A comparison of the safety,efficacy, and longevity of two different hyaluronic acid fillers in filler rhinoplasty: A multicenter study

Filler rhinoplasty is a popular procedure in Asia, and it is of great importance to understand the clinical efficacy and durability of the different filler products that serve this purpose. Here, we aimed to evaluate and compare the safety, efficacy, and longevity of two different hyaluronic acid (HA) fillers in improving the nasal profile in Asians. A multicenter comparative trial was performed for 48 weeks after a single injection of a popular monophasic monodensified, and a newly developed biphasic HA filler. Assessments including patient satisfaction and three‐dimensional (3D) imaging analysis were performed before, immediately after, 2 weeks, 12 weeks, 24 weeks, and 48 weeks after filler rhinoplasty. Twenty‐eight Korean women underwent structured rhinoplasty were divided into monophasic monodensified (n = 14) and biphasic (n = 14) groups. There were significant changes in the facial profile following filler rhinoplasty throughout the study period. Overall, an increase of 1.75 mm in nose height, increase of 3.66° in the nasofrontal angle and 2.77° in the nasolabial angle, and radix elevation of 1.24 mm was noted at week 48 which was statistically different from the baseline values (P < .05). Between the different filler types, statistical difference was only noted in radix elevation (per milliliter of filler material) immediately after filler injection. No serious adverse event occurred during treatment or follow‐up. Nonsurgical rhinoplasty with the specific HA filler products led to significant changes in the facial profile which persisted for 48 weeks. Overall, the clinical efficacy and safety were comparable between the two filler types except for radix elevation which was more prominent with C‐C immediately after filler injection. J‐V was superior to C‐C in maintaining the radix elevation long term.     

Case series of tongue necrosis from vascular complications after chin augmentation with hyaluronic acid: Potential pathophysiology and management

Background

Even though the chin is considered a safe injection area for facial filler augmentation, tongue necrosis is a rare complication in this area.

Objective

Our aim was to present case series of rare complications from chin filler augmentation with possible pathophysiology and management.

Methods

From our thorough literature search found only one case report of tongue necrosis from chin filler augmentation. We present case series of unilateral tongue necrosis from vascular occlusion following hyaluronic acid injection in the chin, which was successfully treated with a high-dose hyaluronidase injection resulting in complete recovery in all patients.

Results

Variation in vascular anastomosis leads to a possible cause of vascular occlusion. The lingual artery is the primary arterial supply for the tongue, which is an exclusive target for embolism. Two main responsible arteries and branches are the deep lingual and sublingual arteries. The submental artery variation was previously described as the cause of this event. We proposed potential pathophysiology of the occlusion, not only the variation of vasculature but bone. The midline lingual foramen, an anatomical bone variation on the surface of the midline inferior jaw, was found to be another possible cause. This foramen contains a branch of the submental and sublingual artery, which includes the perforating artery, median perforating artery, or both. Filler injection with a sharp needle on the bone can potentially increase the risk of this vascular incident. A high dose of hyaluronidase administered with multiplane injections was accomplished with complete recovery.

Conclusions

Tongue necrosis from vascular complications after hyaluronic acid filler injection can occur. Not only vessels but bone variation pathology were possible causes.     

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.     

Factors influencing pre‐injection aspiration for hyaluronic acid fillers: A systematic literature review and meta‐analysis

Pre‐injection aspiration of hyaluronic acid filler is a well‐recognized yet controversial safety technique. Many consider aspiration to be an important safety measure to prevent inadvertent intravascular filler injection. To assess factors influencing pre‐injection aspiration by understanding the relationship between aspiration time and a range of product, needle, and procedural characteristics. We conducted a systematic review and meta‐analysis of data, adopting the preferred reporting items for systematic reviews and metaanalyses guidelines. Our literature search identified four articles presenting data on variables associated with aspiration time for different HA filler brands. Statistical models pooling data from the four articles suggest a robust association between aspiration time and a filler's elastic modulus (G′), drop weight (cohesivity), and cross‐sectional area of the needle lumen. However, there is insufficient evidence to confirm a robust association between aspiration time and HA concentration, viscous modulus (G″), needle length, and pullback volume. A deeper understanding of the relationship between product, needle, and procedural characteristics, and aspiration time can provide a sound base for discussing the role of pre‐injection negative aspiration as a safety measure. The understanding of the effect of various factors on preinjection aspiration would further benefit from studies under clinical conditions.     

