Radiance FN: A New Soft Tissue Filler

Spontaneous and induced degradation of dermal fillers: A review

Dermal fillers are among the most versatile tools in esthetic medicine. A broad range of temporary, semipermanent, and permanent filler products are on the market. We performed a narrative review on spontaneous and induced degradation of dermal fillers in vitro and in vivo. Hyaluronic acid-based fillers are the most frequently used temporary fillers. The products differ in their hyaluronic acid content, cross-linking, and rheological parameters. Endogenous hyaluronidase and reactive oxygen species are responsible for the spontaneous degradation of these fillers. Hyaluronidase digests the filler material by cleavage of the β-1,4 glycosidic linkage between N-acetylglucosamine and D-glucuronic acid. The enzyme can be used for treatment of medical and cosmetic adverse events due to hyaluronic acid-based filler. Higher hyaluronidase content and higher degree of cross-linking are major factors contributing to filler persistence over time. Semipermanent fillers are poly-(D), l-lactic acid and calcium hydroxylapatite. These filler types are decomposed by hydrolysis and osteoclastic enzymes. They usually persist up to 2 years, in single patients even more than 5 years. Sodium thiosulfate can stimulate degradation of calcium hydroxylapatite, but it is slow acting and not effective in case of emergency. Permanent fillers may show some kind of modification in situ, but spontaneous or induced degradation has not been documented. Once implanted the permanent fillers remain lifelong. Intralesional laser treatment supports the removal of permanent filler material as an alternative to surgery. Besides biocompatibility and toxicity, filler materials should also be assessed for degradation to improve patient safety.

Characterization and Comparative Investigation of Hydroxyapatite/Carboxymethyl Cellulose (CaHA/CMC) Matrix for Soft Tissue Augmentation in a Rat Model

This study endeavors to develop an injectable subdermal implant material tailored for soft tissue repair and enhancement. The material consists of a ceramic phase of calcium hydroxyapatite (CaHA), which is biocompatible, 20-60 μm in size, known for its biocompatibility and minimal likelihood of causing foreign body reactions, antigenicity, and minimal inflammatory response, dispersed in a carrier phase composed of carboxymethyl cellulose (CMC), glycerol, and water for injection. The gel formulation underwent comprehensive characterization via various analytical techniques. X-ray diffraction (XRD) was employed to identify crystalline phases and investigate the structural properties of ceramic particles, while thermogravimetric analysis (TGA) was conducted to evaluate the thermal stability and decomposition behavior of the final formulation. Scanning electron microscopy (SEM) was utilized to examine the surface morphology and particle size distribution, confirming the homogeneous dispersion of spherical CaHA particles within the matrix. SEM analysis revealed particle sizes ranging from approximately 20-60 μm. Elemental analysis confirmed a stoichiometric Ca/P ratio of 1.65 in the hydroxyapatite (HA) structure. Heavy metal content exhibited suitability for surgical implant use without posing toxicity risks. Rheological analysis revealed a storage modulus of 58.6 and 68.9 kPa and a loss modulus of 21.7 and 24.8 kPa at the frequencies of 2 and 5 Hz, respectively. 150 μL of sterilized CaHA/CMC was injected subcutaneously into rats and compared with a similar product, Crystalys, to assess its effects on soft tissues. Skin tissue samples of rats were collected at specific intervals throughout the study (30, 45, 60, 90 and 120 days), and examined histologically. Results demonstrated that CaHA/CMC gel led to a significant increase in dermal thickness, elastic fibers, and collagen density. Based on the findings, the formulated CaHA/CMC gel was found to be biocompatible, biodegradable, nonimmunogenic, nontoxic, safe, and effective, and represents a promising option for soft tissue repair and augmentation.

Prospective and randomized comparative study of calcium hydroxylapatite vs calcium hydroxylapatite plus HIFU in treatment of moderate-to-severe acne scars

BACKGROUND

Acne scars are the most common sequelae of the severe inflammatory process of acne, and its managing is a challenge. Objective of this study was to assess safety and effectiveness of calcium hydroxylapatite monotherapy and its association with high-intensity microfocused ultrasound for treating moderate-to-severe atrophic acne scars.

