Hyaluronic Acid Fillers in Facial Rejuvenation

Evaluating the Safety and Satisfaction of HYAcorp MLF2 for Noninvasive Buttock Augmentation: A Multicenter Study

Background

The increasing demand for noninvasive gluteal augmentation using hyaluronic acid (HA) gel highlights the need for research into its safety and effectiveness. This study aimed to assess the safety and satisfaction levels of patients and physicians regarding HA body filler for buttock enhancement. It also explores variations in outcomes across different injection sites and among different practitioners.

Methods

This retrospective, observational, descriptive multicenter study analyzed the outcomes of using a body HA filler (HYAcorp MLF2) for buttock augmentation across 4 Italian centers, with a 6-month follow-up period. Patients' and physicians' satisfaction levels were measured immediately postprocedure, and adverse events were monitored throughout the study period.

Results

Thirty-five subjects received injections, with an average volume of 85.1 ± 42.2 mL per subject injected. Throughout follow-up, 94% of patients and 100% of physicians rated the improvement as "very good" or "good." Adverse events were generally mild-to-moderate, typically resolving within 2-7 days. The most frequently recorded adverse effects were swelling, pain, and redness. No significant differences were observed among injectors (P > 0.05).

Conclusions

HYAcorp MLF2 is safe and effective for buttock augmentation, demonstrated by high satisfaction rates and manageable, mild-to-moderate adverse events, with no significant variation based on practitioner experience or clinic site.

The "4.3," A New Filler Lips Technique

BACKGROUND

The "4.3" technique is a hybrid lip augmentation approach that combines the aesthetic benefits of the vertical-lip technique with the fewer entry points of the retrograde linear technique. This method aims to create natural-looking, harmonious, and defined lips using hyaluronic acid (HA)-based fillers, to enhance volume and contour.

AIMS

The objective of this study is to evaluate the effectiveness, safety, and reproducibility of the "4.3" technique in achieving natural lip augmentation with minimal filler volume and reduced injections. This technique is applied to improve the shape and volume of the lips while minimizing the risk of complications.

PATIENTS/METHODS

The technique was applied to male and female patients with standard anatomical features who desired subtle enhancements in lip contour, projection, and volume. The procedure involved four injections in the upper lip and three in the lower lip, using a combination of retrograde linear and vertical techniques. A total of 0.7 mL of HA filler were used for each patient.

RESULTS

The "4.3" technique achieved consistent and aesthetically pleasing results across all patients, with improvements in lip volume, shape, and definition. The reduced number of injections minimized discomfort and risk of vascular complications. The use of Tri-Hyal technology contributed to smooth, plump lips with harmonious proportions.

CONCLUSIONS

The "4.3" technique is a standardized, intuitive, and reproducible method suitable for most patients, regardless of sex. It allows for natural-looking lip augmentation using a reduced volume of filler and fewer injections, making it a safe and effective option for enhancing lip aesthetics.

The Contribution of Fillers Used in the Correction of Malar Depression to Visual Quality and Quality of Life

Objectives: This study aims to investigate the contributions of the filler procedure performed in the malar region to the patient's appearance as visual quality and quality of life. Methods: A total of 72 patients who underwent a malar filler procedure between March 2022 and March 2023 were included in the study. Each patient received a 2 cc injection of hyaluronic acid filler, with 1 cc administered on the right and 1 cc on the left. Photos before the malar filler procedure and photos taken in the first month after the procedure for individuals included in the study were independently evaluated by 2 physicians. Change criteria were rated on a scale of 1 to 5 as follows: (1) no change, (2) slight change, (3) moderate change, (4) significant change, and (5) very significant change. The satisfaction of the patients related to the malar filler procedure was evaluated by a Visual Analogue Scale (VAS) scale of 1 to 10 (0 showing no satisfaction, 10 showing maximum satisfaction). Results: Physicians evaluated the visual appearance of the patients as a "very significant change" in all patients (100%). Of the 72 patients, 66 (91.6%) expressed satisfaction with the procedure, while 6 (8.4%) found the treatment insufficient and requested further interventions. Conclusion: Hyaluronic acid fillers applied to the malar region caused patient satisfaction in 91.6%. However, a few patients requested further interventions. Patients' requests for unnecessary operations should be noted and treated with caution since they may lead doctors in the wrong direction.

