Soft-tissue augmentation with hyaluronic acid and calcium hydroxyl apatite fillers

Comprehensive assessment of intradermal responses to hyaluronic acid-based skin injection fillers through multi-pathway dynamic synergies

Skin injection filling products must undergo a rigorous evaluation before entering the market, and intradermal reactions are crucial for biocompatibility. However, current evaluation methods for skin injection fillers often lack precision. This study aims to explore a comprehensive evaluation method by incorporating additional indicators: dermoscopy, transepidermal water loss, moisture content, ultrasound, and histological observation. Experimental findings show sodium hyaluronate gel groups exhibited no noticeable erythema or abnormalities, except for skin swelling. The dynamic and quantitative assessment of water content and transdermal water loss provided insights into the injection site skin's edema status. Ultrasound imaging observed subcutaneous material occupation and measured skin protrusion height. Histopathological observations revealed edema and inflammation in positive groups but no significant reactions in any gel samples. The comprehensive use of these methods confirms that the intradermal response of injection fillers in this study is within an acceptable range. However, if solely evaluated based on existing standards, it may exceed the qualified range. Consequently, the study suggests that for sodium hyaluronate gel, a macromolecular injection filler for long-term subcutaneous space occupancy, the traditional intradermal reaction scoring method may be inadequate. The proposed comprehensive evaluation scheme in this study is considered a more objective approach.

Hybrid high and low molecular weight chains of hyaluronan for clitoral injection is an effective modality treatment for increasing female sexual satisfaction: an interventional, randomized-controlled parallel study

Introduction

Hormonal, behavioral, psychological, surgical, and pharmacopsychological treatment approaches contribute to female sexual dysfunction (FSD). Aim: The study is conducted to assess the effectiveness of hyaluronan high and low molecular weight hybrid cooperative complexes (hybrid H-HA/L-HA) in treating females with SD and to compare the female sexual function index (FSFI), dermatological life quality index (DLQI), and female genital self-image scale (FGSIS) before and after therapy.

Methods

We divided the 60 female participants into two groups. Hybrid H-HA/L-HA was administered to form pili of 0.25 cc around the clitoris in the direction of clock positions of 12, 3, 6, and 9. In Skene's gland; 0.25 cc for each and 0.5 cc into the corpus/body of the clitoris. Two treatments were held 30 days apart.The same procedure was repeated on the control group, but with saline as a placebo.

Outcomes

Women completed self-report questionnaires assessing sexual functioning using the FSFI, DLQI, and FGSIS before and after therapy.

Result

There was a significant (P = 634.152; P < .05) increase in the study group's weekly sexual interactions compared with the controls. The study group showed statistically significant amelioration in desire, arousal, lubrication, orgasm, satisfaction domains, overall score, and a decrease in pain following the first and second injection sessions (P = .014, .031, .003, .001, .011, .004, and .011, respectively). A comparison of the results between the two groups revealed significant improvement were found (P = .025).There were significant improvements in the domains of the FGSIS compared with the controls (P = .026). The study group showed a substantial improvement in satisfaction with the way their genital area looked, comfort level when allowing a sexual partner to view their genital area, belief that their genitals smell perfectly fine without being self-conscious about them, and overall score (P = .022, .031, .003, .001, and .004, respectively) (P < .05).The hybrid H-HA/L-HA sessions resulted in significantly greater positive perceptions and feelings, leisure activities, interpersonal interactions, and general assessments (P = .021, .021, and .020, respectively) (P < .05).

Clinical Implications

Female individuals with SD experience sexual improvements after hybrid H-HA/L-HA injection.

Strengths and Limitations

This is the first study focusing on female individuals with SD. We recommend conducting the study on a larger population and including their partners.

Conclusion

Hybrid H-HA/L-HA injection for rejuvenating the clitoral injection appears to be a reliable and safe method for enhancing female genital self-image, sexuality, and quality of life.

