Hyaluronic acid skin fillers: adverse reactions and skin testing

Review of long-term adverse effects associated with the use of chemically-modified animal and nonanimal source hyaluronic acid dermal fillers

Although only recently introduced, chemically-modified hyaluronic acid dermal fillers have gained widespread acceptance as "redefining" dermal fillers in the fields of dermatology and cosmetic facial surgery. Although hyaluronic acid-based dermal fillers have a low overall incidence of long-term side effects, occasional adverse outcomes, ranging from chronic lymphoplasmacytic inflammatory reactions to classic foreign body-type granulomatous reactions have been documented. These long-term adverse events are reviewed.

Hyaluronidase in the office: a necessity for every dermasurgeon that injects hyaluronic acid

Soft tissue augmentation plays an increasingly important role in the management of the aging face. The recent explosion of dermal filler use in aesthetic dermatology has brought with it the expected reporting of rare but significant side effects. These include the too-superficial placement of product which can yield an undesirable bluish discoloration due to the Tyndall effect, the use of excessive product, persistent granulomatous foreign-body reactions and, most significantly, the risk of injection necrosis.

A study of the histological behavior of a rabbit vocal fold after a hyaluronic acid injection

The vocal fold structure is composed of tissues with many cells surrounded by the extra-cellular matrix. One of the most important components of the extra-cellular matrix is Hyaluronic Acid (HA). The aim of the study was to evaluate the inflammatory response of rabbit vocal folds after a local injection of Restylane HA.

METHODS

Twelve adult male rabbits randomly received a 0.1 ml injection of Restylane HA in one vocal fold and 0.1 ml of saline in the other vocal fold. The animals were prospectively subdivided into two groups; animals in one group were sacrificed after one week of follow-up and animals in the other group were sacrificed after 3 months. Slides were Hematoxylin-Eosin (HE), Masson Trichromic and Toluidine Blue stained.

RESULTS

Hyaluronic Acid was found microscopically in all specimens in both groups. There was more connective tissue surrounding HA, always associated with a mild inflammatory response. The longer exposure time did not increase the intensity of inflammation. Tissue necrosis and foreign body inflammatory reaction were not observed in both groups.

CONCLUSION

The study suggests that HA is a good alternative as a filling material in vocal folds when treating glottal insufficiency.

Principles of soft tissue augmentation for the aging face

In the quest for the "ideal" soft tissue filler, many diverse products have been developed. The expanding market of available fillers is a testament that no one product will ideally suit all patients or clinicians. In addition, the challenge of satisfying the criteria of an ideal filler has driven researchers to take a variety of development paths. This has resulted in multiple categories to characterize soft tissue fillers. These fillers are categorized according to: (1) filler material, eg, autologous, natural, synthetic; (2) mechanism of action, eg, void filler, neocollagenesis, fibroblast stimulation; (3) patient type and profile, eg, younger versus older patient, rhytids versus "sinking and sagging" skin; or (4) durability of treatment effects, eg, temporary, semi-permanent, or permanent. Although strategies for soft tissue augmentation may be quite diverse, strategies should share a universal goal to address fat redistribution (atrophy and hypertrophy), the primary underlying morphological cause of facial aging. To accomplish this, volumizers are now available that are injected more deeply, resulting in the restoration of supportive structure and foundation. These can be used in combination with other products that are used more superficially for smoothing skin surfaces. As numerous soft tissue fillers enter the market, mechanisms and injection techniques become more divergent, and therefore require that the dermatologist and cosmetic surgeon receive adequate training to use products safely and effectively. This manuscript provides an overview of soft tissue fillers and their proper use.

Restylane and people of color

BACKGROUND

Ethnic skin presents a unique paradox. Its melanin content provides protection from the sun, but the same skin can react to the slightest of injuries. The safety of Restylane in patients with increased susceptibility to keloid formation, hypertrophic scarring, hypersensitivity, and hyperpigmentation has not been studied. A retrospective review was used to determine whether Fitzpatrick skin types IV to VI are associated with an increased incidence of adverse outcomes related to Restylane use.

