Evaluating safety in hyaluronic acid lip injections

The role of ultrasound in facial hyaluronic acid dermal filler injections - A review article

Injectable dermal fillers have seen a remarkable rise in popularity in recent years for aesthetic enhancements, such as facial contouring and rejuvenation. Hyaluronic acid (HA)-based fillers are especially favored due to their tolerability, minimal invasiveness, and effectiveness. This review examines the applications of ultrasound in HA dermal filler procedures. A literature search was conducted from February 25 to 26, 2024, using Medline and Google Scholar to identify relevant studies on the use of ultrasound for facial HA dermal fillers. Inclusion criteria included peer-reviewed English language studies from the last decade and involving living human subjects. Eleven studies met these criteria. The findings indicate that ultrasound significantly enhances the accuracy and safety of HA filler procedures by enabling precise vascular mapping, filler detection, and complication detection and identification. By presenting evidence of reduced risks and improved outcomes, this review underscores the potential for ultrasound to become a standard tool in HA filler applications, representing an innovation and a new application for ultrasound in the field of aesthetic dermatology.

Adverse effects of the aesthetic use of botulinum toxin and dermal fillers on the face: a narrative review

OBJECTIVE

To evaluate the adverse effects of facial aesthetic treatments using botulinum toxin and biomaterial implants.

METHODS

The bibliographic research for this narrative review considered articles published in journals from the Medline, Pubmed, Embase and Lilacs databases with the following terms: "dermal fillers AND complications, vascular complications AND dermal fillers, adverse reaction, AND toxin botulinum and adverse reaction AND dermal fillers". Inclusion criteria were articles available in English on adverse events with the aesthetic use of botulinum toxin and dermal fillers/biostimulators.

RESULTS

The demonstration of complications increases simultaneously with the progressive performance of facial aesthetic procedures. Quantitative statistics of the procedures and the countries that use them are skillfully classified, as well as the prosperity trends of these procedures. Complications do not receive the same relevance. There is a deficiency in dissemination of the information by the scientific community, or in other words, there is a publication bias in favor of successful results as opposed to adverse events.

CONCLUSION

The lack of knowledge about complications arising from so widely publicized and performed procedures prevents the development of evidence-based guidelines. Complications in aesthetic procedures have become a public health problem, an epidemic that occurs under the supervision of health authorities. Mandatory reporting of adverse events occurring in aesthetic procedures that require medical care aims to fill this gap. With reliable and technical data, it will be possible to identify the causes and perform interventions capable of minimizing irreversible sequelae and deaths. Complications should be promptly recognized by the dermatologist so that, when possible, they can be reversed or adequately managed.

Comparative analysis of in vivo bio-integration of three hyaluronic acid-based fillers for 26 weeks: a histological study

Stabilized hyaluronic acid (HA), produced through diverse cross-linking technology and formulated as an injectable gel, has found widespread utilization in aesthetic industry. Cross-linked HA essentially constitutes a gel particle composition formed by numerous viscoelastic particulates. Various product formulations yield HA gels with distinct properties, including particle size, viscoelasticity, and interaction forces between particles. While previous studies have primarily concentrated on the biological safety and macroscopic expression of fillers, limited research exists on the internal mechanisms governing their macro-performance. This study selected three common dermal fillers for analysis, establishing an animal model to assess their in vivo interaction with surrounding tissues and explore their internal mechanisms. The findings revealed that particle size plays a crucial role in tissue integration.

Comparing the Effects of Different Injection Techniques Used in Lip Augmentation on Filler Migration and Patient Satisfaction

OBJECTIVE

Lip rejuvenation has several aims, including enhancing lip volume, adjusting the upper and lower lip's length, diminishing fine lines, contouring and redefining the cupid bow and vermilion border, and eversion of the vermilion. Within the scope of this research, we aimed to compare popular injection techniques to augment the size of the lips.