Performance and Safety of Amino-Acid- and Hydroxyapatite Enriched-Hyaluronic Acid Intradermal Gel in Facial Skin Defects

Background and Objectives: The facial skin defects associated with aging are common concerns in the aging population. Hyaluronic-acid-based intradermal gels have established themselves as safe and effective treatments for addressing these concerns. Recently developed enriched products aim to enhance the efficacy of these gels, yet their effectiveness lacks thorough validation in the existing literature. Materials and Methods: In this retrospective analysis, we investigated the outcomes of intradermal gel treatments in 103 patients with soft tissue defects. This study included three groups: 35 patients received amino-acid-enriched hyaluronic acid gel, another 35 were treated with hydroxyapatite-enriched hyaluronic acid gel, and the remaining 33 underwent hyaluronic acid treatment only. The efficacy of the treatments was assessed using the Global Aesthetic Improvement Scale (GAIS) score, while patient satisfaction was gauged through a detailed questionnaire. Any adverse event was monitored. Results: The treatments demonstrated remarkable efficacy, as evidenced by mean GAIS scores of 1.714 points for those treated with amino acid-enriched hyaluronic acid gel, 1.886 points for individuals receiving hydroxyapatite-enriched hyaluronic acid gel, and 1.697 for those treated with hyaluronic acid alone, all showing statistical significance (p < 0.0001). Patient satisfaction was very high. Significantly, there were no recorded instances of major adverse events. Conclusions: Hyaluronic gels, particularly those enriched with amino acids and hydroxyapatite, are effective and safe interventions for addressing facial skin aging defects. They serve as valuable tools in mitigating age-related blemishes and contribute to the overall improvement of skin aesthetics.

A Scoping Review of Hyaluronidase Use in Managing the Complications of Aesthetic Interventions

BACKGROUND

Hyaluronidase is used as an adjunct or main treatment to manage complications associated with cosmetic hyaluronic acid (HA) filler injections such as necrosis, blindness, hypersensitivity, delayed nodules, and poor aesthetic outcomes.

OBJECTIVE

To systematically map the available evidence and identify the gaps in knowledge on the effectiveness of hyaluronidase use in managing the aesthetic complications associated with HA injections (vascular occlusion, blindness, nodules, delayed hypersensivity, granuloma, poor aesthetic outcome).

METHODS

PubMed, Medline, Embase and Cochrane databases were used up to May 2022, to look for randomized clinical trials (RCTs), clinical trials, and retrospective case-control studies reporting on the use of hyaluronidase for managing the HA filler injection complications.

RESULTS

The database search yielded 395 studies; of those 5 RCTs (all carried out in the USA) were selected (53 subjects), indicating the effectiveness of hyaluronidase for removal of un-complicated injected HA nodules (forearm, upper arm, or back skin). The follow-ups ranged from 14 days to 4 years. The amount of HA filler injected into each site varied from 0.2 to 0.4 mL. A dose dependent response was observed for most HA fillers. No major adverse reactions were reported. Overall, for removal of every 0.1 mL of HA filler they injected 1.25-37.5 units of hyaluronidase (single injections). When 3 consecutive weekly hyaluronidase injection was used much lower doses of 0.375-2.25 unit was utilised. There was no evidence in a form of RCTs, clinical trials, and retrospective case-control studies on the removal/reversal of HA injections in the facial skin, or management of over-corrections, inflammatory nodules, or tissue ischemia/necrosis associated with HA filler injection.

CONCLUSION

Based on studies on the forearm, upper arm and back skin, hyaluronidase can be used for the reversal of uncomplicated HA filler injection nodule. However, further adequately powered studies are warranted to establish the ideal treatment protocol/dose of hyaluronidase for reversal of HA filler injections in the facial region or management of complications associated with aesthetic HA injection.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Hybrid high- and low-molecular weight chains of hyaluronan is an effective modality treatment for increasing female sexual satisfaction: An interventional, randomized-control parallel study

Background and Aims

Psychological, behavioral, hormonal, surgical, and psychopharmacologic approaches are the only acknowledged treatments for Female Sexual Dysfunction (FSD). The study is conducted to assess the efficacy of hybrid cooperative complexes of high and low molecular weight hyaluronan (hybrid H-HA/L-HA) in treating females with varying of sexual dysfunction and to assess the female genital self-image scale (FGSIS), female sexual function index (FSFI), and dermatology life quality index (DLQI) before and after treatment.