METHODS

Sixty consecutive patients were injected with Restylane by a single surgeon (J.W.F.). Forty patients were categorized as Fitzpatrick skin types I to III and 20 as types IV to VI. Patient charts were reviewed for transient and permanent adverse outcomes related to Restylane injections, such as hypersensitivity, scar formation, altered pigmentation, and contour irregularities. All patients were evaluated at 2 to 4 weeks and 6 to 9 months.

RESULTS

The authors observed that 97.50 percent of the Fitzpatrick type I to III patients had no transient adverse outcomes related to Restylane injections. One patient experienced a 36-hour episode of exaggerated angioedema of the lips after injection, which resolved spontaneously. Another patient had an inclusion cyst that required incision and drainage and a 7-day course of antibiotics. None of the type I to III patients had permanent adverse outcomes related to Restylane. There were no transient or permanent adverse outcomes among the type IV to VI subjects.

CONCLUSIONS

This study demonstrates that with proper and meticulous injection techniques, patients with Fitzpatrick skin types IV to VI can experience the same benefits of Restylane therapy as their lighter-complected counterparts.

Persistent delayed-type hypersensitivity reaction to injectable non-animal-stabilized hyaluronic acid

OBJECTIVE

Injectable hyaluronic acid is a glycosaminoglycan used for soft-tissue augmentation. A number of products that are not Food and Drug Administration (FDA) approved for use in the United States are used commonly in Europe. We report a case of persistent delayed-type hypersensitivity to injected non-animal-stabilized hyaluronic acid. The patient was initially injected in Europe with a non-FDA-approved filler but traveled to the United States for evaluation of this adverse reaction.

METHODS

A case of adverse reaction to non-animal-stabilized hyaluronic acid is described. An overview of selected hyaluronic acid filler products is provided.

RESULTS

The patient developed persistent facial edema after injection of hyaluronic acid filler to the melolabial folds, glabella, lips, and perioral rhytids.

CONCLUSION

Injectable hyaluronic acid can be associated with a variety of complications including immediate and delayed-type hypersensitivity reactions. Physicians should be familiar with products used in other countries, as patients may present for evaluation following adverse reaction to fillers obtained abroad or from American physicians using non-FDA-approved products.

Hyaluronidase offers an efficacious treatment for inaesthetic hyaluronic acid overcorrection

BACKGROUND

Hyaluronic acid is generally accepted today as the "gold standard" filler agent, and its use has subsequently grown enormously. In addition, newer facial volume augmentation indications are constantly evolving. Rare adverse events, such as granulomas, have been described. However, complications are more commonly due to product misplacement or overcorrection leading to unsightly lumps and masses. Hyaluronidase treatment of these latter adverse effects can be both effective and rapid.

OBJECTIVE

This paper aims to confirm the efficacy of hyaluronidase injections in dissolving unsightly hyaluronic acid overcorrection.

METHODS

A case of hyaluronic acid overcorrection is described with evaluation of the effects of hyaluronidase.

RESULTS

The use of hyaluronidase, injected intracutaneously permits the elimination of patient discomfort and inaesthetic lumps within a few hours.

CONCLUSIONS

Hyaluronidase is highly effective in eliminating HA volume overcorrection.

Treatment of Lower Eyelid Retraction by Expansion of the Lower Eyelid With Hyaluronic Acid Gel

PURPOSE

To report our preliminary experience utilizing a nonsurgical alternative in the treatment of lower eyelid retraction: expansion and reinforcement of the lower eyelid with hyaluronic acid gel.

METHODS

Retrospective review of patients with lower eyelid retraction treated with hyaluronic acid gel. Pretreatment, post-treatment, and follow-up photographs were digitized and overall outcomes assessed. Measurements of inferior scleral show were standardized and compared.