A narrative-style review of non-surgical rhinoplasty: Indications, outcomes, and limitations

The aim of this narrative-style review was to evaluate non-surgical rhinoplasty in terms of indications, outcomes, and limitations. Both 'PubMed' and 'Science Direct' were reviewed by all authors, in order to reach consensus with regard to the chosen studies. Studies published from 1980 to 2023 were searched using the key terms "non-surgical rhinoplasty", "dermal filler", "thread lifting", and "botulinum toxin", and relevant papers were selected. Non-surgical rhinoplasty refers to the use of injectable temporary fillers to augment selected areas of the nose, in order to achieve improved appearance or function in select patients. It includes the use of dermal fillers, thread lifting, and botulinum toxin injections. The perfect dermal filler would be inexpensive, safe, painless to inject, hypoallergenic, and long lasting. In addition, it should produce consistent and predictable results, feel natural under the skin, take little time to inject, be ready to use, exert no downtime on the patient, and have a low risk of complications. Regions of the nose treated with filler injections include the frontonasal angle, dorsum, nasolabial angle, and columella. Thread lifting and botulinum toxin injection are the other methods of non-surgical rhinoplasty. Dermal fillers, thread lifting, and botulinum toxin injections can be used as non-surgical rhinoplasty. Dermal fillers and botulinum neurotoxin can be used alongside each other to allow minimally invasive resculpting of the nasal region and midface, compensating for a reduction in tissue volume and the formation of rhytides.

Intracorporeal evaluation of hyaluronic acid fillers with varied rheological properties and correlations with aesthetic outcomes

BACKGROUND

Understanding the differences in soft tissue filler rheology and how these properties can impact clinical results is a fundamental concepts for any injector. This study aimed to assess the tissue integration characteristics of hyaluronic acid (HA) fillers manufactured with different technologies (Non-Animal Stabilized HA [HA-N] or Optimal Balance Technology [HA-O]) using ultra-high-frequency ultrasound.

METHODS

Twelve female participants with mild-to-moderate midface volume loss and temporal hollowing were enrolled and treated with HA-N and/or HA-O. Participants were seen at five visits (screening/baseline [treatment], and Weeks 1 [optional touch-up], 4, 6, and 8 [follow-up visits]). Ultrasound was used to evaluate the degree of product integration.

RESULTS

On ultrasound, HA-N presented with distinct borders, minimal tissue integration, and a capacity to displace tissues. Conversely, HA-O tended to spread horizontally within the same tissue plane and integrated within tissues. The volumizing capacity of the HA-O fillers was dependent on particle size.

CONCLUSION

HA-N is suited for deep injections in areas such as the upper lateral cheek and under the muscle of the temporal region when a lifting effect is desired; HA-O is best suited for subcutaneous injections, in areas of dynamic movement or for patients with thin skin; and can be injected subcutaneously or supraperiosteally when a volumizing effect is desired.

Fillers Around the Nose

OBJECTIVES

The aim of this paper is to review the fillers around the nose.

METHODS

The literature search was performed at the PubMed and Proquest Central database of the Kirikkale University Library.

RESULTS

Characteristics of an ideal dermal filling material would be low cost, high safety, not causing pain during filling, provoking few sensitivity reactions and being durable. The material should allow reproducible results that are in line with expectation and produce a natural texture, be quick to use, be operation-ready, not cause the patient to need to convalesce and rarely cause complications. Nasal contour remodeling using fillers has several advantages: there is a brief recovery period, a general anesthetic is not needed and ecchymosis does not occur. There are a lot of filler materials, such as collagen, hyaluronic acid, Polymethylmethacrylate with Bovine Collagen, Poly-L-Lactic Acid, calcium hydroxylapatite and expanded polytetrafluoroethylene.

CONCLUSION

It is absolutely essential to choose carefully appropriate material and procedure for patients to obtain optimum results.

Delayed Granulomas as a Complication Secondary to Lip Augmentation with Dermal Fillers: A Systematic Review

Introduction  Lip augmentation with dermal filler is rising in popularity. There are generally minimal side effects that are mild and transient. However, long-term complications may occur and include lumps, bumps, nodules, or granulomas. To better understand this uncommon but challenging outcome, we aim to perform a thorough systematic review of the published literature related to nodule or granuloma formation after cosmetic soft tissue augmentation of the lips.

Methods  A search of published literature was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines in April 2021 and included PubMed, ScienceDirect, Embase, Google Scholar, and Cochrane databases. The Medical Subject Headings (MeSH) terms used included the following terms: “lip filler,” “hyaluronic acid,” “lip injection,” “lip augmentation,” “silicone,” “poly-L-lactic acid,” “calcium hydroxyapatite,” “polymethylmethacrylate,” “complications,” “reaction,” “granuloma,” and “nodule.” All studies were reviewed by two independent reviewers. Any discrepancies were resolved by a third reviewer.

Results  The initial search for filler-related nodules or granulomas yielded 2,954 articles and 28 were included in the final analysis containing 66 individual cases of lip nodules. All but one patient was female. The mean age was 50 years. Nodules presented on average 35.2 months or 2.9 years after initial treatment. Thirty-seven nodules underwent histological analysis, the majority of which identified the presence of a foreign-body granuloma. Silicone was the most reported filler used followed by hyaluronic acid. Most cases resolved following multiple treatments including oral antibiotics or steroids followed by surgical excision.

