Injectable neurotoxins and fillers: There is no free lunch

Myth Versus Reality: A Review of Social Media Claims and Scientific Evidence for Arnica Montana in Postinjectable Procedures

BACKGROUND

Reduced bruising and swelling after aesthetic procedures accelerates recovery. Arnica montana is widely used by physicians and promoted on social media, although its efficacy in aesthetic medicine remains uncertain.

OBJECTIVE

To evaluate the validity of social media claims regarding Arnica's therapeutic benefits, focusing on aesthetic injectable procedures.

MATERIALS AND METHODS

Social media platforms, TikTok and Reddit, were searched on April 24, 2024, covering a 2-year period, using terms: "arnica montana," "arnica," "arnica filler," "arnica botox," and "arnica gel." A literature review was conducted using OVID Medline and Embase databases with keywords "arnica" and "arnica montana."

RESULTS

A total of 48 TikTok posts and 305 Reddit entries were identified; with 91.7% and 58% of posts, respectively, endorsing Arnica use, primarily without scientific evidence. The literature review revealed limited and mixed evidence for Arnica's efficacy, with only 1 study addressing dermatologic injectable procedures. Systematic reviews indicated a small effect size for Arnica in surgical settings, with no specific focus on dermatologic applications.

CONCLUSION

Despite its popularity on social media and frequent use by health care providers, scientific evidence supporting Arnica's efficacy in reducing bruising and swelling after aesthetic procedures remains inconclusive. Social media discussions predominantly supported Arnica use, with limited opposition noted.

Agarose Gel: An Overview of the Dermal Filler and a Clinical Experience With 700 Patients

Background

Dermal fillers currently in the market have several advantages and disadvantages over each other. Agarose gel (AG) is a unique material due to its special rheological characteristics and gel-forming capability.

Objectives

The authors aimed to share their clinical experience on AG for a variety of facial augmentation procedures and its long-term results.

Methods

The study population consisted of 700 patients (532 females; 168 males) aged 18 to 52 years. Follow-up visits were at 1, 3, 6, 12, and 24 months after the injections. Patient satisfaction was evaluated on a scale from 0 to 10 using a survey and clinical improvement was evaluated using the Global Aesthetic Improvement Scale (GAIS) by 2 independent plastic surgeons before the injection and at 1-year follow-up.

Results

Eighty-two percent of the patients scored 1 or 2 (exceptional or great improvement) on GAIS. Eighty-five percent of the patients scored 8 or above (very satisfied). Most patients experienced at least 80% persistence of effect at 1-year follow-up.

Conclusions

AG appears to be suitable for a variety of facial augmentation and contouring applications, as it is safe and has long-lasting favorable cosmetic efficacy.

Level of Evidence 3

Unilateral hard palate necrosis following gingival injections with hyaluronic acid

Hyaluronic acid (HA) injections into the oral mucosa have proven to be effective as a non-invasive method for the reconstruction of interproximal papillary defects in aesthetic areas. Despite being a minimally invasive and safe technique, certain side effects may occur after treatment.We report the first case of a patient with unilateral necrosis of the mucosa of the hard palate after HA filling in the maxillary anterior gingiva. Familiarity with these events and competent knowledge of the anatomy is essential to avoid complications, achieve and offer adequate treatment and good results to our patients.

The Aetiopathogenesis of Late Inflammatory Reactions (LIRs) After Soft Tissue Filler Use: A Systematic Review of the Literature

Background

Late inflammatory reactions (LIRs) are the most challenging complications after filler use. The immune system plays a prominent role in its etiology, albeit to an unknown extent. Bacterial contamination in situ has been hypothesized to be causative for LIRs. How this relates to the immunological processes involved is unknown. This article aims to provide an overview of immunological and bacterial factors involved in development of LIRs.

Methods

We undertook a systematic literature review focused on immunological factors and microbiota in relation to LIRs after filler use. This systematic review was performed in accordance with the PRISMA guidelines. PubMed, EMBASE and the Cochrane databases were searched from inception up to August 2019. Included studies were assessed for the following variables: subject characteristics, number of patients, primary indication for filler injection, implant type/amount and injection site, type of complication, follow-up or injection duration, study methods, type of antibiotics or medical therapies and outcomes related to microbiota and immunological factors.

Results

Data on immunological factors and bacterial contamination were retrieved from 21 included studies. Notably, the presence of histocytes, giant cells and Staphylococcus epidermidis within biopsies were often associated with LIRs.

Conclusion

This review provides a clear overview of the immunological factors associated with LIRs and provides a hypothetical immunological model for development of the disease. Furthermore, an overview of bacterial contamination and associations with LIRs has been provided. Follow-up research may result in clinical recommendations to prevent LIRs.

Level of Evidence III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors-www.springer.com/00266..

Supplementary Information

The online version contains supplementary material available at 10.1007/s00266-021-02306-3.