RESULTS

Sixty-five procedures (31 patients; 14 male; mean age 58 years, range, 33-78 years) with lower eyelid retraction of various etiologies were treated with hyaluronic acid gel. A mean change in scleral show of 1.04 mm was found when pre- and post-treatment measurements were compared. The overall mean follow-up period was 6.2 months (range, 1-12 months). During the interval from initial treatment to follow-up visit (mean 4.6 months, range, 1-12 months), the effect of the hyaluronic acid gel diminished, with a mean increase in inferior scleral show of 0.52 mm. Twelve patients underwent a second, and 6 patients underwent a third, maintenance treatment with an improvement in scleral show of 0.87 mm and 1.13 mm, respectively. Complications were minor and included swelling, redness, bruising, and tenderness at the sites of injection.

CONCLUSIONS

Based on our preliminary results, hyaluronic acid gel shows promise as a treatment modality for the management of lower eyelid retraction. Long-term follow-up will better clarify the required frequency of maintenance injections, the degree of hyaluronic acid gel retention, and the position of the lower eyelid over time.

A diagnostic trap for the dermatopathologist: granulomatous reactions from cutaneous microimplants for cosmetic purposes

We present a case of late granulomatous reactions from silicone that first appeared in a site different from that of the injection causing an incorrect diagnosis of liposarcoma in the beginning. The histological picture was a cystic-macrophagic granuloma in both the injection site (upper lip) and the migrating site (paranasal regions). We think that the foreign body has undergone an antigravity migration from the upper lip to the right paranasal region. To our knowledge, such a phenomenon has not been yet reported in literature.

Use of hyaluronic acid fillers for the treatment of the aging face

Hyaluronic acid fillers have become popular soft tissue filler augmentation agents over the past several years. They have helped revolutionize the filler market with a number of new products available for use for our patients. The purpose of this manuscript is to review the characteristics of the HA fillers and to review each of the current products currently available for use in the US.

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.

Facial granulomas secondary to Dermalive microimplants: Report of a case with histopathologic differential diagnosis among the granulomas secondary to different injectable permanent filler materials

Wrinkle reduction and the correction of skin defects using injectable aesthetic microimplants are now widely performed by dermatologists and plastic surgeons. In recent years, dermal filler substances containing polymer particle suspensions such as Bioplastique, Artecoll, and Dermalive are the most commonly used materials. These microimplants are permanent, non-biodegradable, and generally well tolerated, although various adverse reactions are still possible. We describe here a patient with facial granulomas secondary to Dermalive injections for correction of naso-labial folds and wrinkles. The particular shape of the injected particles allows for correct identification of the implanted material. Therefore, histopathologic examination is the best means to obtain the correct diagnosis of foreign body granuloma and to identify the type of filler particles. We discuss the histopathologic differential diagnosis among the granulomas secondary to the most commonly used aesthetic permanent filler materials.

Injectable Soft-Tissue Fillers: Clinical Overview

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Know the composition and biology of injectable fillers. 2. Understand the advantages and disadvantages of each injectable filler. 3. Understand the U.S. Food and Drug Administration regulatory status of each type of injectable filler, including their indications.

BACKGROUND

The use of injectable filling agents for soft-tissue facial defects has a long history of successful use based on xenogeneic collagen materials. New materials of differing compositions for injection treatments either are now available or will soon be available for clinical use.

METHODS

A review of the medical literature was performed to provide chemical compositions, methods of preparation, biological behavior, and clinical outcomes for every known injectable filler material that is either currently used or being evaluated in clinical trials.

RESULTS

Hyaluronic acid-based materials have now replaced animal or human-derived collagen as the standard injection materials. Synthetic alternatives offer the potential of longer lasting results, but the long-term outcome with their use in large numbers of patients is not yet known.

CONCLUSIONS

As there is no single injectable filler that has all of the desired characteristics, understanding the advantages and disadvantages of one filler over another is extremely helpful in guiding the patient to an informed decision. Although all of the reviewed injectable fillers are safe, the concepts of their long-term volume persistence and how they compare with each other remain largely anecdotal, with few prospective controlled clinical trials.

