Injection Guidelines for Treating Midface Volume Deficiency With Hyaluronic Acid Fillers: The ATP Approach (Anatomy, Techniques, Products)

Hyaluronic Acid Filler Usage and Technique for the Facial Upper Third: A Comprehensive Review

Background

Facial aging entails complex alterations across various tissues, prompting individuals to seek aesthetic interventions. The anatomical complexities of the facial upper third and its proximity to vital vascular structures provide inherent risks. We aim to identify and elucidate the safety considerations and avenues for improvement regarding established injection sites and techniques for hyaluronic acid fillers in this area, encompassing the forehead and temporal region.

Methods

We conducted a comprehensive literature search across PubMed, Embase, LILACS, and OpenGrey. Eligible studies were analyzed for injection sites, techniques, safety considerations, and anatomical landmarks. Qualitative synthesis and critical appraisal were used to identify trends, variations, and areas of consensus or controversy. Additionally, medical illustrations were created to deliver a practical overview. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist and the Joanna Briggs Institute's scoping review recommendations.

Results

We included 7 studies in the review. Common injection sites included frontal and temporal regions, with variations in techniques noted across studies. Trends in filler placement and techniques were observed alongside several areas of controversy requiring further investigation.

Conclusions

We underscore the absence of a standardized approach to hyaluronic acid filler injection sites and techniques for the facial upper third. Integrating anatomical knowledge with empirical evidence will be paramount in developing standardized techniques that prioritize patient safety and enhance treatment efficacy.

Hybrid Fillers Personal Experience of Premixing Calcium Hydroxylapatite and Hyaluronic Acid for Natural Face Reshaping

OBJECTIVE

This retrospective study evaluates the efficacy and safety of premixed calcium hydroxylapatite (CaHA) and hyaluronic acid (HA) hybrid fillers for facial reshaping and rejuvenation, focusing on natural outcomes with long-term follow-up over 12 months.

METHODS

Forty-six patients (ages 45-65) underwent hybrid filler treatments using a 1:1 premixed formulation of CaHA and HA. Injection techniques targeted specific facial zones using cannulas for subdermal delivery. Standardized 3D imaging and the Merz Aesthetics Scale (CR-MASJ) were used to assess lifting effects and volume restoration. The Global Aesthetic Improvement Scale (GAIS) measured patient satisfaction.

RESULTS

Improvements in skin laxity, volume restoration, and facial contouring were noted as early as 3 months post-treatment and sustained through 12 months. Premixed hybrid fillers demonstrated enhanced biostimulatory effects compared with standalone CaHA or HA, promoting neocollagenesis and providing immediate and lasting results. Adverse events were minimal, with no significant complications reported.

CONCLUSION

Premixing CaHA and HA offers a safe, effective, and reproducible technique for natural facial reshaping and rejuvenation. The combination enhances skin quality while providing immediate volumization and long-term collagen stimulation, meeting the aesthetic expectations of patients seeking minimally invasive anti-aging solutions.

Integrating Psychological Insights into Aesthetic Medicine: A Cross-Generational Analysis of Patient Archetypes (IMPACT Study)

BACKGROUND

Aesthetic medicine has evolved significantly, accommodating diverse demographics and motivations influenced by societal shifts and technological advancements. The IMPACT (integrative multigenerational psychological analysis for cosmetic treatment) study refines patient archetypes, integrating psychological theories to tailor treatments, especially for younger demographics and LGBTQIA + communities.

METHODS

This cross-sectional study utilized a comprehensive, validated survey with a Cronbach's alpha of 0.89 and a Content Validity Index (CVI) of 0.92, distributed across a globally diverse, generationally stratified sample. Techniques like regression analysis, ANOVA, Bayesian modelling, and factor analysis were employed to analyse the data, focusing on developing nuanced patient archetypes.

RESULTS

Among 5645 participants, 5340 complete responses highlighted significant generational differences in aesthetic preferences. Millennials showed a strong preference for non-invasive procedures (β = 0.65, p < 0.001). ANOVA results confirmed significant variances across generations [F (3, 5118) = 157.6, p < 0.001], with post-hoc analyses delineating specific inter-group differences. Bayesian modelling provided insights into the probability of non-invasive preferences among younger cohorts at over 92% certainty. Factor analysis revealed key dimensions such as 'Generational Influence' and 'Technological Adoption,' which helped in defining archetypes including Dynamic Self-Identity, Digital Native, Stability Seeker, Classic Conservatism, and Holistic Health, collectively explaining up to 78% of the variance in responses.

CONCLUSION

The IMPACT study underscores the influence of generational identity and digital exposure on aesthetic preferences, advocating for personalized, archetype-based treatment approaches. This aligns with enhancing patient satisfaction and treatment outcomes, promoting an adaptive aesthetic medicine practice that meets the evolving needs of modern patients.

LEVEL OF EVIDENCE IV

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 .

