The science and art of hyaluronic acid dermal filler use in esthetic applications

Background The number of dermal fillers has expanded dramatically; clinicians can benefit from practical information on their optimal use. Aims To review key determinants of dermal filler performance, to discuss technical considerations, and to illustrate these factors based on the author’s clinical experience. Methods Current literature pertaining to the physicochemical properties of hyaluronic acid (HA) dermal fillers and implications for clinical use was reviewed. The author provides clinical guidelines for optimizing outcomes, illustrated with three case examples. Results Hyaluronic acids are nonimmunogenic, versatile, reversible, and have excellent benefit–risk profiles, making them near‐ideal filling agents. They differ in their manufacturing processes, viscosity, hardness, cohesivity, ease of injection, and ideal uses. Patient counseling and education with individualized selection of the appropriate agent is critical to provide satisfactory outcomes. Conclusions Clinicians must be technically proficient, balance esthetic need with facial anatomy, and consider HA properties to provide optimal outcomes.     

Adverse reactions to injectable soft tissue fillers

In recent years, injections with filler agents are often used for wrinkle-treatment and soft tissue augmentation by dermatologists and plastic surgeons. Unfortunately, the ideal filler has not yet been discovered and all of them may induce adverse reactions. Quickly biodegradable or resorbable agents may induce severe complications, but they will normally disappear spontaneously in a few months. Slowly biodegradable or nonresorbable fillers may give rise to severe reactions that show little or no tendency to spontaneous improvement. They may appear several years after the injection, when the patient does not remember which product was injected, and treatment is often insufficient. In this review, we discuss the most commonly used fillers, their most frequent adverse reactions as well as the characteristic histopathologic findings that allow the identification of the injected filler agent. In conclusion, histopathologic study remains as the gold standard technique to identify the responsible filler.     

Hyaluronic acid fillers in facial rejuvenation

Nonsurgical procedures have become very popular for the rejuvenation of the aging face. Trends now are for less invasive procedures as well as for more preventative intervention to slow the damage from ultraviolet light and environmental factors, as well as from intrinsic aging. The goal of these procedures is to eliminate or delay the need for corrective surgery. The regular use of sunscreens; retinoids and improved cosmeceuticals; injectable neurotoxins; soft-tissue augmentation products; and minimally invasive laser, light, and radiofrequency treatments are decreasing and delaying need for invasive procedures. Injectable fillers entered mainstream cosmetic medicine with the development of bovine collagen injections in the 1980s. The availability of improved fillers that are less allergenic and longer lasting has resulted in a renaissance in filler techniques. No single filler has proven to be more popular than the category of hyaluronic acids (HA). This article will review the use of the hyaluronic acid fillers that are currently approved for use by the Federal Drug Administration in the United States and describe the significant differences between them to assist the practicing cosmetic physician in choosing and using this category of dermal filler.     

Legal ramifications of off-label filler use

Dermal fillers are often used in an off-label manner. Most off-label use is not only legal, but represents an appropriate physician standard of care. This chapter will first explore what is and what is not considered off-label. Then the chapter will explore manufacturer promotion of off-label use of both drugs and devices. Finally, the legal ramifications of off-label dermal filler use will be discussed.     

Dermal fillers: Complications and informed consent

Dermal fillers are increasingly used for in‐office cosmetic treatments. Although complications are rare, they can occur with any dermal filler. Such complications can lead to adverse medical, legal and economic difficulties. This article reviews the various complications most commonly seen with dermal fillers. In addition the appropriate consent prior to filler use and the legal implications of a lack of consent will be described.     

Dermal fillers: complications and informed consent.

Dermal fillers are increasingly used for in-office cosmetic treatments. Although complications are rare, they can occur with any dermal filler. Such complications can lead to adverse medical, legal and economic difficulties. This article reviews the various complications most commonly seen with dermal fillers. In addition the appropriate consent prior to filler use and the legal implications of a lack of consent will be described.     

