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.     

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.     

3D photography and lip filler: a novel assay.

BACKGROUND: Injectable fillers have been used for a considerable number of years in aesthetic dermatology, including the use of lip augmentation. There has been little attempt to scientifically measure the degree of filler augmentation. METHODS: We report the use of novel photography utilising three-dimensional imagery (Surface Imaging Ltd and Canfield Scientific Vectra 3D Volumetric Analysis System) for evaluating the change in lip volume before and after injection of filler. RESULTS: This is a single-patient case report where computerised three-dimensional photography was taken and subsequently analysed. The increased volume was then measured following lip augmentation with a hyaluronic acid filler (Restylane). CONCLUSIONS: This system would seem to have the potential for analysing the change of volume both for different parts of the face and, in this instance, for lips. Further studies are required and are ongoing to examine its accuracy to measure volume enhancement with other fillers.     

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.     

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.     

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.     

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。     

Filler migration to the forehead due to multiple filler injections in a patient addicted to cosmetic fillers

Filler migration is a potential complication following the injection of multiple fillers. With the increasing popularity of multiple filler injections, migrated granulomas should be an essential differential diagnosis for newly growing facial lumps. It is important for all physicians to be aware that complication induced by dermal fillers can occur in locations other than the planned injected sites. We described a case of filler migration to the forehead in a patient addicted to cosmetic fillers. To our knowledge, it has never been published in dermatology literature so far. A detailed history of cosmetic procedures from the patient addicted to filler injections is necessary for accurate diagnosis. Because account of previous cosmetic filler injections is not always reliable, an early skin biopsy with pathological examination is the gold standard for determining whether multiple filler injections have been performed.     

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.     

3D Photography and lip filler: A novel assay

Background: Injectable fillers have been used for a considerable number of years in aesthetic dermatology, including the use of lip augmentation. There has been little attempt to scientifically measure the degree of filler augmentation. Methods: We report the use of novel photography utilising three‐dimensional imagery (Surface Imaging Ltd and Canfield Scientific Vectra 3D Volumetric Analysis System) for evaluating the change in lip volume before and after injection of filler. Results: This is a single‐patient case report where computerised three‐dimensional photography was taken and subsequently analysed. The increased volume was then measured following lip augmentation with a hyaluronic acid filler (Restylane^TM). Conclusions: This system would seem to have the potential for analysing the change of volume both for different parts of the face and, in this instance, for lips. Further studies are required and are ongoing to examine its accuracy to measure volume enhancement with other fillers.     

Hyaluronic acid filler for a depressed scar

The use of filler for depressed scars has been documented but is rare in the literature. We present a case of a patient treated with hyaluronic acid fillers at the site of a long-standing depressed scar.     

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.     

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.     

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.     

Cosmetic permanent fillers for soft tissue augmentation: a new contraindication for interferon therapies

BACKGROUND: Most of the new fillers used for soft tissue augmentation in aesthetic dermatology are considered well tolerated, but very little data are available on their long-term tolerability, especially in patients receiving immunomodulatory therapy. OBSERVATIONS: A 48-year-old woman presented with disfiguring facial edema 10 weeks after she began antiviral therapy with peginterferon alfa-2a and ribavirin for chronic hepatitis C infection. The major affected sites had been treated 10 years before with Artecoll, a permanent filler containing polymethylmethacrylate. A treatment attempt with allopurinol was initiated while antiviral therapy was continued and was successfully completed after 6 months. Despite significant improvement, extended plastic surgery was necessary for facial reconstruction. CONCLUSIONS: The normal host response to a cosmetic filler is a weak granulomatous reaction. Interferon and other immunostimulatory medications can lead to an exacerbation of this preexisting low-grade chronic inflammation that is quite similar to interferon-triggered sarcoidosis. This potential long-term risk has medicolegal implications for informed consent and for the potential use of both permanent fillers and interferon.     

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.     

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.     

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.     

Extensive necrosis after injection of hyaluronic acid filler: case report and review of the literature

Background Use of dermal fillers for soft tissue augmentation has become an integral part of aesthetic practices. Dermal fillers temporarily remove the appearance of rhytids and reduce the depth of skin folds. Even with the most experienced of injectors, adverse effects can and do occur ranging from mild bruising to severe injection necrosis. Aims Physicians should be able to treat the severe complication of vascular necrosis and detect impending necrosis after injection of a dermal filler, especially with hyaluronic acid fillers. Materials and Methods Case report of a patient who was followed for 6 months from time of injection of hyaluronic acid filler to complete healing of wound. Results Complete wound healing was achieved with early recognition and institution of treatment. Discussion We review a case report of injection necrosis and methods used to prevent and treat this complication. Conclusion Early recognition of vascular necrosis with specific protocol for treatment after injection necrosis with hyaluronic acid fillers improves the outcome of wound healing.