Low-Crosslinked Hyaluronic Acid Injections in the Superficial Fat Layer for Facial Rejuvenation in Chinese Patients: A Retrospective Clinical Study

Objective To evaluate the clinical efficacy of low-crosslinked hyaluronic acid (HA) injections in the superficial fat layer for facial rejuvenation in Chinese patients. Methods A total of 30 patients were treated between July 2023 and October 2024, with three sessions of low-crosslinked HA injections spaced one month apart. The injections were administered using the fanning technique into the superficial fat layer. Patients were followed up at one month and three months post-treatment. Skin improvements were assessed using smart skin analysis equipment, while overall aesthetic improvement was evaluated using the Global Aesthetic Improvement Scale (GAIS). Patient pain levels, satisfaction, and adverse reactions were also recorded. Results Significant improvements in facial wrinkles, pore size, and pigmentation were observed at one and three months post-treatment, as measured by skin analysis equipment, compared to baseline. GAIS scores confirmed facial rejuvenation in all patients. Patient satisfaction was 100% at one month and 93.3% at three months. Mild discomfort was reported by 90% of patients, with an average pain score of 3.40 ± 1.55, resolving within 24 hours. Two patients experienced mild bruising, which resolved within a week. No other adverse reactions were noted. Conclusion Low-crosslinked HA injection in the superficial fat layer is an effective and safe method for facial rejuvenation, offering high patient satisfaction. No serious adverse events were reported during the follow-up period.

Safety and Performance of RHA4 in the Midface Using the Multilayering Technique: Preclinical and Clinical Evidence

Background

Resilient hyaluronic acid (RHA) fillers are used to treat dynamic wrinkles or provide tissue lifting in facial aesthetics. This study explored the biological, biomechanical, and clinical safety and performance of RHA4, a volumizing hyaluronic acid filler tailored for tissue support in dynamic facial areas, upon interaction with human subcutaneous adipose tissue (AT).

Methods

RHA4 underwent cytocompatibility testing with human fibroblasts and adipose stem cells. A 1-year rat in vivo implantation study tracked tissue integration, local effects, and filler degradation. Biomechanical tests assessed RHA4's impact on subcutaneous AT mechanics. Clinical outcomes, safety, injection volumes, and techniques were evaluated in 35 patients, treated in midface deep and superficial fat compartments via a multilayering methodology. Dynamic outcomes and 2-year follow-up of RHA4 in the midface using multilayer treatments were described.

Results

RHA4 demonstrated excellent biocompatibility and tissue integration both in vitro and in vivo, exhibiting minimal local inflammation and rapid collagen bundle formation within the filler. It integrated gradually over time and was well tolerated, allowing for increased extracellular matrix presence, neovascularization, denser collagen deposition, and AT growth. Ex vivo, RHA4 did not impede fat motion biomechanics but visibly lifted the tissue. Clinically, RHA4 proved safe and effective for lifting both deep and superficial fat compartments in the midface without affecting facial expressiveness.

Conclusions

Preclinical and clinical evidence confirmed that RHA4 is a versatile filler capable of lifting tissue efficiently, whether deep or superficial, particularly through the multilayering treatment approach. Importantly, RHA4 preserves AT biomechanics, adapts to the dynamism of the face, and ensures natural-looking outcomes.

Split-Face Comparison of Two Hyaluronic Acid Fillers: Intersection of Rheology and Tissue Behavior in Midface Rejuvenation

Background

Hyaluronic acid (HA) fillers are one of the most popular aesthetic treatments for midface volumization, achieving optimal aesthetic improvements. Given the variety of HA filler products available, it is important for injectors to understand how their rheological properties can influence behavior in tissues.

Objectives

To evaluate and compare (1) product integration and dynamic support and (2) lifting capacity of 2 rheologically different HA fillers (HA Contour [HACON] and HA Voluma [HAJVOL]) through ultrasound and clinical photography.

Methods

Randomized, split-face study (n = 11) comparing 2 midface HA fillers over a 12-month period with initial injection along the zygomatic arch at Day 0 and optional touch-up at Month 1. Eligible patients were aged 22 to 65 years with midface volume loss and contour deficiency. Assessments included ultrasound (neutral and smiling), clinical photography with 3D volume change (lifting capacity) analyses, and adverse event reporting. Volume change was assessed at 2 regions: midface and infraorbital hollow (IOH).

Results

With similar average total injection volumes, both fillers had comparable lifting capacity in the midface (HACON: ≥2.07 mL and HAJVOL: ≥2.08 mL; P > .05) and IOH (HACON: ≥0.45 mL and HAJVOL: ≥0.57 mL; P > .05) areas for up to 12 months. Ultrasound showed that HACON integrated into the tissue, stretching and elongating during a smiling expression, whereas HAJVOL did not integrate as much, with aggregates consistent in size and shape during both neutral and smiling expressions through 12 months. No adverse events were reported during the study.

Conclusions

HACON demonstrated a similar duration of lifting capacity (volumization) as HAJVOL but had more distributed product integration and flexibility to support dynamic expressions through 12 months.

Level of Evidence 3 Therapeutic

Efficacy and safety of different hyaluronic acid fillers on cheek volume augmentation: systematic review and network meta-analysis

BACKGROUND

Various rejuvenation surgeries, including hyaluronic acid (HA) fillers, aim to address mid-face volume loss. However, literature on the comparative efficacy and safety of different HA fillers for the zygomatic area remains limited.

METHODS

This systematic review and network meta-analysis (NMA), adhering to NMA PRISMA 2020 and Cochrane guidelines. Searches were conducted on different bases. Eligible studies included patients with mid-face volume loss undergoing HA interventions. The primary outcome was the Global Aesthetic Improvement Scale (GAIS) at different time points and the incidence of adverse events.

