Principles of soft tissue augmentation for the aging face

A lubcan cross-linked polyethylene glycol dimethyl ether hydrogel for hyaluronic acid replacement as soft tissue engineering fillers

The structure of soft tissues is often destroyed by injury and aging. Injectable fillers eliminate the need for surgery and enhance repair. Hyaluronic acid-based hydrogels are commonly employed for their effectiveness and biocompatibility. However, hyaluronidase breaks them down quickly. Lubcan, a naturally sourced microbial extracellular polysaccharide, has demonstrated significant water absorption and retention capabilities, as well as lubricating properties comparable to those of hyaluronic acid. In this study, a novel injectable and implantable hydrogel was created from lubcan by adding polyethylene glycol diglycidyl ether as a cross-linking agent. Lubcan hydrogels exhibit exceptional thermal stability, favorable swelling behavior, in vitro degradation, compressive strength, injectability, and rheological properties, all while preserving the integrity of their three-dimensional porous structure. In vitro tests indicated that the lubcan hydrogel was non-cytotoxic, did not adhere to blood cells, and exhibited good hemocompatibility. Compared to the subcutaneous injection of commercially available hyaluronic acid hydrogels, lubcan hydrogels demonstrated superior integrity, persistence, and a softer texture in Balb/c mice after 16 weeks. At the same time, lubcan hydrogel is non-toxic to organs, does not affect blood biochemical test values, and is non-immunogenic in mice. These findings suggest that lubcan hydrogel may be a promising new superficial soft tissue filler.

Poly-D,L-Lactic Acid Filler Attenuates Ultraviolet B-Induced Skin Pigmentation by Reducing Destruction of the Basement Membrane

Poly-D,L-lactic acid (PDLLA) filler, which increases volume and collagen synthesis, is used for skin rejuvenation. PDLLA filler also increases M2 macrophages and IL-10. Ultraviolet (UV) radiation induces dermal hyperpigmentation by disrupting the basement membrane (BM), allowing melanin to move into the dermis. Therefore, using UV-irradiated macrophages and animal skin, we determined whether PDLLA filler decreased M1 macrophages and skin inflammation, thereby reducing BM destruction and dermal hyperpigmentation. UV radiation increased the M1 macrophage marker CD86 and TNF-α expression, which was inhibited by the treatment of macrophages with PDLLA. In fibroblasts treated with conditioned medium from UV-irradiated macrophages, NF-κB activity, NLRP3 inflammasome components (NLRP3, ASC, and pro-caspase-1), IL-18, MMP2, and MMP9 increased, but all decreased after PDLLA treatment. Similar to the in vitro study, UV-irradiated mouse skin showed increased CD86, NLRP3, ASC, pro-caspase-1, MMP2, and MMP9, which decreased after PDLLA injection. Disruption of the lamina densa of the BM and dermal pigmentation increased after UV irradiation and decreased after PDLLA injection. In conclusion, PDLLA reduced dermal pigmentation by decreasing BM destruction in UV-irradiated skin. PDLLA has the potential to reduce dermal pigmentation by regenerating the BM.

Autologous fat grafting for cosmetic temporal augmentation: a systematic review

Background

Autologous fat grafting for temporal augmentation is increasingly popular in aesthetic surgery. However, its high absorption rate, unpredictable volume retention rate, and potential safety risks are significant drawbacks. Evaluation methods for the fat graft survival rate, especially volume retention in the temporal area, vary widely and tend to be more subjective than objective. Therefore, this systematic review aims to analyze the unpredictable volume retention rate, associated safety concerns, and the various assessment strategies following autologous fat grafting for cosmetic temporal augmentation.

Methods

We conducted a systematic review of manuscripts listed in the MEDLINE/PubMed database on autologous fat grafting for cosmetic temporal augmentation. Articles had to be available in full text and written in English. Studies not presenting human data or not discussing cosmetic indications were excluded. We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results

Eight articles were included. The average fat volume injected into each temporal region was 10.69 ml (range 6-17.5) on the right and 10.64 ml (range 5.9-17.4) on the left side. All included articles utilized photographic documentation before and after treatment, along with various questionnaires and scales (37.5% Likert Scale, 12.5% Hollowness Severity Rating Scale, 12.5% Visual Analogue Scale, 12.5% Allergan Temple Hollowing Scale). For objective assessment, one article (12.5%) used computed tomography, and another (12.5%) employed a three-dimensional scanning system to objectively evaluate fat graft survival.