Conclusion  Understanding the sequelae of lip augmentation with filler products allows clinicians to provide safe and effective treatment. Nodules that present months to years following dermal treatment may represent a foreign-body granuloma. A combination of oral antibiotics, intralesional or oral steroids, and surgical excision successfully treated the majority of cases in our study.

Comparative Evaluation of Safety and Efficacy of a Novel Hyaluronic Acid-polynucleotide/Poly-L-lactic Acid Composite Dermal Filler

BACKGROUND

Poly-L-lactic acid (PLLA) is widely used in tissue engineering. The natural polymer hyaluronic acid (HA) shows excellent biocompatibility and affects cell signaling, proliferation, and differentiation. In addition, a polynucleotide (PN) induces cell growth of human skin fibroblasts and osteoblasts.

OBJECTIVE

In this study, we evaluated the properties, safety, and efficacy of a novel composite filler consisting of cross-linked HA with PN in combination with monodisperse PLLA microspheres manufactured using Inventage Lab Precision Particle Fabrication method.

MATERIALS AND METHODS

The composition of the filler and characteristics of the microspheres were examined via scanning electron microscopy, particle size analysis, gel permeation chromatography, and rheology and osmolality measurement. Additionally, safety and efficacy of HA-PN/PLLA composite filler were conducted in in vitro and in vivo.

RESULTS

Analysis of PLLA microspheres revealed spherical surfaces and a narrower particle size distribution than that in PLLA filler. HA-PN/PLLA composite filler had higher viscosity and elasticity values and similar osmolality as compared to those of HA and PN fillers. The nontoxicity in in vitro and in vivo tests reflected that the composite filler may be safe for human use. In addition, the composite filler maintained a more stable volume than did HA filler for 24 weeks after administration in HWY/Slc hairless rats. Furthermore, the results support the effect of HA-PN/PLLA in restoring skin structure.

CONCLUSION

Altogether, these data suggest that the novel composite filler might be a safe and effective option in terms of tissue integration, clinical management during delivery and high esthetic durability.

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 .

A prospective, open-label, multicentric, single-arm, post-marketing clinical study to evaluate effectiveness and safety of Cross-Linked Sodium Hyaluronate 24mg with Lidocaine 3mg Injection in subjects undergoing treatment for facial wrinkles and lip augmentation

BACKGROUND

Hyaluronic acid (HA) fillers are quite commonly used since several years for soft tissue augmentation.

AIM

The purpose of this study was to evaluate primarily the safety and secondarily the clinical effectiveness of Cross-Linked Sodium Hyaluronate 24 mg with Lidocaine 3 mg (Jeunesso 24L) injection, in subjects undergoing treatment for facial wrinkles and lip augmentation.

METHOD

Patients between the age groups of 18 and 75 years, who were seeking soft tissue augmentation treatment on the face and with wrinkle severity score (WSS) ≥2 for bilateral Nasolabial Folds (NLF), were included in the study. The appropriate quantity of the filler was injected at the treatment site. Clinical efficacy assessments were conducted independently at 3 and 6 months after baseline. Clinical efficacy was assessed using Wrinkle Severity Rating Scale (WSRS) and a Global Aesthetic Improvement Scale (GAIS).

RESULTS

The mean pain score was found to be 2.57 ± 2.06 immediately after injection which was reduced to 0.1 ± 0.675 at 15 min and this further subsided to "No Pain" in any of the participants at 60 min post the injection. WSRS mean score before treatment was 2.76, which were significantly reduced to 2.14, at 3 months. Majority of participants found an improvement in the marionette line severity. Also, significant improvements were seen in the perioral and lip areas. The Study filler was well-tolerated and no side effects were reported.

CONCLUSION

The study indicates that this particular filler, HA+L, is useful for cosmetic improvements in the nasolabial folds and for enhancement of the lips.

A new three-point filler technique to maximize safety for the correction of glabellar rhytids: Evaluation of 50 patients

BACKGROUND

Hyaluronic acid (HA) fillers have been widely used for reversing the signs of the aging face. Injectable fillers are particularly effective in treating vertical glabellar wrinkles.

AIMS

The aim of this study was to share our own safe glabella filling technique and to evaluate our results in 50 patients with facial rejuvenation.

METHODS

A total of 50 patients consisting of women and men with moderate to severe glabellar rhytids were enrolled in the study. Patients were evaluated before the injection procedure and 2 weeks after the procedure by using the Rao-Goldman scale. We have described a new three-point filler technique.

RESULTS

Of 50 patients, 39 were females and 11 males, and the mean age was 39.82 ± 6.44 years. The mean volume of HA that was injected into the glabellar wrinkles was 0.61 ± 0.12 mL. Eight patients had experienced mild complications related to the procedure. None of the patients had experienced skin necrosis and visual impairment.

CONCLUSION

Our technique is a simple and safe procedure to correct glabellar rhytids. Practitioners should be aware of the safe injection techniques, potential complications, and management of these complications for a good clinical practice.