RESULTS

Among 1742 articles, six randomized controlled trials (RCTs) met the inclusion criteria with a total of 579 patients. The studies evaluated Giselleligne, VYC-20, Neuramis Lidocaine and ART-Filler. Results showed that Giselleligne demonstrated superior safety compared to VYC-20, ART-Filler and Neuramis-Lidocaine (Risk Ratios (RR) = 0.27, 95% Confidence interval (CI) [0.14; 0.54]), (RR = 0.36, 95% CI [0.17; 0.75], & RR = 0.22, 95% CI [0.07; 0.67]) respectively However, there were no significant differences in the Global Aesthetic Improvement Scale Assessment (GAIS) scores between HA fillers at 1, 3, and 6 months.

CONCLUSION

While no significant differences were observed in efficacy among HA fillers, Giselleligne emerged as a potentially safer option for the cheeks volume restoration. The study emphasizes the need for further well-designed RCTs to explore the long-term safety and durability of HA fillers. These findings contribute valuable insights for clinicians and patients in making evidence-based decisions regarding mid-face rejuvenation options.

Facial Artery Branch Thrombolysis for Nasal Vascular Embolism Induced by Hyaluronic Acid Injection

BACKGROUND

Vascular embolism is a severe complication following hyaluronic acid (HA) filler injections, with hyaluronidase injection being the most effective treatment. The nasal region, including the nose and nasolabial fold, is the most common site of vascular embolism after facial HA injections. Currently, there is insufficient clinical evidence regarding the benefits of facial artery thrombolysis.

OBJECTIVES

This article aimed to evaluate the efficacy of hyaluronidase injection via the facial artery as an emergency treatment for vascular embolism induced by facial aesthetic HA fillers.

METHODS

We reviewed 14 patients who experienced nasal vascular embolism following facial HA filler injections. All 14 patients underwent percutaneous facial artery thrombolysis with a combination of hyaluronidase and urokinase administered intravascularly. For patients with longer occlusion duration and severe necrosis, femoral artery interventional thrombolysis was performed, with local injection of platelet-rich plasma to promote recovery. Follow-up ranged from 1 month to 1 year.

RESULTS

Following facial artery hyaluronidase injection, all cases showed improvement in nasal skin lesions. Twelve patients fully recovered, while 2 patients were left with minor superficial scars and defects in the nasal wings.

CONCLUSIONS

Early thrombolysis postnasal embolism is crucial, and percutaneous facial artery puncture is an effective emergency treatment. Arterial intervention targeting the facial artery in the nasolabial fold may offer more precise thrombolysis. The combined use of hyaluronidase and urokinase is both safe and effective.

New Aesthetic Unit (NAU) Method: A Comprehensive Method Based on Accurate Anatomical Assessment and Precise Multilayering Panfacial Treatment for Hyaluronic Acid Fillers

BACKGROUND

Recent progress in anatomy enables a more sophisticated approach to treat patients with facial aesthetic concerns (PFAC) with HA fillers. Furthermore, advances in rheology have offered a range of HA fillers with different biomechanical properties adapted to different indications.

METHODS

Based on recent anatomical and rheological progresses, the author has developed a new methodology that couples an accurate patient assessment tool and a panfacial precise treatment instrument. In the presented method, the face is divided into 6 units called New Aesthetic Units (NAU). NAUs are classified on the extent of volume deficiency and asymmetry, ranging from none to moderate to severe deficiencies. After discussion with the patient regarding the assessment findings, a customized treatment plan, including timelines and number of sessions, is recommended. The modalities of the treatment are exhaustively described for each NAU based on multilayering, best practice medicine, and expert consensus available in the literature.

RESULTS

Before-and after-case studies are presented to illustrate how the NAU method is used in routine practice for the treatment of two patients with HA fillers.

CONCLUSION

The NAU method is not only a practical and accurate roadmap for the assessment and treatment of PFAC with HA fillers, but also facilitates communication between injectors and patients and data analysis.

LEVEL OF EVIDENCE IV

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 .

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.

Three Key Submuscular Points for Nonsurgical Rejuvenation of the Midface in Caucasian Patients: A Methodological Approach Using Injectable Hyaluronic Acid Fillers

INTRODUCTION

Since aesthetic medical treatments providing natural results are becoming increasingly popular, we developed an innovative hyaluronic acid infiltration technique for midface rejuvenation.

METHODS

In this prospective study, only patients with a negative or neutral lower eyelid vector were included. Treatment consisted in injecting three hyaluronic acid boluses at the cutaneous projections of the levator labii superioris, zygomatic major and minor muscles insertions. All patients were administered before treatment the FACE-Q questionnaire, whereas after treatment, they were administered the FACE-Q questionnaire and the Global Aesthetic Improvement Scale (GAIS). All treatments were documented with standardized photographs. A plastic surgeon from another Institution reviewed the photos and scored the treatments according to the GAIS scale.