Conclusion

Autologous fat grafting effectively addresses temporal hollowness, with high patient satisfaction and a favorable safety profile. However, the variability in fat retention rates highlights the need for more controlled studies to establish reliable, validated methods for evaluating fat graft survival in the temporal area, and to further assess the safety of this procedure.

Poly-D,L-Lactic Acid Filler Increases Extracellular Matrix by Modulating Macrophages and Adipose-Derived Stem Cells in Aged Animal Skin

Poly-D,L-lactic acid (PDLLA) filler corrects soft tissue volume loss by increasing collagen synthesis in the dermis; however, the mechanism is not fully understood. Adipose-derived stem cells (ASCs) are known to attenuate the decrease in fibroblast collagen synthesis that occurs during aging, and nuclear factor (erythroid-derived 2)-like-2 factor (NRF2) increases ASCs survival by inducing M2 macrophage polarization and IL-10 expression. We evaluated the ability of PDLLA to induce collagen synthesis in fibroblasts by modulating macrophages and ASCs in a H₂O₂-induced cellular senescence model and aged animal skin. PDLLA increased M2 polarization and NRF2 and IL-10 expression in senescence-induced macrophages. Conditioned media from senescent macrophages treated with PDLLA (PDLLA-CM_MΦ) reduced senescence and increased proliferation and expression of transforming growth factor-β (TGF-β) and fibroblast growth factor (FGF) 2 in senescence-induced ASCs. Conditioned media from senescent ASCs treated with PDLLA-CM_MΦ (PDLLA-CM_ASCs) increased the expression of collagen 1a1 and collagen 3a1 and reduced the expression of NF-κB and MMP2/3/9 in senescence-induced fibroblasts. Injection of PDLLA in aged animal skin resulted in increased expression of NRF2, IL-10, collagen 1a1, and collagen 3a1 and increased ASCs proliferation in aged animal skin. These results suggest that PDLLA increases collagen synthesis by modulating macrophages to increase NRF2 expression, which stimulates ASCs proliferation and secretion of TGF-β and FGF2. This leads to increased collagen synthesis, which can attenuate aging-induced soft tissue volume loss.

Comparative Evaluation of Physical Characteristics and Preclinical Data of a Novel Monodisperse Polycaprolactone Microspheres Filler

BACKGROUND

Demand for dermal fillers has been increasing gradually over the past decade. Polycaprolactone (PCL) fillers, a biodegradable polymer, not only naturally maintain the volume of the skin, but also stimulate collagen production by microsphere. However, inflammation can be caused by several factors such as large diameters, non-uniformity, uneven surfaces and non-spherical shapes of microspheres in use. Thus, a filler using microspheres with a uniform diameter of more than 20 μm and spherical shape was developed.

OBJECTIVE

The main purpose of this study was to evaluate the efficacy and safety of newly monodisperse polycaprolactone microspheres fillers, IVL-F001 with smaller microsphere size and better morphology against a conventional commercial PCL filler.

MATERIALS AND METHODS

The morphology and diameters of microsphere included in IVL-F001 and the PCL filler were analyzed, and the viscoelasticity and inject ability of both fillers were examined. After intradermal injection to hairless mice, the durability and efficacy of both fillers were evaluated through PRIMOS^LITE and Folliscope for 24 weeks. Histology was performed to assess the biocompatibility, inflammation, and collagen synthesis.

RESULTS

Microspheres of IVL-F001 demonstrated a narrow size distribution with average diameter of 34.16 μm and distribution of 4.11. The level of injection force was low and the elasticity (G') was high compared to the licensed PCL filler. In the histopathological evaluation, IVL-F001 had significantly lower inflammatory reactions and higher collagen synthesis compared to the licensed PCL filler.