Methods

Sixty female patients were divided into two groups. The study group enrolled 30 female patients injected with hybrid H-HA/L-HA, while the control group enrolled 30 female patients injected with saline. Patients were recruited from the clinic searching for medical advice. Controls were selected from close associates of the cases who were attending with the patients or healthy escorts of dermatology patients attending the dermatology outpatient clinic. We assessed socio-demographic, clinical evaluation, the (FGSIS), (FSFI), and (DLQI) before and after treatment. The first assessment was conducted at the first visit, and the second assessment was conducted after 1 month of the second injection.

Result

Significant increase in the frequency of sexual intercourse/week in the study group after the first and second injection sessions compared to the controls was observed (p < 0.05). There was statistically significant amelioration in desire, arousal, lubrication, orgasm, satisfaction domains, and total score of the FSFI (p ≤ 0.05). The study demonstrated significant increasing differences in all domains of the FGSIS (p ≤ 0.05). The symptoms and feelings, leisure, personal relationships, and total scores were significantly higher post first and second injection of (hybrid H-HA/L-HA) sessions compared to the controls (p < 0.05).

Conclusion

The (hybrid H-HA/L-HA) injection for rejuvenating the genital area appears to be a safe and effective way to enhance female genital self-image, sexuality, and quality of life with high levels of satisfaction as a minimally invasive method.

Tear Trough Filler Techniques Utilizing Hyaluronic Acid: A Systematic Review

BACKGROUND

Hyaluronic acid soft-tissue augmentation fillers are commonly injected into multiple areas of the face, including the tear trough. Despite well-documented risks, there is no standardized, evidence-based approach to inject filler in this area, be it using a hypodermic needle or a microcannula. The authors, therefore, sought to establish a preference between the two methods to facilitate progression toward standardization and prevention of adverse events.

METHODS

This is a systematic review of articles discussing hyaluronic acid tear trough injection techniques performed in vivo and related outcomes. Searches were conducted across The Cochrane Library, PubMed, Scopus, Web of Science, and Embase to yield relevant articles published before February of 2020. All selected articles incorporated discrete patient cases and were analyzed by a variety of variables assessing evidence strength, outcomes, technique, and patient safety.

RESULTS

After appraisal, 42 articles met eligibility criteria: 20 using needles, 12 using cannulas, and 10 focusing on adverse events. Level III was the most commonly awarded evidence grade, corresponding to retrospective, nonexperimental descriptive studies. There were no statistically significant differences in reported aesthetic results, patient satisfaction, or incidence of adverse events across the needle-based and cannula-based articles. Some technique trends, such as targeted anatomical plane and needle position, emerged in subsequent articles.

CONCLUSION

Given that there were no statistically significant differences in patient safety or outcomes, an evidence-based preference for needle or cannula injection into the tear trough cannot be made at this time. Current inconsistencies make tear trough injection procedures difficult to replicate, making standardization based on avoidance of adverse events not feasible.

Late-Onset Upper Eyelid and Brow Edema as a Long-Term Complication of Hyaluronic Acid Filler Injection

BACKGROUND

Late-onset upper eyelid edema is an uncommonly recognized complication of hyaluronic acid (HA)-based filler injection to the supraorbital area.

OBJECTIVES

The authors sought to report their experience in diagnosing and managing late-onset upper eyelid edema.

METHODS

This was a noncomparative, retrospective study of a series of 17 consecutive patients who presented with upper eyelid edema 6 to 24 months after uneventful HA filler injection in the supraorbital area.

RESULTS

The study group included 17 female patients. The average time of presentation was 13.9 months. Thirteen patients (76.4%) were satisfied after hyaluronidase and requested no further treatment (observation only); 4 patients (23.5%) elected to receive HA filler re-treatment, with satisfactory results. All patients were followed-up for at least 6 months after the re-treatment.

CONCLUSIONS

The incidence of late-onset upper eyelid edema is likely to increase as the number of patients undergoing HA filler injection to the supraorbital area increases. Our study emphasizes the importance of recognizing this condition and suggests a suitable noninvasive treatment with satisfying results for both the patient and the physician.

