Hyaluronic Acid Filler in HIV-Associated Facial Lipoatrophy: Evaluation of Tissue Distribution and Morphology with MRI

Hyaluronic Acid Filler Longevity in the Mid-face: A Review of 33 Magnetic Resonance Imaging Studies

Background

Recent evidence challenges the conventional belief that hyaluronic acid (HA) fillers have a short lifespan of 3-12 months. This study, using extensive patient data and long-term imaging post-injection, suggests a need to reconsider refilling protocols and underscores the critical role of precise clinical photography for accurate comparisons.

Methods

The study enrolled 33 patients who received HA fillers in the mid-face, excluding those with recent injections, permanent fillers, or specific medical histories. Magnetic resonance imaging (MRI) was conducted on 24 asymptomatic and nine edema-concerned patients over 2.5 years. Two blinded radiologists assessed filler presence and longevity based on requested MRI observations.

Results

MRI scans confirmed HA presence in all 33 patients, with no complete dissipation observed over a 2-year period post injection. Among them, 21 had not received injections for 2-5 years, 12 for over 5 years, and some for up to 8-15 years. Varying volumes of HA were noted: mild in nine patients, moderate in 13, and severe in 11. The study reported HA longevity of up to 15 years across different products, with a 95% confidence interval of 84.47% ± 4.43%, demonstrating the persistence of cross-linked HA fillers in the mid-face.

Conclusions

HA fillers remained detectable for at least 2 years in all 33 patients, with one patient showing filler longevity of up to 15 years. These findings suggest significant implications for filler management practices. Further research with larger cohorts and ongoing imaging follow-up is warranted to fully understand HA filler longevity and optimize clinical protocols.

Comparative Clinical and Histomorphologic Evaluation of the Effectiveness of Combined Use of Calcium Hydroxyapatite and Hyaluronic Acid Fillers for Aesthetic Indications

Hyaluronic acid and calcium hydroxylapatite (CaHA) have been used for in the field of soft tissue augmentation. Both materials have been used in combination to enhance tissue remodeling and provide a more rejuvenated look. Sequential injections of Belotero Volume (CPM-HA V) and CaHA had a relatively greater remodeling effect on one's skin compared with the simultaneous injections of CPM-HA V and CaHA. Simultaneous injection of the studied products is possible from the point of view of safety, but different levels of administration will be more optimal, which will provide a more pronounced remodeling effect on the skin.

Imaging Features and Complications of Facial Cosmetic Procedures

Facial aesthetic procedures have become increasingly popular and complex, making knowledge of facial anatomy crucial for achieving desired outcomes without complications. Some of the most common procedures include blepharoplasty, bichectomy, face-lifts, facial implants, thread lifting, and fillers. Blepharoplasty and bichectomy are surgical procedures that respectively aim to restore youthful contours to the periorbita and create a slimmer lower face by removing Bichat fat from the maxillofacial region. Facial implants are used for aesthetic augmentation of the skeletal structure and restoration of facial contour by using biomaterials or autogenous bone grafts. Face-lift surgeries involve incisions and removal of excess skin, and thread lifts involve less invasive procedures performed by inserting threads beneath the skin, with the aim to lift the skin and thus reduce wrinkles and sagging. Fillers improve wrinkles and loss of facial volume, with biologic types made from animal, human, or bacterial sources (such as hyaluronic acid), while synthetic fillers include substances such as paraffin, silicone, calcium hydroxyapatite, polymethylmethacrylate microspheres, polyacrylamide hydrogel, hydroxyethyl-ethyl methacrylate, and poly-l-lactic acid. Synthetic fillers can be classified as rapidly resorbable (<12 months), slowly resorbable (<24 months), or permanent. Imaging modalities such as US, CT, and MRI can help identify and analyze each type of facial aesthetic procedure or filler, as well as their possible complications such as foreign-body granuloma, noninflammatory nodule, late intermittent persistent edema, filler migration, infection, or complications after removal of the buccal fat pad. ©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center The online slide presentation from the RSNA Annual Meeting is available for this article.

A Rare Case of Migration of Hyaluronic Acid Gluteal Injection to the Medial Thigh Presenting as a Soft Lump

Introduction Hyaluronic acid (HA) is a widely accepted agent most commonly used as a dermal filler in facial aesthetic/cosmetic medicine. More recently, HA has been utilized for gluteal augmentation. The common side effects of HA injection are often minor and self-limiting. HA migration is a very rare complication.