CONCLUSION

These data indicated that IVL-F001 has lower inflammatory reaction and improved persistence compared with commercial PCL filler.

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.

A new phytocosmetic preparation from Thymus vulgaris stimulates adipogenesis and controls skin aging process: In vitro studies and topical effects in a double-blind placebo-controlled clinical trial

BACKGROUND

The use of the injectable products for soft tissue augmentation and treatment of skin aging is an uncomfortable, invasive and related to several complications, and chronic reactions, mainly after long-term application. Efforts to develop new topically active anti-aging products with fewer adverse effects are a huge challenge that should be faced.

AIMS

We evaluated the anti-aging effects of a phytocosmetic preparation containing Thymus vulgaris associated with lecithin (ThymLec) on the facial wrinkles, expression lines, and face oval remodeling using a double-blind placebo-controlled clinical trial and in vitro cell culture assays.

METHODS

A clinical trial was conducted to evaluate the effects of ThymLec 2% on the area, length, and depth of the perioral and crow's feet wrinkles, nasolabial and smile lines, as well as face oval remodeling in female volunteers using a sophisticated Bio3D Structured-light Scanner. In the in vitro studies using 3T3-L1 mouse embryonic fibroblasts, adiponectin was measured by immunoenzymatic assay, adipogenesis by the AdipoRed reagent method, and the PPAR-γ expression by RT-PCR analysis.

RESULTS

Topical treatment with ThymLec 2% reduced facial wrinkles and expression lines promoting a face oval remodeling. In the in vitro studies, ThymLec upregulated the PPAR-γ expression increasing adiponectin production and stimulating the adipogenesis process.

CONCLUSIONS

The phytocosmetic preparation containing Thymus vulgaris and lecithin is an innovative and safe topical anti-aging product promoting fat tissue augmentation by adipogenesis stimulation via the upregulation of PPAR-γ expression and adiponectin production.

Quantitative evaluation of facial sagging in different body postures using a three-dimensional imaging technique

BACKGROUND

The possible contribution of head flexion posture while using a smartphone to the formation of "smartphone face," is an increasing concern. Smartphone face describes the facial changes in a stooped posture receiving more gravitational pull on the jowl area.

AIMS

In this study, we quantified facial sagging in different postural changes using a three-dimensional imaging technique.

METHODS

Faces of 21 young (30.45 ± 2.81 yo, n = 11) and old (59.50 ± 3.37 yo, n = 10) Korean female subjects were scanned in different body postures including standing, supine, and head flexion (30°, 45°). The landmark displacements and volumetric changes in facial areas were assessed and correlated with skin elasticity. In addition, 22 Korean female subjects (45.45 ± 3.81 yo) were recruited to test the anti-gravity effect of facial cream A, which was formulated with Stem III complex™, for 8 weeks.

RESULTS

The landmarks shifted inferior-laterally with the supine posture, while the upper face shifted more laterally and the lower face shifted more inferiorly. With a head flexion posture, facial sagging occurred mainly toward the anterior direction with more prominent changes in the lower face. The changes were greater in the older group, and skin elasticity exhibited negative correlation with the shifting distances. A significant decrease in facial sagging was noted after an 8-week treatment of facial cream A.

CONCLUSION

The use of a three-dimensional imaging technique could accurately assess the gravity-induced facial changes in different postures. The head flexion posture particularly gives more gravitational pull to the lower face, which could contribute to the drooping jawline.

Botox and Dermal Fillers: Review and Its Role in the Dental Office

For the general dentist, the use of BTA and dermal fillers confers the ability to exert control over the soft tissues surrounding the mouth to better create a harmonious smile. The injection of BTA and fillers into the facial musculature and dermis requires a level of finesse to achieve the desired outcomes. A sound understanding of the mechanisms of action and the ability to manage potential complications are also necessary, because the dentist administering BTA and dermal fillers must be competent to the same level as other providers who have traditionally been the gatekeepers of such agents.