Filling the Periorbital Hollows With Hyaluronic Acid Gel: Initial Experience With 244 Injections

PURPOSE

To review our initial experience using hyaluronic acid gel (Restylane) as a filler to treat the periorbital hollows.

METHODS

This is a retrospective, anecdotal case review of 244 cosmetic hyaluronic acid gel injections in 155 patients. An average volume of 0.9 ml per injection session was used in an individualized pattern that variably included the orbital rim hollow, zygomatic hollow, septal confluence hollow, and eyebrow and cheek fat pad. To achieve smooth contours, a layered, feathered threading technique was used, placing the filler deep to the orbicularis. Hyaluronidase injections were used in 11% of patients at follow-up visits to "dissolve" some of the filler to reduce contour irregularities.

RESULTS

One hundred eight of 121 (89%) patients with follow-up visits were satisfied with the cosmetic improvement after hyaluronic acid gel injections. For maintenance, the interval to second injection averaged 6.5 months. Side effects included lumps or contour irregularities (11%), bruising (10%), color change (7%), and fluid (15%). Twelve patients were unsatisfied and were not interested in additional injections: 5 with malar fluid, 3 with lumpy irregularity, and 3 with color change.

CONCLUSIONS

Complex 3-dimensional contours and thin skin over bone render periorbital filling difficult. However, with individualized planning and with care taken to create smooth, feathered contours, it is possible to achieve acceptable improvement. We found that most patients considered themselves improved cosmetically, despite occasional side effects including contour irregularity or lumps, bruising, color change, and fluid accumulation. Patients with very thin skin, preexisting color problems, or preexisting eyelid fluid may not be good candidates for periorbital filling with hyaluronic acid gel. The effect of the filler is temporary, of course, and we counsel patients to anticipate maintenance injections at 6- to 12-month intervals.

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.

Injectable hyaluronic acid implant for malar and mental enhancement

BACKGROUND

The use of a thicker injectable implant version of one of the hyaluronic acid dermal fillers (Restylane SubQ, Q-Med, Uppsala, Sweden) is described.

OBJECTIVE

A group of treated patients has been studied for more than 1 year. Restylane SubQ was injected to the submuscular plane of the upper cheeks and chin to observe efficacy of augmentation and side effect profile, and further observations were made of the duration of benefit.

METHODS

Patient details--72 patients were treated, 68 for upper cheek augmentation, 2 for chin augmentation, and 2 for both areas. Four patients received second injections 8 weeks after the first to increase augmentation.

RESULTS

Patients all showed a persistence of benefit during the posttreatment observation period of up to 64 weeks. Four patients had minor side effects that resolved with local treatment and time. Four patients had second injections to complete augmentation without complications.

CONCLUSIONS

Restylane SubQ is a useful injectable agent to augment and lift upper cheeks and recontour chins. Further efficacy studies seem justified.

Hypersensitivity reaction to nonanimal stabilized hyaluronic acid

Soft tissue augmentation has become a cornerstone of facial rejuvenation. The bovine collagens were historically considered the "gold standard" as they had an extensive safety history and were effective. However, because of their brief duration and the approximate 1.0% to 3.0% incidence of hypersensitivity, alternatives were sought. A new class of agents, the hyaluronans, was recently granted approval by the Food and Drug Administration. The hyaluronans are indicated for injection into the mid to deep dermis for correction of moderate to severe facial wrinkles and folds (eg, the nasolabial folds). The hyaluronans have two derivations: nonanimal stabilized hyaluronic acid (NASHA) and an additional formulation of avian origin. Both are considered major advancements as they are not species specific and therefore theoretically do not elicit humoral or cell-mediated immune reactions. To date there have been a few reports of allergic reactions to the NASHA hyaluronans, primarily to Restylane. We report what to our knowledge is the first hypersensitivity reaction to the second brand of NASHA, Captique.

