A practical guide to selecting facial fillers

Background

Dermal fillers have created a multi-billion-dollar industry. They are the second most popular form of injectable, as they primarily address volume loss, augmentation, and provide immediate results. The most popular form includes hyaluronic acid-based fillers, however, alternatives exist.

Objective

To create clinical charts to help with filler selection, injection, and addressing common complications.

Methods

The current literature and expert opinions form our two senior authors were used to create a numerical and color-coded chart based on G-prime for filler selection, as well as an anatomical table with current recommendations and pearls. We have also included a safety table with current clinical recommendation to deal with common filler-related complications.

Conclusion

Fillers are a safe and reliable method to achieve augmentation. Filler selection in various anatomical planes plays a significant role in achieving favorable results.     

High‐frequency sonography of temporary and permanent dermal fillers

Background: Dermal fillers are used widely; some have a permanent effect, whereas others are temporary. The aim of this study is to describe the ultrasonographic features of permanent and temporary fillers injected into patients for cosmetic purposes. Materials and methods: Between December 2006 and April 2009, 36 subjects, aged 25–45, who had received lips or nasolabial fold filler augmentation, were enrolled for a high‐frequency sonographic examination by a blinded investigator. The criteria for exclusion were a history of autoimmunity, infection, neoplastic diseases or episodes of local reactions to the injected filler. Twenty patients underwent a sonographic exam after the injection of a temporary filler (collagen or hyaluronic acid) by FRG; the rest were enrolled among patients seeking a consultation for further cosmetic reasons, but had been treated with an identifiable filler before. Results: It was always possible to identify the filler at the site of injection. Seldom was it possible to discover a silent inflammatory reaction, otherwise unsuspected. The sonographic images differed according to the temporary or the permanent nature of the filler. Conclusion: Ultrasonography has proved to be a useful, non‐invasive tool for the identification of the presence and type of the filler injected.     

The histological aspects of fillers complications

The histological aspects of resorbable heterologous fillers (bovine collagen, acid hyaluronique), autologous fillers (lipofilling, dermis-fat graft), biodegradable fillers (New-Fill), and permanent fillers (silicone, Artecoll, Evolution, Aquamid, DermaLive, DermaDeep, Bioplastique, Paraffin) are described. This article relates the morphological aspect of these materials, the normal tissue reaction after injection, and its chronological evolution as the morphological aspects from the different side effects, more frequently observed for the permanent fillers. They mainly consist of granulomatous reactions which may appear long after injection.     

Hyaluronic acid fillers

Although hyaluronic acids are a relatively new treatment for facial lines and wrinkles, they have provided numerous advances in the area of cosmetic surgery. This article discusses the inherent properties of hyaluronic acid fillers that make them ideal for treatment of facial lines. It encompasses a review of the current literature on U.S. Food and Drug Administration-approved hyaluronic acid fillers and the role that each of these fillers currently has in facial cosmetics. This article also discusses the potential pitfalls and adverse effects that can be associated with using hyaluronic acids for filling facial lines. Finally, it serves as an overview of current techniques for clinical assessment of patients as well as administration and treatment of facial lines and wrinkles.     

Collagen fillers

Collagen implants, both animal and human derived, have been used for soft tissue augmentation for many years. Bovine collagen fillers were the most popular injectable implants for nearly two decades in the United States. Since then, human bioengineered collagen products have been available in addition to hyaluronic acid-containing fillers. This article outlines the different types of injectable collagen implants, injection techniques, preferred methods of treatment, and possible adverse reactions to the injectable materials.     

Breakthroughs in US dermal fillers for facial soft-tissue augmentation

Abstract

Over the last 20 years, developments in injectable dermal fillers have led to a revolution in facial soft-tissue augmentation. The demand for dermal fillers for facial soft-tissue augmentation procedures has increased due in part to the less invasive nature of these products compared with surgical procedures. Available options in the United States have expanded from autologous tissues and animal-derived collagens to bacterially fermented biopolymers and synthetic implants. Beyond their physical composition, currently available products are further differentiated by their recommended depth of injection, suitability for different facial areas, and duration of aesthetic improvement. While older dermal fillers rely on the integrity of the injected material to achieve their clinical effects, some newer products are postulated to act by stimulating the patient's own biological and cellular processes. This article examines breakthroughs in facial soft-tissue augmentation that have expanded the palette of options available to physicians.     

