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Shaping Lips with Fillers

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Abstract

The lips and the eyes enhance facial beauty, and they have been highlighted since time immemorial. Rejuvenating the lips with fillers, frequently hyaluronic acid (HA), is a common procedure but requires expertise. The objective of this text is to describe the procedure in detail and cover the practical aspects of injecting lips with fillers. An analysis of treating lips with needles and cannulae has been made with special emphasis on achieving optimum results.
© 2015 Journal of Cutaneous and Aesthetic Surgery | Published by Wolters Kluwer - Medknow 139
INTRODUCTION
The lip region is an extremely important area when it
comes to facial aesthetic enhancement. The lips have
since time immemorial been highlighted along with the
eyes as the two most beautiful regions of a woman’s or
a man’s face.
With the passage of time, photodamage, hereditary
factors, and smoking contribute to loss of lip volume,
perioral rhytides, and prominence of mentolabial folds.
Genetically thin lips and cosmetic asymmetries of the
lips are also issues that can be dealt with similarly, that
is, by soft tissue augmentations using llers. Successful
rejuvenation of the perioral region requires sophistication
in using a combination of technologies and injectables.
Various llers, temporary and permanent, have been
tried in shaping the lips, with gratifying results. Disasters
in the form of granulomas have been reported with both
temporary and permanent llers, more often with the
latter.
Hyaluronic acid (HA) and polyacrylamide (PA) are the
two main llers widely available. HA is the predominant
one, with PA being virtually out of the race because of
fears of granuloma. Worldwide usage and published
reports clearly conrm the efcacy and safety of HA
llers. They are one of the key components of successful
combination treatments of the aging face and lips.[1]
Common commercial preparations of HA that are
widely available include the Anteis range (Fortélis®
and Esthélis®, Switzerland), Galderma range, USA
(Restylane and Perlane), and the Allergan range, Irvine,
CA 92612 (Juvéderm Ultra® and Juvéderm Ultra Plus®).
Other brands such as Revanesse®, Prollenium Medical
Technologies Inc., Canada and Amazing Fill® are also
available.[2]
ANATOMY
The upper lip extends from the base of the nose superiorly
to the nasolabial folds laterally and to the free edge of
the vermilion border inferiorly. The lower lip extends
from the superior free vermilion edge superiorly, to the
commissures laterally, and to the mandible inferiorly.
Around the circumferential vermilion/skin border, a
ne line of pale skin accentuates the color difference
between the vermilion and normal skin. Along the upper
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DOI:
10.4103/0974-2077.167269
Shaping Lips with Fillers
Amit Luthra
Ishira Skin Clinic, Delhi, India
Address for correspondence: Dr. Amit Luthra, 24-A, Pocket-A, Ashok Vihar-3, Delhi - 110 052, India. E-mail: amit_skin01@yahoo.com
The lips and the eyes enhance facial beauty, and they have been highlighted since time immemorial. Rejuvenating
the lips with fillers, frequently hyaluronic acid (HA), is a common procedure but requires expertise. The objective
of this text is to describe the procedure in detail and cover the practical aspects of injecting lips with fillers. An
analysis of treating lips with needles and cannulae has been made with special emphasis on achieving optimum
results.
KEYWORDS: Dermal fillers, hyaluronic acid (HA), lip rejuvenation, needles, canulae
ABSTRACT
JCas symposium
How to cite this article: Luthra A. Shaping lips with llers. J Cutan
Aesthet Surg 2015;8:139-42.
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Luthra: Shaping lips with llers
Journal of Cutaneous and Aesthetic Surgery - Jul-Sep 2015, Volume 8, Issue 3
140
vermilion/skin border, two paramedian elevations of
the vermilion form the Cupid’s bow. Two raised vertical
columns of tissue form a midline depression called the
philtrum.
WHAT TO TREAT
A deating vermilion (the red part) is the most common
complaint, followed by drooping angles of the mouth.
These two together complete the picture of a sorry
face. Lips that have good volume can be highlighted
by dening them and injecting into the white margins
(the vermilion border) [Figure 1]. Pouts can be created
by injecting the ller below the muscle [Figure 2].
