皮肤填充剂

现在越来越多求美者选择皮肤填充剂来修复面部老化,这使得市面上皮肤填充剂种类日益增多.到目前为止,美国食品药品管理局批准人胶原、牛胶原、透明质酸、左旋聚乳酸、钙羟磷灰石作为皮肤填充剂用于恢复年龄相关性面部皱纹及脂肪萎缩.这些皮肤填充剂具有各自不同的适应证、优缺点和维持时间,但这些填充剂仍不是最理想的皮肤填充剂.临床医师应结合求美者的具体情况加以考虑,选择适合的填充剂以达到满意的美容效果.     

皮肤填充剂

现在越来越多求美者选择皮肤填充剂来修复面部老化,这使得市面上皮肤填充剂种类日益增多.到目前为止,美国食品药品管理局批准人胶原、牛胶原、透明质酸、左旋聚乳酸、钙羟磷灰石作为皮肤填充剂用于恢复年龄相关性面部皱纹及脂肪萎缩.这些皮肤填充剂具有各自不同的适应证、优缺点和维持时间,但这些填充剂仍不是最理想的皮肤填充剂.临床医师应结合求美者的具体情况加以考虑,选择适合的填充剂以达到满意的美容效果.     

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.     

Delayed adverse reactions caused by consecutive injections of different fillers in the same region: Murine skin study

Background: With the introduction of new injectable filler substances and the discontinuation of others, the combination of different types of fillers in a same area is more likely to happen. Naturally, a growing number of concerns regarding the combining of different types of fillers in single area may increase the risk of adverse reactions. Therefore, it has been recommended not to inject a filler in an area previously injected with another type of a filler, especially if that filler is a permanent filler. However, until now, no experimental study has been conducted to estimate the adverse reaction caused by sequential different filler injections. Objective: The aim of this study is to investigate the reactions after consecutive injections of different types of fillers in the same region in in vivo model in order to estimate the safety of the combination method. Methods: We used six healthy rats and three different types of fillers to make single injection or consecutive injections in order to compare adverse reactions. Results: Histopathology showed a granulomatous reaction in combined filler areas that were identified with different types of micro-implants in the same biopsy.     

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.     

Dermal fillers

The new bioengineered human collagen products and the various hyaluronic acid (HA) fillers are all safe and effective agents for soft tissue augmentation. There is no one best filler for all purposes and optimal results are achieved by using these products in various combinations. In my opinion, HA-containing products provide volume while collagen products are better suited to provide structural support. Less downtime is associated with the collagen products, due to the platelet-aggregating effects of collagen and the eosinophil-stabilizing effects of lidocaine. Using collagen in combination with HA, during the same office visit, may help reduce some of the bruising and swelling seen with HA alone.     

Surgery for foreign body reactions due to injectable fillers

BACKGROUND: An increasing number of soft tissue fillers have been introduced to the beauty market and these filler substances are widely used as non-toxic, non-immunogenic and relatively harmless injectable alternatives to surgical rejuvenation. Generally, facial fillers are injectable - or surgically insertable - products that are used to fill up the volume loss in the aging face. Depending on bioavailability, chemical composition and degradation, fillers can be classified as temporary or permanent, organic or inorganic and autologous or heterologous. OBJECTIVE: A plethora of new products has swamped the beauty market since face rejuvenation has become socially acceptable as well as affordable to a wider population, but adverse reactions cannot be excluded. We present 4 patients with complications after injection of facial fillers [including Artecoll(polymethylmethacrylate microspheres), Restylane (hyaluronic acid), DermaLive (hyaluronic acid plus acrylic hydrogel particles) and Newfill (polylactic acid)] and surgical correction. RESULTS: Surgical intervention led to good aesthetic and functional results after multiple unsuccessful conservative therapies. CONCLUSION: We recommend that only physicians familiar with the injection techniques and the biological and chemical characteristics of the various injectable products should perform such interventions. Especially permanent fillers should be used with utmost reticence in cosmetic surgery and we would recommend their application only in reconstructive procedures. Additionally, documentation and reporting of all adverse effects must be mandatory.     

Non-hyaluronic acid fillers

Fillers are numerous, and the products currently available have effects that may last from a few months to many years. These are used to treat facial wrinkles, and some of the new fillers exert a stimulatory effect, restoring volume in focal areas of the face by inducing collagen fibers. The dermasurgeon should thoroughly understand the indications and uses of these fillers to meet fully a patient's expectations. Some fillers are biodegradable (12-18 months), others slowly biodegradable (2-5 years), whereas others are permanent implants.