MATERIALS AND METHODS

This randomized retrospective study included 216 female patients aged 19 to 39, who desired a lip filler treatment from 2017 to 2023. Pre- and post-procedure results were elaborated with top-to-the-bottom technique in Group 1, bottom-to-the-top technique in Group 2, and lateral-to-medial techniques in Groups 3 and 4.Once the patients were sufficiently anesthetized, the hyaluronic acid at a concentration of 20 mg/mL with 0.3% (3 mg/mL) lidocaine, was used in all groups. Patients were followed up for three weeks. Patient satisfaction scores were evaluated on a scale from 0 to 5 using a survey on the last follow-up day.

RESULTS

A statistically significant difference was found between the groups regarding satisfaction scores (p<0.05). The patient satisfaction scores after injection were 4.78/5 in Group 1, 3.70/5 in Group 2, 4.15/5 in Group 3, and 3.85/5 in Group 4. Kruskal-Wallis variance analysis for more than two groups revealed statistically significant differences between Group 1 and Group 2 (p<0.001), Group 1 and Group 3 (p<0.001), Group 1 and Group 4 (p<0.001), and Group 2 and Group 3 (p=0.009) (Mann Whitney U-Test with Bonferroni adjusted). No major complication was observed in any of the patients.

CONCLUSION

In this study, patient satisfaction was found to be highest in the group with needle orientation top to bottom, taking into account migration to the upper lip. These findings showed that the direction of the needle during injection also determines the direction of distribution of the filler on the lip and may be an important factor in patient satisfaction.

Botulinum Toxin Type A and Hyaluronic Acid Dermal Fillers in Dentistry: A Systematic Review of Clinical Application and Indications

Background

Botulinum toxin type A (BoNT-A) and hyaluronic acid (HA) dermal fillers are increasingly utilized in dentistry for therapeutic and aesthetic purposes. However, a comprehensive synthesis of their clinical applications and indications in dentistry is lacking. This systematic review aimed to analyze the clinical application and indications of BoNT-A and HA dermal fillers in dentistry, providing insights into their efficacy, safety profiles, and limitations.

Methods

A systematic search was conducted in PubMed/MEDLINE databases to identify relevant studies published between 2018 and 2024. Medical Subject Headings (MeSH) terms and keywords related to BoNT-A, HA dermal fillers, dentistry, clinical applications, and indications were used. Study selection criteria included randomized controlled trials (RCTs) and non-RCTs involving human participants of any age group. Data extraction and synthesis followed established guidelines, focusing on study characteristics, participant demographics, intervention details, outcome measures, and key findings related to BoNT-A and HA dermal fillers' clinical application in dentistry.

Results

Systematic searches across electronic databases and grey literature identified 857 records, with an additional 73 from hand searches. After screening titles and abstracts, 542 records were excluded, leaving 374 full-text publications for evaluation. Ultimately, 12 RCTs and 13 non-RCTs were included. The systematic review encompassed diverse geographic locations: Brazil, Italy, Spain, Syria, India, Egypt, Korea, and the Netherlands, involving samples sizes ranging from 14 to 143 participants. The review synthesized findings on HA's efficacy in various areas, including bone repair, gingivitis management, temporomandibular joint disorders, postoperative swelling reduction, periodontal defect treatment, chin and check projection and lips augmentation. BoNT-A exhibited promising efficacy in managing orofacial pain conditions, gummy smile treatment and neuromodulation of the lower third muscles. Safety profiles varied among studies, with some reporting minimal adverse effects while others noted dose-related concerns.

Conclusion

BoNT-A and HA dermal fillers offer a wide array of clinical applications in dentistry, ranging from therapeutic interventions to aesthetic enhancements. Despite promising efficacy, careful consideration and monitoring of safety outcomes are essential when integrating these interventions into clinical practice. Further research addressing methodological limitations and safety concerns is warranted to optimize their utilization and improve patient care in dentistry.

