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.     

Consensus statement on the management of urticaria

This consensus statement was developed by Special Interest Group - Urticaria (IADVL). Urticaria, a heterogeneous group of diseases, often cannot be recognized by its morphology. Due to non-specific and non-affordable diagnosis, management of urticaria, especially chronic urticaria, is very challenging. This guideline includes definition, causes, classification and management of urticaria. Urticaria has a profound impact on the quality of life and causes immense distress to patients, necessitating effective treatment. One approach to manage urticaria is identification and elimination of the underlying cause(s) and/or eliciting trigger(s), while the second one is treatment aimed at providing symptomatic relief. This guideline recommends use of second-generation non-sedating H1 antihistamines as the first-line treatment. The dose can be increased up to four times to meet the expected results. In case patients still do not respond, appropriate treatment options can be selected depending on the cost.     

Consensus statement on the management of chronic hand eczema

The management of chronic hand eczema is often inadequate. There are currently no evidence-based guidelines specifically for the management of chronic hand eczema, and evidence for established treatments for hand eczema is not of sufficient quality to guide clinical practice. This consensus statement, based on a review of published data and clinical practice in both primary and secondary care, is intended to guide the management of chronic hand eczema. It describes the epidemiology and pathogenesis of hand eczema, its diagnosis and its effect on patients' quality of life. Management strategies include a skin education programme, lifestyle changes, and the use of emollients, barriers and soap substitutes. Topical drug therapy includes topical steroids and calcineurin inhibitors. Treatment with psoralen ultraviolet A and systemic therapies may then be appropriate, although there is no strong evidence of efficacy. Alitretinoin has been shown to be effective in a randomized controlled trial, and is currently the only treatment specifically licensed for the treatment of hand eczema. Recommendations for management are summarized in a treatment algorithm.     

Clinical outcomes after lip injection procedures—Comparison of two hyaluronic acid gel fillers with different product properties

Background

Transient swelling is common after lip injections with hyaluronic acid (HA) based fillers. Swelling and other injection-site reactions may relate to the injection procedure itself, or to gel properties, which differ between fillers due to differences in manufacturing methods.

Objectives

To evaluate safety and effectiveness of lip injections with two HA fillers manufactured using different gel technologies.

Methods

In a study sample of 40 subjects, treatment with two soft tissue filler product (HA_RK or HA_JUS) was randomly assigned. Subjects were injected with 0.5 cc per upper and lower lip using a standardized injection procedure. Early-onset adverse events (AEs) were assessed by evaluation up to Day 14. Aesthetic improvement, subject satisfaction, and AEs post-Day 14 were assessed up to 24 weeks.

Results

In subjects treated with HA_RK, the intensity of early onset swelling, erythema, and pain/tenderness was lower than in subjects treated with HA_JUS. Aesthetic improvement was achieved in both groups, and most subjects were satisfied with the appearance of their lips. Treatment-related AEs post-Day 14 mostly related to the implant site; most were mild-to-moderate, and none were serious.

Conclusions

The intensity of early-onset swelling, and other injection-site reactions was lower in subjects treated with HA_RK than in subjects treated with HA_JUS. Since both the injection volume and injection procedure were standardized, the difference in local tolerability between the two HA fillers may relate to differences in gel properties. Aesthetic improvement, subject satisfaction, and AE profiles post-Day 14, however, were similar between filler groups.     

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.     

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.     

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.     

Delayed immune-mediated adverse effects related to hyaluronic acid and acrylic hydrogel dermal fillers: clinical findings, long-term follow-up and review of the literature

Introduction Implantation of dermal filler for cosmetic purposes is becoming increasingly common worldwide. It is thought that hyaluronic acid (HA) alone or combined with acrylic hydrogels (HA‐AH) does not have severe nor persistent side‐effects. However, recent evidence may show that major, local and/or systemic, immediate or delayed adverse effects may appear in relation with its use. Objective To evaluate the clinical complaints, laboratory data, treatment and follow‐up of patients with delayed adverse effects related to HA and HA‐AH implant fillers. Design Prospective, case‐series study of patients filled with HA and HA‐AH compounds. Setting The study has been done in a tertiary, teaching university hospital. Patients We report on a series of 25 patients, 15 of them in prospective manner, with severe, delayed side‐effects related to HA‐AH. Inclusion criteria have been drawn up. Patients with immediate side‐effects were excluded. Patients were submitted to a clinical follow‐up, battery of blood tests and thorax X‐ray films. Besides, a review of the literature was made. We undertook a computed‐assisted (MEDLINE), National Library of Medicine, Bethesda, MD, USA, search of the literature from 1996 up to December 2005. Main outcome Clinical evaluation of granulomas, skin manifestations and other local and systemic immune‐mediated disorders possibly related to HA and HA‐AH fillers or their cumulative interaction with previously administered fillers. Results Of 25 cases, 16 were filled with HA alone and 9 with a HA‐AH compounds. Of 15 cases analysed and with long‐term follow‐up, 10 were filled with HA alone, and the remaining five were filled with a HA‐AH. Time latency average up to beginning of symptoms was 13.7 months. Three of these 15 cases had been filled before with silicone and another one with Artecoll. Tender nodules were seen in 14 patients. Systemic manifestations appeared in three cases. Laboratory abnormalities were noted in all studied cases. After 16‐month average follow‐up, seven patients seem to be cured, and six have recurrent bouts. Two cases were lost during follow‐up. Conclusion Although in some cases, these clinical complications might have been associated with previous fillers or with other unknown foreign bodies, we feel that, although infrequently, delayed and recurrent chronic inflammatory and granulomatous reactions may complicate HA and HA‐AH implant fillers.