Novel management of granuloma formation secondary to dermal filler: A multi-modality approach

Background

Dermal fillers for soft tissue augmentation have become increasingly popular among patients of all ages and ethnicities. With more widespread use, there has been an increased incidence of adverse reactions, one of which is the granulomatous foreign body reaction (GFBR).

Materials & Methods

We present a three patient case series in which GFBR secondary to dermal filler was successfully treated with a multi-leveled approach. The first modality involves intralesional injection of a mixture containing 1 cc of 5-fluorouracil (5-FU), 0.5 cc of dexamethasone sodium phosphate, and 0.1 cc of triamcinolone 10. The lesion is injected intradermally in small aliquots, similar to scar treatment. The patient then takes colchicine 1.2 mg loading dose on day 1, then 0.6 mg twice per day for 4 days concurrently with naproxen 500 mg orally once daily for 5–7 days. This process may be repeated in 6 weeks if the lesions have not resolved and PDL laser may be employed for residual post-inflammatory erythema.

Results

All three patients presented in this case series had significant aesthetic improvement in their dermal filler-derived foreign body granulomatous reactions.

Conclusion

GFBR provides both a medical and aesthetic issue for these patients including mental distress, pain, and dysfunction, therefore having an effective treatment for GFBR will affect medical management of these patients, improving patient outcomes and satisfaction. Our proposed regimen for GFBR has been shown to be highly efficacious and safe for these patients, providing a significant improvement in both function and cosmesis of the area.     

Satisfaction outcomes for patients and physicians following use of a new hyaluronic acid fillers

Background

The aesthetic appearance of the skin, with the emergence of wrinkles, blemishes, and infraorbital hollowing, can be a cause of social distress and is a process exacerbated by aging. The presence of skin imperfections and aging is partly due to a loss of hyaluronic acid (HA), which normally contributes to a maintain a healthy and voluminous skin. Attempts to restore volume and revert the signs of aging have therefore focused on the use of dermatologic fillers based on HA.

Aim

Here, we tested the safety and efficacy of MelHA®-Monophasic Elastic Hyaluronic Acid (Concilium FEEL® filler products) containing HA at different concentrations and injected at different sites according to recommendations.

Methods

Five different physicians assessed 42 patients across five different medical facilities in Italy, where they performed the treatment and assessed the patients after a follow-up visit. Safety and efficacy of the treatment and change in quality of life after treatment were evaluated with two surveys, one directed to medical personnel, and one directed to patients.

Results

Our results show that, across all products and personalized treatments, patients', physicians' and “independent photography reviewer” satisfaction was very high and that the treatment show a favorable safety profile.

Conclusion

These results are promising and suggest the use of Concilium Feel® filler products can contribute to an increased self-esteem and quality of life in aging patients.     

Efficacy and durability of hyaluronic acid fillers for malar enhancement: A prospective,randomized, split-face clinical controlled trial

Various hyaluronic acid fillers can be used for facial attenuation and rejuvenation. The efficacy and durability of hyaluronic acid fillers are of major concern to dermatologists and patients. This study aimed to evaluate three-dimensional morphology, tissue distribution, and changes in volume after injection of two different hyaluronic acid fillers. Ten Korean women were enrolled in this study. Each subject was injected with monophasic hyaluronic acid filler in one malar area and biphasic filler in the other. Clinical outcome was measured before and after injection, and after 2, 4, 6, 8, 12, and 24 weeks, using the Global Aesthetic Improvement Scale, photographs and Moire’s topography. Facial magnetic resonance imaging (MRI) was performed twice over six months. Both products showed good results after injection and demonstrated good durability over time. MRI was a useful modality for assessing tissue distribution and volume changes. The effects and durability after injection of monophasic hyaluronic acid filler and biphasic hyaluronic acid filler are generally comparable.     