Typically, the upper lip is treated more often than
the lower. The best approach to lip augmentation
depends on the nature of the defect and the subject’s
aesthetic desires. For genetically thin lips, structural
augmentation with a deeper-placed filler followed
by volume correction with a supercial ller is ideal.
For pure cosmetic enhancement of lips, a supercially
placed filler with emphasis on the white roll and
expansion of the vermilion is ideal.[3]
Female lips are, on average, a little fuller than male lips.
They bulge forward more than male lips — In other
words, they are slightly more “pouty.” Female lips are
not noticeably bigger when you see them from the front
but they do bulge forward more as seen from the side.
We need to keep this in mind while treating male and
female lips. Overvolumization of the male lip can result
in feminization of the area.
PATIENT SELECTION AND OUTCOMES
Careful patient selection, history, and a detailed
consultation outlining the benefits, limitations, and
adverse events of lip reshaping go a long way toward
providing the desired results. Discussing the immediate
aftermath of a lip augmentation, that is, swelling and
bruising, is a key component to counselling as often
patients tend to be secretive about these procedures
and do not wish to disclose any treatment taken. The
existence of downtime, varying from 2 days to 2 weeks,
needs to be emphasized; the recent use of cannulae
instead of needles has helped to reduce it. What the
patient may desire may not be realistically possible and
it is crucial to align them on what to expect [Box 1 and
Figure 3].
History of herpes labialis, and aspirin and vitamin E
usage needs careful consideration for a better outcome.
TREATMENT STRATEGY
Lip augmentation consists of the reshaping and/
or enlargement of the visible portion of the lip, the
vermilion. Alteration of the shape of the Cupid’s bow
and of the relationship between the vermilion and the
skin underlying the nasal columella also falls within the
category of lip augmentation.
Figure 1: Lip: Anatomical landmarks (from
elementsofmorphology.nih.gov)
Figure 2: Histology of the lip in a section (from imargade.com)
Figure 3: Swelling of the lips immediately after HA injection
with needles
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Luthra: Shaping lips with llers
Journal of Cutaneous and Aesthetic Surgery - Jul-Sep 2015, Volume 8, Issue 3 141
It is also important to consider the relationship between
lip height and incisor shown in the anatomic analysis, to
evaluate possible maxillary hypoplasia and protrusion,
and to consider the patient’s occlusion status.
TREATMENT TECHNIQUES[3-7]
Anesthesia is rst administered with either a eutectic
mixture of lidocaine and prilocaine or regional blocks
(infraorbital for the upper lip and mental for the lower
lip). It is critical not to distort the shape of the lips. Using
premixed HA with lidocaine as an add-on reduces the
pain of the injection. Some patients may experience
anxiety over the amount of swelling and bruising, and
may require ice soaks, nonsteroidal anti-inammatory
drugs (NSAIDs; not in the first 6 h as that might
mask any signs of vascular compromise), and even
prednisolone.[3]
Medium-depth llers such as Restylane®, Juvéderm
Ultra®, and Esthélis Basic® are preferred, using either a
30-G needle or a 27-G cannula.
Expected postprocedure outcomes of lip augmentation
include edema, bruising, and ecchymosis. Complications
are extremely rare and include nodules and lumps, which
can be massaged in or dissolved with hyaluronidase
injections. Intravascular injections may result in
immediate blanching, but the collateral circulation of
the lips is highly forgiving. Warm compresses, use of
hyaluronidase, and topical nitroglycerin help. Herpetic
reactivation can be prevented with oral antivirals
(acyclovir, famciclovir or valaciclovir) [Figure 4].
The occurrence of adverse reactions relates to both the
inherent properties of the product and inappropriate
delivery or dilution of the ller, which may lead to
harmful sequelae.[8-11]
Underscoring the need for product-specic training,
uneven distribution of injected products, due to poor
technique, can also lead to postinjection lumps and
nodules.[12-14] This is of particular concern with more
permanent products because the undesired results are
also long-lasting. Overaggressive injection may lead
to irregularity or lumpiness, whereas if the product is
placed too supercially, beading can occur.[15,16]
Overcorrection is not indicated. Simultaneous vermilion and
vermilion border augmentations result in a complete effect.
The techniques for injection of HA for lip augmentation
have included serial puncture and linear threading,
which may be antegrade or retrograde. The choice
of one technique over another or a combination of
techniques may be inuenced by aesthetic goals and
patient factors.