LEVEL OF EVIDENCE: 4

Rehabilitation of the Dysmorphic Lower Eyelid From Hyaluronic Acid Filler: What to Do After a Good Periocular Treatment Goes Bad

BACKGROUND

Chronic, long-lasting edema accompanied by the Tyndall effect as a delayed reaction to hyaluronic acid (HA) filler injection seems to occur exclusively in the eyelids.

OBJECTIVES

The authors sought to present a treatment algorithm for management of patients with chronic lower eyelid edema as a delayed complication of HA filler injection.

METHODS

Retrospective study including 61 patients with delayed-onset chronic periocular edema following uneventful HA filler injection in the lower eyelids or cheeks. All patients underwent hyaluronidase enzyme dissolution followed by secondary treatment. Three retreatment options were presented: (1) observation, (2) secondary treatment with HA filler, and (3) lower eyelid blepharoplasty.

RESULTS

All patients underwent filler dissolution using hyaluronidase. The mean age was 48 years and 97% of the patients were female. Single treatment was effective in 92% of patients with 8% requiring another hyaluronidase injection to completely eradicate residual edema. Six patients (10%) were satisfied after hyaluronidase only and 6 patients (10%) underwent lower eyelid blepharoplasty. Secondary treatment with HA filler was performed in 48 patients (80%). All were satisfied with final results without further edema in the follow-up period.

CONCLUSIONS

Delayed-onset chronic lower eyelid edema is a frequent HA-related complication and cause of concern when considering periocular HA treatment. Previous treatment has been limited to either hyaluronidase only or blepharoplasty as a secondary solution after hyaluronidase, with only a minority of patients satisfied. Hyaluronidase, shortly followed by HA filler retreatment, is a safe and effective solution.

LEVEL OF EVIDENCE: 4

Confocal microscopy and imaging profilometry: A new tool aimed to evaluate aesthetic procedures

According to the American Academy of Aesthetic Plastic Surgeons, more than 11 million cosmetic surgical and nonsurgical procedures were performed by board-certified plastic surgeons, dermatologists and otolaryngologists in the United States, totaling more than 12 billion dollars. We performed a retrospective observational multi-centric study on patients treated with a non-animal origin cross-linked hyaluronic acid with different molecular weights for nasolabial folds, evaluating through a new imaging system, profilometric techniques with the confocal microscopy, the durability, the efficacy and the safety of this product. From 25 patients, 150 silicone casts were obtained: 75 casts of the right nasolabial fold and 75 casts of the left nasolabial fold. Roughness arithmetical average of the right fold at T2 decreased by 50% versus T0 and by 40% compared to T1; at T2, it decreased by the 45% versus T0 and by 35% compared to T1. No side effects were reported. Results proved that the analysis of the skin microreliefs through confocal microscopy is a new imaging system that allows to evaluate with precision and safety the results of aesthetic treatments such as fillers objectively.

Efficacy and tolerance of an injectable medical device containing stable hybrid cooperative complexes of high- and low-molecular-weight hyaluronic acid: a monocentric 16 weeks open-label evaluation

BACKGROUND

An injectable medical device containing stable hybrid cooperative complexes of high- and low-molecular-weight hyaluronic acid (HA) has been developed with characteristics suited for a global improvement of facial esthetics.

OBJECTIVE

To evaluate the HA product performance in improving some key facial esthetic features. The study employed clinical scales, subjective evaluations, and facial skin objective measurements.

METHODS

A single Italian site treated 64 female subjects aged 38-60 years, with injections at five predetermined points, on each side of the face, with a 4-week time lapse between the first and the second product administration. Subjects were evaluated after 4, 8, 12, and 16 weeks, using validated clinical scales, subjective evaluation, and objective quantitative outcome measures. Assessment of esthetic results included photographic documentation.

RESULTS

Both the clinical and subjective assessments, and the majority of objective instrumental parameters indicated an improvement throughout the study and were already significant at week 4 or 8 and were still significant at week 16 (3 months after the second treatment). Minor and temporary local skin reactions were observed in 23% of subjects at the site of the injections, and the global judgment on tolerability was good or excellent, both in the investigators' opinion and volunteers' self-evaluation.