METHODS

Women with moderate-to-severe atrophic scars of the face were enrolled on the study. Assessments were made by digital macrophotographs, Vectra H2, and Antera 3D.

RESULTS

From October to December 2019, twenty women which fitted the inclusion criteria signed a consent form and received 3.0 mL of calcium hydroxylapatite and after 4 weeks, 400 lines of HIFU. No major side effects were reported during the study, and all patients completed the follow-up after 6 months. At 1 month, patients treated with calcium hydroxylapatite (group 1) improved wrinkles and skin texture compared to placebo (group 2). At 3 and 6 months, all patients improved acne scars.

CONCLUSION

Our study showed that that both calcium hydroxylapatite and HIFU in monotherapy were safe and effective treatments for atrophic scar acne. Calcium hydroxylapatite was clinically effective when compared with placebo, though the combination of calcium hydroxylapatite and HIFU did not enhance the clinical efficacy compared to monotherapy.

Use of hyaluronic acid filler for enhancement of nipple projection following breast reconstruction: An easy and effective technique

Background

Breast reconstruction improves the psychological well-being of patients with breast cancer. Patients who complete nipple-areolar reconstruction are even more satisfied with their final reconstructive result. Nipple flattening is a common complication. We hypothesized that injectable soft-tissue filler can be used to augment nipple projection in patients who underwent breast reconstruction.

Methods

This is a retrospective study of patients who underwent breast reconstruction and desired an enhanced postoperative nipple projection. The patients underwent a single session of injection with a hyaluronic acid filler as an outpatient. The filler was injected intradermally at the base of the nipple until the desired nipple projection was obtained.

Results

Twelve patients and 22 breasts were included in this study. Enhanced nipple projection was observed in all cases, with an average increase of 3.0 mm in nipple height (range 2.5-4.5 mm). All injected nipples remained soft to the touch. All results were stable at a median of 7.5 months follow-up. No complications were observed.

Conclusions

The use of injectable fillers for enhanced nipple projection is a useful adjunct treatment in patients undergoing breast reconstruction. Advantages include the ability to obtain nipple projection in patients who opt to forgo nipple-areola reconstruction with local flaps, to augment reconstructed nipples in patients with thin mastectomy skin flaps especially following implant-based reconstruction, and to improve projection of the native nipple following nipple-sparing mastectomy. Another benefit of this adjunct treatment is that the injection is reversible. Filler injection is a safe and simple solution to the problem of insufficient nipple projection.

A systematic review of dermal fillers for age-related lines and wrinkles

BACKGROUND

Dermal fillers are gaining popularity for rapid aesthetic improvement. Long-term efficacy and safety have not been well documented. The aim of this systematic review was to assess the safety and efficacy of injectable dermal fillers compared with other facial augmentation techniques for the management of age-related lines and wrinkles.

METHODS

Studies including patients receiving injectable semi-permanent or permanent dermal fillers for age-related lines and wrinkles were included in this review. Efficacy outcomes (including changes in skin thickness and patient satisfaction) and safety outcomes (including mortality, lumps and infections) were examined.

RESULTS

Three randomized control trials and six case series were included. Permanent and semi-permanent dermal fillers improved subjective ratings of appearance and resulted in higher patient satisfaction than temporary fillers. Long-term efficacy appeared good in the few studies that reported it. Short-term safety appeared favourable. Lumps were reported in all but one study but received little follow-up. Long-term safety data were limited.

CONCLUSIONS

The treatment of age-related lines and wrinkles with permanent and semi-permanent dermal fillers is more efficacious compared with temporary fillers in those studies that compared them. Case series evidence suggests that these fillers achieve their objective, which is to decrease the visible effects of age-related changes. These fillers appear at least as safe as temporary fillers in the short term in those studies that compared them. Long-term safety could not be determined.