The use of cannulae has cut down the downtime involved
in this procedure and increased the percentage of
patients returning for repeat augmentations [Figure 5].
Only one point each on either side at the oral commissure
is utilized to reach both the upper and the lower lip. This
technique needs getting accustomed to and is difcult
for a beginner. The author advises using needles initially
but ultimately moving to a cannula—it pays off in the
long run with better results and less downtime [Figures 6
and 7].
Box 1: Patient alignment checklist
Patient alignment checklist
Synchronization of patient and physician expectations
Information on immediate and late postprocedure outcomes
Number of syringes and cost
Longevity of product used
Repetitive and temporary nature of treatment
Adverse events
Postprocedure care
Figure 4: Herpetic reactivation after llers Figure 5: Lip augmentation with a cannula
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Luthra: Shaping lips with llers
Journal of Cutaneous and Aesthetic Surgery - Jul-Sep 2015, Volume 8, Issue 3
142
CONCLUSION
Lip augmentation with the use of injectable fillers
achieves quick results with minimal downtime.
Signicant ease of use, “off-the-shelf” availability, and
widespread acceptance by the public make HA one of
the most commonly used llers. Lip augmentation with
llers can be performed by injecting the material in any
or all of the anatomic parts of the lip, allowing for a very
controlled and predictable result. Precautions regarding
mode of injection and quantity of the substance injected
vary widely with patient proles. At times, budgetary
constraints decide treatments, but that should be
avoided, and patients need to be told about the optimum
ller requirements.
Optimizing the aesthetic outcome of lip augmentation
with dermal fillers, such as HA, requires skillful
application of a suitable injection technique. Moreover,
achieving aesthetic goals with minimal risk for adverse
events requires knowledge of lip anatomy and function,
clinical experience in the use of various injection
techniques, and an individualized treatment approach.[6]
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conicts of interest.
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2. Luthra A, Kumar V. Fillers and autologus fat. In: Khunger M, editor. Step
by Step Treatment of Acne Scars. India: Jaypee Brothers; 2014. p. 153-71.
3. Carruthers J, Narurkar VA. Management of the lips and mouth corners.
In: Carruthers J, Carruthers A, editors. Soft Tissue Augmentation.
Philadelphia: Saunders; 2006. p. 109-19.
4. Godin MS, Majmundar MV, Chrzanowski DS, Dodson KM. Use of
radiesse in combination with restylane for facial augmentation. Arch
Facial Plast Surg 2006;8:92-7.
5. Kanchwala SK, Holloway L, Bucky LP. Reliable soft tissue augmentation:
A clinical comparison of injectable soft-tissue fillers for facial-volume
augmentation. Ann Plast Surg 2005;55:30-5.
6. Sclafani AP. Soft tissue fillers for management of the aging perioral
complex. Facial Plast Surg 2005;21:74-8.
7. Smith SR, Lin X, Shamban A. Small gel particle hyaluronic acid
injection technique for lip augmentation. J Drugs Dermatol
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8. Lowe NJ. Temporary dermal fillers — European experiences. In: Lowe
NJ, editor. Textbook of Facial Rejuvenation. London: Martin Dunitz/
Taylor and Francis; 2002. p. 177-88.
9. Klein AW. Collagen substances. Facial Plast Surg Clin North Am
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10. DeLustro F, Condell RA, Nguyen MA, McPherson JM. A comparative
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11. DeLustro F, Smith TS, Sundsmo J, Salem G, Kincaid S, Ellingsworth L,
et al. Reaction to injectable collagen in human subjects. J Dermatol
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12. Cotran RS, Kumar V, Robbins SL. Pathologic Basis of Disease. 5th ed.
Philadelphia: W.B. Saunders; 1994. p. 51-93.
13. Rudolph CM, Soyer HP, Sculler-Petrovic S, Kerl H. Foreign body
granulomas due to injectable aesthetic microimplants. Am J Surg Pathol
1999;23:113-7.
14. Duranti F, Salti G, Bivani B, Calandra M, Rosati ML. Injectable hyaluronic
gel for soft tissue augmentation. A clinical and histological study.
Dermatol Surg 1998;24:1317-25.
