Prospective, Split-Face, Randomized, Long-Term Blinded Objective Comparison of the Performance and Tolerability of Two New Hyaluronic Acid Fillers

Efficacy and Safety of Hyaluronic Acid Fillers With or Without Lidocaine in the Treatment of Nasolabial Folds: An Updated Systematic Review and Meta-Analysis

OBJECTIVE

To update the evidence on the effectiveness and safety of hyaluronic acid gel combined with lidocaine for treating nasolabial folds.

METHODS

We searched electronic databases including PubMed, Embase, Cochrane Central Register of Controlled Trials, and Web of Science using subject headings and keywords associated with hyaluronic acid and lidocaine in the context of nasolabial folds. Inclusion criteria were met by randomized controlled trials (RCTs) comparing the efficacy and safety of hyaluronic acid gel with or without lidocaine. Outcomes measured included visual pain analog scale (VAS) scores, wrinkle severity scale scores, and adverse events. The quality of RCTs was evaluated using the Cochrane Randomized Controlled Trials Scale, which encompasses criteria such as randomization, allocation concealment, blinding, dropout, and withdrawal rates, and was assessed by two independent reviewers.

RESULTS

No significant difference in overall wrinkle severity rating scale scores was observed between HA with lidocaine and HA without lidocaine [MD = 0.08, 95% CI (- 0.09, 0.24), P = 0.36]. However, there was a significant reduction in pain scale scores (VAS) [SMD = -2.47, 95% CI (- 4.15, - 0.79), P = 0.004]; no significant differences were noted in the ncidence of at least one adverse event [RR = 0.97, 95% CI (0.90, 1.05), P = 0.51]; and there were no significant differences in swelling [RR =  0.99, 95% CI (0.92, 1.06), P = 0.80], erythema [RR = 1.01, 95% CI (0.91, 1.11), P = 0.91], bruising [RR = 0.99, 95% CI (0.89, 1.13), P = 0.86], itching [RR = 1.03, the 95% CI (0.88, 1.21), P = 0.74], induration [RR = 1.04, 95% CI (0.92, 1.17), P = 0.55], and papules [RR = 0.77, 95% CI (0.58, 1.02), P = 0.07]. There was a significantly lower incidence of tenderness [RR = 0.91, 95% CI (0.86, 0.97), P = 0.002] only in the control group. Sensitivity analysis confirmed the stability of results across all outcome indicators with low sensitivity and high confidence. Subgroup analysis indicated higher wrinkle severity scores among East Asians compared to Europeans and Americans.

CONCLUSIONS

HA containing lidocaine significantly reduces pain and is comparable in effectiveness and safety of HA without lidocaine. The clinical effects appear more pronounced in East Asians. Due to the limited number of related studies, further research is necessary.

LEVEL OF EVIDENCE I

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A Natural Flat Volumized Lips Filler Technique: Retrospective Analysis of 920 Patients

BACKGROUND

Traditionally, hyaluronidase (HYAL) is used after hyaluronic acid (HA) injection to dissolve the undesired migration of product.

OBJECTIVE

To describe a novel lip augmentation technique that uses HA and HYAL simultaneously in patients who previously had HA migration.

METHODS AND MATERIALS

Nine hundred twenty female patients were included. In the first group ( n = 793), HA injections were performed in subcutaneous plane of the lips. In the second group who had previous product migration ( n = 127), 7.5 units of HYAL is injected in 4 points in ergotrid area before proceeding with HA injection.

RESULTS

The medicis lip fullness scale scores after 2 weeks improved in all patients, while 92% of patients perceived the results as "very much improved" with Global Aesthetic Improvement Scale ( p ˂ .001). There was no difference between 2 groups regarding the patient satisfaction rates ( p ˃.05), while filler migration was seen in 0.2% ( n : 15) of patients in the first group during the follow-up period.

CONCLUSION

The new vertical injection approach provided an increased vertical height, optimal eversion, and an incisor display on the lips. The simultaneous use of HYAL before HA injection seems to be a safe and effective practice in 1-stage treatment of the previously injected lips with filler migration into ergotrid area.

A prospective multicenter clinical trial evaluating the efficacy and safety of a hyaluronic acid-based filler with Tri-Hyal technology in the treatment of lips and the perioral area

BACKGROUND

Age-related changes of facial soft tissue cause clinical signs of facial aging such as lip atrophy, marionette lines, and an accentuated nasolabial fold. These changes can be modified using dermal fillers.

AIMS

To evaluate efficacy, longevity, and safety of a cross-linked hyaluronic acid-based filler with Tri-Hyal technology in the treatment of lips, nasolabial folds, and marionette lines.

MATERIALS AND METHODS

This prospective, multi-center trial evaluated injections of three different areas (lips, nasolabial fold alone, or with marionette wrinkles) with a soft tissue filler containing 25 mg/ml cross-linked hyaluronic acid and 0.3% lidocaine. Primary endpoint was the aesthetic correction 3 weeks after one injection session without touch-up. Follow-up was 18 months. Assessments were performed using the Global Aesthetic Score (GAS), clinical scoring based on photographic scales, high-frequency ultrasound imaging, and the Global Aesthetic Improvement Scale (GAIS).

RESULTS

In total, 100 subjects were injected. GAS improved significantly for all treatment indications at 3 weeks (p < 0.0001). Success rates were highest for nasolabial folds (98.4%), followed by marionette lines (94.4%) and lips (73.5%). After 18 months post-injection, success was observed in 91%, 88%, and 33% of subjects injected into nasolabial folds, marionette lines, and lips, respectively. GAIS scored highest for nasolabial folds (SGAIS: 71%; IGAIS: 40%), followed by marionette lines (SGAIS: 56%; IGAIS: 33%) and lips (SGAIS: 30%; IGAIS: 22%) at 18 months follow-up.