RESULTS

We included 567 patients (101 males and 466 females) who met the inclusion criteria. The mean age was 41 years, and mean follow-up time was four months. The FACE-Q scores after treatment were significantly higher (p < 0.001) in every domain investigated. The GAIS scores demonstrated significant improvement posttreatment in 89.8% of patients. An average of 1.5 ml of hyaluronic acid (VYC-20) was used for each zygomatic region. No major complications were reported; only 27 patients reported bruising, which resolved spontaneously. In all patients, there was an inversion of the lower eyelid vector, which had transitioned from neutral or negative to positive.

CONCLUSION

Lifting the insertions of three selected muscles with hyaluronic acid allows a midface upward repositioning. This technique provides a reproducible and safe approach for midface rejuvenation through tissue repositioning rather than augmenting facial volume.

LEVEL OF EVIDENCE V

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 .

Profhilo® Structura, Current Status and Future Perspectives: A Practical Review

Hyaluronic acid (HA)-based injectables continue to grow in popularity and are used worldwide to improve facial changes associated with aging. Profhilo® Structura (IBSA Farmaceutici Italia, Lodi, Italy) is a novel HA-based product that uses nano hybrid complex of hyaluronic acid (NAHYCO)® technology to create hybrid cooperative complexes consisting of high and low molecular weight HA. Profhilo® Structura's high concentration (45 mg of total HA) and rheological properties (ie, viscosity [resistance to flow] and elasticity [stickiness]) have been specially formulated to restore facial adipose tissue. Because of their early involvement in the facial aging process, the superficial medial and lateral-temporal cheek fat compartments are good candidates for treatment. However, recommendations and guidelines are necessary to ensure that treatment is safe and effective. Three experts were invited to IBSA Farmaceutici Italia Srl to discuss clinical rationale, optimal injection techniques, and clinical outcomes for treating the superficial medial and lateral-temporal cheek fat compartments with Profhilo® Structura. These techniques were developed using patients presenting with either initial hypotrophy of fat compartments within the preauricular area (ie, sinkers) or jowl sagging due to hypotrophy within the preauricular and zygomatic areas (ie, saggers). Targeting these areas using the optimal injection site can maximize product diffusion and minimize the risk for vascular compromise. Targeting these areas also leads to lateral tightening and lipolifting effects due to adipose tissue restoration. The experts agreed that Profhilo® Structura is currently the first and only HA-based injectable treatment that can integrate and restore the adipose tissue in these affected fat compartments.

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.

Combined multilevel anti-aging strategies and practical applications of dermocosmetics in aesthetic procedures

Management of the signs of facial aging and other cosmetic skin problems have greatly evolved in the past years. People are also seeking to improve their well-being and global skin appearance, and when they consider using cosmetic procedures, they expect natural and long-lasting aesthetic results. Combined dermocosmetic approaches that address the signs of facial aging at all levels are increasingly being used by dermatologists to meet patient expectations while ensuring their safety. Minimally invasive and reversible procedures that can be performed in only one session are popular approaches for skin restructuring and volumizing as they are flexible, rapid and less burdensome for patients. These interventions can achieve even better outcomes when they are combined with cosmeceuticals as pre- or post-procedural adjuvants to prepare the skin, accelerate recovery and sustain results. The use of topical dermocosmetics is also recommended as part of the daily skin care routine to improve skin quality and help maintain skin barrier function. This review thus outlines the most commonly used combined multilevel anti-aging strategies, which start by addressing the deepest skin layers and then the more superficial signs of skin aging. Examples of multi-active cosmeceuticals and skin delivery enhancing systems are also presented, together with examples of the use of dermocosmetics as supportive care for aesthetic procedures, to provide insights into current applications of dermocosmetic products.

Efficacy and Safety of Type III Collagen Lyophilized Fibers Using Mid-to-Deep Dermal Facial Injections for the Correction of Dynamic Facial Wrinkles

BACKGROUND

This study aimed to evaluate the therapeutic efficacy and safety of injecting Type III collagen lyophilized fibers into the mid-to-deep layers of the facial dermis to ameliorate dynamic facial wrinkles.

METHODS

In this retrospective analysis, clinical data were collected from patients exhibiting dynamic facial wrinkles (encompassing frown lines, forehead lines, and crow's feet) with a wrinkle severity rating scale (WSRS) score of 3 or higher. In the control group, 75 participants received collagen implant injections into the mid-to-deep facial dermal layers, whereas 76 participants in the experimental group received injections of Type III collagen lyophilized fibers in similar layers. The study analyzed and compared clinical efficacy, WSRS score alterations, patient satisfaction, and safety profiles between the groups over the 30-day and 90-day treatment periods.

RESULTS

At the 30-day mark, the therapeutic efficacy was not significantly different between the two groups (P > 0.05). However, at 90 days, the treatment efficacy in the experimental group surpassed that in the control group, showing a statistically significant difference (P < 0.05). After 30 days of treatment, the WSRS score improvement in the experimental group was significantly superior to that in the control group (P < 0.05). Conversely, at the 90-day mark, the results revealed no significant variation in WSRS score improvements between the two groups (P > 0.05). Regarding treatment satisfaction among researchers and participants post-30 and 90-day treatment in both groups, no statistically significant differences were observed (P > 0.05). Similarly, the incidence of adverse reactions between the groups was not statistically significant (P > 0.05).