Use of calcium hydroxylapatite (Radiesse) for facial augmentation

Radiesse^® (Bioform Inc, USA) is a sterile, latex-free, non-pyrogenic, semi-solid, cohesive subdermal, injectable implant, whose principal component is synthetic calcium hydroxylapatite, a biocompatible material with over 20 years of use in medicine. The semi-solid nature of the product is created by suspending calcium hydroxylapatite microspheres of 25–45 microns diameter in a gel carrier of carboxymethylcellulose. The product has FDA approval for esthetic facial augmentation in the US. Such approval includes the long-lasting correction of moderate to severe facial wrinkles and folds and the treatment of facial fat loss due to immunodeficiency virus infection. Diverse facial regions can be injected in order to ameliorate or enhance some features: glabellar lines, subdermal support of the brows, malar and buccal fat pads, tear troughs, nasolabial folds, nose, lips, perioral region, marionette lines, oral commisures and chin among others, as well as saucerized acne scars. Other medical indications include nipple projection for nipple areolar reconstruction, urinary incontinence, vesicoureteral reflux, vocal cord augmentation, and use as a radiographic tissue marker. The average lasting result is from 12 to 18 months. Radiesse can be considered an effective soft-tissue filler for overall longevity, biocompatibility, and low rate of side effects.

Dermal fillers for facial soft tissue augmentation

Nowadays, patients are demanding not only enhancement to their dental (micro) esthetics, but also their overall facial (macro) esthetics. Soft tissue augmentation via dermal filling agents may be used to correct facial defects such as wrinkles caused by age, gravity, and trauma; thin lips; asymmetrical facial appearances; buccal fold depressions; and others. This article will review the pathogenesis of facial wrinkles, history, techniques, materials, complications, and clinical controversies regarding dermal fillers for soft tissue augmentation.

Adverse Effects When Injecting Facial Fillers

Facial soft-tissue augmentation has become ubiquitous in cosmetic dermatology. In the appropriate patient and with appropriate training, fillers can temporarily eliminate rhytides, creases, and defects, thereby producing a rejuvenated appearance. Yet, even in the most experienced injectors, there can be complications. These adverse effects can be divided into early and late and range from bruising to necrosis. Understanding the anatomy, limitations of the filler and proper technique can reduce the risk of adverse effects. When a complication occurs, the practitioner should understand how to manage them from observation to surgical intervention.

Calcium Hydroxylapatite Gel (Radiesse) Injection for the Correction of Postrhinoplasty Contour Deficiencies and Asymmetries

OBJECTIVES

To describe our technique for the injection of calcium hydroxylapatite gel (Radiesse) to treat postrhinoplasty contour defects and to evaluate the agent's efficacy, duration of action, required dosage, complication rates, and patient satisfaction. Slight defects or asymmetries are not uncommon, even after well-executed rhinoplasty surgery in the most expert of hands. These contour deformities have been treated with filler agents in the past, but with mixed results. Calcium hydroxylapatite gel was recently introduced as a filler agent in facial plastic surgery, but its use has not yet been described in the correction of postrhinoplasty nasal contour defects.

DESIGN

A prospective before-and-after trial conducted in a private-practice facial cosmetic surgery office. Eligible patients had postrhinoplasty contour irregularities or asymmetry. Postrhinoplasty irregularities at the nasal dorsum or tip underwent subcutaneous injection with calcium hydroxylapatite. Main outcome measures included number of treatments, posttreatment injection pain score, required dose and complications, natural feel, patient satisfaction, and length of follow-up. Digital photographs were evaluated by blinded observers.

RESULTS

Thirteen patients were followed up prospectively for a mean of 2.5 months. The mean injection pain score was 1.9 (scale, 0-5); the mean dose, 0.19 mL. Patient satisfaction was good to excellent in 11 (85%) of 13 cases. Photographic improvement was seen in 15 (88%) of 17 treatment sites.

CONCLUSIONS

Calcium hydroxylapatite gel has been shown in this study to improve postrhinoplasty nasal symmetry and smooth the curves and lines that constitute the contour of the nose. The longevity of nasal augmentation by calcium hydroxylapatite remains unsettled; long-term safety is also unknown. Long-term studies of safety and efficacy are indicated.

Technique for calcium hydroxylapatite injection for correction of nasolabial fold depressions

BACKGROUND

Injectable calcium hydroxylapatite is a soft-tissue augmentation material that is used off-label for facial augmentation, including repletion of depressed nasolabial folds.