CONCLUSION

Both subjective and objective improvement of the facial parameters was consistent with the bio-remodeling purpose, and persistent and still statistically significant at the end of the study. The tolerability and safety profile of the product were judged good or excellent both by investigators and volunteers. This study supports the claim for bio-remodeling of these stable hybrid cooperative complexes of low- and high-molecular-weight HA.

Effect of molecular weight of hyaluronic acid (HA) on viscoelasticity and particle texturing feel of HA dermal biphasic fillers

Background

Hyaluronic acid (HA) dermal biphasic fillers are synthesized for their efficacy in correcting aesthetic defects such as wrinkles, scars and facial contouring defects. The fillers consist of crosslinked HA microspheres suspended in a noncrosslinked HA. To extend the duration of HAs within the dermis and obtain the particle texturing feel, HAs are crosslinked to obtain the suitable mechanical properties.

Results

Hyaluronic acid (HA) dermal biphasic fillers are prepared by mixing the crosslinked HA microspheres and the noncrosslinked HAs. The elastic modulus of the fillers increased with raising the volume fraction of the microspheres. The mechanical properties and the particle texturing feel of the fillers made from crosslinked HA (1058 kDa) microspheres suspended in noncrosslinked HA (1368 kDa) are successfully achieved, which are adequate for the fillers.

Conclusions

Dermal biphasic HA fillers made from 1058 kDa exhibit suitable elastic moduli (211 to 420 Pa) and particle texturing feel (scale 7 ~ 9).

Long-lasting and bioactive hyaluronic acid-hydroxyapatite composite hydrogels for injectable dermal fillers: Physical properties and in vivo durability

Hyaluronic acid (HAc)–hydroxyapatite (HAp) composite hydrogels were developed to improve the biostability and bioactivity of HAc for dermal filler applications. Two kinds of HAc-HAp composite fillers were generated: HAcmicroHAp and HAc-nanoHAp composites. HAc-microHAp was fabricated by mixing HAp microspheres with HAc hydrogels, and HAc-nanoHAp was made by in situ precipitation of nano-sized HAp particles in HAc hydrogels. Emphasis was placed on the effect of HAp on the durability and bioactivity of the fillers. Compared with the pure HAc filler, all of the HAc-HAp composite fillers exhibited significant improvements in volumetric maintenance based on in vivo tests owing to their reduced water content and higher degree of biointegration between the filler and surrounding tissues. HAc-HAp composite fillers also showed noticeable enhancement in dermis recovery, promoting collagen and elastic fiber formation. Based on their long-lasting durability and bioactivity, HAc-HAp composite fillers have great potential for soft tissue augmentation with multifunctionality.

A blinded, randomized, split-face pilot study of bruising and pain with hyaluronic acid for correction of perioral lines using no lidocaine, lidocaine alone, and lidocaine and epinephrine

BACKGROUND

Hyaluronic acid (HA) fillers are sometimes mixed with lidocaine to mitigate pain. Whether the addition of epinephrine to lidocaine provides greater benefits in bruising and pain has not been fully reported.

OBJECTIVES

The investigators explored the severity of bruising and pain in patients treated with the cohesive polydensified matrix HA (CPMHA) in 3 different preparations: CPMHA (Belotero Balance [BEL]), CPMHA with lidocaine (BEL-L), and CPMHA with lidocaine and epinephrine (BEL-LE).

METHODS

In a blinded, split-face, 14-day study, 30 patients were divided into groups of 10. One group received 1.0 mL BEL in the perioral lines on 1 side and 1.0 mL of BEL-LE on the other side. A second group received 1.0 mL of BEL on 1 side and 1.0 mL of BEL-L on the other side. The third group received 1.0 mL of BEL-L on 1 side and 1.0 mL of BEL-LE on the other side. Over 3 visits, the treating investigator, the patients, and a blinded investigator rated the bruising.

RESULTS

Bruising occurred in each treatment group by day 1 but resolved for half of the patients by day 7 and for all patients by day 14. Split-face comparison did not reveal a significant difference in pain and bruising scores among the 3 preparations.

CONCLUSIONS

No significant difference was found in bruising or pain in patients treated with BEL, BEL-L, and BEL-LE. Studies with a considerably larger sample size are warranted to determine statistically significant and clinically meaningful differences between and among the various formulations.