In Vitro Evaluation of the Biological Availability of Hyaluronic Acid Polyethylene Glycols-Cross-Linked Hydrogels to Bovine Testes Hyaluronidase

During last years, hyaluronic acid- (HA-) based dermal fillers have grown rapidly and continuously, as reported by the American Society of Aesthetic Plastic Surgery (ASAPS). In fact, HA fillers are considered the gold standard technique for soft tissue augmentation, deep skin hydration, and facial recontouring, playing a key role as an alternative to plastic surgery. HA fillers are less invasive, more biocompatible, and safer and with a more natural and immediate result if compared to plastic surgery. Hence, the safety of HA-based dermal fillers plays a crucial role, mostly in terms of biocompatibility and adjustability in case of unpleasant results and side effects such as, tyndall effect, edema, or granulomas. Hyaluronidase is a naturally occurring enzyme, present in the human body, and can degrade HA fillers avoiding more severe complications. In this article, we analyzed the bioavailability of hyaluronidase degradation of five fillers of Neauvia® hydrogels line (MatexLab SA, Lugano, CH), composed of pure hyaluronic acid and based on PEGDE cross-linking (polyethylene glycol) technology that guarantees a higher biocompatibility and an optimal biointegration and rheological characteristics. The performed in vitro testing is based on the colorimetric determination of the N-acetyl-D-glucosamine (NAG) present in solution after incubation with hyaluronidase, determined at different time points in order to assess the kinetic of each product degradation (1h, 3h, 6h, 24h, 48h, 72h, 120h, and 168h). The aim of this study was to assess, in vitro, how the difference in HA content and PEGDE concentration of the analyzed fillers can influence the product biocompatibility, intended as product enzymatic clearance and duration in time. The results demonstrated that the method was reproducible and easy to perform and that all the analyzed fillers are naturally immediately available for hyaluronidase-mediated degradation.

Consensus statement on prevention and management of adverse effects following rejuvenation procedures with hyaluronic acid-based fillers

Facial fillers play an important role in the correction of facial changes associated with ageing. They offer quick treatments in the outpatient setting with minimal subsequent downtime that provide predictable, natural-looking, long-lasting results. Adverse reactions after hyaluronic acid injections tend to be mild or moderate and rather temporary. However, as with all injected or implanted biomaterials, severe adverse events can occur and patients must be fully informed of potential risks prior to undergoing treatment. A panel of experts from Germany (D), Austria (A) and Switzerland (CH) developed recommendations, and this study provides the 'DACH Consensus Recommendations' from this group specifically on the use of hyaluronic acid fillers. The aim is to help clinicians recognize potential risks and to provide guidance on how best to treat adverse events if they arise. Contraindications to hyaluronic acid fillers are also detailed, and ways to prevent adverse events occurring are discussed. Hyaluronic acid-based products are claimed to be very close to an ideal tissue augmentation agent; nevertheless, profound medical, anatomical and product knowledge are of paramount importance to minimize the occurrence of adverse reactions.

Durability of Three Different Types of Hyaluronic Acid Fillers in Skin: Are There Differences Among Biphasic, Monophasic Monodensified, and Monophasic Polydensified Products?

Background

Hyaluronic acid fillers are used for facial rejuvenation and are classified as non-cross-linked or cross-linked (monophasic mono- or polydensified).

Objectives

To histologically assess the intradermal durability of three types of fillers (biphasic, monophasic monodensified, and monophasic polydensified), to compare the durability of the products over 6 months, and to evaluate the structural changes after application.

Methods

In all, 25 volunteers received injections of three different fillers in the dermis of the right lumbar region (in one line), and equal amounts of the fillers were injected into three different sites (in the same column), yielding nine points of application in each patient. Each line was biopsied on days 2, 92, and 184; these skin samples were analyzed histologically, and the presence or absence of these fillers was verified by a dermatopathologist.

Results

The histological analysis showed that over 182 days, the amount of the injected monophasic polydensified, monophasic monodensified, and biphasic filler products decreased by 62.5%, 25%, and 12.5%, respectively.

Conclusions

The biphasic and monophasic monodensified fillers presented greater intradermal durability than did the monophasic polydensified filler at 6 months after intradermal injection.

Level of Evidence 2

Injectable Shape-Memorizing Three-Dimensional Hyaluronic Acid Cryogels for Skin Sculpting and Soft Tissue Reconstruction

INTRODUCTION

Hyaluronic acid (HA)-based fillers are used for various cosmetic procedures. However, due to filler migration and degradation, reinjections of the fillers are often required. Methacrylated HA (MA-HA) can be made into injectable shape-memorizing fillers (three-dimensional [3D] MA-HA) aimed to address these issues. In this study, shape retention, firmness, and biocompatibility of 3D MA-HA injected subcutaneously in mice were evaluated.