Case Report We describe a rare case of HA buttock injection migration in a transgender patient, appearing as a superficial lump on right thigh representing a diagnostic dilemma. We highlight the need of a clinical suspicion and discuss the appropriate investigations for guided management of such patients.

Conclusion It is essential for reporting radiologist to be aware of the commonly used injectable fillers, their complications, and imaging findings to avoid misdiagnosis and guide optimal patient management.

Infraorbital Hyaluronic Acid Filler: Common Aesthetic Side Effects with Treatment and Prevention Options

Background

Infraorbital hollows can give a fatigued or aged appearance, which can be treated by volumizing the segmented transition from the tear trough to the cheek with hyaluronic acid filler. Due to thin skin and the complex anatomy of the infraorbital area, both short- and long-term side effects (SEs) from this treatment are very common. While some patients are clear surgical candidates vs filler candidates, in real-world practice, many, if not most, patients are on a continuum where either procedure is appropriate, and the treatment decision is individualized based on each person’s risk vs benefit profile.

Objectives

Common aesthetic SEs from hyaluronic acid filler treatment in the infraorbital area will be reviewed, including their etiology, prevention, detection, and treatment.

Methods

The author’s experience from injecting the infraorbital areas of more than 800 patients in private clinical practice and observations from both short- and long-term follow-ups over 8 years is leveraged to provide detailed guidance.

Results

Recommendations on injection techniques, patient selection, and patient education are presented along with algorithms for the prevention and management of bruising, short- and long-term swelling, bumps, and blue discoloration (which is usually secondary to swelling from the filler rather than just the filler alone placed or migrating too superficially).

Conclusions

For nearly all patients, complete dissolution of filler with hyaluronidase is not required to address the issue, and the guidelines provided here will assist clinicians in the management of SEs to increase patient satisfaction with their treatment and aesthetic outcome.

Level of Evidence: 5

MRI Visualization and Distribution Patterns of Foreign Modeling Agents: A Brief Pictorial Review for Clinicians

Since the ancient Egyptians, people have always been worried about their physical appearance. Nowadays, for some cultures like Latin American, physical appearance depends on the context, and the concept of beauty is to have wider hips and more prominent buttocks. One way to achieve these goals is to inject foreign modelants that include some oils to modify certain body regions. Until today, the search continues to find a modelling agent that is nonteratogenic, noncarcinogenic, and not susceptible to infection and can stay at the spot where it was injected (not migration). This review is aimed at providing a brief, comprehensive assessment of the use of modeling agents and summarizes some key imaging features of filler-related complications. The topics of this review are historical data, epidemiology, classification of dermal fillers (xenografts, hyaluronic acid derivatives, autografts, homografts, synthetic materials), adverse reactions, imaging method used in the detection of injectable fillers, MRI patterns observed in complications of injectable fillers, and histological findings of immune response, treatment, and conclusions. We present several classifications of injectable fillers based on composition, degradation, and complications. Additionally, readers will find some representative cases of the most common locations of injectable fillers demonstrating their infiltrative MRI patterns.

Hyaluronic Acid Filler Longevity and Localization: Magnetic Resonance Imaging Evidence

SUMMARY

Hyaluronic acid is the most commonly used facial dermal filler in aesthetic medicine. Identification of placement, longevity, and localization of hyaluronic acid fillers are becoming increasingly important. This article proposes a practical approach to monitoring the location and longevity of hyaluronic acid, using magnetic resonance imaging.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

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.

Histological and Quantitative Appraisal of the Intradermal and Subcutaneous Distribution of the Hyaluronic Acid Injected into the Nasolabial Fold

BACKGROUND

Histological analysis of hyaluronic acid (HA) applied in the nasolabial fold (NLF) studied gel distribution into the dermis and subcutaneous fat, correlating density of NLF tissues, with cohesivity, concentration and degradation of HA.

METHOD

Ten patients received two injection points on each NLF. They were intradermal near the nasal ala and subcutaneous near the oral commissure. Injection points received 0.1 ml of 24 mg/ml HA cross-linked by BDDE 2.0 ppm through a bolus technique injection without retrograde backflow. Biopsies were taken 72 h and 9 months after application to histological analysis.

RESULTS

Dermis density fragmented the gel into small nodules, spreading it into the reticular dermis. Seventy-two hours after application, average diameter of the small nodules was 0.30 mm and at month nine 0.05 mm. Softness of the subcutaneous fat and high concentration of HA created a single and compact nodule. Seventy-two hours after application, average of nodule diameters was 1.05 mm and at month nine 0.49 mm. HA biodegradation occurred on the external surface of the gel. The single nodule offered small contact surface to enzymes, slowing gel degradation. The sum average of the diameters of the small nodules offered a large contact surface to enzymes, accelerating gel degradation.