More than just a filler – the role of hyaluronan for skin homeostasis

In recent years, hyaluronan (HA) has become an increasingly attractive substance as a non‐immunogenic filler and scaffolding material in cosmetic dermatology. Despite its wide use for skin augmentation and rejuvenation, relatively little is known about the molecular structures and interacting proteins of HA in normal and diseased skin. However, a comprehensive understanding of cutaneous HA homeostasis is required for future the development of HA‐based applications for skin regeneration. This review provides an update on HA‐based structures, expression, metabolism and its regulation, function and pharmacological targeting of HA in skin.     

The duration of hyaluronidase and optimal timing of hyaluronic acid (HA) filler reinjection after hyaluronidase injection

Background: Hyaluronidase injection is a commonly performed treatment for overcorrection or misplacement of hyaluronic acid (HA) filler. Many patients often wants the HA filler reinjection after the use of hyaluronidase, though the optimal timing of reinjection of HA filler still remains unknown. Objectives: To provide the optimal time interval between hyaluronidase injections and HA filler reinjections. Methods: 6 Sprague–Dawley rats were injected with single monophasic HA filler. 1 week after injection, the injected sites were treated with hyaluronidase. Then, HA fillers were reinjected sequentially with differing time intervals from 30 minutes to 14 days. 1 hour after the reinjection of the last HA filler, all injection sites were excised for histologic evaluation. Results: 3 hours after reinjection of HA filler, the appearance of filler material became evident again, retaining its shape and volume. 6 hours after reinjection, the filler materials restored almost its original volume and there were no significant differences from the positive control. Conclusions: Our data suggest that the hyaluronidase loses its effect in dermis and subcutaneous tissue within 3–6 hours after the injection and successful engraftment of reinjected HA filler can be accomplished 6 hours after the injection.     

Unilateral facial edema after filler injection of the lower eyelid

The use of hyaluronic acid (HA) gel fillers for rejuvenation of the face has been increasing in popularity over the years. This nonsurgical, temporary technique is commonly used in the periocular region to restore volume. The aim of this study was creating awareness in the potential causes of edema after hyaluronic acid gel filler injections under the eyes. A 32‐year‐old woman presented for a cosmetic consultation to address unilateral swelling of the left check. She states she had an HA filler injected in the tear trough on both sides. Extensive evaluation and ultrasound were performed by physicians of different specialties. Intra‐oral and radiological examination revealed a tooth‐related cause known as apical periodontitis. Removal of this tooth resulted in complete resolution of the patient's presenting symptoms. Familiarity with all the potential causes of adverse events after injections with hyaluronic acid gel fillers accelerates the treatment and healing of the patient with complications. Reporting this case should raise awareness about possible teeth‐related complications.     

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.     

Hyaluronic acid filler injections with a 31‐gauge insulin syringe

Hyaluronic acid gel is a commonly used skin/soft tissue filler in cosmetic dermatology. Hyaluronic acid fillers are packaged in proprietary luer‐lock syringes that can be injected via a 30‐gauge, 27‐gauge or larger diameter needle depending on the consistency of the gel. A method of decanting proprietary hyaluronic acid fillers into multiple 31‐gauge insulin syringes for injection is described. The use of a 31‐gauge insulin syringe for filler injections can potentially enhance the injection process through more accurate product delivery and placement. This has the potential to produce a more balanced and symmetrical outcome for patients. Additional benefits include less injection pain, less bleeding/bruising and higher levels of patient satisfaction.     

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.     

Adverse reactions to injectable soft tissue fillers: Memorable cases and their clinico-pathological overview

Background: Filler injection is a minimally invasive procedure widely used for soft tissue augmentation. Although the safety profile is favorable, adverse events can occur, especially after illegal filler injection. Objectives: The authors present memorable cases of filler complications and review their clinico-pathological features and treatment strategies. Patients and methods: This is a retrospective, single-center case series. The authors identified eight patients with significant complications following filler injection. A medical record review was performed for clinical history, histopathological studies, and treatment. Results: Six female and two male subjects presented with significant filler complications. The time interval between filler injection and the development of a complication varied greatly among cases (immediately afterwards to 14 years following filler injection). Four of the patients received illegal filler injection where the injected material was either unknown (25%) or was told as paraffin (12.5%) or Vaseline^® (12.5%). Hyaluronic acid fillers were used in two patients (25%) and the rest were injected with porcine atelocollagen (12.5%) and polyacrylamide hydrogel (12.5%). The complications were classified as an allergic reaction (25%), filler material migration (12.5%), injection necrosis + embolism (25%), and foreign body granuloma (37.5%), based on their clinico-pathological features and were treated accordingly. Conclusion: Adverse effects are not uncommon following filler injection. Physicians should be aware of the potential side effects, recognize their presentations, and understand how to manage them.     