MATERIALS AND METHODS

Fifteen mice, each receiving two subcutaneous injections in their back, were divided into four groups receiving HA, MA-HA, 3D MA-HA, or saline, respectively. Digital imaging, scanning electron microscope (SEM) and in vivo imaging system (IVIS), durometry, and histology were utilized to evaluate in vitro/vivo degradation and migration, material firmness, and the angiogenic (CD31) and immunogenic (CD45) response of the host tissue toward the injected materials.

RESULTS

Digital imaging, SEM, and IVIS revealed that 3D MA-HA fillers maintained their predetermined shape for at least 30 days in vitro and in vivo. Little volume effects were noted in the saline and other control groups. There were no differences in skin firmness between the groups or over time. Histology showed intact skin architecture in all groups. Three-dimensional MA-HA maintained its macroporous structure with significant angiogenesis at the 3D MA-HA/skin interfaces and throughout the 3D MA-HA. There was no significant inflammatory response to any of the injected materials.

CONCLUSION

3D MA-HA showed remarkable tissue compatibility, compliance, and shape predictability, as well as retention, and thus might be suitable for various skin sculpting and soft tissue reconstruction purposes.

Shaping Lips with Fillers

The lips and the eyes enhance facial beauty, and they have been highlighted since time immemorial. Rejuvenating the lips with fillers, frequently hyaluronic acid (HA), is a common procedure but requires expertise. The objective of this text is to describe the procedure in detail and cover the practical aspects of injecting lips with fillers. An analysis of treating lips with needles and cannulae has been made with special emphasis on achieving optimum results.

Effects of PMMA and Cross-Linked Dextran Filler for Soft Tissue Augmentation in Rats

This study was conducted for evaluation of the ability to maintain efficacy and biocompatibility of cross-linked dextran in hydroxypropyl methylcellulose (DiHM) and cross-linked dextran mixed with PMMA in hydroxypropyl methylcellulose (PDiHM), compared with hyaluronic acid (HA) filler. Saline and HA solution was administered in the negative and positive control groups, and DiHM and PDiHM were administered in the test groups (n = 10 in each group). The site of cranial subcutaneous injection was the mid-point of the interpupillary line, and the site of intraoral submucosal injection was the ridge crest 2 mm below the cervical line of the mandibular left incisor. Before and immediately after filler injection, intraoral photos and lateral cephalometric radiographs were taken for analysis and comparison of the effect of the filler on the injection sites. The filler injected areas were converted into sequential size changes (%) of the baseline. Histomorphologic examination was performed after 12 weeks. The smallest value in the filler injected area was observed during the experimental period in the normal saline group (p < 0.001), which was almost absorbed at 4 weeks (7.19% ± 12.72%). The HA group exhibited a steady decrease in sequential size and showed a lower value than the DiHM and PDiHM groups (saline < HA < DHiM, PDHiM, p < 0.001). DiHM and PDiHM tended to increase for the first 4 weeks and later decreased until 12 weeks. In this study on DiHM and PDiHM, there was no histological abnormality in cranial skin and oral mucosa. DiHM and PDiHM filler materials with injection system provide an excellent alternative surgical method for use in oral and craniofacial fields.

Interdental papilla loss: treatment by hyaluronic acid gel injection: a case series

OBJECTIVES

The purpose of this prospective clinical trial was to examine the clinical and patient outcomes following esthetic reconstruction of interdental papilla loss in anterior teeth, using an injectable, non-animal-based, hyaluronic acid gel.

MATERIALS AND METHODS

Ten systemically healthy adults, with at least one anterior site with class I or II interdental papilla loss, were recruited. Following local anesthesia, ∼0.2 ml of hyaluronic acid gel was injected directly into the base of the papilla. The injection was repeated twice 21 days later. Patients were seen monthly for follow-up. Lost papilla surface area was calculated from digital clinical photographs taken at baseline and at 4 and 6 months postoperatively. Differences in lost papilla surface area between baseline and postoperative time points were statistically analyzed. Participants completed questionnaires (satisfaction surveys).

RESULTS

Seventeen sites (13 maxillary, 4 mandibular) were treated in 9 females who completed the study. The lost inderdental papilla area at baseline and at the 4- and 6-month postoperative visits was 1.2 ± 1.8 mm(2) (mean ± SD), 0.6 ± 0.9 mm(2), and 0.7 ± 0.7 mm(2), respectively. Differences between baseline and postoperative visits were statistically significant (p < 0.0001). Two thirds of the patients would choose to undergo the procedure again.

CONCLUSIONS

Use of hyaluronic acid gel to treat interdental papilla loss resulted in significant improvement at 6 months. Patients expressed satisfaction with the obtained improvement and dissatisfaction with the associated procedure discomfort.

CLINICAL RELEVANCE

Treatment of interdental papilla loss (black triangle) by hyaluronic acid gel injection appears a promising modality to address this esthetic patient concern.