CONCLUSIONS

Injections of lyophilized type III collagen fibers into the mid-to-deep layers of the facial dermis have a definitive therapeutic effect on dynamic facial wrinkles. This treatment not only substantially diminishes wrinkle severity but also has a commendable safety profile.

LEVEL OF EVIDENCE I

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 .

Lower Eyelid Dark Circles (Tear Trough and Lid-Cheek Junction): A Stepwise Assessment Framework

BACKGROUND

Despite increasing popularity, the use of hyaluronic acid (HA) fillers for the correction of dark under-eye shadows remains challenging. Specific guidance on patient assessment is limited.

OBJECTIVES

The aim of this study was to develop a stepwise assessment framework for lower eyelid dark shadows to help practitioners classify patients based on their underlying problems and facilitate a more strategic approach to treatment.

METHODS

Literature review and peer collaboration informed the current availability of educational material for use by experienced injectors when assessing patients presenting with dark circles. A practitioner survey provided insight into current practices. A focus group convened to review the survey results and discuss best practice approaches to patient assessment.

RESULTS

Surveyed practitioners (n = 39) reported patient concern about under-eye hollows (91%), dark eye circles (80%), and looking tired (60%). All (100%) agreed that midcheek volume was critical when treating tear-trough depression, and only 26% reported use of a tear-trough classification system. The focus group developed a framework for assessing tear-trough depression and the lid-cheek junction in patients presenting with dark circles. Key factors within this framework included the importance of appropriate lighting when conducting a visual inspection, regional inspection of the cheek and tear trough, palpation of the orbital rim and soft tissues, determination of the orbital vector, and assessment of lower eyelid pigmentation and skin quality.

CONCLUSIONS

Careful step-by-step assessment can reduce the challenges of treating dark circles by identifying patients in whom dark eye circles may be improved without the need to directly inject filler into the tear trough.

LEVEL OF EVIDENCE: 5

Ellansé: Advanced Technology and Advantageous Selection of New Collagen Stimulating Agents for Face Rejuvenation

Facial injections have a comparative mature market and system in China, but all kinds of injection materials have their own advantages and disadvantages, even hyaluronic acid, as the most common injection material, can form an unnatural stiffness after injection. Currently, Ellansé, a biodegradable collagen stimulator, has shown superior aesthetic results while ensuring safety and naturalness, making it a more preferable choice for a variety of facial injections. The purpose of this review is to introduce the features and benefits of Ellansé, so that doctors in the field can better understand and learn how to use it properly and minimize the risk of complications, and have a better choice for the medical aesthetic field in China in numerous aspects. The papers with the keyword "Ellansé" is very few in number, and there is a lack of systematic overview. Ellansé itself has unique advantages for the Chinese population, as it is an attractive option for the treatment of aging face due to high patient satisfaction, long-lasting results and low side effects (Guo et al. in J Cosmet Dermatol 21(5):1959-1966, 2022). More clinical data will be available in the future to confirm its performance and longevity in various sites. LEVEL OF EVIDENCE V: 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 15% Trichloroacetic Acid + 3% Glycolic Acid Chemical Peel Series Improves Appearance of Hand Lentigines: An Evaluator-Blinded, Split-Hand Prospective Trial

BACKGROUND

Improving the appearance of lentigines on the hands is a key component to hand rejuvenation. Soft tissue fillers revolumize hands, but do not address pigmentary changes. OBJECTIVE: This study investigated the effiacy of a 15% trichloroacetic acid (TCA) + 3% glycolic acid (GA) combination peel in improvement of appearance of hand lentigines.

METHODS

A prospective evaluator-blinded, split-hand study was performed using a 15% TCA + 3% GA peel to treat patients with hand lentigines. Subjects received a total of 3 treatments at 4-week intervals on 1 hand, with the other hand serving as an untreated control. Final photographs were taken 12 weeks after the last treatment. Two blinded board-certified dermatologists graded improvement in hand lentigines using a 5-point scale.

RESULTS

Eighteen of 20 patients completed the study (90%). The mean age was 64.4 years (SE 1.6, range 51-71). The mean pain scores were 3.8 (SE 0.4) on a 10-point scale (1 = no pain, 10 = extremely painful). Blinded evaluators correctly identified the after-treatment photographs in 16 patients (88%). Physician and patient-graded mean improvement of lentigines was significant for treated versus control hands ( p < .01). No adverse events were noted.

CONCLUSION

A series of three 15% TCA + 3% GA peels are effective and safe in the treatment of hand lentigines.

Personalized Research on the Aging Face-A Narrative History

Throughout history, people have struggled to find out the secret of youth. The aim of the manuscript is to review the main achievements regarding the exploration of the aging face phenomenon. It should be very important to know the evolution in this field due to the increase in life expectancy among the population. Our purpose is for the current study to serve as a starting point towards exploring novel research avenues in molecular biology and the confocal immunofluorescence of cervicofacial soft tissues, employing cutting-edge techniques. All changes in the shape of the facial skeleton, soft tissue, retaining ligaments, fat compartments, and the skin envelope contribute to facial aging to varying degrees.