CONCLUSIONS

The filler demonstrated high efficacy and safety in all indications. Regional differences in longevity were evident. Thus, the necessity of regional retreatments should be discussed with patients before injection.

Midface Multilayering Filler Injection Technique: Understanding of the Dynamic Facial Anatomy Through a "Smiling Cadavers" Anatomical Study

BACKGROUND

Understanding age-related changes in compartmentalized facial fat and their role in facial dynamics and aesthetics is essential to target filler injections for midface rejuvenation.

METHODS

A novel anatomical approach ("smiling cadavers") was used to identify the main midface fat compartments involved during muscular contraction when smiling and their motion and behavior with and without filler injections. Based on these insights and the literature, a multilayering filler injection approach was developed to optimize midface rejuvenation by restoring fat volumes using rheologically different products injected into different fat compartments.

RESULTS

Twenty-four hemifacial dissections confirmed the presence of two fat compartment layers, separated by the orbicularis oculi muscle in the horizontal plane and by the septa in the vertical plane, and revealed the anatomical effects of facial movement. The midface is composed of deep static fat compartments and a superficial dynamic adipose layer that follows the facial movements, creating a natural dynamic appearance. A proof-of-concept study involved 130 White patients (36 to 56 years; 91 percent women). After the procedure, 95 percent of patients and 98 percent of practitioners rated facial appearance as "improved" or "much/very much improved." No major complications were reported.

CONCLUSIONS

The smiling cadavers method enhances understanding of dynamic facial anatomy by showing the superficial and deep fat compartments of the midface at rest and their motion during a procedure to represent a smile. The multilayered injection technique takes into account these anatomical findings to rejuvenate the midface, achieving a natural appearance at rest and during motion.

Triple Cross-Linked Hyaluronic Acid Based on Tri-Hyal Technique Has More Durable Effect on Dermal Renewal

Background

Hyaluronic acid (HA)-based fillers are applied to treat facial wrinkles and volume loss. Many efforts have been made to improve properties of HA to prolong the duration in aesthetic indications. A new cross-linking technique called “Tri-Hyal”, could make HAs to achieve desired rheological characteristics. HAs synthesized by Tri-Hyal are triple cross-linked and sustained-release, which could increase duration of promoting skin rejuvenation after injection.

Purpose

To evaluate the efficiency and persistence of HAs with Tri-Hyal on skin rejuvenation and further investigate underlying mechanisms, we compared the performances of cross-linked HA (AF) based on Tri-Hyal with another highly acceptable HA filler (Res) in vivo and in vitro.

Methods

Male BALB/c mice were divided into three groups, treated with AF, Res and vehicle, respectively. Skin biopsies were taken on day 0, 30, 90 and 180 after injection and hematoxylin and eosin (H&E), Masson’s trichrome (MT), immunohistochemical (IHC) stainings for CD31, TGF-β and MMP9 were performed. EdU incorporation, cell counting kit-8 (CCK-8), SA-β-Gal staining and activity were measured by biochemical analysis. RFP-GFP-LC3 adeno virus was used for autophagic flux detection. Protein levels of CD44, P62 and LC3I/II were detected by Western blot. Reactive oxygen species (ROS) level was detected by flow cytometry with DCFH-DA probe.

Results

The AF synthesized by Tri-Hyal showed persistent dermal structural correction without attenuation up to 6 months, which was illustrated by skin thickness, formation of elastic fibers and vascular density. Consistently, in fibroblasts the AF improved cell proliferation and slowed the senescent in vitro. Furthermore, it promoted cellular autophagy to reduce ROS level, which would account for its function in skin renewal.

Conclusion

The HA with Tri-Hyal could stimulate the production of extracellular matrix components more persistently than traditional HA fillers. In terms of mechanisms, it delayed senescence in dermal fibroblasts through reducing oxidative stress mediated by induction of autophagy.

Objective 18-month Comparison of the Tolerability of 2 Dermal Fillers Formulated with Tri-Hyal Technology

Supplemental Digital Content is available in the text.

Background:

The first phase of this study showed that ART FILLER Universal filler (AFU; FILORGA Laboratories) and ART FILLER Fine lines (AFFL) were non-inferior to JUVÉDERM Ultra 3 (Allergan) and FIRST LINES PureSense (Teoxane), respectively. The clinical benefits of AFU and AFFL on nasolabial folds and crow’s feet persisted until at least Day 180. This article reports results from an open-label extension phase that assessed the tolerability and efficacy of AFU and AFFL for up to 18 months based on clinical evaluation and ultrasound high-frequency imaging.

Methods:

Eligible subjects were enrolled at D180 and assessed on D270, D360, and D540. The primary outcome measured was local tolerability. Secondary outcomes measured included: proportion of subjects in whom the severity of nasolabial folds and crow’s feet remained at least 1 point below the baseline measurement (Lemperle scale); general safety; Global Aesthetic Improvement Scale scores by subjects and investigators; wrinkle volumes; and skin thickness by high-frequency ultrasound.

Results:

Adverse events were consistent with the product information and the initial study. No serious adverse events were recorded. In exploratory analyses, wrinkle correction with AFU and AFFL is sustained for at least 18 months: 48.4% and 98.3% of subjects respectively still showed at least a 1-point decrease in the mean Lemperle score compared with the baseline. The benefits were sustained irrespective of whether subjects received additional injections. Modifications in wrinkle volume and skin thickness at D540 were statistically significant compared with the baseline.

Conclusion:

AFU and AFFL were well tolerated and, in exploratory analyses, showed a sustained efficacy for at least 18 months.