A new option for volumetric restoration: poly-l-lactic acid

OBJECTIVES

The market for products and techniques that correct the visible signs of facial ageing is now huge. There is a diversity of devices and treatments now vying for a share of this growing marketplace, including polymer implants and injectable preparations that are based on an array of substances. The vast majority of these devices can only provide temporary correction of superficial lines and wrinkles, with volumetric augmentation being beyond their capabilities. The products and procedures suitable for the restoration of facial volume are discussed here.

RESULTS

The restoration of facial volume has long been neglected in cosmetic rejuvenation as surgical procedures increase skin tension but do nothing to restore the underlying facial volume, which is a subtle yet important characteristic of the youthful face. Fortunately, devices are now available which can augment facial volume for long periods of time or even permanently. These include implants based on expanded polytetrafluoroethylene and silicone rubber, which provide permanent restoration of volume, but require invasive surgery and do not age with the surrounding tissues eventually resulting in an unnatural appearance. The cosmetic rejuvenation market now abounds with various injectable devices, including: poly-L-lactic acid (PLLA), polymethylmethacrylate, collagens, hyaluronic acids, silicone and calcium hydroxylapatite. The choice of which one to use in practice is physician led, based on facial assessments, product characteristics and the desires of the patient.

CONCLUSION

Although there is a wealth of products available, injectable PLLA (Sculptra) can restore volume to the face providing a natural look. Not only are the results of volume augmentation using this device long lasting, but they are also safe.

Biocompatibility of Two Novel Dermal Fillers: Histological Evaluation of Implants of a Hyaluronic Acid Filler and a Polyacrylamide Filler

BACKGROUND

Several biomaterials are currently available for soft-tissue augmentation. Biocompatibility is an indispensable condition for any such product. Appropriate histologic evaluation is a prerequisite for understanding the responses of tissues to implant materials. Recently, hyaluronic acid and polyacrylamide gel products have been introduced as dermal fillers. Both types of product are widely considered to be biocompatible.

METHODS

The present study compared tissue responses in a rat in vivo model (n = 80) to a hyaluronic acid filler (Restylane Perlane; Q-Med AB, Uppsala, Sweden) and a polyacrylamide gel filler (Aquamid; Contura SA, Montreux, Switzerland). Four groups were evaluated: group 1 (n = 20) received the Restylane Perlane implant, group 2 received the Aquamid implant (n = 20), group 3 comprised a placebo group (n = 20), group 4 was the control group (n = 20). Responses and biocompatibility were assessed by histopathologic and histomorphometric evaluations between 1 week and 8 months after implantation.

RESULTS

The two products induced very different tissue responses. The polyacrylamide gel filler was highly bioactive, undergoing cell infiltration and integration into tissues. The hyaluronic acid filler underwent minimal cell infiltration, and the product remained surrounded by a uniformly thin capsule.

CONCLUSIONS

This study reveals that two soft-tissue fillers considered to be biocompatible induce very different tissue reactions. This indicates that their behavior in clinical practice is likely to be different.

Safety and Efficacy of Nonanimal Stabilized Hyaluronic Acid for Improvement of Mouth Corners

BACKGROUND

Esthetic concern with downturned mouth corners ("mouth frown") is increasing in the aging baby-boomer generation. A new technique to offer structural support using the recently approved filler nonanimal stabilized hyaluronic acid (NASHA; Restylane, Q-med Inc., Uppsala, Sweden) is described.

METHOD

Fifteen women with prominent downturned mouth corners met the inclusion criteria for the study. All were photographed before and at 1 week, 3 months, 4.5 months, and 6 months after treatment using a standardized clinical photographic system. NASHA was injected using a standardized technique with nerve block anesthesia to ensure patient comfort.

RESULTS

All 15 women noted swelling, redness, and some local discomfort for several days after the injection. All noted an improvement in the downward angulation of their mouth corners at the first post-treatment visit, with at least partial improvement maintained through the 6-month post-treatment follow-up visit.