CONCLUSION

Permanence of the HA into the tissues depended on the relationship between the gel distribution and its degradation. Due to the small contact surface of the single nodule to enzymes, permanence of the HA into the subcutaneous fat was more extended than into the dermis.

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 .

Quantitative magnetic resonance imaging: differentiating soft tissue implants and fillers used in cosmetic and reconstructive surgery

OBJECTIVE

To evaluate the value of synthetic magnetic resonance imaging (MRI) and T2 mapping in distinguishing between different types of fillers in soft tissues.

MATERIALS AND METHODS

Ex vivo fillers of buttock soft tissues (silicone, collagen, and different types of hyaluronic acid) were scanned using a synthetic MRI sequence at 1.5 and 3 T and an optimized T2 mapping sequence to measure the T2 relaxation times of the fillers ex vivo. Three patients addressed to assess complications with buttock fillers underwent MRI with the standard morphological sequences and an additional synthetic MRI sequence; T2 mapping was not performed for the patients. Two patients had silicone fillers, whereas the exact filler composition for the third patient was unknown.

RESULTS

Measurements of T1 and T2 relaxation times of ex vivo fillers at 1.5 and 3 T using synthetic MRI showed that the silicone, collagen, and hyaluronic acid had distinct relaxation time characteristics. In vivo, the synthetic MRI correctly identified silicone in the two patients with known silicone fillers, showing low T1 and T2 values, whereas in the third patient with an unknown filler type, the synthetic MRI suggested a collagen filler, with intermediate relaxation time values.

CONCLUSION

Quantitative sequences have the potential to differentiate between filler types in a noninvasive fashion.

Injectable fillers: imaging features and related complications

Background

Injectable fillers are currently widely used in the clinical practice; there are many indications for injectable fillers including facial and gluteal rejuvenation, management of post-traumatic facial disfiguring, and pathological volumetric loss secondary to certain disease medications like human immune deficiency virus (HIV) medications.

Radiologists should be familiar with the specific imaging features of the injectable fillers, characteristic anatomical locations, and possible complications to avoid diagnostic pitfalls especially when incidentally discovered while imaging of other pathological process like neoplastic work up or granulomatous lesions follow-up.

Results

The study included 48 patients (45 females and 3 males): 44 patients with facial injectable fillers and four patients with pelvic injectable fillers.

Of the 48 patients, 37 patients showed unremarkable fillers features with normal morphological features and anatomical distribution, and eleven patients showed complications: six patients showed one complication, and five patients showed more than one complications.

Dedicated fillers imaging study was done in 22 patients, while in the other 26 patients, imaging was done for other reasons, and fillers were notified and documented.

Magnetic resonance imaging (MRI) was done for 46 patients; two patients were subjected to combine ultra-sonographic and CT examinations with no clinical indication for MRI study assessment.

Conclusion

Magnetic resonance imaging (MRI) is an effective tool for evaluation of facial and gluteal region fillers with delineation of their imaging features and related potential complications.

Differentiation between fillers and neoplastic or granulomatous lesions could be accurately done with MRI.

Safety and Localization of Mesenchymal Stromal Cells Derived from Human Adipose Tissue-Associated Hyaluronic Acid: A Preclinical Study

Millions of plastic surgeries are performed worldwide every year with the objective of correcting lipodystrophies stemming from lesions, tumor resections, birth defects, and AIDS-associated antiretroviral therapy. Besides that, a large number of clinical research have assessed the outcome of procedures that rely on combinations of dermal fillers and autologous cells. However, little is known about the safety of these combinations and the localization of the injected cells. The aim of this study was to test the toxicity of a solution containing 1% hyaluronic acid (HA) and adipose-derived stromal cells (ASCs) from the human adipose tissue and to assess the localization of the injected cells, with and without HA, labeled with technetium-99m. Rats received subcutaneous and intraperitoneal injections of a solution containing 1% HA/adipose-derived stromal cells isolated from the human fat tissue. The animals were then observed for up to forty-two days. The solution tested in this study did not result in systemic, biochemical, or anatomic alterations that could represent toxicity symptoms. The association of HA and ASCs labeled with technetium-99m remained at the site of the injection within a period of twenty-four hours, as demonstrated by a whole-body imaging software fusion of SPECT and CT. In conclusion, our study shows that the subcutaneous and intraperitoneal injection of HA associated with adipose-derived stromal cells (ASCs) is safe. The association of HA and ASCs did not induce local or systemic toxicity. Thus, the administration of volume equal to or less than 0.2 mL of the agent filler (1 × 10⁶ ASC+HA 1%) should be considered for subsequent studies and may be an alternative to dermal fillers due to the expected lasting effects.