The Anatomical Layering Assessment: The Construction of Beauty

Restructuring an aging face from bone structure to the surface of the skin can be metaphorically compared to building and renovating a house. While each anatomical layer of the face undergoes an aging process of its own, there is also an interdependency of superficial structures on deeper layers, so that a change in one layer may lead to changes to the adjacent layers. This interaction among the structures deep into the skin, along with the skin's ability to envelope them is what determine the aspect of the aging face. Thus, a careful assessment of all the layers is imperative and we describe herein a step-by-step facial layering assessment and facial restructuring approach from bone structure to the surface of the skin to implement a treatment plan able to deliver a harmonious rejuvenating outcome.

Estimating the Change in Facial Subunits During Positive and Negative Facial Expression Using Three-Dimensional Stereophotogrammetry Facial Analysis

Background: A more refined and clinically related facial expression analysis is required for patients who wish to be perceived more emotionally positive. Objective: To measure the change in skin vector and volume in facial subunits when expressing positive expression (happiness) compared with negative expressions (sadness, fear, disgust, and anger), using three-dimensional (3D) stereophotogrammetry analysis. Methods: This study took 3D photographs of 20 volunteers' face at rest and during positive and negative expression. The directions of skin vector and volume changes in each facial subregion were recorded and calculated. Results: In the positive expression, 78.3% (95% confidence interval [CI] 66.8-89.9) of the medial midfacial subregions presented superolateral vector and volume increase, whereas volume decrease in 82.5% (95% CI 78.5-86.5) of the lip subregions could be observed. In the negative expression, the vector changes were predominantly inferomedial in 26.0% (95% CI 15.4-36.5) of the forehead and 36.8% (95% CI 33.2-40.3) of the upper eyelid subregions, whereas volume increases in 34.0% (95% CI 30.4-37.7) of the upper eyelid subregions were observed. Conclusions: This 3D stereophotogrammetry analysis presents the morphological difference between the positive and negative expression.

Facial cosmetic injection: A bibliometric analysis of research status and hotspots

BACKGROUND

The increasing popularity of cosmetic injections using various fillers and neuromodulators for facial rejuvenation has brought both new opportunities and challenges to this field.

AIM

Our study was designed to employ bibliometric and visual analysis for a qualitative and quantitative evaluation of facial cosmetic injections, as well as to identify research trends and hotspots in this field.

METHODS

All publications covering facial cosmetic injection during 2002-2023 were retrieved and extracted from the Web of Science database. The VOSviewer 1.6.18 software and the online tool (http://bibliometric.com/) were applied to analyze the publication trend.

RESULTS

A total of 3797 articles related to facial cosmetic injection were identified during the period 2002-2023. The United States had the largest volume of publications (1520, 40.0%), followed by China (333, 8.8%) and Germany (282, 7.3%). Among the institutions and journals, the University of California system and Plastic and Reconstructive Surgery accounted for the most papers related to facial cosmetic injection, respectively. Facial anatomy and injection techniques, prevention and management of complications, regenerative medicine, efficacy and safety of various soft-tissue fillers, as well as botulinum toxin injections for facial rejuvenation were identified as hotspots for facial cosmetic injections.

CONCLUSIONS

Facial cosmetic injections are showing an increasing trend in terms of both the number of published papers and operations performed. Despite the notable advancements in this field, numerous challenges persist, including safety concerns and the level of research evidence. With the emergence of novel technologies and materials, scholars from diverse countries and institutions should engage in more extensive collaboration, thereby directly expediting the progress of this field.

Real-World Outcomes of Lip Augmentation Using a Hyaluronic Acid-Based Filler With Low 1,4-Butanediol Diglycidyl Ether Content: A Prospective, Open-Label, Multicenter, Post-marketing Study

Background 1,4-butanediol diglycidyl ether (BDDE) is the most common cross-linker used to produce hyaluronic acid (HA)-based dermal fillers. However, BDDE may have cytotoxic and potentially mutagenic effects, raising safety concerns. Consequently, manufacturers are developing new HA filler formulations with reduced BDDE levels to mitigate potential biological risks. Here, we sought to evaluate the clinical outcomes of lip augmentation performed using an HA-based filler with a reduced BDDE content (Agex Fill Volume®; Biodue SpA, Barberino Tavarnelle, Italy) in a real-world clinical setting. Methods This was a prospective, open-label, multicenter, post-marketing study conducted over six months. Thirty adult subjects (29 women and one man) who desired a ≥1-point improvement on the validated Lip Fullness Scale 2 (LFS2) were enrolled. The primary efficacy endpoint was the post-procedural increase in the investigator-reported LFS2 compared to baseline. Other endpoints included self-perceived happiness assessed using the Happiness Measure Scale (HMS) and safety. Results Of the study participants, 73% (22/30) demonstrated an improvement of at least one point in their LFS2 scores immediately after treatment compared to baseline, thus qualifying as responders. Six months later, the responder rate, based on LFS2 scores, remained steady at 66.7% (20/30). Importantly, these aesthetic improvements were consistently associated with a positive impact on subject-reported HMS, with a significant difference (p < 0.001) between post-treatment and baseline scores. All adverse events (AEs) reported after treatment were mild. Conclusions Agex Fill Volume®, a HA filler with low BDDE content, provides a safe and effective option for enhancing lip volume in real-world aesthetic settings.

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.

Comparison of 2 Fillers for Lip Injection-A Randomized-Controlled Clinical Trial Assessed by 3D Imaging

Background

Lip aging is a concern for many, and hyaluronic acid (HA) injections are a popular solution.