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 use of algeness in the face and neck: a safe, alternative filler for cosmetics and reconstruction

Background

The search for effectiveness and safety in the use of dermal fillers, is an ongoing challenge for aesthetic physicians, plastic surgeons and the science of bioengineering. Understanding the variety of characteristics, capabilities, advantages and disadvantages of available injectables is essential to reduce complication rates and achieve satisfying aesthetic and functional results.

Methods

Algeness is a 100% natural, biodegradable tissue implant, consisting of a gel derived from agarose. This paper analyzes the use of this newly introduced agarose gel as an alternative filler in the face and neck for aesthetic and functional indications. All participants gave informed consent before taking part and there was no ethics approval required. As this work describes opinions based on clinical experienced physicians and not the results of a monocentric study.

Results

Algeness is competitive with other available hydrophilic biomaterials, such as hyaluronic acid, and has the advantage of its unique hydrocolloid nature.

Conclusions

Compared to other injectables, it exhibits good tolerability, excellent persistence, negligible immunological reaction, biocompatibility and maximal safety—all properties combined with immediate volume restoration and predictable outcomes. “What you see (on injection), is what you get (as a result)”. Level of evidence: Level V, opinions based on clinical experience.

Clinical uses of botulinum toxin A in smile aesthetic modification

In this article we review the pharmacodynamics of commercially available preparations of botulinum toxin type A, and discuss the potential uses of the drug in smile modification. A major emphasis is placed on applications relevant to modern dental practice, and to the complications arising from its use. Botulinum toxin A, when applied correctly, is a safe and effective means of achieving aesthetic smile modification, with limited data on any demonstrable long-term adverse effects.

A Recipe for Improved Nonsurgical Cosmetic Outcomes: Know Your Herbs and Spices

The nonsurgical cosmetic arena continues to grow, with more people consistently seeking minimally invasive procedures for facial rejuvenation. However, although these prospective patients are not seeking surgical correction to obtain their results, there is still the potential for nonsurgical procedures to yield adverse events posttreatment. Patients often do not realize that their dietary regimens may affect their nonsurgical cosmetic outcomes. For example, many patients desiring these types of treatments are often found to be taking prescription medications, herbs, and spices on a daily basis that may have the capacity to potentiate adverse outcomes such as bleeding and/or bruising. For these reasons, it is important for clinicians to be inclusive while taking health histories and to properly educate their patients so that administered treatments have the best chance of yielding the desired results. The focus of this article is to provide health care providers information on many of the herbs and spices that have the potential to negatively impact nonsurgical cosmetic outcomes.

An Overview of Vascular Adverse Events Associated With Facial Soft Tissue Fillers: Recognition, Prevention, and Treatment

Minimally invasive facial cosmetic surgery procedures have seen an exponential increase in numbers over the past decade. The most commonly performed procedures are neuromodulator and soft tissue filler procedures. Although soft tissue fillers have a high safety and predictability profile, these procedures recently have been associated with serious and dire adverse events. This article will discuss some of the vascular complications associated with facial soft tissue fillers. Management and prevention of these adverse events also will be discussed.

Granulomatous foreign-body reactions to permanent fillers: detection of CD123+ plasmacytoid dendritic cells

BACKGROUND

Soft-tissue augmentation with permanent fillers can lead to severe granulomatous foreign-body reactions (GFBRs), but the immune pathomechanism of this complication is still unknown. We performed conventional histologic examination and immunostaining for plasmacytoid dendritic cells (pDCs) in skin sections from patients with GFBR to 4 permanent filler agents, which have been widely used in recent decades.

METHODS

Twenty-one skin biopsies were studied from 19 patients with GFBR to polyalkylimide 4% gel (PAIG, n = 10), polyacrylamide 2.5% gel (PAAG, n = 2), hydroxyethyl methacrylate/ethyl methacrylate in hyaluronic acid (HEMA/EMA, n = 4), or liquid injectable silicone (n = 5). GFBRs were analyzed in hematoxylin and eosin stained sections and pDCs detected using CD123 antibodies. Anti-CD11c immunostaining was performed for comparison.

RESULTS

Grading of the inflammatory infiltrates observed histologically did not correlate with the clinical features of inflammation. Immunostaining for CD123 did not detect pDCs in 8 of 10 polyalkylimide gel, 1 of 2 polyacrylamide gel, and the 5 liquid injectable silicone biopsies. In contrast, all 4 HEMA/EMA biopsies contained collections of pDCs in lymphocytic infiltrates close to filler particles and adjacent sarcoidal granulomas.

CONCLUSIONS

Our data suggest that pDCs contribute to the sarcoidal granulomas associated with injected HEMA/EMA. Recruited pDCs may exert their pro-inflammatory effects by the release of interferon-α at the site of these filler deposits.