15. Lemperle G, Romano JJ, Busso M. Soft tissue augmentation with
Artecoll: 10-year history, indications, techniques, and complications.
Dermatol Surg 2003;29:573-87.
16. Mullins RJ, Richards C, Walker T. Allergic reactions to oral, surgical
and topical bovine collagen. Anaphylactic risk for surgeons. Aust N Z
J Ophthalmol 1996;24:257-60.
Figure 6: Shaping of upper and lower lips with 1 mL of HA:
Pre-treatment
Figure 7: Shaping of upper and lower lips with 1 mL of HA:
After treatment
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... Particularly, lip fullness is a key factor associated with attractiveness, beauty and youth (2,3). A number of noxious and hereditary factors contribute to the deterioration of the perioral tissues with age (2,(4)(5)(6)(7). Consequently, volume loss of the lips may occur with other signs of aging, such as the appearance of perioral lines, marionette lines and flattening of the cupid bow (2). ...
... Since the approval of the first non-animal based HA in 2004 (8) several clinical trials aimed to reveal its true potentials. HA is believed to be an excellent candidate for soft tissue augmentation to restore lip fullness, cosmetic asymmetries and to deal with rhytids due to the loss of elasticity of connective tissue (7). However, clinical studies investigating effectiveness were conducted with small sample sizes and with short follow-up periods. ...
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Introduction: The lips and the mouth play an indispensable role in vocalization, mastication and face aesthetics. Various noxious factors may alter and destruct the original structure, and appearance of the lips and the anatomical area surrounding the mouth. The application of hyaluronic acid (HA) may serve as a safe method for lip regeneration. Although a number of studies exist for HA effectiveness and safety, its beneficial effect is not well-established. Aim: The present meta-analysis and systematic review was performed to investigate the effectiveness of HA on lip augmentation. We also investigated the types and nature of adverse effects (AEs) of HA application. Methods: We reported our meta-analysis in accordance with the PRISMA Statement. PROSPERO protocol registration: CRD42018102899. We performed the systematic literature search in CENTRAL, Embase, and MEDLINE. Randomized controlled trials, cohort studies, case series and case reports were included. The untransformed proportion (random-effects, DerSimonian-Laird method) of responder rate to HA injection was calculated. For treatment related AEs descriptive statistics were used. Results: The systematic literature search yielded 32 eligible records for descriptive statistics and 10 records for quantitative synthesis. The results indicated that the overall estimate of responders (percentage of subjects with increased lip fullness by one point or higher) was 91% (ES = 0.91, 95% CI:0.85−0.96) 2 months after injection. The rate of responders was 74% (ES = 0.74, 95% CI:0.66−0.82) and 46% (ES = 0.46, 95% CI:0.28−0.65) after 6 and 12 months, respectively. We included 1,496 participants for estimating the event rates of AEs. The most frequent treatment-related AEs were tenderness (88.8%), injection site swelling (74.3%) and bruising (39.5%). Rare AEs included foreign body granulomas (0.6%), herpes labialis (0.6%) and angioedema (0.3%). Conclusion: Our meta-analysis revealed that lip augmentation with injectable HA is an efficient method for increasing lip fullness for at least up to 6 months after augmentation. Moreover, we found that most AEs of HA treatment were mild or moderate, but a small number of serious adverse effects were also found. In conclusion, further well-designed RCTs are still needed to make the presently available evidence stronger.
... Welldefined and full lips give a youthful and attractive appearance 4 . A variety of absorbing and permanent fillers were used to shape the lips 5 . In recent years, the fillers derived from hyaluronic acid have become the most effective medium to correct soft tissues, and the best filler for lips augmentation 6 . ...
... When looking at aged lips, there are two essential points to observe: the first is the shape of the lips and the second is their relationship with the other parts in the lower third of the face, especially the support provided by the bone structures and teeth 7 . Lip augmentation includes the reshaping and / or increasing the size of the visible part of the lips, the vermilion, changing the shape of the Cupid's bow and the relationship between the vermilion and the skin below the columella of the nose, all of which is considered within lip filling 5 . The lips augmentation can be done using either surgical or injection procedures to increase the size and obtain well-defined borders of the lips 8 . ...
