marionette lines and lip augmentation have significant associations with the perception of improved attractiveness and several personality traits. Additionally, casual observer demographic subgroups may influence perceptions.

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 .

Temporal Fossa Atrophy in Aesthetic Medicine: Anatomy, Classification, and Treatment

Hyaluronic acid fillers indisputably represent an important tool for face rejuvenation and volume restoration. The temporal area has recently been considered as a potential site of injection. As it happens in the middle face and in other regions of the face, the temporal fossa changes according to the aging process. In a young person, the temple profile has a fullness aspect, and this contributes to giving the face a beautiful and healthy appearance. With age, the loss of volume leads the bone prominences to be visible. The aim of this article is to classify the temporal fossa atrophy and get better into the anatomy, identifying the ideal plane to inject in, through the use of a safe and reliable technique. Cadaver dissections have been performed to specifically describe the anatomy of the temple layer by layer. The authors’ preferred technique, called interfascial by cannula implantation, is discussed. All the treated patients reported a good improvement by survey according to the Global Aesthetic Improvement Scale scale. No major complications were detected. No ecchymosis neither swelling were documented. Although further studies are necessary to broaden the casuistry and better verify the potentiality of this technique, the authors do believe that it could be considered a very reliable procedure with pretty consistent results, if supported by an adequate and imperative anatomical knowledge.

Better Results in Facial Rejuvenation with Fillers

Facial rejuvenation is a rapidly advancing field in aesthetic medicine. Minimally invasive techniques represent a powerful tool for rejuvenation, and fillers are a popular modality with which to restore and optimize facial proportions. Currently, our filler armamentarium is characterized by products with an increasing variety of biochemical compositions warranting tailored injection approaches. An intimate knowledge of anatomy, product characteristics, and appropriate injection techniques is essential to achieve optimal results while maintaining patient safety. Here, we review facial anatomy, structural changes secondary to aging, appropriate filler selection, safe injection techniques, and complications.

Hyaluronic acid-based two-stage medical therapy to unfold the aged face: The centrifugal approach

BACKGROUND

Facial aging is a multifactorial process characterized by structural changes to the dermis and ligaments, lipoatrophy in the fat pads and hypodermis, remodeling of the bony skeleton, change in muscle tonicity and tissue descent.

AIMS

The purpose of this study is to evaluate the efficacy of a hyaluronic acid-based treatment for the aging face that addresses all its causes in a caudal to cranial and medial to lateral direction: the centrifugal technique.

METHODS

Between March 2015 and January 2018, 187 patients were treated with a high G' hyaluronic acid in two sessions, one/two weeks apart, to improve signs of facial aging, starting from the lower centrofacial area and progressing laterally and cranially. Results were assessed using a Global Aesthetic Improvement Scale (GAIS) judging pre- and post-treatment (32 weeks) pictures.

RESULTS

The technique effectively treated the aging face. The investigator and all patients evaluated the results improved or very much improved and agreed that the results were very natural looking.

CONCLUSION

Use of a systematic centrifugal technique to address the signs of facial aging resulted in significant and long-lasting improvement, as judged by the investigator and high patient acceptance and satisfaction.

Cross-linked hyaluronic acid filler hydrolysis with hyaluronidase: Different settings to reproduce different clinical scenarios

Skin necrosis is the most severe complication arising from hyaluronic acid (HA) injection. To avoid skin necrosis, hyaluronidase should be injected along the course of the involved artery, to allow blood flow restoration. We evaluated the ability of hyaluronidase to degrade a HA filler in two simulated clinical situations-a compression case and an embolization case-to identify differences in the hyaluronidase injection. In the compression case, a bolus of HA filler was directly soaked in hyaluronidase solution; in the embolization case, a vein harvested from a living patient was filled with the same HA filler and then soaked in hyaluronidase. We then evaluated the quantity of HA remaining after 2 hr. While we found hydrolysis of HA in both cases, in the compression case, we detected almost complete hydrolysis, whereas in the embolization case we observed a reduction of the 60%. Our results support the hypothesis that vessel compression can be resolved with only one injection of hyaluronidase, while in the case of vascular embolization, repeated perivascular injections should be performed owing to the reduction of hyaluronidase activity.

Prevention and Management of Serious Complications After Facial Fat Grafting

Facial fat grafting is increasing worldwide. Although there are few reports in the literature on complications following facial lipofilling, rare but serious complications include embolic risk to local end organs such as the skin and eye, and the central nervous system. Treatment strategies are outlined. The key to prevention of complications is understanding the regional anatomy. It is imperative to adhere to the safe and efficacious techniques to minimize risk. Every surgeon who performs facial fat grafting should establish a systematic method to deliver safe, consistent, and long-term results for their patients.