Delayed immune mediated adverse effects to hyaluronic Acid fillers: report of five cases and review of the literature

Hyaluronic acid (HA) fillers in cosmetic medicine have been considered relatively safe, though fillers used in European countries and throughout the world are not necessarily approved by the Food and Drug Administration. As their use continues to expand worldwide, physicians in a wide range of medical specialties are authorized to perform HA injections, including general medicine practitioners and even dentists. An increasing number of reports have appeared regarding side effects to these products. It is now known that reactions to Hyaluronic acid are related not only to technical faults of the injections, but also to immune responses, including delayed hypersensitivity and granulomatous reactions. Herein, we describe five cases treated by a variety of treatment modalities, all with delayed reactions to different brands of hyaluronic acid fillers. As there is currently no standardization of treatment options of adverse effects, these cases accentuate the debate regarding the approach to the individual patient and the possible need for pre-testing in patients with an atopic tendency.

Complications Associated with Facial Soft-Tissue Fillers

Minimally invasive facial cosmetic surgery procedures have seen an increase in numbers over the past decade. The two most common procedures are Botulinum toxin type A injection and soft-tissue fillers. Although soft-tissue fillers have a high safety profile, these materials have been recently associated with serious and irreversible complications. This article reviews complications associated with facial soft-tissue fillers and their management. In addition, ways to prevent these unwanted complications are discussed.

Avoiding the "danger zones" when injecting dermal fillers and volume enhancers

Aesthetic providers need to be aware of the serious potential complications that can result from occlusion of specific facial arterial and venous structures. This article focuses on the anatomical "danger zones" to avoid during dermal filler and volume enhancer injection procedures. Clinical pearls are provided on how to avoid these "danger zones" and what to do if a rare complication (e.g., skin necrosis or vision loss) does occur.

Dermal fillers: facts and controversies

Dermal fillers have been used for decades in soft tissue augmentation. Currently, filler implementation is among the most common minimally invasive procedures for rejuvenation and body sculpturing. There is a broad variety of filler materials and products. Despite immense experience, a number of controversies in this topic exist. Some of these controversies are addressed in this review, for example, who should perform filler injections, the difference between permanent and nonpermanent fillers, the off-label use of liquid silicone, and the role of pain reduction. Implementation of guidelines and restriction of filler use by trained physicians can improve safety for patients.

Complications associated with injectable soft-tissue fillers: a 5-year retrospective review

IMPORTANCE

Even when administered by experienced hands, injectable soft-tissue fillers can cause various unintended reactions, ranging from minor and self-limited responses to severe complications requiring prompt treatment and close follow-up.

OBJECTIVES

To review the complications associated with injectable soft-tissue filler treatments administered in the Williams Rejuva Center during a 5-year period and to discuss their management.

DESIGN AND SETTING

Retrospective medical record review in a private practice setting.

PARTICIPANTS

Patients receiving injectable soft-tissue fillers and having a treatment-related complication.

INTERVENTIONS

Injectable soft-tissue filler treatments.

MAIN OUTCOME MEASURES

A retrospective medical record review was conducted of patients undergoing treatment with injectable soft-tissue fillers between January 1, 2007, and December 31, 2011, and identified as having a treatment-related complication.

RESULTS

A total of 2089 injectable soft-tissue filler treatments were performed during the study period, including 1047 with hyaluronic acid, 811 with poly-L-lactic acid, and 231 with calcium hydroxylapatite. Fourteen complications were identified. The most common complication was nodule or granuloma formation. Treatment with calcium hydroxylapatite had the highest complication rate.

CONCLUSIONS AND RELEVANCE

Complications are rare following treatment with injectable soft-tissue fillers. Nevertheless, it is important to be aware of the spectrum of potential adverse sequelae and to be comfortable with their proper management.

LEVEL OF EVIDENCE

4.

Complications of minimally invasive cosmetic procedures: prevention and management

Over the past decade, facial rejuvenation procedures to circumvent traditional surgery have become increasingly popular. Office-based, minimally invasive procedures can promote a youthful appearance with minimal downtime and low risk of complications. Injectable botulinum toxin (BoNT), soft-tissue fillers, and chemical peels are among the most popular non-invasive rejuvenation procedures, and each has unique applications for improving facial aesthetics. Despite the simplicity and reliability of office-based procedures, complications can occur even with an astute and experienced injector. The goal of any procedure is to perform it properly and safely; thus, early recognition of complications when they do occur is paramount in dictating prevention of long-term sequelae. The most common complications from BoNT and soft-tissue filler injection are bruising, erythema and pain. With chemical peels, it is not uncommon to have erythema, irritation and burning. Fortunately, these side effects are normally transient and have simple remedies. More serious complications include muscle paralysis from BoNT, granuloma formation from soft-tissue filler placement and scarring from chemical peels. Thankfully, these complications are rare and can be avoided with excellent procedure technique, knowledge of facial anatomy, proper patient selection, and appropriate pre- and post-skin care. This article reviews complications of office-based, minimally invasive procedures, with emphasis on prevention and management. Practitioners providing these treatments should be well versed in this subject matter in order to deliver the highest quality care.