The effect of combined of hyaluronic acid dermal filler and microfocused ultrasound treatment: A clinicopathological study

Objectives

Microfocused ultrasound (MFU) and hyaluronic acid (HA) filler injection are increasingly popular aesthetic procedures. HA filler injection is generally recommended after MFU if combined treatment is required in a single visit. However, data regarding the safe and optimal time of MFU treatment after HA injection is still limited. The purpose of this study was to evaluate the degree of HA loss when performing MFU treatment after dermal filler injection.

Methods

Fourteen subjects were recruited in this pilot study. HA was injected intradermally on four 2 × 2 cm areas at the abdomen (0.25 ml/site). Site A was served as control whereas site B, C, D were treated with MFU using 1.5 mm transducer at 60 min, Day 14, and Day 28 after the injection, respectively. All experimental sites were biopsied using a 3-mm punch biopsy to evaluate the histopathological profile at baseline and Day 56. Grading of the quantity of retained HA was evaluated by a blinded experienced dermatopathologist.

Results

All 14 subjects completed the study. One subject has been excluded due to the poor quality of histopathologic slides. Seven subjects (53.9%) at site B and 6 subjects (46.2%) at site C had HA loss at Day 56 compared with baseline. The mean HA grading at baseline and Day 56 was 3.7 vs. 2.8 (p < 0.001) at site B and 3.7 vs. 3.0 (p = 0.001) at site C, respectively. There was no statistical difference between the mean HA grading at baseline and Day 56 at site D (3.7 vs. 3.3, p = 0.073). No inflammation or granuloma was observed on Day 56 of the study.

Conclusions

MFU treatment after HA injection appears to be safe. However, some degree of HA loss was observed if MFU treatment was done within 2 weeks after HA injection.     

Treatment of glabella skin necrosis following injection of hyaluronic acid filler using platelet-rich plasma

Hyaluronic acid (HA) fillers have been widely used for soft-tissue augmentation. However, there can be various complications following HA filler injection. Skin necrosis is rare but one of the most disastrous side effects that, if not treated promptly and effectively, can result in permanent and potentially disfiguring scarring. Thus, early proper management is important. Herein we report a patient who experienced tissue necrosis of the glabellar area after receiving filler injections that was successfully treated using platelet-rich plasma and provide full follow-up clinical photographs.     

Comparative clinical study for the efficacy and safety of two different hyaluronic acid-based fillers with Tri-Hyal versus Vycross technology: A long-term prospective randomized clinical trial

Background

Hyaluronic acid-based fillers have an immediate volumizing effect for the treatment of dermal contour deformities and to smooth dermal depressions formed by the loss of volume. A previous study on 2016–2018 has shown the efficacy and safety of the HA-based filler ART FILLER® Volume on the midface only, but not in a comparative manner.

Methods

In this context, an 18 months prospective randomized single-blind study of the non-inferiority of ART FILLER® Volume versus the reference product Juvéderm Voluma® was performed on the midface, temple, and jawline, and non-comparative study on the chin. The efficacy and the longevity were evaluated for the selected face areas via dedicated clinical scoring systems after a single filler injection without any re-touch or re-injection. The short- and long-term adverse effects were also recorded.

Results

The observations confirmed the non-inferiority of ART FILLER® Volume versus the reference product on the different injected areas. For both fillers, the beneficial effects on volumes restoration were maintained 18 months post-injection; however, these effects were diminished among the time. Furthermore, injections of Art Filler® Volume were well tolerated by the subjects and showed less acute side effects compared with the reference product that may be explained by a lower induction of inflammation.     