A Review of New Facial Filler Techniques for Facial Rejuvenation

Introduction:

Over the recent years, the use of facial fillers for rejuvenation of the aging face has continued to increase in popularity. As the demand for noninvasive cosmetic enhancements increases, so does the need for new cosmetic techniques that will increase patient satisfaction while decreasing complications. In the past, facial fillers were mostly used for lip augmentation, nasolabial folds, and marionette lines. However, because of advances in cosmetic techniques and types of dermal fillers, cosmetic surgeons today are able to correct lines, wrinkles, and volume loss seen in crow's feet, around the eyes, chin, and cheeks.

Materials and Methods:

A literature search was performed from 2006 to 2013 to determine new cosmetic techniques used for facial rejuvenation of the aging face.

Results:

Advances in facial rejuvenation are helping to give cosmetic surgeons better results with little discomfort when using dermal fillers around the eyes, cheeks, and chin to improve the overall look of wrinkles and volume loss.

Conclusions:

The development of new techniques and injectable dermal fillers will continue to advance with the increasing demand for a youthful appearance. Up until recently, facial fillers were used mainly to improve the effects of aging seen around the lips, nasolabial folds, and marionette lines. Today, because of advances in the type of facial filler and used techniques, facial fillers can be used to improve volume loss, lines, and wrinkles around the eyes, cheeks, and chin.

Experimental and Clinical Efficacy of Two Hyaluronic Acid-based Compounds of Different Cross-Linkage and Composition in the Rejuvenation of the Skin

BACKGROUND

In the field of aesthetic medicine there is an increasing demand for safe and effective hyaluronic acid (HA) fillers to counteract the aging process.

METHODS AND AIMS

We designed a study to evaluate the safety and histological biocompatibility of Aliaxin® Global Performance, a cross-linked HA filler and Viscoderm® Skinkò E, a product composed of non-cross-linked HA and a complex including vitamins, antioxidants, amino acids and minerals injected into the skin of guinea pigs. Then, we translated our findings into the clinical setting, administering a combination of these compounds to patients seeking a facial rejuvenation procedure targeting moderate-to-severe wrinkles affecting the nasolabial folds.

RESULTS

The animal study showed that the two compounds did not induce any significant inflammatory reactions and increased collagen and elastic fibers in the skin. In the clinical setting, injection of Aliaxin® Global Performance, followed by Viscoderm® Skinkò E, resulted in a higher improvement in nasolabial fold hydration, trans-epidermal water loss and wrinkle aesthetic appearance, if compared with a protocol based on Aliaxin® Global Performance alone.

CONCLUSION

In summary, we show evidence on the safety and mechanism underlying two new HA-based compounds of different cross-linkage and composition, proposing that they can be safely used in combination in patients seeking facial rejuvenation procedures with long-lasting efficacy.

Granulomatous foreign body reaction to dermal cosmetic fillers with intraoral migration

OBJECTIVE

We report intraoral granulomatous foreign body reactions in patients treated with calcium hydroxylapatite (CHA) or poly-l-lactic acid (PLA).

STUDY DESIGN

Clinical and histopathologic data were obtained from 25 patients who developed orofacial nodules or swelling after dermal filler injections.

RESULTS

All 25 patients were women aged 35 to 78 years (median, 55 years). All had a history of injection of CHA (n = 13) or PLA (n = 12) to the lips, nasolabial area, or mental area. Two patients developed cutaneous nodules at the sites of injections; all others presented with intraoral nodules (labial/buccal or vestibular mucosa) distant from the site of injections, suggestive of filler migration. Five of 21 cases presented with pain. Histopathologically, CHA presented as a diffuse mass of mauve-gray or beige, nonrefractile spherules, and PLA as rice- or spindle-shaped, geometric, refractile bodies within circumscribed nodules.

CONCLUSIONS

Cutaneous injections of CHA and PLA fillers may induce granulomatous reactions presenting as intraoral nodules distant from the injection sites.