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Background: well-defined plump lips display a young and attractive appearance. In the last few years, lip filler injections have become rather popular amongst female patients. One of the main features involved in a well structured smile is The amount of vertical tooth exposure whilst smiling. This study aims to evaluate the effect of hyaluronic acid lip fillers on the vertical tooth exposure in a smile. Methods: a total of 25 females between 19 and 40 years old were involved in this study. Hyaluronic acid was injected to enhance their lips. The amount of vertical tooth exposure in smiling (lip line) was evaluated by comparing the photographs taken before, two weeks after, and two months after the injection. An AutoCAD 2017 engineering drawing program was used for image processing and dimensional calculations. The T-Student test for a paired sample was used to compare the measurements of the studied variables between the three time periods of the study using SPSS V24. Results: there was no statistically significant difference (p value <0.05) when using hyaluronic acid in lips augmentation on the amount of vertical tooth exposure in the enhanced smile. Conclusions: the injection of hyaluronic acid for lips augmentation does not affect the amount of vertical tooth exposure in smiling.
... Injections are used to treat lip asymmetry, lack of vermillion volume, vertical lip lines, downturned oral commissures, and/or an elongated upper lip, features which are normal consequences of aging. 1 Lip enhancement or augmentation with injectable fillers is rising in popularity as these treatments achieve rapid results with generally predictable outcomes. 2 This aesthetic treatment is also favorable due to its less invasive nature and minimal down time compared with surgical cosmetic procedures. ...
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... In thin lips, we prefer to address first the ratio by injecting into the thinner lip, then the volume by injecting into the vermillion, and lastly the shape by injecting into the vermillion border when necessary. 33 In aged lips, we proceed as in thin lips, but we also inject HA into the vertical upper lip lines in a particularly modest manner to avoid distortions. Moreover, each target group has different reasons for undergoing this cosmetic procedure, and the injector should take these into consideration to better educate the patients, manage their expectations 2,6,21 and set accordingly their aesthetic goals. ...
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The lips are two pliable and mobile muscular folds that surround the oral cavity and assist in a variety of functions which enable both human survival and communication. In addition to their functional purpose, the lips are frequently cosmetically enhanced, in terms of color and gloss, through the application of lipsticks. Understanding both the biophysical and surface properties of lips is crucial for the successful formulation and development of lipsticks, particularly those with long‐wear or transfer‐resistant claims. Various in vitro methods provide a clear insight as to the stability, physical properties, and visual characteristics of a lipstick formulation, but a correlation between such results and consumer use experience is still lacking. This book chapter provides an overview of the lip anatomy and lip surface properties, which can be used to provide a general knowledge for lipstick formulation. While much is known in regards to the structure and functionality of the lip tissue, obtaining further knowledge can assist in the development of superior performing lipstick formulations. Classic in vitro test methods for long‐wear lipsticks, in addition to such test results correlations with consumer sensory testing, are also discussed. It is important to note that although there is an abundance of in vitro methods available in order to characterize long‐wear and transfer‐resistant lipsticks, there is still a definite need to develop new methods that better correlate with consumer experience. Existing methods have the potential to be further improved with new knowledge of lip properties and use of better test substrates to illustrate the benefits of new product innovations.
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Defining the ideal dimensions and proportions of the human face has been attempted for centuries, popularised in the Renaissance period by artists including Leonardo Da Vinci. The lips are part of the lower third of the face and are central to lower face aesthetics and the overall symmetry of the face. They also place an important part in conveying facial emotions and expressions. Full lips with well-defined Cupid’s bow have always been associated with youth and beauty. The approval of hyaluronic acid use for tissue augmentation and the prevalence of social media have caused an exponential increase in lip augmentation procedures (Linkov et al. in Arch Plast Surg 46(3):248–254, 2019), as such researchers and aestheticians have focused on characterising the ideal lips mathematically to help guide clinicians. This narrative review will summarise the available evidence in the literature pertaining to the ideal lips, taking into account age, ethnicity and gender differences. 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.