The disadvantage of the traditional biodegradable fillers is their short duration (6-12 months). Over the past decade, semipermanent fillers (polylactic acid and ceramics) have been used: they do have a longer effect, but they might induce granulomas especially on the lips. Also, permanent fillers are traditionally linked to a higher incidence of granulomas and extrusions, although with the new formulations, the adverse events are decreased.     

An experimental study of the vascular embolism caused by recombinant type III collagen implants and hyaluronic acid

Background

There are significant differences in the reported incidence of vascular complications that result from the injection of different soft tissue fillers. This study aimed to compare the risk of vascular embolism after recombinant type III collagen implants and hyaluronic acid (HA) injection into arteries.

Methods

Different concentrations of recombinant type III collagen and Restylane were injected into the central ear artery of rabbits, to construct an immediate embolization model. We screened for vascular recanalization and tissue necrosis at 30 min, 1 day, and 7 days after injection, and histopathology examination was processed on Day 7.

Results

At 30 min after injection, complete recanalization of the central ear artery was observed in 17 rabbits in the C1 group while none in the HA group. On Day 1 after injection, complete recanalization of the CEA main trunk was observed in all rabbits in the collagen group while 50% in the HA group. There was a significant difference between the C1 group and the HA group in terms of vascular recanalization and skin necrosis.

Conclusion

Under the present experimental conditions, the risk of causing vascular embolism was much lower with collagen than with Restylane. Different doses of collagen at different injection rates have the same safety profile.     

Facial aesthetic injections in clinical practice: Pretreatment and posttreatment consensus recommendations to minimise adverse outcomes

Facial aesthetic treatment with injectable neuromodulators and hyaluronic acid fillers is well established, with favourable safety profiles and consistent outcomes. As with any medical treatment, adverse events and complications may occur. Adverse events associated with these products are typically transient and mild to moderate in severity. Serious adverse events, such as infection and intravascular occlusion, are rare. Proper patient selection, consent and counselling, preparation and impeccable injection technique are important risk reduction strategies. Both clinicians and patients must be alert to the signs and symptoms of complications so that appropriate treatment can be started promptly. In this article, the authors review the current literature and provide their consensus recommendations for minimising adverse outcomes when treating patients with botulinum toxin or hyaluronic acid fillers.     

The Effect of Glycolic Acid on Cultured Human Skin Fibroblasts: Cell Proliferative Effect and Increased Collagen Synthesis

Glycolic acid peeling is known to improve photoaging processes such as wrinkling and roughness, but this effect has not been clearly defined, even though functional activation of fibroblasts has been suggested. The study was aimed to determine the effects of glycolic acid and malic acid (AHA: alpha hydroxy acid) on cultured dermal fibroblasts. Whether it directly increases cell proliferation may be an important factor influencing the production of extracellular matrix such as type I collagen. Cultured human skin fibroblasts were treated for 24 hours with glycolic acid and malic acid at different concentrations (10⁻⁴, 10⁻⁵, 10⁻⁶ M), and cell proliferation was measured by MTT assay. Then quantitative analysis of collagen synthesis was performed by PICP (Procollagen Type I C-peptide) enzyme immunoassay and radioisotope (³H-proline) labelled collagen assay. The results showed increased cell proliferation and collagen production in response to glycolic acid in a dose dependent manner. The range of cell proliferation and collagen production were significantly higher with glycolic acid treatment than with malic acid or control. It was suggested that the favorable effects of glycolic acid treatment on aging skin were mediated by increased cell proliferation in addition to functional activation of fibroblasts.     

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.     

Historie und Anwendung der Filler zur Faltenbehandlung

The development of injectable fillers for filling in depressions or wrinkles in the face is reviewed. After the hesitant interest on fillers to correct scars and depressions which started at the end of the 19th century, the development of new substances continued at a dizzying pace when public demand to treat the signs of aging increased dramatically starting in the mid 1980s. This led to a countless number of different substances. To obtain an optimal result in treating facial wrinkles or depressions the appropriate filler must be injected with a technique that suits best the individual indication. Fillers are classified in resorbable and non-resorbable permanent fillers. With resorbable fillers only a temporary result can be obtained, which means that the patient has to undergo repetitive treatments. With permanent, non-resorbable fillers long lasting results can be obtained that may last for years and even decades. All fillers may have side effects like swelling, erythema, nodules right after treatment and in very rare cases years after the injection foreign body granulomas may develop that may be resistant to treatment.     