Combination therapy with BOTOX and fillers: the new rejuvnation paradigm

Until relatively recently, restoration of appearance by replacement of lost facial volume and muscular relaxation has been an illusory goal. With advances in the commercial availability of newer filling agents and a better understanding of the clinical esthetic effects of botulinum toxin A, remarkably sophisticated and refined results can now be achieved by using these noninvasive techniques. The combined use of BTX-A and filling agents, such as collagen and hyaluronic acid, can restore facial appearance by the dual mechanisms of reflation and relaxation. In addition, their combined use appears to increase the longevity of tissue dwell time of the filling agent. Current practices now strive to correct wrinkles by restoring volume and also relaxing the pull of muscles that create negative facial expressions such as glabellar folds, mouth frown, crow's feet, horizontal forehead lines, and perioral and cervical rhytides. As with any of the new technological innovations currently available, understanding of the differing properties of the agents used and education in optimal technique is essential to clinical and esthetic success.     

The effect of combined hyaluronic acid filler injection and radiofrequency treatment: A clinic histological analysis

Background

Hyaluronic acid (HA) filler injections have increased in popularity. They are usually performed in combination with other treatment modalities, including lasers and energy-based devices, to enhance cosmetic results. Theoretically, HA and other filler injections should be performed after laser- or energy-based device treatments. In some instances, however, practitioners are asked to administer laser- or energy-based device treatment after HA dermal filler injection. There is a concerning possibility of HA filler degradation as a result of bulk heating generated by lasers or energy-based devices, especially radiofrequency (RF).

Aim

To evaluate the effect of RF treatment at different time points on HA degradation in vivo, using clinicohistological analysis.

Patients/methods

Fourteen volunteers were recruited and received intradermal HA filler injections in four sites on the abdomen. One site served as the control, and the other three sites were treated with monopolar RF on the same day after injection, at 14 and 28 days post-injection. Skin biopsies were performed at baseline and 56 days after HA injection. Histopathological sections were reviewed for residual filler in the tissue.

Results

The results showed that HA grading scores decreased in five (35.71%), one (7.14%), and one (7.14%) participants when RF was performed immediately, 14 and 28 days after injection, respectively.

Conclusion

In conclusion, RF treatment after HA filler injection may affect the integrity of the HA filler in the tissue, especially if RF treatment was performed on the same day after HA injection.     

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.     

Use of high-frequency ultrasound in the assessment of injectable dermal fillers

Background: The use of dermal fillers for enhancing lips and reducing wrinkles is currently one of the fastest growing sectors of the cosmetic surgery market. There are numerous fillers available, some are synthetic others are isolated from biological material. Once injected the fillers have a varied lifespan ranging from months to years depending upon the material, site of injection and individual response. Current assessment techniques of filler performance are mostly limited to evaluations of the skin surface topography, and not to what is happening to the filler beneath the skin surface. The aim of this work was to see if high‐frequency ultrasound could be used to image and measure filler dimensions in situ. Method: This was a pilot study of six healthy female volunteers aged 36–53 visiting the surgical outpatients department of a hospital in Glasgow. Volunteers had been injected with filler material into their upper lip 6 months before the visit. The patients all had their upper lip scanned using high‐frequency ultrasound. The subsequent images were then assessed using the scanner software to assess the dimensions of the filler. Results: The filler material was clearly visible with the ultrasound and subsequently measurable in each scan. Each scan procedure was completed within a short time period meaning quantitative data could be acquired with minimum trauma to the volunteer. The scan images and data also provided valuable information for the volunteers and reinforced their perception of the fillers effect on their features. Conclusions: High‐frequency ultrasound scanning provides a non‐invasive, convenient and rapid technique for the assessment of filler performance. This pilot study produced three valuable pieces of information: ? The ultrasound can image the filler material from which quantitative measurements can be made. ? The technique is rapid and cost effective …? This investigation helped to reinforce the volunteer's perception of the filler effect.