String Fat/Dermis Graft for Correction of Wrinkles and Scars

Established creases and wrinkles do not predictably respond to the fat injection technique. The authors describe a minimally invasive yet simple technique to address recalcitrant facial rhytides and minor depressed scars. This technique optimally requires a concomitant procedure whereby suitable fat or dermis graft could be available for grafting without having to make another incision. However, if needed, the graft can be harvested from an easily concealed area such as postauricular sulcus. Preferably, dermis or a combination of fat and dermis is harvested in the form of strings using a pair of straight iris scissors. The sharp end of an 18-gauge needle is then used to create a tunnel in the subcutaneous plane beneath each line while releasing any fibrous bands. The string of dermis/fat is then engaged at the end of the 18-gauge needle and delivered into the subcutaneous tunnel with rotation and advancement of the needle. The authors have used this graft on 49 sites on 39 patients. The mean age of the patients was 57.6 years, with eight male and 31 female patients. The sites included rhytides in upper and lower lips, oral commissure, labial mental groove, and frown lines, and scars in the forehead, nasal dorsum, nasal tip, and eyebrows. String fat grafting is a simple and reliable method to address limited rhytides or depressed scars. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V.

Thermistor-controlled subdermal skin tightening for the aging face: Clinical outcomes and efficacy

Objective

Patients are increasingly seeking nonsurgical treatment for the aging face. The purpose of this study was to evaluate the clinical efficacy and outcomes of a thermistor‐controlled subdermal skin tightening device (ThermiTight) as a treatment modality for the aging face.

Methods

A retrospective analysis of 12 patients was completed on patients having undergone ThermiTight for midface and neck skin tightening. Only five patients had a greater than 1 year follow‐up and were included in the study. Two blinded reviewers assessed photographs taken pre‐procedure and 1 year post‐procedure using a standardized skin laxity scale. Patient charts were reviewed to assess for complications up to 12 months post‐treatment.

Results

The mean age of included patients was 57 years, and all five patients were female. One (20%) patient treated with ThermiTight was also treated with injectables (Botox, Juvéderm) simultaneously. One (20%) patient developed a wound complication. One (20%) patient complained of incisional site pain at her first postoperative visit that subsequently self‐resolved. On a five‐point scale to assess facial skin laxity, there was an average improved score of 0.85 per patient (P < .001) at one year post‐procedure. Two blinded reviewers correctly categorized photographs as either being “baseline” or “post‐procedure” 100% of the time. There was no significant difference between the skin laxity scores by the blinded reviewers (P = .05).

Conclusion

ThermiTight is a new technology used for nonsurgical treatment of the aging face. Long‐term outcomes demonstrate the safety and efficacy of the procedure. Complications are rare, but possible, in the use of ThermiTight.

Level of Evidence: 3

Accurately Assessing Lines on the Aging Face

The ongoing positive aging trend has resulted in many research studies being conducted to determine the characteristics of aging and what steps we can take to prevent the extrinsic signs of aging. Much of this attention has been focused on the prevention and treatment of facial wrinkles. To treat or prevent facial wrinkles correctly, their causative action first needs to be determined. published very compelling evidence that the development of wrinkles is complex and is caused by more factors than just the combination of poor lifestyle choices.

Osteoma Cutis of the Face in CBCT Images

Osteoma cutis (OC) is a rare benign disorder where osseous nodules form in the reticular layer of normal skin. These nodules are formed by the deposition of lamellar bone and are characterized by osteocytes in the core and osteoclasts around the periphery. Interpretation of osteoma cutis cases has always been challenging especially using conventional two-dimensional (2D) radiographs, owing to difficulty in localization. Cone beam CT (CBCT), with its three-dimensional (3D) capabilities, offers a great tool to help detect and diagnose these calcific entities. We report a case of miliary type OC incidentally detected in the maxillofacial region using CBCT imaging.

Durability of Three Different Types of Hyaluronic Acid Fillers in Skin: Are There Differences Among Biphasic, Monophasic Monodensified, and Monophasic Polydensified Products?

Background

Hyaluronic acid fillers are used for facial rejuvenation and are classified as non-cross-linked or cross-linked (monophasic mono- or polydensified).