Absorption, distribution, metabolism and excretion of the biomaterials used in Nanocarrier drug delivery systems

Nanocarriers (NCs) are a type of drug delivery system commonly used to regulate the pharmacokinetic and pharmacodynamic properties of drugs. Although a wide variety of NCs has been developed, relatively few have been registered for clinical trials and even fewer are clinically approved. Overt or potential toxicity, indistinct mechanisms of drug release and unsatisfactory pharmacokinetic behavior all contribute to their high failure rate during preclinical and clinical testing. These negative characteristics are not only due to the NCs themselves but also to the materials of the drug nanocarrier system (MDNS) that are released in vivo. In this article, we review the main analytical techniques used for bioassay of NCs and MDNS and their pharmacokinetics after administration by various routes. We anticipate our review will serve to improve the understanding of MDNS pharmacokinetics and facilitate the development of NC drug delivery systems.

Patterns of Superficial Midfacial Fat Volume Distribution Differ by Age and Body Mass Index

BACKGROUND

The changes that occur to midfacial fat with increasing age and BMI are poorly understood. The aim of this study was to determine how superficial cheek fat volume and distribution are differentially predicted by changes in BMI versus age.

METHODS

We conducted a retrospective observational study of patients with facial computed tomography scans. Superficial cheek fat volumes were measured, and multiple linear regression analysis was performed to model the relationships between cheek fat and corresponding sex, age, and BMI data.

RESULTS

A total of 109 patients were included in our analysis (51 male, 58 female). The subjects' ages ranged from 21.7 to 91.1 years with a mean (SD) age of 59.7 (15.0) years. The mean (SD) superficial cheek volume of the subjects was 10.46 (2.57) cc. Female subjects had a significantly greater mean total superficial cheek fat volume compared to male subjects (11.18 cc vs. 9.64 cc; P < 0.001). The results of multiple linear regression analysis indicated that together, age, sex, and BMI explained 50.8% of the variance in cheek fat volumes (R² = 0.51, P < 0.001). BMI significantly predicted total cheek fat volume (β = 0.239, P < 0.001), in addition to age (β = 0.029, P < 0.017) and sex (β = - 1.183, P = 0.001; female = 0, male = 1). Age predicted the greatest gain of fat in the caudal subdivision of cheek (β = 0.015, P < 0.001), whereas BMI predicted the greatest gain in the cephalad subdivision (β = 0.106, P < 0.001).

CONCLUSIONS

Age, sex, and BMI are important predictors of midfacial fat volume. This study shows that increases in age and BMI differentially predict the distribution of superficial cheek fat.

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 .

Cohesive Polydensified Matrix® cross-linked hyaluronic acid volumizing gel: a magnetic resonance imaging and computed tomography study

Background

Concentrated hyaluronic acid (HA) gels with a high degree of cross-linking such as Cohesive Polydensified Matrix^® (CPM) HA have been designed for long-term facial volume restoration.

Objective

To determine the behavior and longevity of CPM HA gel, a case series of subjects underwent magnetic resonance imaging (MRI) or computed tomography (CT) scans several years after their initial treatment.

Methods

Six subjects, three from the initial CPM HA Conformité Européenne registration study and three from private practice who had received prior injection of CPM HA for facial volumizing indications agreed to undergo an MRI or CT scan at intervals ranging from 1 to 4 years after the initial treatment. The amount of HA gel originally injected was compared with the amount estimated from volumetric analysis of the MRI and CT scans. The scans were also examined for the signs of any abscess or granuloma formation and to determine the behavior of the HA gel over time.

Results

CT and MRI imaging of the six study subjects indicated CPM HA gel persisted for 2–4 years after only a single treatment. In some patients, product was evident in deeper facial fat compartments than originally injected suggesting some diffusion of product had occurred. There was no MRI or CT evidence of abscess or granuloma formation.

Conclusion

Our findings indicate that CPM HA volumizing gel has substantial longevity when injected subcutaneously or in deep soft tissues.