Hyaluronidase in the correction of hyaluronic acid‐based fillers: a review and a recommendation for use

Background Hyaluronic acid (HA) preparations are the most commonly used injectable fillers in esthetic medicine. In contrast to other injectable fillers with hyaluronidase, there is a tool available to reduce unwanted depots of this filler. Aims The aim of this paper is to give an overview on the present literature and in addition to give some recommendations for use based on the experience of the authors. Methods The overview is based on a literature search. Results There is some evidence from two smaller clinical trials that hyaluronidase will effectively decrease injected depots of HA. It has further been shown from case series and case reports that this reduction is clinically relevant. There is less evidence that hyaluronidase is also helpful in adverse reactions to HA‐based fillers. Conclusions The reports suggest that the treatment is safe. However, adverse reactions to hyaluronidase such as allergic reactions have been reported. Patient should be informed about that before treatment.     

The potpourri approach to hyaluronic acid filler injections

There is an ever-expanding range of hyaluronic acid fillers with varying physical characteristics available to cosmetic dermatologists. These fillers are commercially packaged in syringes of approximately 1 mL (range 0.5–2 mL) volume. Filler injectors are currently qualitatively and quantitatively restricted to fillers packaged in ready-to-go syringes. Patients often present for pan-facial rejuvenation requiring varying amounts of fillers as well as more than one type/subtype of filler for optimum correction. The potpourri approach allows access to a range of prepared hyaluronic acid filler subtypes that can be used on the same patient in the one session. The potpourri method centres on the use of multiple 31-gauge insulin syringes prepared with a range of different hyaluronic acid filler products that are ready for use. This increases flexibility with filler selection and has the potential to provide better filler-to-tissue match for patients.     

Adverse reactions to dermal fillers: a review of European experiences.

BACKGROUND: In Europe, numerous dermal fillers have been utilized for the past decade. A lot of drawbacks have been reported and sometimes, severe complications occurred. OBJECTIVE: Our purpose is to report the clinical aspects of the adverse reactions following injections of some of the dermal fillers. Histological aspects of complications are also described. RESULTS: Adverse reactions secondary to biodegradable products are usually time limited, but with the non-biodegradable products, we have observed severe, persistent, and recurrent complications. Histological examinations, in cases of non-biodegradable products, may show the presence and persistence of the filler. CONCLUSION: For the moment, there is no ideal dermal filler. All fillers can lead to adverse events and we need to inform patients fully before injecting. Clinical studies with long-term follow-up before launching a new product on the market are recommended. We believe that in Europe, at present, the CE mark is not a guarantee of safety of dermal fillers.     

Alopecia with foreign body granulomas induced by Radiesse injection: A case report

Radiesse is a soft tissue filler which has been widely used for cosmetic enhancement. The safety of Radiesse has been thoroughly investigated via numerous studies. A late-onset complication of Radiesse injection consists of foreign body granulomas, with only three case reports in over 10 years of clinical use. Herein, we describe the case of a patient who experienced alopecia with foreign body granulomas at the injection region one month after receiving a Radiesse injection. To our knowledge, this is the first report in the English literature of alopecia as an adverse event associated with Radiesse injection. The present case reminded physicians to evaluate more cautiously the necessity of injecting filler into hair-bearing area for lifting purpose. This procedure may cause foreign body granulomatous reaction, which may result in hair loss at the injection region.     

Facial volume restoration of the aging face with poly-l-lactic acid

The purpose of this article is to discuss current techniques used with poly-l-lactic acid to safely and effectively address changes observed in the aging face. Several important points deserve mention. First, this unique agent is not a filler but a stimulator of the host's own collagen, which then acts to volumize tissue in a gradual, progressive, and predictable manner. The technical differences between the use of biostimulatory agents and replacement fillers are simple and straightforward, but are critically important to the safe and successful use of these products and will be reviewed in detail. Second, in addition to gains in technical insights that have improved our understanding of how to use the product to best advantage, where to use the product to best advantage in facial filling has also improved with ever-evolving insights into the changes observed in the aging face. Finally, it is important to recognize that a patient's final outcome, and the amount of product and work it will take to get there, is a reflection of the quality of tissues with which they start. This is, of course, an issue of patient selection and not product selection.     