OBJECTIVE

We sought to assess the safety of calcium hydroxylapatite injection for correction of nasolabial fold depressions. Specifically, we sought to obtain a quantitative assessment of injection-related adverse events using a reproducible placement technique with long-term follow-up.

METHODS

We conducted an open-label, single-center prospective study using reproducible technique with 1- to 1.5-year follow-up. All patients were treated with infraorbital nerve blocks. Then, parallel linear threading technique using 27-gauge/1.25-in needles was used to place 1 to 2 mL of injectant at the dermal subcutaneous junction into each pair of depressed folds. A triangular array of injectant was deposited under the melonasal junction. At follow-up at 2 to 3 weeks and at 1 to 1.5 years, respectively, patients were asked to report and characterize injection-related redness, swelling, bruising, nodule or granuloma formation, asymmetric correction, textural change, hypersensitivity reactions, degree of correction remaining, and overall satisfaction. In addition, patients who had received other injectable soft-tissue materials were asked to compare these with calcium hydroxylapatite in terms of risk profile and longevity of effect.

RESULTS

In all, 22 patients were treated and complete follow-up data were obtained from 18. Of the 18 patients, all reported at least mild postinjection redness and swelling, which abated within 1 to 5 days. Bruising was reported by fewer than half, and resolved within 4 to 10 days. Palpable but not visible nodules were reported by 2 of 18 patients; these resolved within 3 months of injection. Asymmetric correction, textural change, granulomas, and hypersensitivity reactions were not reported. In all, 14 of 18 patients reported that cosmetically significant correction lasted longer than 1 year. Two thirds of injected patients who had received other fillers for nasolabial fold correction preferred calcium hydroxylapatite, with the primary reason being increased longevity of effect.

LIMITATIONS

There was a lack of objective outcomes measures.

CONCLUSIONS

When a consistent, defined injection technique is used, injectable calcium hydroxylapatite appears to be a well-tolerated soft-tissue augmentation material for correction of nasolabial fold depressions. A long duration of effect may make this material particularly desirable for some patients.

Calcium Hydroxylapatite: Radiesse

Among the array of choices for aesthetic soft tissue fillers, Radiesse occupies a unique niche as a safe, easily administered, "semi-permanent" material. Composed of calcium hydroxylapatite in a gel matrix, it has a proven safety profile and has been approved by the US Food and Drug Administration for use in the nasolabial folds and for HIV lipoatrophy. Radiesse have evolved quickly into a effective filler for moderately deep facial folds with high patient and physician approval.

Calcium Hydroxylapatite Facial Filler (Radiesse™): Indications, Technique, and Results

This article discusses the use of Radiesse; a semisolid, cohesive subdermal injectable implant. Through direct and invaluable experience gained over time, plastic surgeons will decide which areas of the face may best be suited for Radiesse and which may be appropriate for other fillers.

Calcium Hydroxylapatite for Facial Rejuvenation

Porous calcium hydroxylapatite has been used in otolaryngology, dentistry and radiology for many years. Currently, calcium hydroxylapatite is gaining popularity for facial esthetics in the form of the product Radiesse (San Mateo, CA). Although Radiesse is not yet approved in the United States for cosmetic use, it is being used off-label by an increasing number of dermatologists and plastic surgeons for facial soft-tissue augmentation. Preliminary clinical and histologic studies have shown safety, efficacy and durability in various esthetic applications including the nasolabial folds and HIV lipoatrophy.

Use of Radiesse in Combination With Restylane for Facial Augmentation

OBJECTIVES

To report the long-term results of 72 consecutive patients treated with Radiesse (BioForm Inc, Franksville, Wis) and 29 patients treated with Radiesse and Restylane (Q-Medical, Uppsala, Sweden) and to share recommendations based on our experience.

METHODS

A total of 72 patients were treated with Radiesse between October 2003 and December 2004. Of these patients, 29 also received Restylane for facial augmentation. Forty-six Radiesse-treated and 15 Radiesse and Restylane-treated patients completed questionnaires detailing their experience with the procedure, postoperative sequelae, overall satisfaction, and satisfaction at each site treated.