Imaging features of midface injectable fillers and associated complications

Injectable fillers are increasingly used for midface augmentation, which can be performed for facial rejuvenation and treatment of HIV facial lipoatrophy. A variety of temporary and permanent filler agents has been developed, including calcium hydroxylapatite, collagen, liquid silicone, polytetrafluoroethylene, hyaluronic acid, poly-l-lactic acid, and polyacrylamide gel. Facial fillers are sometimes encountered on radiologic imaging incidentally and should not be mistaken for pathology. Alternatively, patients with facial fillers may undergo imaging specifically to evaluate associated complications, such as infection, overfilling, migration, foreign-body reaction, and scarring. Therefore, it is important to be familiar with the imaging appearances of the various filler materials and their complications.

Semipermanent volumization by an absorbable filler: onlay injection technique to the bone

BACKGROUND

Hyaluronic acid (HA) fillers have become the most popular tool for wrinkle treatment and volumization, although HA is generally absorbed within 6-12 months and requires repeated treatments to maintain the effects.

METHODS

HA was injected onto the bone for volumization with a small 30-gauge needle to examine the long-lasting effects. Of the 63 Japanese patients with 97 treated sites followed up more than 12 months, 51 had HA injections for cosmetic purposes and 12 were treated for reconstructive volumization of facial deformity such as localized scleroderma and postsurgical bony deformity. Treated sites included the forehead, temple, nasal root, mentum, tear trough, and infraorbital sulcus.

RESULTS

After long-term follow-up (12-93 months, mean = 21.6), persistent volumizing effects were observed in most patients. In fact, 86.6% of the treated sites showed >50% volume retention and 49.5% showed >75% retention. Magnetic resonance imaging analyses revealed that the injected space was well maintained, capsulated, and filled with heterogeneous content. Magnetic resonance imaging quantitative T2 maps indicated that much of the injected HA was replaced with other materials. Together with clinical inspection, these findings suggest that onlay injection of HA on the bone induced formation of capsule, fibrosis, and/or calcification/ossification, which contributed to persistent volumization.

CONCLUSIONS

Semipermanent volumizing effects can be achieved by HA injection if the target area has an underlying bony floor. Periosteal stem cells may be activated by HA injection and may contribute to persistent volumizing effects. This treatment may be a much less invasive alternative to fat or bone grafting.

Knowledge and attitude of dentists towards the use of botulinum toxin and dermal fillers in dentistry, Riyadh, Saudi Arabia

INTRODUCTION

Botulinum toxin (BTX) and dermal fillers (DFs) are considered as quick and effective non-surgical solutions for enhancing facial appearance.

OBJECTIVE

To evaluate dentists' knowledge and attitude towards using Botulinum toxin and DFs in dental treatment in Riyadh, Saudi Arabia.

METHODS

Five hundred questionnaires were distributed in Riyadh city to government and private sectors to determine awareness and attitude towards using Botulinum toxin and DFs in dental clinics for therapeutic and aesthetics uses.

RESULTS

Botulinum toxin: A total of 1.2% is practising it. Only 34.8% could recognise its composition. Use of Botulinum toxin in wrinkle reduction was the most reported (73.7%). A total of 81.1% believed that Botulinum toxin has side effects; allergic reaction was the most reported (57.5%). A total of 47.8% reported that higher doses are more toxic, and that males need higher doses than females (10.2%). Dermal fillers: A total of 0.9% is practising it. The most reported type (47.8%) was Fat transfer. Filling of wrinkles was the most reported use (57.8%). A total of 69% believed that DFs has side effects; allergic reaction was the most reported (53.4%). Attitude: A total of 37.8% would like to practise Botulinum toxin/DFs, mostly for aesthetic dental reason. However, 60.2% rejected the idea, mainly due to lack of knowledge and experience (44%).

CONCLUSION

Limited knowledge regarding Botulinum toxin and dermal fillers is found among dentists in Riyadh, Saudi Arabia.

Production of glucuronic acid-based polysaccharides by microbial fermentation for biomedical applications

This review provides an overview of the properties, different biosynthetic machineries, and biotechnological production processes of four microbially derived glucuronic acid-based polysaccharides that are of interest for diverse biomedical purposes. In particular, the utilization of hyaluronic acid and heparin sulfate in high-value medical applications is already well established, whereas chondroitin sulfate and alginate show high potential within this ever-growing field. Furthermore, new strategies exploiting genetically engineered microorganisms generated through improving naturally existing pathways or de novo designed ones are described. These new developments result in increased fermentation titers, and thereby, pave the way towards feasible, or at least improved, process economy. Moreover, these strategies also allow for the future possibility of producing tailor-made biopolymers with specified characteristics, even novel molecules.

Clinical results of skin remodeling using a novel pneumatic technology

BACKGROUND

A myriad of technologies are available for the treatment of aging skin. These, however, still lack the ability to combine immediate, short-term and long-term aesthetic results with no downtime. Furthermore, the treatment of fine wrinkles on large surfaces remains challenging, as does the treatment of delicate regions, such as the dorsal hand, neck, and chest.