External vascular compression by hyaluronic acid filler documented with high‐frequency ultrasound

We present a case report of a hyaluronic acid filler‐induced complication documented using high‐frequency ultrasound. We regard the scientific value of the case as indicating the benefit that ultrasound provides for the management and documentation of this complication. This technology has been becoming increasingly widespread in the care of patients who experience unwanted effects of hyaluronic acid filler because it can be used for the high‐resolution visualization of skin layers as well as the differentiation of filler types and their relationships with adjacent tissues (via gray scale or B‐mode ultrasound) and blood vessels (via color Doppler ultrasound). In addition, it was possible to conclude that external vascular compression causes clinical repercussions, a fact that is often questioned by some dermatologists. This questioning is based on the vast vascularization and anastomosis of arteries of the face, which should permit compensation for vascular compression. However, in this case, there was no doubt that compression caused a region of low output with the clinical manifestation of peri‐oral pallor. Ultrasound was used to document the compression of a vessel by the filler; after application of hyaluronidase, increased vessel lumen and clinical reversal of hypoperfusion in the affected area were observed.     

Treatment of Linear Morphea (en Coup de Sabre) with Micronized Acellular Dermal Matrix Filler: A Case Report

En coup de sabre variant of linear morphea (LM) is a rare sclerotic skin disorder characterized by disfiguring linear depression of the frontal or frontoparietal forehead. Current attempts for cosmetic correction of atrophic lesions must be preceded by an evaluation of disease activity of LM, either by a sufficient clinical assessment or histologic evidence. Corrective procedures including corrective surgery, autologous fat grafting, hyaluronic acid filler injections were performed with varying degrees of success; still, there is a need for treatment options with non-invasive and long-term maintenance effects. Herein we report the use of micronized acellular dermal matrix filler as a novel and successful treatment for the atrophic defect of LM in a 24-year-old female. Molecular characteristics of the micronized acellular dermal matrix filler give enhanced durability and prolonged volume consistency, which results in a long-term extracellular matrix remodeling effect.     

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

Background

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

Objective

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

Methods

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

Results

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

Conclusion

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

Dithranol in a cream preparation: disperse or dissolve?

In the search for the ideal dithranol cream preparation for short-contact treatment of psoriasis, we investigated the clinical efficacy, side effects and patient appreciation of two dithranol cream preparations (cream A and B) in a double-blind left-right comparing study. Dithranol was dissolved at preparation in cream A and dispersed in cream B. Cream A is known to have a shelf life of 1 year, while cream B has a much shorter shelf life (several months). Ten patients with chronic plaque-type psoriasis were treated during 7 weeks in a short-contact regimen. The clinical efficacy was monitored by scoring of erythema, induration, scaling and involved area (PASI); skin irritation was scored visually, and patient appreciation was evaluated by means of a multiple-choice questionnaire. Dispersion of dithranol in a cream was associated with less irritation and less discoloration of the skin, and its efficacy was comparable with that of the cream in which the dithranol was dissolved. As the dispersed dithranol formulation is easier to be manufactured, its quality will be less depending on the pharmacist's experience and equipment, and so more reliable. Besides, it will be less expensive to prepare. We advise to use this formulation for short-contact treatment.     

Biocompatibility of microparticles into soft tissue fillers

The increasing need for long-lasting injectable soft tissue fillers for the treatment of wrinkles and folds requires a critical discussion of the biocompatibility on a scientific background. Since biological fillers made of collagen and hyaluronic acid will be resorbed over time, copolymer biomaterials with microparticles have been developed in recent years. The microparticles followed special and essential demands because of the interaction with the tissue. In search of an ideal soft tissue filler substance, a variety of biomaterials with microparticles suspended have been created for injecting into dermal defects, into the urethra of patients with urinary incontinence, and in patients with vocal cord insufficiency. The particles differ in chemical composition, surface structure, surface charge, and particle size and evoke different host reactions, accordingly.     