Concealing of under eye orbital fat pads with hyaluronic acid filler: A case report

Under eyelid bags and tear troughs are the two most common concerns for the patients coming to an aesthetic center, and specially their correction without undergoing a surgery. Efficacy of hyaluronic acid fillers has been proven successfully in correction of periorbital volume loss but no reports have been published for their role in concealing infraorbital fat pads. Hence, the effectiveness and safety of hyaluronic acid filler in treatment and correction of tear troughs thereby concealing under eyelid bags are being reported in this article. A 43‐year‐old woman who presented with grade 3 tear troughs and bulged out infraorbital fat pads underwent a single treatment session with 1ml 15mg/mL cross‐linked hyaluronic acid filler (Juvederm Volbella®). Assessment of the periorbital area was done immediately after the procedure and after 3 days. Hyaluronic acid filler injection not only showed significant improvement in periorbital hollowness but also concealed the bulge of infraorbital fat pads remarkably. Correction of tear troughs is known to be done with the help of hyaluronic acid but it can also become an excellent alternative to surgery for concealing under eye orbital fat pads without any formation of lumps and irregularity.     

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.     

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.     

A prospective,open‐label,multicenter, observational,postmarket study of the use of a 15 mg/mL hyaluronic acid dermal filler in the lips

Hyaluronic acid (HA)‐based injectable fillers three‐dimensionally restore the natural contours of the lips and perioral area, thereby reducing some signs of aging lips. To evaluate the short‐term aesthetic impact of treatment with the HA dermal filler Juvéderm^® VOLBELLA^® with Lidocaine, formulated utilizing VYCROSS^? technology, for enhancement or correction of asymmetry of the lips, evaluated using a patient‐centric approach. Sixty‐two subjects were enrolled in this study, conducted at two sites in Germany. Primary endpoints were satisfaction with improvement, look and feel of the lips, assessed by subject and physician at first visit and 4 weeks post‐treatment. Immediately after injection at first visit, 83.6% of subjects were Extremely Satisfied, Very Satisfied or Satisfied with improvement in the lips, which increased to 94.1% and 93.0% of subjects with/without top‐up treatment at follow‐up, respectively. After injection at first visit, 61.7% of subjects rated the look and feel of their lips as Extremely Natural or Very Natural, which increased to 75.0% and 93.0% of subjects with/without top‐up treatment, respectively. The HA dermal filler was associated with minimal discomfort, bruising or swelling of the lips; almost two‐thirds of subjects (62%) returned to social engagements on the same day. The high degree of subject satisfaction with aesthetic improvement in the lips, as well as the natural look and feel, indicates that this HA dermal filler represents an effective treatment option for patients requiring lip enhancement.     

Granulomatous reaction to Belotero Balance: A case study

Objective: The most commonly used dermal fillers are hyaluronic acids (HAs), and in general, are well tolerated with mild to moderate risk of adverse events. The most frequently reported side effects are injection site erythema and bruising. We present the first case of a patient who developed a severe granulomatous foreign body reaction to the HA filler, Belotero Balance. In our review of the literature, a granulomatous reaction has never before been reported as a side effect of this particular HA filler (1). Case: On exam, the patient had firm erythematous, granulomatous plaques on her bilateral cheeks, with a tender, fluctuant nodule on her right cheek. Complete resolution of this delayed reaction was achieved after several injections of intralesional Kenalog (IL-K) 2.5 mg/cc, and further fine-tuning was achieved through laser resurfacing. Conclusion: Granulomatous reactions can occur with any HAs, though such incidents are not commonly reported. These delayed reactions are generally localized immunological reactions, though biofilm infections should be excluded where appropriate. It is only with long-term (5-year) longitudinal studies that accurate numbers of such reactions will be known.     

Delayed skin necrosis following hyaluronic acid filler injection: A case report

Vascular compromise is a rare but serious complication of dermal filler injection. Vessel occlusion tends to have a more immediate onset of symptoms. We report a case of skin necrosis that started with pain, erythema and edema two days after hyaluronic acid filler on the forehead of a 57‐year‐old woman. The patient was treated with less than 24 hours the onset of symptoms, leaving discreet scar. The current theories that explain skin necrosis caused by HA fillers include angiospasm and embolization. The frontal region has many anastomoses, the embolized proximal vessel initially did not lead to symptoms. However, the HA inside the artery may have traveled over time and reached a terminal distal branch, which generated localized skin damage and pain. The urgent treatment of arterial occlusion and thromboembolism caused by HA injection is intralesional high‐dose hyaluronidase.