Evaluation of the In Vivo Kinetics and Biostimulatory Effects of Subcutaneously Injected Hyaluronic Acid Filler

BACKGROUND

Because subcutaneously injected hyaluronic acid filler is absorbed over 6 months to 1 year after the treatment of facial wrinkles, frequent retreatment may be required. However, persistent long-term effects are often clinically observed when hyaluronic acid filler is injected as a bolus for facial augmentation. Therefore, the authors investigated, over time, the changes in volume and histologic features of subcutaneous bolus injections of hyaluronic acid.

METHODS

Hyaluronic acid filler was subcutaneously injected as a bolus into the dorsum of 6-week-old rats. At several time points (immediately after injection and 4, 8, 16, 32, and 64 weeks thereafter), magnetic resonance imaging was introduced to observe morphologic changes and to measure volume. Histologic examination of sectioned tissues was also performed.

RESULTS

The average volume increased for up to 4 weeks after injection and then gradually decreased, with 74.8 percent of the injected volume remaining after 64 weeks, with no statistical difference compared to the initial volume. Histologic analysis revealed that lattice structures were created by fibroblasts and collagen fibers, and blood vessels and adipocytes were also generated in the filler.

CONCLUSIONS

Although subcutaneous bolus injections of hyaluronic acid filler exhibited flattening, the total volume was maintained even after 64 weeks. Histologically, hyaluronic acid filler acted as a scaffold for autogenous tissue replacement by means of fibroblast migration and proliferation, collagen induction, and angiogenesis, followed by proliferation of adipocytes. This study demonstrates that the total volume is maintained long-term by replacing part of the injected hyaluronic acid filler with autologous tissues.

Parry-Romberg Syndrome Augmented by Hyaluronic Acid Filler

Parry Romberg Syndrome (PRS), also known as idiopathic progressive hemifacial atrophy, is a rare neurocutaneous disorder characterized by loss of skin and subcutaneous fat of face, muscles, and bones causing unilateral atrophy. Most patients require only soft tissue augmentation although syndrome has varying grades of severity. In the majority of reported cases, it has been treated with surgical flap or autologous fat transplantation. However, these treatments need complicated surgical skills which take a lot of time and cost. Herein we report the first case of PRS augmented by hyaluronic acid (HA) filler in a 42-year-old female patient to suggest that HA filler could be a safe, simple, and even rational economic alternative to surgical treatment.

Assessment of in vivo degradation profiles of hyaluronic acid hydrogels using temporal evolution of chemical exchange saturation transfer (CEST) MRI

Hyaluronic acid (HA) hydrogels have found a wide range of applications in biomedicine: regenerative medicine to drug delivery applications. In vivo quantitative assessment of these hydrogels using magnetic resonance imaging (MRI) provides an effective, accurate, safe, and non-invasive translational approach to assess the biodegradability of HA hydrogels. Chemical exchange saturation transfer (CEST) is an MRI contrast enhancement technique that overcomes the concentration limitation of other techniques like magnetic resonance spectroscopy (MRS) by detecting metabolites at up to two orders of magnitude or higher. In this study, HA hydrogels were synthesized based on different crosslinking agents and assessed using CEST MRI to investigate the in vivo degradation profiles of these gels in a mouse subcutaneous injection model over a three-month period. Nature of crosslinking agents was found to influence their degradation profiles. Since CEST MRI provides a unique chemical signature to visualize HA hydrogels, our studies proved that this technique could be used as a guide in the hydrogel optimization process for drug delivery and regenerative medicine applications.

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.

Effectiveness evaluation of two volumizing hyaluronic acid dermal fillers in a controlled, randomized, double-blind, split-face clinical study

Background

Enhancement of the midface can be achieved with volumizing hyaluronic acid (HA) fillers.

Objective

The objective of this study was to compare the safety and effectiveness of Cohesive Polydensified Matrix^® 26 mg/mL HA gel (CPM-26) and Vycross^® 20 mg/ml HA gel (VYC-20) in a controlled, randomized, evaluator-blind, split-face clinical study.

Patients and methods

Subjects with moderate-to-severe malar volume loss on the Merz Aesthetics Scale (MAS) received CPM-26 on one side and VYC-20 on the contralateral side of the face. Effectiveness assessments were performed by blinded evaluators including photographic and live MAS ratings and live Global Aesthetic Improvement Scale (GAIS) ratings. Calculations of anatomical volume variations at month 3 (M3), month 6 (M6), month 12 (M12) and month 18 (M18) were also performed.