OBJECTIVES

The aims of this study were to evaluate the short-term as well as the long-term efficacy and safety of a new skin remodeling device that pneumatically accelerates a jet of hyaluronic acid (HA) solution under high pressure into the dermis.

METHODS

Thirty-four participants at three clinical sites underwent treatments with the Airgent device on the face, neck, chest, and dorsal hands for a total of 69 sites. Safety and efficacy were evaluated in short-term (1-3 months) and long-term follow-up (up to 18 months) by photography, by an independent reviewer and by participant self-evaluation. Histology was assessed before and 4 months after the third treatment.

RESULTS

A total of 69 treatment areas were evaluable at 1-3 months follow-up. Photographic analysis demonstrated improvement in skin variables at all body sites treated. Treatment of the face and neck reduced the mean Fitzpatrick-Goldman Wrinkle Classification score by 39.4 and 30.4%, respectively, representing a full wrinkle class improvement. Treatments of the chest demonstrated significant visual improvement. Treatment of the dorsal hands produced good overall improvement (OI), with good improvement of protruding veins. Overall improvement increased with increasing number of treatments. A total of 56 treatment areas were evaluable for long-term follow-up. Treatment of the face and neck reduced the mean Fitzpatrick-Goldman Wrinkle Classification score by 27.6 and 21.2%, respectively. Improvement after treatment of the face represented a full wrinkle class reduction. Treatment of the chest and dorsal hands yielded significant visual improvement. Overall, 80% of subjects were satisfied with the treatment outcome and would recommend the treatment to friends and family. Histological analysis demonstrated increased dermal collagen ΙΙΙ.

CONCLUSIONS

Pneumatic injection of HA under high pressure provides a safe, well-tolerated and effective method for improving the appearance of wrinkles on the face, neck, chest, and dorsal hands. Improvement can be seen as early as 1 month and as long as 18 months after treatment.

Lower eyelid swelling as a late complication of Bio-Alcamid filler into the malar area

PURPOSE

To report the late complications associated with permanent filler injections into the malar area for rejuvenation.

METHODS

A retrospective case series of three patients who presented with lower eyelid swelling several years following injection of polyalkylimide (Bio-Alcamid) into the malar area.

RESULTS

All patients presented with lower eyelid swelling which developed as a result of spontaneous migration of filler to the lower eyelid. Iatrogenic migration of the filler from the lower eyelid following a trial to remove resulted in an abscess formation which further complicated the removal.

CONCLUSIONS

Lower eyelid swelling may be one of the late complications associated with the permanent fillers into the malar area. An attempt at removal of filler by aspiration or bimanual expression may result in late migration of the product and the development of eyelid swelling.

Collagen-derived dipeptide, proline-hydroxyproline, stimulates cell proliferation and hyaluronic acid synthesis in cultured human dermal fibroblasts

Orally ingested collagen undergoes degradation to small di- or tripeptides, which are detected in circulating blood 2 h after ingestion. The influence of collagen-derived peptides on dermal extracellular matrix components and cell proliferation was studied using cultured human dermal fibroblasts. Of the various collagenous peptides tested here, the dipeptide proline-hydroxyproline (Pro-Hyp) enhanced cell proliferation (1.5-fold) and hyaluronic acid synthesis (3.8-fold) at a dose of 200 nmol/mL. This was concomitant with a 2.3-fold elevation of hyaluronan synthase 2 (HAS2) mRNA levels. Small interfering RNA (siRNA)-mediated knockdown of the HAS2 gene in human dermal fibroblasts inhibited Pro-Hyp-induced HAS2 mRNA transcription and cell mitotic activity. Addition of genistein or H7, a protein kinase inhibitor, abolished the Pro-Hyp-induced HAS2 mRNA stimulation. Pro-Hyp elevated phosphorylation of signal transducer and activator of transcription 3 (STAT3) within a short time period (60 min). These results suggest that Pro-Hyp stimulates both cell mitotic activity and hyaluronic acid synthesis, which is mediated by activation of HAS2 transcription.

Update on botulinum toxin and dermal fillers

PURPOSE OF REVIEW

The art and science of facial rejuvenation is an ever-evolving field of medicine, as evidenced by the continual development of new surgical and nonsurgical treatment modalities. Over the past 10 years, the use of botulinum toxin and dermal fillers for aesthetic purposes has risen sharply. Herein, we discuss properties of several commonly used injectable products and provide basic instruction for their use toward the goal of achieving facial rejuvenation.

RECENT FINDINGS

The demand for nonsurgical injection-based facial rejuvenation products has risen enormously in recent years. Used independently or concurrently, botulinum toxin and dermal filler agents offer an affordable, minimally invasive approach to facial rejuvenation.