Objectives

This study compared 2 different HA gel technologies (OBT and NASHA) for lip augmentation in 20 volunteers.

Methods

Both groups received treatment from the same injector using the same method. Lip volume was measured with a 3D stereophotogrammetry device before, immediately after, and 30 days posttreatment. Patient satisfaction and adverse events were assessed through FACE-Q scales analysis.

Results

The NASHA group showed an immediate volume increase (P = .01), which decreased after 30 days. The OBT group did not show a significant immediate growth (P = .535) but did exhibit a significant increase after 30 days (P = .014). After 30 days, there were no significant volume differences between the groups (P = .802 and P = .999). FACE-Q analysis revealed no significant differences among groups after 30 days.

Conclusions

This study highlights that less cohesive gels may modify faster in dynamic lip areas, emphasizing the importance of selecting products based on their physicochemical and rheological properties. In the context of lip augmentation with HA, it is important not to consider immediate aesthetic changes as definitive results, as volume changes may persist and develop over time after the treatment.

Level of Evidence 2

Long-term Performance and Safety of Princess VOLUME PLUS Lidocaine for Midface Augmentation: The PRIMAvera Clinical Study

BACKGROUND

Hyaluronic acid-based dermal fillers are the most applied medical devices for midface augmentation.

OBJECTIVES

This postmarket investigation evaluated the long-term performance and safety of and patient satisfaction with Princess VOLUME PLUS Lidocaine (PVPL; now Saypha VOLUME PLUS Lidocaine) for the correction of midface volume deficit (MVD).

METHODS

This was an open-label, prospective, interventional, multicenter, noncomparative, postapproval study of 91 patients with moderate or severe MVD (grade 2 or 3 on the 5-point Midface Volume Deficit Severity Scale, or MVDSS). At Day 0 (Visit 1), patients were treated with PVPL; they returned for follow-up assessments at weeks 2, 4, 12, 24, 36, and 52 and had long-term follow-up until 36 months. A touch-up treatment could be done at week 2. The performance was assessed with the MVDSS, Global Aesthetic Improvement Scale (GAIS), and a subject satisfaction scale. Adverse events were collected to assess safety throughout the study.

RESULTS

Four weeks after treatment, 100% of injected patients improved by ≥1 grade on the MVDSS compared to baseline, with improvements still visible in 77% of patients 52 weeks after treatment. Based on the GAIS and post hoc survival analysis, the treatment effect was maintained for a median of 386 days, and in severe cases the effect lasted longer, which seemed to be independent of the volume injected at baseline. No serious side effects were reported. Results were substantiated by high patient satisfaction.

CONCLUSIONS

Princess VOLUME PLUS Lidocaine was perceived as safe and effective by patients and investigators, with long-term aesthetic improvement in moderate and severe cases.

LEVEL OF EVIDENCE: 3

Achieving the Attractive Asian Midface Profile with Hyaluronic Acid-Based Fillers

Despite different ethnic origins among Asians, midface enhancement is the most frequent noninvasive procedure for hyaluronic acid injection either as a stand-alone treatment or as part of the pan-facial beautification strategy. Because Asians often have an aesthetically undesirable wide, flat, and short face, improving the projection of midface and midline facial structures is an indispensable aesthetic procedure in creating a smaller facial appearance with better three-dimensionality. Achieving an oval facial shape together with increased facial height is also required in most circumstances for a natural and balanced result.

Safety and efficacy of hyaluronic acid injectable filler in the treatment of nasolabial fold wrinkle: a randomized, double-blind, self-controlled clinical trial

INTRODUCTION

The injectable skin fillers available for soft tissue augmentation are constantly growing, providing esthetic surgeons with more options in the treatment of scars, lines, and wrinkles. Hyaluronic acid (HA)-derived injectable fillers are ideal to reduce the appearance of nasolabial folding. This study investigated the efficacy and safety of the commercially available HA filler from Maxigen Biotech Inc. (MBI-FD) in the treatment of nasolabial folds (NLFs).

METHODS

We analyzed 1,4-butanediol diglycidyl ether (BDDE) residues and injection force test and observed the protein content in MBI-FD, and then was cultured in fibroblast L929 cells and examined for cytotoxicity. Finally, 95 healthy participants underwent dermal filler injection therapy to evaluate the efficacy and safety for 24 and 52 weeks, respectively.

RESULTS

BDDE residues in MBI-FD was <0.125 µg/mL. MBI-FD was fitted using 27- and 30-G injection needles with an average pushing force of 14.30 ± 2.07 and 36.43 ± 3.11 N, respectively. Sodium hyaluronate protein in MBI-FD was 7.19 µg/g. The cell viabilities of 1× and 0.5× MBI-FD were 83.25% ± 3.58% and 82.23% ± 1.85%, respectively, indicating MBI-FD had no cytotoxicity, and decreased NLF wrinkles with no serious adverse events.

CONCLUSION

MBI-FD is an effective filler for tissue augmentation of the NLFs and may be a suitable candidate as an injectable dermal filler for tissue augmentation in humans in the future.