CONCLUSIONS

NASHA injection to support the age-related downturn of lateral lip corners was effective, safe, and well tolerated in a small prospective study of middle-aged female subjects. Esthetic satisfaction was greatest in the first 3 months post-treatment, but 40% of subjects still noted improvement at the 6-month follow-up visit.

Facial Sculpting and Tissue Augmentation

BACKGROUND

Until recently, deep facial sculpting was exclusively the domain of surgical interventions. Recent advances in the available array of dermal and subdermal fillers combined with an esthetic appreciation by both surgeons and nonsurgeons alike of the positive effect of filling the volume-depleted face have led to an expansion in the indications for the use of soft tissue augmenting agents.

METHOD

Subdermal support of the lateral two-thirds of the brow, the nasojugal fold, the malar and buccal fat pads, the lateral lip commissures, and the perioral region, including the pre-jowl sulcus, all restore youthful facial contour and harmony. An important advance in technique is the subdermal rather than the intradermal injection plane.

RESULTS

"Instant" facial sculpting giving a brow-lift, cheek-lift, lip expansion, and perioral augmentation is possible using modern soft tissue augmenting agents. The softer, more relaxed appearance contrasts to the somewhat "pulled" appearance of subjects who have had surgical overcorrections. Treatments can be combined with botulinum toxin and other procedures if required.

CONCLUSION

Newer advances in the use of fillers include the use of fillers injected in the subdermal plane for "lunchtime" facial sculpting. Using the modern esthetic filler compounds, which are biodegradable but longer lasting, subjects can have a "rehearsal" treatment or make it ongoing. Some individuals, such as those with human immunodeficiency virus (HIV)-related lipoatrophy or those who desire to obtain a longer-lasting effect, may elect to use a nonbiodegradable filling agent.

Successful Treatment of Granulomatous Reactions Secondary to Injection of Esthetic Implants

BACKGROUND

In recent years, various injectable materials have come into use to improve esthetic appearance.

OBJECTIVE

We describe the clinical and histopathologic aspects of two patients who received intradermal injections of an unknown dermal filler and the different diagnostic tools used to identify the unknown injected material (reflexion electron microscopy, electron dispersing x-ray) and discuss the possibility of a metastatic granulomatous reaction in one patient. We also describe two treatments for this complication and evaluate the legal considerations of the use of materials that have been adulterated and/or whose composition is unknown to the patient.

METHODS

We present two patients who developed a granulomatous foreign-body reaction after the subcutaneous injection of an esthetic implant. We treated patient 1 with isotretinoin and 2 months later with doxycycline. We administered isotretinoin to patient 2.

RESULTS

We observed a partial improvement in patient 1 after isotretinoin treatment and a remarkable improvement after administration of doxycycline. In patient 2, we observed an excellent response to isotretinoin.

CONCLUSION

Isotretinoin and doxycycline, when administered separately, seem to offer effective treatment for reactions resulting from silicone implants. However, further studies that include a larger number of patients and those with reactions secondary to other fillers are clearly needed before the effectiveness of this treatment can be confirmed.

Consensus recommendations for soft-tissue augmentation with nonanimal stabilized hyaluronic acid (Restylane)

The American Society for Aesthetic Plastic Surgery recently reported that there were nearly 12 million cosmetic procedures (2.1 million surgical and 9.7 million nonsurgical) performed in the United States in 2004. Almost 900,000 of the nonsurgical procedures were soft-tissue augmentation procedures using hyaluronic acid fillers. Restylane (Medicis Aesthetics, Inc., Scottsdale, Ariz.), nonanimal stabilized hyaluronic acid, was approved for use in the United States in December of 2003. Although the use of all fillers increased from 2003 to 2004, use of hyaluronic acid fillers increased nearly 700 percent. The dramatic increase in all cosmetic procedures reflects the growing trend, especially with increasing job competition, to maintain a youthful lifestyle and appearance. Basic recommendations for aesthetic use of Restylane were established based on short- and long-term efficacy and safety studies (Medicis Aesthetics, package insert). With the widespread and growing use of Restylane, a cross-sectional panel of experts with extensive clinical experience, including cosmetic dermatologists and surgical specialists (cosmetic, plastic, and ocular), convened to develop consensus guidelines for the use of Restylane. This supplement reviews the aesthetic affects of aging on the face, the role of fillers in facial soft-tissue volume replacement, and general principles for the use of Restylane, including patient comfort and assessment techniques. Specific recommendations for Restylane use in each potential target area, including type of anesthesia, injection techniques, volume for injection, use in combination with other procedures, and expected longevity of corrections, are provided. Techniques for optimizing patient outcomes and satisfaction and for minimizing and managing expected problems and potential complications are described.