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Most of the biologic filler materials that increase the thickness of the corium in a wrinkle line are phagocytosed within a certain time. Therefore, a lasting effect can only be achieved with nonresorbable synthetic substances. Artefill consists of 20 volume percent microspheres of polymethyl-methacrylate and 80 volume percent of bovine collagen. Beneath the crease, the microspheres with their exceptional surface smoothness stimulate fibroblasts to encapsulate each individual one of the 6-million microspheres contained in 1 mL of Artefill. Collagen is merely a carrier substance that prevents the microspheres from agglomerating during tissue ingrowth. The 20 volume percent of microspheres in Artefill provides the scaffold for the 80% volume of connective tissue deposition, a complete replacement of the injected collagen. The filler material beneath a crease acts like a splint and prevents the possibility of its further folding, thereby allowing the diminished thickness of the corium in a crease to recover. This recovery process is well known even in older patients with facial paralysis or after a stroke, whose facial wrinkles and furrows on the paralyzed side disappear over time.
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Optimizing the aesthetic outcome of lip augmentation with dermal fillers, such as small gel particle hyaluronic acid (SGP-HA), requires skillful application of a suitable injection technique. Moreover, achieving aesthetic goals with minimal risk for adverse events requires knowledge of lip anatomy and function, clinical experience in the use of various injection techniques, and an individualized treatment approach. Clinician-patient discussion of the initial assessment of lip presentation and global appearance of lip shape and proportion is important in setting treatment expectations and establishing a basis for follow-up assessment of the effectiveness of treatment. The effectiveness and safety of SGP-HA for lip augmentation was demonstrated in a recent randomized controlled trial. This review discusses factors influencing the choice of one or a combination of techniques for injection of SGP-HA for aesthetic lip augmentation. J Drugs Dermatol. 2013;12(7):764-769.
Background: Two cases of allergic (IgE-mediated) reaction to bovine collagen are described. Both patients developed conjunctival oedema in response to the topical application of highly purified bovine collagen to the eye during opthalmic surgery (corneal shields and catgut suture material). One patient developed periocular angioedema and angioedema of the throat after the ingestion of bovine collagen in the form of gelatin-containing foods. Methods: The presence of allergen-specific IgE was evaluated by skin prick testing with collagen-derived products, and by topical challenge with a highly purified bovine collagen-derived corneal shield. Results: In both patients, application of collagen to the eye reproduced the original subconjunctival oedema. In one patient, skin testing with purified and crude extracts of bovine collagen in the form of a corneal shield, catgut suture material and edible gelatin demonstrated evidence of collagen-specific IgE. Conclusions: Clinical reactions to collagen are rare. Neverthless, patients with a history of allergic reactions to bovine collagen-derived products should be investigated because of the widespread use of collagen-derived therapeutic devices, the potential for immunological cross-reactivity with dietary collagen (gelatin) and the potential for anaphylaxis.
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We examined collagen materials for soft tissue augmentation [Zyderm Collagen Implant (ZCI), glutaraldehyde cross-linked (GAX) collagen, and Koken Atelocollagen (Atelocollagen)]; hemostatic collagens [Gelfoam Gelatin Powder (Gelfoam), Avitene Microfibrillar Collagen Hemostat (Avitene), and Collastat Collagen Hemostat (Collastat)]; and reconstituted, intact fibrillar collagen from bovine skin in a subcutaneous guinea pig model. After 11, 25, and 39 days in situ, explants from animals injected with GAX collagen demonstrated greater wet-weight persistence than all other materials. Conversely, at all time points, the explants of Atelocollagen were the least persistent. Following 25 days in vivo, explants were examined using differential scanning calorimetry; ZCI and Atelocollagen displayed thermal transition temperatures of 58 degrees C. Avitene and Gelfoam explants displayed transition points of 30 degrees C and 32 degrees C, indicating denatured or cleaved collagen. By contrast, GAX collagen explants had a high (68 degrees C) transition temperature, reflecting its cross-linking. With respect to immunogenicity, day 39 sera from ZCI treated animals showed significantly lower titers in the ELISA to their respective implant collagen than all other groups examined, while antibody activity in the GAX collagen, Gelfoam, Atelocollagen, and intact collagen groups were not significantly different. Collastat elicited antibodies with a greater affinity than observed in these previous groups. Sera from Avitene treated animals demonstrated the highest antibody levels and were the only sera which reacted with bovine serum albumin. Thus, Avitene was the most immunogenic of the collagen materials examined, while GAX collagen demonstrated the greatest persistence and minimal immunogenicity, and ZCI was the least immunogenic.