Objectives

To histologically assess the intradermal durability of three types of fillers (biphasic, monophasic monodensified, and monophasic polydensified), to compare the durability of the products over 6 months, and to evaluate the structural changes after application.

Methods

In all, 25 volunteers received injections of three different fillers in the dermis of the right lumbar region (in one line), and equal amounts of the fillers were injected into three different sites (in the same column), yielding nine points of application in each patient. Each line was biopsied on days 2, 92, and 184; these skin samples were analyzed histologically, and the presence or absence of these fillers was verified by a dermatopathologist.

Results

The histological analysis showed that over 182 days, the amount of the injected monophasic polydensified, monophasic monodensified, and biphasic filler products decreased by 62.5%, 25%, and 12.5%, respectively.

Conclusions

The biphasic and monophasic monodensified fillers presented greater intradermal durability than did the monophasic polydensified filler at 6 months after intradermal injection.

Level of Evidence 2

Lower face lifting and contouring with a novel internal real-time thermosensing monopolar radiofrequency

As demand for a youthful appearance has increased, various techniques for face lifting and contouring have been used to reduce excess fat deposition and improve skin laxity. Recently, radiofrequency (RF)-assisted lipolysis and liposuction (RFAL) has been introduced for body and face contouring. This study aimed to evaluate the clinical improvement and safety of a new RFAL device for face lifting and contouring. A prospective study was conducted in 20 Korean patients who underwent an internal real-time thermosensing monopolar RFAL procedure. Prior to treatment and 12 and 24 weeks after treatment, digital photographs were taken, and the degree of improvement as measured by investigators and patients was recorded. Skin elasticity was measured using a Cutometer (CT575, Courage and Khazaka®, Cologne, Germany). Safety profiles were also evaluated at each visit. Results showed favorable improvement in skin laxity and fat deposition. Both investigators' evaluations and patients' evaluation showed significant improvement between 12 and 24 weeks. Although the changes in skin elasticity measured by the Cutometer were not statistically significant, all three treated regions showed a trend toward improvement. No major side effects such as infection or burn were observed. The internal, real-time thermosensing monopolar RFAL device showed clinical efficacy and safety. After further studies with more patients and longer follow-up periods, internal real-time thermosensing monopolar RF devices might become one of the popular treatment options for face lifting and contouring.

The life cycles and biological end pathways of dermal fillers

BACKGROUND

There is an increased demand for soft tissue augmentation procedures. A wide range of products can provide correction through different mechanisms and it is important for clinicians to understand the biological pathways of each material. This study presents a systematic review of the pathways of commonly used fillers, with consideration of the complications associated with each.

METHODS

The PubMed (National Library of Medicine) database was searched for MeSH headings for different types of fillers, including trade names, between January 1, 2000, and January 1, 2013. Article titles were screened, and only studies designed to determine the mechanism of action and histopathology of complications were included.

RESULTS

When restricted to studies on biological mechanisms, 109 manuscripts were identified and the mechanisms of action of short-term and long-term degradable as well as permanent fillers were reviewed. Hyaluronic acid fillers, which are the most commonly used, form a fibrous capsule and induce limited de novo collagen. Poly-l-lactic acid and calcium hydroxylapatite are semipermanent fillers that provide long-term restoration of tissue volume by stimulating fibroblasts to lay down a matrix of collagen and elastic fibers. Polymethyl methacrylate is the only FDA-approved permanent implant that is held in place by encapsulation, providing a scaffold upon which the dermis can recover to its original thickness.

DISCUSSION

Soft tissue augmentation products are variable, and no single product can be considered the most effective or ideal. An understanding of biological mechanisms may help guide physicians choose the best suited product among the various options available while minimizing the occurrence of complications.

Filling effects, persistence, and safety of dermal fillers formulated with stem cells in an animal model

BACKGROUND

Research is scarce regarding the effectiveness of dermal fillers containing autologous stem cells.

OBJECTIVES

The authors sought to determine the local and systemic effects of adipose-derived stem cells (ADSCs) as a component of dermal fillers in an animal model.