Randomized, double-blind comparison of the efficacy of two hyaluronic acid derivatives, restylane perlane and hylaform, in the treatment of nasolabial folds

BACKGROUND

Cross-linked hyaluronic acid gels may offer longer-lasting cosmetic correction and a lower risk of immunogenicity than other soft tissue augmentation agents.

OBJECTIVE

To compare the efficacy and safety of a non-animal-stabilized hyaluronic acid gel (Restylane Perlane, Q-Med, Uppsala, Sweden) with that of a hylan B gel (Hylaform, Genzyme Corp., Cambridge, MA, USA), a cross-linked hyaluronic acid from chicken combs, for treatment of nasolabial folds.

METHODS

One hundred fifty patients with moderate or severe nasolabial folds were randomized to contralateral treatment with Restylane Perlane and Hylaform. Efficacy was assessed using semi-objective outcome instruments at 3, 4.5, and 6 months after achievement of an "optimal cosmetic result". Patients subsequently underwent open-label bilateral retreatment with Restylane Perlane (if required) and were followed up for a further 6 months.

RESULTS

The two products were equally effective in producing an optimal cosmetic result, although fewer treatment sessions were required with Restylane Perlane. At 6 months post-treatment, a higher proportion of patients showed a > or = 1-grade improvement in Wrinkle Severity Rating Scale (WSRS) score with Restylane Perlane (75%) than with Hylaform (38%). Restylane Perlane was considered superior in 64% of patients, whereas Hylaform was superior in 8% of patients. Treatment-related adverse events tended to be more frequent with Restylane Perlane. Local injection-site reactions were generally transient and mild or moderate in intensity and were no more frequent after Restylane Perlane retreatment.

CONCLUSIONS

Restylane Perlane provides a more durable esthetic improvement than Hylaform and offers acceptable tolerability.

Clinical comparison between two hyaluronic acid-derived fillers in the treatment of nasolabial folds: hylaform versus restylane

BACKGROUND

Hyaluronic acid-derived injectible fillers are ideal to reduce the appearance of nasolabial folding because their effect is relatively long-lasting, the material is malleable and easy to use, and there is a very low incidence of allergic reaction.

OBJECTIVE

To compare the tolerability and efficacy of two commercially available hyaluronic acid-based fillers, Hylaform (INAMED Aesthetics, Inc., Santa Barbara, CA, USA) and Restylane (Medicis Pharmaceutical Corporation, Scottsdale, AZ, USA), in the treatment of nasolabial folds.

METHODS

Eight healthy adult female subjects underwent filler injection therapy for tissue augmentation of their nasolabial folds. Each subject was randomized to receive Restylane 0.7 mL to either the right or the left nasolabial fold and Hylaform 1.0 mL to the contralateral side. High-quality digital photography was performed both at baseline and at 12 weeks post-treatment. These photographs were assessed by four blinded, independent dermatologist reviewers for improvement. Subjects completed questionnaires to document tolerability and satisfaction.

RESULTS

All subjects found the procedure to be tolerable and completely pain free after the use of oral infraorbital regional anesthesia blocks. The average subject satisfaction score was 3.00 of 5 for Hylaform and 3.78 of 5 for Restylane. The blinded, independent reviewer panel attributed an average improvement score of 2.86 of 5 for Hylaform and 3.78 of 5 for Restylane.