Development and Validation of the Jawline Subject Satisfaction Scale

Introduction: Research in aesthetic medicine commonly includes evaluations of subject satisfaction with treatment results. However, conventional analytic methods typically generate statistically imprecise ordinal scores. To overcome this limitation, researchers have begun employing the Rasch model, an analytical framework grounded in item response theory. The Rasch model permits scale modifications capable of enhancing measurement accuracy. This study focuses on using the Rasch model to evaluate a scale measuring subject satisfaction following aesthetic treatments to the jawline. Objective: To develop and validate a multiitem, self-administered questionnaire measuring patient satisfaction with aesthetic treatment of the jawline. Methods: A 10-item questionnaire [The Jawline Subject Satisfaction Scale (JS3)] was devised to measure subject satisfaction following aesthetic treatments of the jawline. Each question was responded to using a 5-point Likert scale, with response selections ranging from "very much satisfied" to "very much dissatisfied" or "strongly agree" to "strongly disagree." The scale's psychometric properties (reliability and separation for items and persons, item and person fit statistics, and unidimensionality and local independence) were validated using a Rasch model based on a dataset collected from a sample of forty subjects. Results: The results of the Rasch analysis revealed high internal consistency of the JS3, with a person reliability estimate of 0.86 and an item reliability estimate of 0.96. The separation estimates for persons and items were 2.50 and 4.72, respectively, demonstrating the scale's ability to differentiate between high and low responders and validating the instrument's construct. All infit and outfit values fell within the established range (0.5-1.5), and the data fit the model of unidimensionality and local independence. Raw score transformations into logits were conducted, which were then converted to Rasch measurements. These measurements are available for use in practice for conducting standard statistical analyses evaluating treatment and/or group effects. Conclusions: The application of the Rasch model produced a valid and reliable scale (ie, JS3) for measuring satisfaction with the appearance of the jawline following aesthetic treatments.

Clinical Management With High-Frequency Ultrasound of Recurrent Submental Abscess Formation After Filler Placement: Bacterial Contamination or Immune-Mediated Adverse Event?

The authors present a case of a 29-year-old female patient with a recurrent submental abscess formation after chin augmentation with highly reticulated hyaluronic acid filler. We evaluate the possible cause of this complication and the result after clinical management with ultrasound-guided injection of hyaluronidase. We highlight the prevention, assessment and treatment with real-time imaging of hyaluronidase injection in the affected area, as a predictable approach for both the patient and the physician.

Clinical Perspectives on the Injectability of Cross-Linked Hyaluronic Acid Dermal Fillers: A Standardized Methodology for Commercial Product Benchmarking with Inter-Injector Assessments

The injectability of cross-linked hyaluronic acid (HA) dermal fillers is influenced by polymer concentration, polymer cross-linking type and degree, the presence of lidocaine or other functional excipients, types of syringes, and injection techniques. Finished product injectability constitutes a critical quality attribute for clinical injectors, as it strongly influences product applicability and ease of use in aesthetic medicine. While injectable product extrusion force specifications are provided by the respective device manufacturers, the qualitative informative value of such datasets is low for injectors wishing to compare product brands and technologies from an injectability standpoint. Therefore, the present study comparatively assessed 28 cross-linked HA dermal fillers (JUVÉDERM®, Restylane®, BELOTERO®, TEOSYAL RHA®, and STYLAGE® brands) using various injectability benchmarking setups for enhanced clinical-oriented relevance. Manual product injections were performed by three specialized and experienced clinicians, whereas automatic product extrusion was performed using a Texture Analyzer instrument. The various hydrogel products were injected into ex vivo human skin and into SimSkin® cutaneous equivalents to appropriately account for injection-related counterpressure. The injectability results revealed important variability between and within product brands, with a strong influence of the local anesthetic lidocaine, HA contents, and needle gauge size. Critical appraisals of the investigated products were performed, notably from manufacturing process-based and clinical ease of application-based standpoints, centered on respective experimental injectability quality levels. Generally, it was confirmed that each HA-based dermal filler product requires specific expertise for optimal injection, mainly due to differing viscoelastic characteristics and injectability attributes. Overall, the present study set forth evidence-based and clinical-oriented rationale elements confirming the importance for injectors to work with injectable products with which they are experienced and comfortable to optimize clinical results.