RESULTS

On a 10-point scale, the overall satisfaction with Radiesse averaged 7.6, and 30 patients (65%) would recommend this procedure to others. Of the 72 patients, 2 (3%) reported persistent nodules, and both required removal of a small amount of the material. The overall satisfaction with the Radiesse and Restylane-combined treatment averaged 8.1, and 12 patients (79%) would recommend this procedure to others. No patients reported persistent nodules.

CONCLUSIONS

The use of Radiesse and Restylane in combination is an excellent option for facial enhancement. With long-term experience, complications in the lip area with Radiesse treatment are now avoided with the use of Restylane. In contrast to patients treated with Radiesse alone, the combination treatment group in this study tended to have greater immediate and overall satisfaction scores and was more likely to recommend the combination procedure to others.

Correction options for lipoatrophy in HIV-infected patients

Lipoatrophy (LA) is a form of lipodystrophy, characterized by volume depletion caused by fat loss in the limbs, buttocks, and face. Facial volume loss is the most obvious outward sign of LA because it alters the facial contours in the cheeks, temples, and orbits. Lipodystrophy and LA are most commonly seen in patients with HIV on highly active antiretroviral therapy (HAART), which was introduced in the mid-1990s for the management of HIV, and is currently considered the mainstay therapy for HIV-infected patients. However, the etiology of LA is likely multifactorial as underlying patient conditions, including duration and severity of HIV and increasing age, have also been found to contribute to its occurrence. The volume loss of LA can be very dramatic with some patients exhibiting no signs of facial fat. As a result, many HIV-infected patients with associated LA suffer from psychological and lifestyle effects, which can lead to noncompliance with HAART. Thus, increases in facial volume and improvement in morphology is anticipated to reduce anxiety caused by LA in HIV-infected patients, and improve quality of life. This review discusses the benefits and limitations of several treatment options available to correct the volume depletion associated with LA, including antiretroviral switching, permanent surgical implants and injectables, poly-L-lactic acid, collagen, and hyaluronic acid derivatives.

Caring for HIV-positive and aging patients with associated facial lipoatrophy

Facial lipoatrophy is characterized by fat loss and redistribution. It is a natural, biological phenomenon that occurs over time, presenting as mild-to-moderate volume depletion that gives the skin the appearance of sagging. More recently, highly active antiretroviral therapy, introduced for the management of human immunodeficiency virus, has been associated with moderate-to-severe facial lipoatrophy, and is characterized by sunken cheeks, accentuated nasolabial folds, and protruding musculature and bones. Furthermore, the consequences of facial lipoatrophy have been found to substantially impact patient quality of life. Nurses play an integral role in the treatment of facial lipoatrophy by educating the patients on available therapies and assisting them in making informed treatment decisions. It is important that treating nurses conduct a well-organized interview to understand patient treatment goals. This article will discuss several treatment options available to correct facial lipoatrophy-associated volume deficits, including collagen, hyaluronic acid, calcium hydroxylapatite, poly-L-lactic acid, and permanent implants and injectables.

The Evolution of Soft Tissue Fillers in Clinical Practice

To remain experts in skin care and treatment, every dermatologist must be aware of the evolving role of soft tissue fillers in dermatology. Patients with facial scarring, lipodystrophy, contour abnormalities, and age- and sun-induced rhytids can be successfully treated. A literature review, industry recommendations, and the authors' experience serve to highlight fillers most appropriate for each patient's complaint. Newer agents, including the hyaluronic acids and human collagens, and long-lasting materials, such as polymethlymethracrylate and calcium hydroxlyapatite, are reviewed. This discussion of the specific risks, indications, and technical pearls for the various fillers will allow clinicians to accurately advise or treat patients.

Les produits injectables lentement et non résorbables

Products which are non absorbable or slowly absorbable make the correction of facial wasting of any origin possible. These highly efficient products are unfortunately sometimes responsible for complications or even undesirable after effects. In order to avoid this the following are necessary: clinical and histological analysis of facias granulomas, a proposal for guidelines for their use which would predict in situ tolerance.