CONCLUSION

Both Hylaform and Restylane are effective fillers for tissue augmentation of the nasolabial folds. Restylane demonstrated higher efficacy and subject satisfaction than Hylaform. With regional nerve blocks prior to injection, both agents are completely painless.

Efficacy and safety of polyacrylamide hydrogel for facial soft-tissue augmentation

BACKGROUND

Polyacrylamide is a nonabsorbable soft-tissue filler that has been used for body contouring for more than 10 years. Aquamid is a soft-tissue filler containing polyacrylamide hydrogel. Safety and aesthetic results after injection of polyacrylamide hydrogel for facial soft-tissue enhancement were assessed at a 1-year follow-up.

METHODS

In a prospective, multicenter study, 251 patients were enrolled and assigned for injection of polyacrylamide hydrogel (Aquamid) as a means of facial augmentation and enhancement of facial contours. Subjects with facial contour deformities or soft-tissue deficiencies caused by aging, acne, trauma, surgery, or other causes were included. Persons presenting with connective tissue disorders, skin disorders affecting the face, uncontrolled diabetes mellitus, compromised immune functions or acute inflammatory diseases, known substance abuse, or mental disorders were excluded from participation in the study, as were those who had experienced treatment with any nonabsorbable filler within 6 months before the start of the study. To assess the safety and efficacy of the treatment, follow-up visits were scheduled for day 7, day 28, and 3 months, 6 months, and 12 months after the first injection. Standardized photographs were taken before treatment and during month-3 and month-12 visits. Blood and urine samples were collected and analyzed before injection and at 6 and 12 months after injection. The most common sites of injection were the nasolabial folds (48 percent) and lips (25 percent) followed by glabella folds (8 percent) and other sites. The amount of injected gel ranged from 0.2 to 12 ml.

RESULTS

Two hundred twenty-eight patients were followed for 12 months after treatment. In 93 percent, results were judged to be good or very good by the investigators and satisfactory or very satisfactory by the patients. Adverse events that could be ascribed to the treatment were observed in 37 cases, most commonly presenting as transient swelling, hematoma, redness, and pain or itching. In one case, a slight change of skin color at the site of injection was reported. No severe adverse events related to the gel were observed. In one case, neutropenia was detected in month-12 blood samples. The other values were within the normal ranges.

CONCLUSIONS

Aquamid is an easy-to-use soft-tissue filler. The effect of tissue enhancement lasted over the entire study period. Transient local tissue reactions observed were attributable to the injection procedure rather than the chemical properties of the gel. During the first year after treatment, no permanent soft-tissue reaction was observed. Long-term results need to be evaluated in the future.

A histologic study of adverse effects of different cosmetic skin fillers

OBJECTIVE

This study was designed to describe the histologic aspects of the cutaneous and mucosal adverse reactions to fillers used for cosmetic purposes.

METHODS AND MATERIALS

Eleven specimens of adverse reactions caused by Restylane, Artecoll, Metacril, New-Fill, Aquamid, and liquid silicone were processed and stained by hematoxylin-eosin and Alcian blue and submitted to polarized light.

RESULTS

Most of the reactions were foreign-body granulomas.

CONCLUSIONS

The type of granuloma and the characteristics of the agent were determined, contributing to the histologic identification of the material used. In the cases involving Restylane and Aquamid, it was possible to identify the material using Alcian blue stain and by the presence of necrosis. This stain was strongly positive in Restylane and faintly positive in Aquamid, and intense necrosis was observed in Aquamid cases. In the other cases the filler material itself was recognized and identified.

Delayed Inflammatory Reaction to Hyaluronic Acid (Restylane®)

A 45-year-old man received an injection of Restylane (cross-linked hyaluronic acid) to a mid-forehead furrow line in an attempt to reduce its prominence. The injection was uncomplicated and successful in reducing the line. Five months after the injection, he returned with an inflammatory reaction in the area of injection that resolved without treatment over a period of 3 weeks.