Strengthening the Key Features of Volumizing Fillers: Projection Capacity and Long-Term Persistence

Volumizing fillers aim to create or restore facial volume in fat layers. To provide strong tissue lifting and long-term persistence, gels are generally designed with stiff properties, characterized by a high storage modulus (G'). However, clinical evidence shows a discrepancy between high G' and good lifting capacities, especially after skin tension has been exerted on the gel. To better explore the in vivo behavior of a gel, we first evaluated the elastic moduli of five commercial volumizers (RHA4, JUVVOL, RESVOL, RESLYFT, and BELVOL) in dynamic compression mode, E'. We further developed a Projection Index score based on the rheological assessment of creep in compression to mimic skin tension-induced stress relaxation (flattening). Finally, the ability of a gel to resist enzymatic degradation was analyzed with a multidose approach. Despite similar clinical indications, volumizers exhibited distinct behaviors. RHA4 and BELVOL showed the highest E' values (resistance to strain), RHA4, JUVVOL, and RESVOL exhibited the greatest projection capacities, while JUVVOL and RHA4 offered the largest persistence to enzymatic degradation. In this article, we introduce the use of the Projection Index to efficiently assess the ability of a gel to lift tissues, thus increasing preclinical models' efficiency and reducing the need for animal studies.

Creation and Validation of a Photonumeric Scale for Assessment of Infraorbital Hollows

BACKGROUND

Validated clinical scales are needed to assess aesthetic improvement of the infraorbital hollows (IOHs) after treatment with dermal fillers.

OBJECTIVE

To develop an IOHs scale and establish its reliability and sensitivity for grading subjects in clinical trials or routine practice.

METHODS AND MATERIALS

The Teoxane IOHs Scale (TIOHS), a 5-grade photonumeric scale, was developed based on real-subject photographs and validated through photographic and live subjects' evaluation.

RESULTS

Clinician intra- and inter-rater agreements during the TIOHS validation were excellent. The mean intrarater-weighted Kappa score between the 2 sessions of photographic validation was 0.92, while inter-rater interclass correlation coefficient (ICC) was 0.92 for the combined sessions. The average intrarater-weighted Kappa score and inter-rater ICC for the live validation reached 0.80 and 0.76, respectively. In addition, evaluators identified clinically significant differences between photographs of subjects presenting a 1-grade or 2-grade difference in 82% and 86% of cases, respectively.

CONCLUSION

The intrarater Kappa scores and inter-rater ICCs met their predetermined acceptance criteria of >0.70. The TIOHS is a repeatable and reproducible clinician-reported outcome for health care providers to classify IOHs in clinical trials and routine patient care. A 1-grade difference on the TIOHS can detect a clinically meaningful difference in infraorbital hollowing.

Introducing an esthetic treatment of malocclusion: Ultrasound-assisted augmentation of premaxilla with injectable hyaluronic acid filler

With advances in the ultrasound-assisted esthetic procedures, filler injection can successfully be used for cosmetic correction of face structural imperfections. Here, we present a new filler injection method by targeting two anatomic landmarks which effectively improved the appearance of a mandibular prognathism case who was a maxillofacial cosmetic surgery candidate.

Efficacy and Safety of Resilient Hyaluronic Acid Fillers Injected with a Cannula: A Randomized, Evaluator-Blinded, Split-Face Controlled Study

Purpose

Cannulas are increasingly used for injecting hyaluronic acid fillers, as they are thought to improve patient comfort safety and treatment tolerability. This study aimed to demonstrate the non-inferiority of a Resilient Hyaluronic Acid 4 (RHA 4) filler injected with a cannula versus a needle for the treatment of moderate to severe nasolabial folds (NLF).

Patients and Methods

A total of 50 subjects were included in a randomized, evaluator-blinded, split-face trial. The NLF were injected with RHA 4 using a cannula on one side of the face and using a needle on the other side on Day 0. A touch-up could be performed 4 weeks later. The subjects were followed up for 12 weeks after the last injection, ie, injection on Day 0 or touch-up. Efficacy was evaluated using a Wrinkle Severity Rating Scale (WSRS), the Global Aesthetic Improvement Scale (GAIS), and patient-reported outcomes. Safety assessments included the injection-site pain, common treatment reactions (CTRs), and adverse events (AEs).

Results

Twelve weeks after the last injection, the efficacy of the cannula treatment was found to be non-inferior to that of the needle treatment, based on the WSRS score improvements. The other study endpoints showed the equivalent efficacy and safety of the two methods. No serious or unexpected AEs were reported.

Conclusion

RHA 4 may be effectively and safely injected into the NLF using a cannula or a needle, provided it is administrated by a trained practitioner.

Superselective Ophthalmic Artery Thrombolytic Therapy for Hyaluronic Acid Embolization: A Case Report

Blindness caused by embolization of fillers is a rare but catastrophic complication after cosmetic injection. Vision improvement is rarely reported among the various studies on potential clinical treatments. In this case, the patient suffered from ophthalmic artery occlusion with no light perception 48 h after hyaluronic acid injection. After two intra-arterial thrombolytic therapy sessions and traditional sequential therapy, ocular appearance was restored to normal, blood supply to the retina and visual function were improved, and visual acuity was restored to hand motion levels. Our results suggest that intra-arterial thrombolytic therapy with hyaluronidase and papaverine has a positive effect on hyaluronic acid-induced visual loss and is worthy of clinical promotion.