Inadvertent intra‐arterial injection of deoxycholic acid: A case report and proposed protocol for treatment

Deoxycholic acid (ATX‐101) is a secondary bile acid that was approved as an injectable drug for the reduction of submental fat. Necrosis, an uncommon but serious adverse event, can occur due to inadvertent superficial injection or intra‐arterial injection of the acid. The management of the intra‐arterial injection of deoxycholic acid has not been well characterized. Here, we discuss methods to decrease the risk of such injections and draw on existing protocols for the inadvertent intra‐arterial injection of sclerotherapy solutions and dermal fillers to propose a safe, practical approach to treatment. A case report is presented of a 42‐year‐old woman who received a deoxycholic acid injection for the correction of submental fullness, which was complicated by the inadvertent intra‐arterial injection of the acid. The adaptation of published treatment protocols for the inadvertent injection of sclerosing solutions and dermal fillers allowed for a good outcome in this patient. The inadvertent intra‐arterial injection of deoxycholic acid is a rare event. The risk of such injections can be reduced with attention to injection technique and can be managed successfully following the adaptation of protocols in the literature for similar events from vascular compromise due to dermal fillers and sclerosing solutions.     

Increased risk of late‐onset,immune‐mediated,adverse reactions related to dermal fillers in patients bearing HLA‐B*08 and DRB1*03 haplotypes

Even though manufacturers claim that the dermal fillers are nontoxic and nonimmunogenic, adverse events may occur. Clinically and histologically, most of the late onset adverse events present as an inflammatory response. To assess whether HLA polymorphisms are associated with late‐onset inflammatory adverse events related to dermal fillers. A total of 211 patients were included, of whom 129 experienced late‐onset inflammatory adverse events to different fillers (Inflammation group) and 82 who did not (Reference group). Patients completed a standardized questionnaire and provided a blood sample or oral swap for HLA testing. The study population consisted of 188 (89%) women and 23 (11%) men. The two study groups were similar in the distributions of filler type, location of injecting, allergy, autoimmune disease, gender, age, ethnicity, and smoking status. Of the 211 patients in the sample, 25 had the combination of HLA subtype‐B*08 and HLA subtype‐DRB1*03. This was 16.3% of the inflammatory group and 4.9% of the reference group. This combination of HLA subtypes was associated with an almost 4‐fold increase in the odds of developing immune mediated adverse events (odds ratio = 3.79, 95% CI 1.25‐11.48). Genetic polymorphisms such as HLA combinations may identify patients at risk of developing late onset immune mediated adverse events to dermal fillers.     

Management of complications after implantation of fillers

Soft tissue augmentation is widely practised by a variety of different practitioners. A new classification of filler substances and procedures, taking into account long-term safety and reversibility of side effects, is proposed: i non-permanent and biodegradable, ii semi-permanent and biodegradable, iii permanent and reversible, iv permanent and non-reversible. Complications and adverse effects occur with all fillers and all filler procedures. Insufficient experience is an important contributory factor. Underreporting is probably common. Commonest are haematomas, ecchymoses, infections, papulopustular or acneiform lesions, non-hypersensitivity related swelling and oedema, erythema, changes in pigmentation, palpability of the implant and necrosis of overlying tissue. Specific therapeutic approaches for these complications and practical recommendations to minimize or avoid them are discussed. Hypersensitivity reactions and granuloma formation are the most distressing adverse effects. They can occur with most fillers. Mostly these hypersensitivity reactions are local granulomas but, rarely, generalized reactions also occur. Case reports of systemic reactions after injection of hyaluronic acid are documented. Treatments include steroids, minocycline and immunomodulatory agents, such as cyclosporin, tacrolimus and ascomycin. In selected cases, surgical procedures are necessary to elimirate granulomatous reactions. Implant migration and facial lipoatrophy are encountered with certain compounds. Extreme caution is therefore advocated before using permanent and non-reversible products for soft tissue augmentation. Those who use fillers need to be familiar with the complications of fillers and with the treatment of those complications.     

Inflammatory Nodules Following Soft Tissue Filler Use: A Review of Causative Agents, Pathology and Treatment Options

Nodule development is a common complication following the use of fillers for soft tissue augmentation and is commonly categorized as inflammatory or non-inflammatory in nature. Inflammatory nodules may appear anywhere from days to years after treatment, whereas non-inflammatory nodules are typically seen immediately following implantation and are usually secondary to improper placement of the filler. Although inflammatory nodules are more common with permanent fillers such as silicone, inflammatory nodule development following administration of temporary fillers such as hyaluronic acid and collagen has also been reported. Treated many times with corticosteroids due to their anti-inflammatory properties, inflammatory nodules may be secondary to infection or biofilm formation, warranting the use of alternative agents. Appropriate and prompt diagnosis is important in avoiding delay of treatment or long-term complications for the patient. This paper addresses the etiology, development, and studied treatment options available for inflammatory nodules secondary to each of the major classes of fillers. With this knowledge, practitioners may expeditiously recognize and manage this common side effect and thus maximize functional and aesthetic benefit.