METHODS

Wistar rats were injected with 1 of the following dermal fillers: ADSCs combined with hyaluronic acid (ADSC-HA), ADSCs combined with fish collagen (ADSC-COL), HA alone (CONTROL-HA), or COL alone (CONTROL-COL). Fillers were injected into the glabella, dorsum, and chest of each animal. The ADSCs were labeled with PKH26 to assess cell migration. Filling effects (FEs) were measured immediately after injection and at 1.5 months and 3 months after injection. Skin specimens were stained with hematoxylin and eosin to assess localization and persistence of ADSCs.

RESULTS

Mean FEs in animals implanted with ADSCs were greater and persisted longer than those of controls. No inflammatory responses were observed in any group. Three months after injection, PKH26-positive cells comprised nearly 70% of cells at the injection site in animals treated with ADSC-HA. PKH26 fluorescence also was detected in the spleen but not in the brain, kidney, or lung.

CONCLUSIONS

Stem cells have the potential to improve the aesthetic effects and longevity of dermal fillers.

Gold-wire artifacts on diagnostic radiographs: A case report

This report described a case in which diagnostic radiographs showed irregular dense radiopaque strings and curved lines in the head and neck area. These artifacts could lead to misinterpretation since they may obscure anatomical structures and/or mask critical structures/pathologies. A more detailed history of the patient indicated that these strings originated from a facelift procedure in which a gold-wire technique was used. Considering that such intervention may cause a radiodiagnostic burden, it should be included in the anamnesis prior to radiography.

Efficacy, patient-reported outcomes and safety profile of ATX-101 (deoxycholic acid), an injectable drug for the reduction of unwanted submental fat: results from a phase III, randomized, placebo-controlled study

Background

Unwanted submental fat (SMF) may result in an unattractive chin profile and dissatisfaction with appearance. An approved and rigorously tested non-surgical method for SMF reduction is lacking.

Objective

To evaluate the efficacy and safety of ATX-101 for the pharmacological reduction of unwanted SMF in a phase III randomized, double-blind, placebo-controlled study.

Methods

Patients (n = 360) with moderate or severe SMF were randomized to receive ATX-101 1 or 2 mg/cm² or placebo injected into their SMF for up to four treatments ∼28 days apart, with a 12-week follow-up. Coprimary efficacy endpoints were the proportions of treatment responders, defined as a ≥1-point reduction in SMF on the Clinician-Reported Submental Fat Rating Scale (CR-SMFRS), and those satisfied with their appearance in association with their face and chin after treatment on the Subject Self-Rating Scale (SSRS score ≥4). Secondary efficacy endpoints included a ≥1-point improvement in SMF on the Patient-Reported Submental Fat Rating Scale (PR-SMFRS) and changes in the Patient-Reported Submental Fat Impact Scale (PR-SMFIS). Additional patient-reported outcomes and changes in the Skin Laxity Rating Scale were recorded. Adverse events (AEs) and laboratory test results were monitored.

Results

Compared with placebo, a greater proportion of patients treated with ATX-101 1 and 2 mg/cm² showed a ≥1-point improvement in CR-SMFRS (58.3% and 62.3%, respectively, vs. 34.5% with placebo; P < 0.001) and patient satisfaction (SSRS score ≥4) with the appearance of their face and chin (68.3% and 64.8%, respectively, vs. 29.3%; P < 0.001). Patient-reported secondary efficacy endpoints showed significant improvements in SMF severity (PR-SMFRS; P = 0.009 for ATX-101 1 mg/cm², P < 0.001 for ATX-101 2 mg/cm² vs. placebo) and emotions and perceived self-image (PR-SMFIS; P < 0.001). No overall worsening of skin laxity was observed. AEs were mostly transient, mild to moderate in intensity and localized to the treatment area.

Conclusion

ATX-101 was effective and well tolerated, and may be an alternative to surgery for patients desiring improvement of their submental profile.

Does platelet-rich plasma enhance the survival of grafted fat? An update review

Autologous fat grafting enables repair and augmentation of soft tissues and is increasingly used in plastic and reconstructive surgery. The main limitation of fat grafting is unpredictable graft resorption. To obviate this disadvantage, several studies have searched for new ways of increasing the viability of the transplanted tissue. One promising approach has been to mix the fat graft with Platelet-Rich Plasma (PRP) before transplantation. The purpose of this article is to review systematically the available comparative evidence about PRP-assisted fat grafting.