Management of acne scarring, part II: a comparative review of non-laser-based, minimally invasive approaches

Acne scarring is a commonly encountered yet extremely challenging problem to treat for the dermatologist. As acne scarring can lead to significant psychological distress and low self-esteem, it is of utmost importance to have effective and satisfying treatments in the physician's armamentarium. However, many treatments are unsatisfying, leading to patient disappointment and frustration. Although early treatment of acne lesions and inflammation with isotretinoin is beneficial in preventing acne scarring, many patients still present with troubling noticeable scars. Despite the advances in pharmacology and technology, scar treatment still remains suboptimal and is tainted with several adverse effects. However, some treatments can provide benefits. This review article exhaustively discusses and analyzes the various minimally invasive approaches to the treatment of acne scarring with an emphasis on pharmacologic agents, such as isotretinoin for atrophic acne scars and corticosteroids and chemotherapeutic drugs for hypertrophic scars. Intralesional injections of corticosteroids are efficacious in reducing keloid scar formation in addition to preventing recurrence following surgical excision. In-office and minimally invasive procedural management, including chemical peels, dermabrasion, tissue augmentation, and punch excision is also discussed. Superficial chemical peels are efficacious in treating atrophic scars with relatively few adverse effects and complications. Although dermabrasion is used less often with the advent of laser resurfacing, this technique remains as a viable option for those with atrophic scars. Post-inflammatory hyperpigmentation can be managed successfully with topical agents such as azelaic acid and hydroquinone. The efficacy of various treatment modalities is highlighted with a focus on choosing the correct modalities for specific scar types.

Volumetric considerations for lower eyelid and midface rejuvenation

PURPOSE OF REVIEW

With the accepted understanding of volume loss as one of the main factors in facial aging, oculofacial surgeons are embracing the concept of 'removing' less and 'filling' more. The purpose of this review is to present an update of the different alternatives and techniques for lower eyelid and midface restoration/rejuvenation using filler agents.

RECENT FINDINGS

When a filler agent is chosen, the aim is to provide some lift, support and sculpting to the treated area. Nonpermanent or semi-permanent fillers are most widely accepted by physicians mainly because there is a lower possibility of complications. The involutional changes in the facial structures are a continuous process; this requires reassessment and variation in techniques in addition to choosing different products at different ages. Safety, support capability, ease of injection and cost are the factors to consider when choosing an injectable implant. But, physicochemical structure or rheological properties, such as viscosity and elasticity, enable the clinician to objectively select the most appropriate injectable implant depending on the specific anatomical area. An injectable with low viscosity may be ideal for lip enhancement wherein softness is required, whereas a higher viscosity filler or a harder filler may be better indicated for structure and support in the midface.

SUMMARY

Given the wide variety of filler materials available, clinicians and surgeons must be able to select products based on safety, lifting or sculpting capability and rheological properties, such as viscosity and elasticity. These factors provide an objective parameter of how the filler agent will perform in a specific area.

A novel injectable chitosan/polyglutamate polyelectrolyte complex hydrogel with hydroxyapatite for soft-tissue augmentation

This study demonstrated a chitosan (CS)/polyglutamate (PG) polyelectrolyte complex (PEC) hydrogel combined with spherical hydroxyapatite (HAp) particles as an injectable dermal filler for soft-tissue augmentation. The CS/PG PEC hydrogel with oppositely charged ionic cross-linking, a high gel content, and low degradation rate was introduced as a carrier to achieve high shape and volume stability. An MTT assay indicated that the CS/PG PEC had satisfactory cell biocompatibility. This PEC/HAp hydrogel showed good structural integrity in a PBS solution for up to 60 days. Clinical manageability was indexed by an injection force measurement through sterile 27-gauge needles using a texture analyzer. In an animal study, 0.2 mL of the PEC and PEC/hydroxyapatite (HAp) were implanted within the dorsal dermis of a swine ear. Injected tissue areas were biopsied 2 weeks, and 2 and 6 months after the injection. According to the histomorphometric results, the PEC and PEC/HAp groups showed percentages of retention of the maximum height of the cross-section of about 44% and 73% at 6 months. New collagen was observed in the central position indicating a possible collagenesis effect. These results suggest that this PEC/HAp system can be used as an alternative for soft-tissue augmentation.