Comparative split‐face study of durational changes in hyaluronic acid fillers for mid‐face volume augmentation

Subsequent changes after injection should be considered when determining the precise volume of injected dermal filler. Several studies have used scoring systems to evaluate facial volumes; however, these scoring systems are not particularly objective. This present study aimed to evaluate the volumetric changes over time on three‐dimensional (3D) images and the maintenance potential of various hyaluronic acid (HA) fillers used for mid‐face volume augmentation. This split‐face clinical study included nine Korean subjects who each received a mid‐facial injection of the test filler (B) on one side and a random control filler (J, R, or Y) on the contralateral side. Global, photographic, and 3D scanning assessments were conducted at baseline and after 30 min, 3 days, and 2, 4, 12, and 24 weeks. In all nine cases, the 3D images revealed the largest differences in height where the test filler (B) was injected. The results of subjective scoring systems correlated with the results of 3D imaging. The volumes of monophasic fillers (B and J) were maintained for longer periods of time than those of biphasic fillers (R and Y). The B filler yielded excellent volumizing and spreading effects and good injectability. This filler would be suitable for injection into high‐pressure areas, such as the lateral cheek, chin, and nasolabial fold. Moreover, the 3D imaging analysis provided objective and digitized data. The present authors hope that their data will allow physicians to better understand the durational changes in HA fillers and, thus, provide accurate predictions to their patients.     

A case of cellulitis-like foreign body reaction after hyaluronic acid dermal filler injection

A 58-year-old female presented with 3 weeks history of painful skin lesion on the right cheek. Diagnosis was cellulitis based on the clinical manifestation and laboratory test. However, skin lesion did not improve with antibiotics, and as a consequence, biopsy was performed. Based on histopathological findings and additional information of her previous history of intradermal filler injection, the lesion was diagnosed to be foreign body reaction. Previous reported cases of foreign body reaction induced by hyaluronic acid dermal filler typically manifested as nodular lesions, but cellulitis-like cutaneous manifestation has not been reported. Therefore, we report this interesting case of foreign body reaction after hyaluronic acid dermal filler injection.     

非透明质酸类皮肤软组织填充剂及其研究进展

随着透明质酸类软组织填充剂在世界各地广泛应用之际,其他非透明质酸类填充材料在临床应用及研究中显示出的独特优点亦受到新的关注。本文将对非透明质酸类填充材料的研发历史、理化特性以及临床应用研究进展做一介绍。     

Periorbital venous stasis may be involved with filler induced malar edema—A duplex ultrasound-imaging-based case series

Introduction

Filler injections in the periocular region are regarded as a challenging and advanced maneuver in a high-risk area. Adverse events as malar edema due to filler treatment may occur. To evaluate the possible reasons, the ultrasound images, and medical data of patients that were prospectively referred with malar edema were evaluated.

Materials and Methods

A total of 17 patients (26 eyes) with malar edema after hyaluronic acid filler treatment were included. All cases were assessed with an 18 MHz linear ultrasound device. Exact location of the filler material was noted. Relations with clinical data were analyzed using chi-square tests.

Results

Onset of malar edema after treatment showed a wide range from immediate (0 days) to 3 years. Most patients had an early onset N = 13 (76%), a minority showed late onset N = 4 (24%). In 23 eyes, the filler material was found to be located inside the SMAS. In 3 cases filler material was located on the periosteum of the orbital rim. After duplex-ultrasound guided filler removal, restored venous flow could be seen in the superficial and/or deep fatty layer often accompanied by flow piercing through the SMAS. Minutes after treatment, clinical improvement of malar edema was observed.

Conclusion

Malar edema after by filler treatments in the periocular region may be caused by veno-lymphatic compression by filler deposits.