SUMMARY

Botulinum toxin and dermal fillers can be used to diminish facial rhytides, restore facial volume, and sculpt facial contours, thereby achieving an aesthetically pleasing, youthful facial appearance.

Volumizing effect of a new hyaluronic acid sub-dermal facial filler: a retrospective analysis based on 102 cases

INTRODUCTION

Many signs of aging are due to the loss of subcutaneous fat. Dermal fillers are non-surgical cosmetic treatments used to restore facial volume. Voluma is a new hyaluronic acid sub-dermal facial filler. The objective of this study was to assess its effectiveness in maintaining increased volume for up to 18 months post-treatment and its safety.

METHODS

Retrospective record analysis was made for 102 patients (93 females, nine males; mean age: 51.27 years) who received Voluma injected into the midface. All patients were assessed at baseline and at 1 month and 6-18 months post-injection.

RESULTS

Investigator Global Aesthetic Improvement assessment after 1 month and 6-18 months showed that most patients were 'much' or 'very much' improved. Investigator volume loss assessment confirmed that most patients were either stage 1 or 2 (normal or slight ptosis) 1 month post-treatment, which was maintained at 6-18 months. Patient efficacy assessment was 'very good' or 'good' in most cases.

CONCLUSIONS

Voluma provides aesthetic improvements according to investigator and patient assessment for up to 18 months post-treatment. Combination treatment comprising facial fillers and botulinum neurotoxin can enhance treatment benefits. Further methodologically rigorous studies are required to establish the performance of Voluma alone and in combination.

Injectables and fillers in male patients

Traditionally, in facial plastic surgery, male patients were known to focus on function over form. Men typically did not consider rejuvenation surgery until they had advanced changes associated with aging, and it was often coupled with a functional concern. However, over the last several years, the number of men seeking minimally invasive cosmetic products, such as dermal fillers and injectables, has increased significantly. Motives include the desire to be more competitive and youthful in the workforce, the growing social acceptability of cosmetic procedures, and increased awareness of nonsurgical options. The optimal use of these products and procedures requires appropriate patient selection, knowledge of the products, and a thorough understanding of the regional anatomy and clinical applications.

Hyaluronic acid gel fillers in the management of facial aging

Time affects facial aging by producing cellular and anatomical changes resulting in the consequential loss of soft tissue volume. With the advent of new technologies, the physician has the opportunity of addressing these changes with the utilization of dermal fillers. Hyaluronic acid (HA) dermal fillers are the most popular, non-permanent injectable materials available to physicians today for the correction of soft tissue defects of the face. This material provides an effective, non invasive, non surgical alternative for correction of the contour defects of the face due to its enormous ability to bind water and easiness of implantation. HA dermal fillers are safe and effective. The baby-boomer generation, and their desire of turning back the clock while enjoying an active lifestyle, has expanded the popularity of these fillers. In the US, there are currently eight HA dermal fillers approved for commercialization by the Food and Drug Administration (FDA). This article reviews the innate properties of FDA-approved HA fillers and provides an insight on future HA products and their utilization for the management of the aging face.

The effect of hyaluronic acid size and concentration on branching morphogenesis and tubule differentiation in developing kidney culture systems: potential applications to engineering of renal tissues

Hyaluronic acid (HA) is a glycosaminoglycan of tissue engineering importance that plays a vital role in mammalian development. In vitro kidney culture methods were utilized to investigate the importance of HA during renal organogenesis. We found that HA has the ability to simultaneously modulate ureteric bud (UB) branching, promote mesenchymal-to-epithelial transformation, and promote differentiation of both metanephric mesenchyme (MM) and the UB depending on the concentration and molecular weight (MW) of HA. Hyaluronidase inhibited branching morphogenesis in both isolated UB and whole kidney cultures, suggesting endogenous HA is required for branching morphogenesis. HA exhibited morphogen-like properties, stimulating branching morphogenesis at low concentrations (0.1%) and low MW (6.55 kDa), but inhibiting at high concentrations (3.75%) and high MW (234.4 kDa). Furthermore, HA of every MW tested promoted collecting duct differentiation as measured by AQP-2 expression. E-cadherin immunostaining and qPCR of nephron differentiation markers (OAT-1, NaP(i)-2, AQP-1, and THP) demonstrated that HA of a variety of MWs strongly promotes mesenchymal epithelialization and nephron differentiation in a concentration-dependent manner. Since the HA synthesis and degradation genes, has-2 and hyal-2, are highly expressed during kidney development, this data suggests that specific sizes and concentrations of HA may act to independently regulate UB branching and promote tubular maturation, representing a potential switch for ending branching morphogenesis, as well as initiating nephron differentiation. In addition, the ability of HA to promote in vitro embryonic kidney growth and maturation, together with the biocompatibility and crosslinking capability of HA, suggests a potential use of HA for both creating an instructive, 3D scaffold for in vitro kidney engineering from developmental tissues, as well as promoting tubule regeneration in injured or cryopreserved kidneys.