Facial bone density: effects of aging and impact on facial rejuvenation

BACKGROUND

Facial bone aging has recently been described as primarily resulting from volume loss and morphologic changes to the orbit, midface, and mandible.

OBJECTIVE

The authors demonstrate how the facial skeleton bone mineral density (BMD) changes with age in both men and women and compare these changes to those of the axial skeleton. They also explore the aesthetic implications of such changes in bone density.

METHODS

Dual-energy X-ray absorptiometry (DXA) scans of the facial bones and lumbar spine were obtained from 60 white subjects, 30 women and 30 men. There were 10 men and 10 women in each of 3 age categories: young (20-40 years), middle (41-60 years), and old (61+ years). The following measurements were obtained: lumbar spine BMD (average BMD of L1-L4 vertebrae), maxilla BMD (the average BMD of the right and left maxilla), and mandible BMD (the average BMD of the right and left mandibular ramus).

RESULTS

The lumbar spine BMD decreased significantly for both sexes between the middle and old age groups. There was a significant decrease in the maxilla and mandible BMD for both sexes between the young and middle age groups.

CONCLUSIONS

Our results suggest that the BMD of the face changes with age, similar to the axial skeleton. This change in BMD may contribute to the appearance of the aging face and potentially affect facial rejuvenation procedures.

The evolving role of hyaluronic acid fillers for facial volume restoration and contouring: a Canadian overview

Recent advancements, including more versatile facial fillers, refined injection techniques and the adoption of a global facial approach, have contributed to improved patient outcome and increased patient satisfaction. Nine Canadian specialists (eight dermatologists, one plastic surgeon) collaborated to develop an overview on volume restoration and contouring based on published literature and their collective clinical experience. The specialists concurred that optimal results in volume restoration and contouring depend on correcting deficiencies at various layers of the facial envelope. This includes creating a foundation for deep structural support in the supraperiosteal or submuscular plane; volume repletion of subcutaneous fat compartments; and the reestablishment of dermal and subdermal support to minimize cutaneous rhytids, grooves and furrows. It was also agreed that volume restoration and contouring using a global facial approach is essential to create a natural, youthful appearance in facial aesthetics. A comprehensive non-surgical approach should therefore incorporate combining fillers such as high-viscosity, low-molecular-weight hyaluronic acid (LMWHA) for structural support and hyaluronic acid (HA) for lines, grooves and furrows with neuromodulators, lasers and energy devices.

A multicenter, double-blind, placebo-controlled trial of autologous fibroblast therapy for the treatment of nasolabial fold wrinkles

BACKGROUND

Changes associated with aging are partly due to loss of collagen and elastin. Treatment with autologous fibroblasts grown in culture (azficel-T) can help correct the appearance of aging by replacing lost dermal constituents.

OBJECTIVE

To demonstrate the safety and effectiveness of autologous fibroblasts in the treatment of nasolabial fold (NLF) wrinkles.

METHODS AND MATERIALS

Adults with moderate to very severe NLF wrinkles were randomized to receive three treatments with autologous fibroblasts or placebo at 5-week intervals. Blinded evaluators and subjects assessed efficacy using a validated wrinkle assessment scale.

RESULTS

Three hundred seventy-two subjects were enrolled and underwent treatment. Seventy-eight percent of subjects treated with autologous fibroblast therapy and 48% of subjects treated with placebo achieved at least a 1-point improvement on the subject assessment at 6 months (p < 0.001), and 64% of subjects treated with autologous fibroblast therapy and 36% of those treated with placebo showed at least a 1-point improvement evaluator's assessment (p < 0.001). Adverse events were generally mild, and the treatment was well tolerated.

CONCLUSION

Autologous fibroblast therapy is safe and effective for the treatment of NLF wrinkles. The availability of autologous cell therapy marks the beginning of a new phase in aesthetic therapy.