Results

Non-inferiority of CPM-26 versus VYC-20 was demonstrated at M3 (primary end point) based on MAS. GAIS rating showed that significantly more subjects had better improvement with CPM-26 than with VYC-20 at month 1, M3, M12 and M18 (p=0.0032, p=0.0074, p=0.0384 and p=0.0110, respectively). Standardized evaluation of volume variations from baseline to M3, M12 and M18 showed that CPM-26 created more volume augmentation at all time points, and the difference was significant at M3.

Conclusion

CPM-26 was non-inferior to VYC-20 based on MAS ratings at M3 and demonstrated a favorable safety and effectiveness profile for midfacial volume enhancement with results lasting up to M18.

Ultrasound and Histologic Examination after Subcutaneous Injection of Two Volumizing Hyaluronic Acid Fillers: A Preliminary Study

Supplemental Digital Content is available in the text.

Background:

This study examined the influence of hyaluronic acid (HA) crosslinking technology on the ultrasound and histologic behavior of HA fillers designed for subcutaneous injection.

Methods:

One subject received subcutaneous injections of 0.25 ml Cohesive Polydensified Matrix (CPM) and Vycross volumizing HA in tissue scheduled for abdominoplasty by bolus and retrograde fanning techniques. Ultrasound analyses were performed on days 0 and 8 and histologic analyses on days 0 and 21 after injection. A series of simple rheologic tests was also performed.

Results:

Day 0 ultrasound images after bolus injection showed CPM and Vycross as hypoechogenic papules in the hypodermis. CPM appeared little changed after gentle massage, whereas Vycross appeared more hyperechogenic and diminished in size. Ultrasound images at day 8 were similar. On day 0, both gels appeared less hypoechogenic after retrograde fanning than after bolus injection. Vycross was interspersed with hyperechogenic areas (fibrous septa from the fat network structure) and unlike CPM became almost completely invisible after gentle massage. On day 8, CPM appeared as a hypoechogenic pool and Vycross as a long, thin rod. Day 0 histologic findings confirmed ultrasound results. Day 21 CPM histologic findings showed a discrete inflammatory reaction along the injection row after retrograde fanning. Vycross had a more pronounced inflammatory reaction, particularly after retrograde fanning, with macrophages and giant cells surrounding the implant. Rheologic tests showed CPM to have greater cohesivity and resistance to traction forces than Vycross.

Conclusions:

CPM HA volumizer appears to maintain greater tissue integrity than Vycross after subcutaneous injection with less inflammatory activity.

Hyaluronic acid fillers with cohesive polydensified matrix for soft-tissue augmentation and rejuvenation: a literature review

Background

Cohesive monophasic polydensified fillers show unique viscoelastic properties and variable density of hyaluronic acid, allowing for a homogeneous tissue integration and distribution of the material.

Objective

The aim of this paper was to review the clinical data regarding the performance, tolerability, and safety of the Belotero^® fillers for soft-tissue augmentation and rejuvenation.

Methods

A literature search was performed up until May 31, 2015 to identify all relevant articles on Belotero^® fillers (Basic/Balance, Hydro, Soft, Intense, Volume) and equivalent products (Esthélis^®, Mesolis^®, Fortélis^®, Modélis^®).

Results

This comprehensive review included 26 papers. Findings from three randomized controlled trials showed a greater reduction in nasolabial fold severity with Belotero^® Basic/Balance than with collagen (at 8, 12, 16, and 24 weeks, n=118) and Restylane^® (at 4 weeks, n=40), and higher patient satisfaction with Belotero^® Intense than with Perlane^® (at 2 weeks, n=20). With Belotero^® Basic/Balance, an improvement of at least 1 point on the severity scale can be expected in ~80% of patients 1–6 months after injection, with an effect still visible at 8–12 months. Positive findings were also reported with Belotero^® Volume (no reduction in hyaluronic acid volume at 12 months, as demonstrated by magnetic resonance imaging), Soft (improvement in the esthetic outcomes when used in a sequential approach), and Hydro (improvement in skin appearance in all patients). The most common adverse effects were mild-to-moderate erythema, edema, and hematoma, most of which were temporary. There were no reports of Tyndall effect, nodules, granulomas, or tissue necrosis.

Conclusion

Clinical evidence indicates sustainable esthetic effects, good safety profile, and long-term tolerability of the Belotero^® fillers, particularly Belotero^® Basic/Balance and Intense.