Ultra-High-Frequency Ultrasound as an Innovative Imaging Evaluation of Hyaluronic Acid Filler in Nasolabial Folds

Dermal hyaluronic acid (HA) fillers are used for nasolabial fold correction, but no study is still available on the use of ultra-high-frequency ultrasound (UHFUS) with 70 MHz probes for the evaluation of HA distribution and wrinkle amelioration. We selected 13 patients who received HA filler, evaluated before (Time (T) 0) and after injection (T1), and after 24 weeks (T2). The dermal thickness and distribution of HA were registered, as well as the Wrinkle Severity Rating Scale (WSRS), Global Aesthetic Improvement Scale (GAIS), and wrinkle 3D fullness. The UHFUS dermal thickness was increased by 11% for both sides at T1 and by 7.4% and 6.8% for the right and left side, respectively, at T2 (p < 0.01). The 3D wrinkle fullness showed a T1 increase (+0.59 cc and +0.79 cc for the right and left side, respectively) with a T2 maintenance of 45% of the T1 fullness (p-value < 0.001). The only clinical score significantly modified was WSRS, with a reduction of 56% at T1 and of 47.1% at T2 (p-value < 0.001). Our study then demonstrated the efficacy of UHFUS in the assessment of nasolabial fold correction, representing also the first multi-modal evaluation of HA persistence and its visual subsequent aesthetic results.

Awareness and Knowledge of the Adverse Effects of Dermal Fillers Among the Saudi Population: A Cross-Sectional Study

Introduction Dermal filling for aesthetics and facial rejuvenation is one of the most common aesthetic procedures, with hyaluronic acid (HA) being the most commonly used filler due to its high safety profile. Nevertheless, adverse effects have been reported that people should be aware of before the procedure. This study aims to assess Saudi Arabians' awareness of dermal fillers, their side effects, and information sources. Methods This cross-sectional study used an online questionnaire to determine participants' level of knowledge, from January 2, 2022, to February 19, 2023. Statistical analysis and ordinal logistic regression were used to assess the respondents' knowledge of dermal fillers and other parameters. Results Of the 1,208 respondents, 290 reported using fillers, and 44% reported that complications were mentioned to them before the procedure. The results also showed that the primary source of information was social media (44.8%), followed by the Internet, physicians, and books. Respondents to whom physicians explained complications reported bruising, bluish discoloration at the injection site, redness, swelling, and accumulation of body cells under the skin, as discussed with them. Bruising and bluish discoloration were the significantly reported complications in people who received fillers, whereas lumps, epistaxis, ulceration/loss of skin, and swelling/accumulation were reported in those who did not receive fillers. Conclusion Although some adverse effects may occur with HA, its enormous advantages led to its use in facial rejuvenation. With social media as a major source of information, many respondents reported unlikely adverse effects as common ones, suggesting that information sources need to be corrected by physicians to raise awareness of the adverse effects of cosmetic procedures and enhance informed decision-making by patients.

Dentistry and Drug Adverse Events: Between Responsibilities and Regulations

The purpose of this paper is to renew interest and attention to the medical history, prescription, and/or use of drugs during dental practice. The work analyzes the issue of the use of drugs in dentistry from both a clinical and a medical-legal point of view. The laws governing the matter were also taken into consideration, relating them to the roles of prescriber and user that the dentist can acquire. Analysis of various aspects of this matter demonstrates that it is necessary for dentists to know the drugs and medical substances, their characteristics and properties, related effects, and interactions in order to use them appropriately and adequately. Knowledge of interferences, reactions, and adverse events or complications helps to reduce errors and protect patients' health. Furthermore, knowledge of the national and international reference standards relating to the use of drugs leads to a reduction in medico-legal questions. In conclusion, knowledge and adequate and appropriate use of drugs reduces the possibility of accidents, adverse events, medico-legal consequences, and disputes with patients. Documented and traceable choices allow the analysis and valuation of professional conduct. Authors perceived the topic of informed consent of patients as relevant to the adequate procedure of prescribing drugs related to dentistry practice; therefore, representative conditions of patients at risk should be illustrated in practice. Legal duties related to physician drug prescription and use must be considered and carefully checked.