Lip nodules caused by hyaluronic acid filler injection: report of three cases

Many dermal fillers have been used for reducing facial skin lines and for providing lip augmentation, and hyaluronic acid (HA) is one of the most widely used agents. One of the main commercial forms of HA is Restylane (Q Med, Sweden) produced by microbiological engineering techniques. Although HA is non-immunogenic, hypersensitivity and Granulomatous foreign body reactions have been reported. Herein, we report three female patients (average age 56 years) who presented with firm nodular lesions of the lip and a history of injection with HA (Restylane, Q Med, Sweden). Histopathologically, all cases showed pools of amorphous hematoxyphilic material surrounded by bands of densely collagenized connective tissue with no inflammation or foreign body reaction. Histochemical stains confirmed the presence of acid mucopolysaccharides such as hyaluronic acid. We conclude HA (Restylane, Q Med, Sweden) is an inert filler that may persist at an injection site, resulting in a tumor-like nodule.

High-density hyaluronic acid for the treatment of HIV-related facial lipoatrophy

BACKGROUND

Facial lipoatrophy is a stigmatizing hallmark of HIV. The injection of facial fillers has an essential role in the treatment of this condition. The objective of our study was to verify the safety and efficacy of a new formulation of high-density hyaluronic acid for the injectable treatment of HIV-related facial lipoatrophy.

METHODS

We treated with high-density hyaluronic acid injections HIV patients affected by moderate to severe facial lipoatrophy and evaluated them at last follow-up, at a minimum of 36 weeks. Physician-related outcomes included pre-and post-treatment ultrasound measurement of the soft-tissue thickness of the cheeks and qualitative assessment of aesthetic results by means of the Global Aesthetic Improvement Scale using pre- and post-treatment photos of the patients. Patient satisfaction outcomes were evaluated with the VAS-face scale and Freiburg test.

RESULTS

Fifty-four patients were studied. The median number of treatment sessions was 3 and the median length of treatment was 5.5 months. The thickness of the soft tissues of the cheek increased significantly from 9.45 to 13.12 mm (p<0.0001). On the basis of the Global Aesthetic Improvement Scale, 87.5% of the patients were judged as "much improved" or "improved." Patient satisfaction at 1 year from the end of treatment was proven (VAS-face: 77.9; Freiburg questionnaire: 93.6% of patients were satisfied or very satisfied). Complications were limited to mild redness and swelling in the early postoperative period.

CONCLUSION

Long-term improvement of facial contour and excellent patient satisfaction, in the absence of severe side effects, were obtained by the injection of high-density hyaluronic acid (STYLAGE® XL) in HIV patients with facial lipoatrophy.

Plastering the head with crushed snails to treat pediatric hydrocephalus: an ancient therapy with a pharmacological basis

In the Middle Ages, medical therapy for pediatric hydrocephalus was characterized by the application of drying substances to decrease the size of the heads of affected children. A poultice of crushed snails applied to the head was considered to be one of the most powerful therapies for reducing swelling caused by excessive humors. Incunabula (texts printed in Europe before 1501 CE) and Renaissance texts document the extended use of this therapy, which was considered by physicians to be effective and less dangerous than surgical treatment.

Cosmetic procedures in children

PURPOSE OF REVIEW

Cosmetic procedures are being performed with increased frequency in the United States and worldwide. Many of these procedures are being performed on children for aesthetic reasons and for the management of dermatological conditions such as psoriasis and vitiligo. This review serves as an overview of selected cosmetic procedures with pediatric applications.

RECENT FINDINGS

Recent developments in laser technology have improved our ability to treat a large number of pediatric cutaneous disorders. The vast majority of these technologies were first developed for aesthetic dermatology in adults. Collagen-stimulatory agents such as poly-L-lactic acid were first approved for lipoatrophy associated with human immunodeficiency virus. Poly-L-lactic acid and dermal fillers have potential therapeutic applications in children with atrophic disorders such as lipoatrophy and morphea. Injection of botulinum toxin is very successful in the treatment of hyperhidrosis in adults and can be utilized to improve quality of life in children with hyperhidrosis.

SUMMARY

The field of cosmetic dermatology is evolving quickly, with limited safety and efficacy studies in the pediatric age group. Children may benefit from thoughtful application of these technologies.