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Several biomaterials are available for the purpose of soft tissue augmentation, but none of them has all the properties of the ideal filler material. The recent development of hyaluronic acid gels for dermal implantation give the physician new possibilities of effective treatment in this field. This study provides a clinical and histological evaluation of safety and efficacy of a cross-linked stabilized non-animal hyaluronic acid gel (Restylane, Q-Med, Uppsala, Sweden) to determine its characteristics, advantages, disadvantages, and side-effects. 158 patients were treated with facial intradermal implant of hyaluronic acid gel for augmentation therapy of wrinkles and folds, and for lip augmentation and/or recontouring. The results were evaluated in all patients by subjective judgement by the physician and the patient, and by photographic method at time 0 and after 1, 2, 4 and 8 months from the procedure. In addition, a smaller histological study was carried out in five volunteer patients for a term of 52 weeks to determine the interaction and duration of the material in human healthy skin. Clinically, both the physicians' and patients' evaluations revealed very satisfactory results, with a global 78.5% and 73.4% respectively of moderate or marked improvement after eight months, independent of the treated area. The photographic evaluation revealed even better results with a 80.4% of moderate or marked improvement after 8 months. The safety evaluation showed a 12.5% of postoperative immediate adverse events, that were localized and transient. There was no evidence of major systemic side effects. Histologically, the product was shown to be long-lasting and well tolerated as judged by histological techniques. Stabilized, non-animal, hyaluronic acid gel is well tolerated and effective in augmentation therapy of soft tissues of the face. This material presents several advantages in comparison to previously used injectable biomaterials and expands the arsenal of therapeutic tools in the field of soft tissue augmentation.
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We present two types of "new" foreign body granulomas caused by the injectable aesthetic microimplants Bioplastique and Artecoll. We report the clinical and histopathologic findings in five patients who had undergone treatment of mainly facial contour abnormalities with one of these implants. All patients were women, and the mean age was 45 years (age range 24-72 years). Two patients presented after treatment with Bioplastique; in three patients, augmentation was achieved by using Artecoll. Unsatisfactory cosmetic effects led to excision of the implants in four patients; in one patient, parts of the implant were excised during another cosmetic intervention. Subsequent histopathologic examination showed features of foreign body granulomas with distinctive cystic spaces. The clue to the diagnosis is the particular configuration of these cystic spaces and the characteristic shape of the foreign bodies. Bioplastique granuloma presents with irregularly shaped cystic spaces of varying size containing jagged, translucent, nonbirefringent foreign bodies whereas Artecoll granuloma shows numerous round vacuoles nearly identical in size and shape enclosing round and sharply circumscribed, translucent, nonbirefringent foreign bodies. These specific histopathologic findings unequivocally allow the correct diagnosis in spite of sparse clinical information.
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Soft tissue enhancement has become increasingly important as more patients seek aesthetic improvement without major surgical procedures. Injectable Zyderm bovine collagen has come to be regarded as the "gold standard" of injectable or implantable fillers, against which all other fillers are measured. This article describes the techniques of injection for bovine collagen and discusses the indications, allergenicity, and adverse responses. Other types of available collagen substances are also discussed.
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While injectable fillers for facial-volume augmentation have been extensively marketed, there are few published reports comparing the clinical efficacy and cost-effectiveness of multiple injectable agents for soft-tissue augmentation in the face. We present our experience in 976 patients with the use of 4 common injectable agents: autologous fat, Hylaform, Restylane, and Radiesse. We analyzed the injection characteristics of each filler, including injection volume, complication rate, revision rate, and longevity, across 3 commonly treated anatomic regions: the nasolabial fold, glabella, and lips. We subsequently performed a detailed cost-effectiveness analysis of each filler in each anatomic region. Our results demonstrate that autologous fat transplantation is ideally suited for the treatment of the nasolabial fold and glabella, particularly in combination with other procedures. Fat grafting to the lips is limited to use as an adjunct to other facial surgery due to the prolonged recovery time required. We prefer Radiesse for the isolated treatment of the nasolabial folds and glabella. However, Radiesse is not recommended in the lips due to the increased incidence of complications. Last, the hyaluronic fillers Restylane and Hylaform have an excellent safety profile and are our first choice for isolated lip augmentation procedures.