Optimizing Injectable Poly-L-Lactic Acid Administration for Soft Tissue Augmentation: The Rationale for Three Treatment Sessions

BACKGROUND

The availability and variety of different injectable modalities has led to a dramatic increase in soft tissue augmentation procedures in recent years. Injectable poly-L-lactic acid (PLLA) is a synthetic, biodegradable polymer device approved in the United States for use in immunocompetent patients as a single regimen of up to four treatment sessions for correction of shallow to deep nasolabial fold contour deficiencies and other facial wrinkles. Injectable PLLA is also approved for restoration and/or correction of signs of facial fat loss (lipoatrophy) in individuals with HIV.

METHODS

The present article provides an overview of previous studies with injectable PLLA, and specifically focuses on the number of recommended treatment sessions and intervals between treatment sessions. The authors also provide two case studies to support their recommendations for an average of three treatment sessions.

RESULTS

Although the specific mechanisms remain hypothetical, injections of PLLA are believed to cause a cascade of cellular events that lead to collagen repair and subsequent restoration of facial volume. Because the development of a response to injectable PLLA is gradual and its duration of effect is long lasting, sufficient time between treatment sessions should be allocated to avoid overcorrection.

CONCLUSION

Studies of injectable PLLA support the hypothesized mode of operation, and the experience and clinical recommendations of the authors that suggest that three treatment sessions are an optimal regimen for use of injectable PLLA in the majority of patients.

Optimizing injectable poly-L-lactic acid administration for soft tissue augmentation: The rationale for three treatment sessions

BACKGROUND

The availability and variety of different injectable modalities has led to a dramatic increase in soft tissue augmentation procedures in recent years. Injectable poly-L-lactic acid (PLLA) is a synthetic, biodegradable polymer device approved in the United States for use in immunocompetent patients as a single regimen of up to four treatment sessions for correction of shallow to deep nasolabial fold contour deficiencies and other facial wrinkles. Injectable PLLA is also approved for restoration and/or correction of signs of facial fat loss (lipoatrophy) in individuals with HIV.

METHODS

The present article provides an overview of previous studies with injectable PLLA, and specifically focuses on the number of recommended treatment sessions and intervals between treatment sessions. The authors also provide two case studies to support their recommendations for an average of three treatment sessions.

RESULTS

Although the specific mechanisms remain hypothetical, injections of PLLA are believed to cause a cascade of cellular events that lead to collagen repair and subsequent restoration of facial volume. Because the development of a response to injectable PLLA is gradual and its duration of effect is long lasting, sufficient time between treatment sessions should be allocated to avoid overcorrection.

CONCLUSION

Studies of injectable PLLA support the hypothesized mode of operation, and the experience and clinical recommendations of the authors that suggest that three treatment sessions are an optimal regimen for use of injectable PLLA in the majority of patients.

Counseling patients on facial volume replacement and adherence with posttreatment instructions

Use of injectable volume replacement products has increased dramatically in the US in recent years. An optimal outcome with volume replacement depends on a thorough knowledge of the products on the part of the dermatologic/aesthetic physician specialist, identification of patients with a likelihood of benefiting from volume replacement procedures, selection of an appropriate product for the individual patient, and effective patient counseling to ensure adherence to posttreatment care instructions. Adherence to physician instructions in the field of dermatology appears limited, and there is very little published information on adherence to physician instructions following facial volume replacement procedures. The purpose of this review is to provide strategies for understanding and overcoming the barriers to adherence with the widely used dermal fillers. Strategies include using patient-centered techniques, such as a motivational interview encouraging the patient to follow postprocedure care instructions, eg, massage. In this case, demonstrating massage techniques while the patient is still in the office, with patient participation and detailed feedback, also contributes to good adherence with posttreatment care instructions. Telephone counseling, reminder postcards, and text messages may help improve clinic attendance for follow-up. Motivated patients who demonstrate good adherence to physician instructions generally respond well to volume replacement treatments, and usually experience fewer adverse events than patients who do not follow instructions. Although promoting adherence to pretreatment and posttreatment protocols remains a challenge, patient counseling throughout the treatment process can lead to successful results.