Article

Effective Rejuvenation with Hyaluronic Acid Fillers: Current Advanced Concepts

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Abstract

Learning objectives: After studying this article, the participant should be able to: 1. Process several patient-specific factors before reaching an optimal treatment strategy with appreciation for facial balance. 2. Define the advantages and disadvantages of various hyaluronic acid preparations and delivery techniques, to achieve a specific goal. 3. Perform advanced facial rejuvenation techniques adapted to each facial zone, combining safety considerations. 4. Prevent and treat complications caused by inadvertent intraarterial injections of hyaluronic acid. Summary: The growing sophistication and diversity of modern hyaluronic acid fillers combined with an increased understanding of various delivery techniques has allowed injectable filler rejuvenation to become a customizable instrument offering a variety of different ways to improve the face: volume restoration, contouring, balancing, and feature positioning/shaping-beyond simply fading skin creases. As more advanced applications for hyaluronic acid facial rejuvenation are incorporated into practice, an increased understanding of injection anatomy is important to optimize patient safety.

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... Various treatment modalities are of current use for the treatment of postacne scars, with growing trends towards the non-ablative lasers, in combination with other modalities, such as ller injections, as previously mentioned. [1][2][3][4][5][6][18][19][20][21][22] Fractional nonablative lasers are considered safer modalities compared to the ablative ones as they allow less pain, safer side e ect pro le and a shorter downtime, as demonstrated in previous studues. [8][9][10][11][12][13][14][15][16][17] We presented a novel combination treatment protocol, which overall demonstrated an average mild to moderate improvement in postacne facial scars appearance, with high patient satisfaction three months after treatment and a good safety pro le. ...
... [2][3][4] Hyaluronic acid injectables have been used for biomedical applications, including for osteoarthritis treatment, tissue augmentation, and ocular surgery, and as sca old for tissue engineering. 18,23 In particular, it has been well established that HA is associated with tissue repair, being involved in cell proliferation and migration, partly due to its hydrophilic and highly osmotic features. 18,[22][23][24][25] In addition, it has been shown to propagate the in ammatory response through the induction of macrophages and chemokine response, thus contributing to the healing process. ...
... 18,23 In particular, it has been well established that HA is associated with tissue repair, being involved in cell proliferation and migration, partly due to its hydrophilic and highly osmotic features. 18,[22][23][24][25] In addition, it has been shown to propagate the in ammatory response through the induction of macrophages and chemokine response, thus contributing to the healing process. [23][24][25][26][27][28] The use of a highly puri ed hyaluronic acid injectable, has been shown to have an e ect in wound healing in in-vitro studies, promoting broblast and keratinocyte proliferation and migration. ...
Article
Background: Postacne facial scars are often associated with significant patient distress. Energy-based devices, including non-ablative lasers, are commonly used for the treatment of postacne scarring. There is relatively limited data regarding the combination of non-ablative lasers with hyaluronic acid injections for postacne scarring. Objective: We aimed to evaluate the efficacy of a non-ablative 1,540-nm erbium:glass laser combined with a hyaluronic acid injectable for the treatment of postacne scars. Methods: This was a retrospective analysis of 12 patients who underwent the full treatment protocol. A before and after blinded clinical evaluation was performed independently by two dermatologists and graded on a scale from 0 (indicating a worsening of scarring) to 4 (indicating a 76-100% improvement in scarring). Pain perception, adverse effects, and patient satisfaction were evaluated. Results: A mean correct blinded before and after evaluation by two dermatologists was 96 percent. Patients demonstrated mild to moderate improvement as assessed by a quartile scale of improvement (25-50%). Mild transient pain was reported by most patients. The satisfaction level of the patients was high (4 out of 5). Limitations: The limitations of our study include the small cohort, retrospective design, and lack of a histological correlation. Conclusion: Our results suggest that this combination treatment using 1,540-nm fractional erbium:glass laser and hyaluronic acid injections is both safe and effective for patients with postacne facial scars.
... e skin of the forehead loses its elasticity over time, resulting in an irregular and wrinkled forehead with changes in its color [33,34]. e lower third of the forehead also appears slightly concave due to the formation of more wrinkles on the forehead and plateauing between the eyebrows [35]. Although it is fixed by facial loose tissue, the interval of facial loose tissue will shrink and decrease over time, resulting in skin wrinkling [36]. ...
... Hyaluronic acid is very popular among beauty seekers because of its good performance as a filler. It can also be used to fill scars caused by trauma and surgery, asymmetries resulting from congenital defects, and pits from acne scars [35]. Hyaluronic acid injections are administered in rhinoplasty. ...
... No surgery was performed. e changes are due to providing prominence or lift, restoring the structure and volume to the cheek mound and mid-cheek (marked in blue), weakening the shadows of the cheeks (marked in purple), and repairing the borders of the mandible (marked in white)[35]. ...
Article
Full-text available
Objective: This review aims to summarize different kinds of applications of minimally invasive surgery in improving facial aging to provide a comprehensive and accurate introduction on the issue of esthetic treatment of facial skin. Overview. In the twentieth century, facial rejuvenation has become a new beauty trend. Facial cosmetology has entered a period of antiaging and rejuvenation therapies and microplastic surgery. The pursuit of beauty has promoted the development of minimally invasive plastic surgery. This review introduces the possible causes of facial aging and its related topics with a focus on facial injectable drugs, such as botulinum toxin, main filler materials (hyaluronic acid, calcium hydroxyapatite, poly L-lactic acid, collagen, autologous fat, and polymethyl methacrylate), and some current antiwrinkle technologies, such as thread lift and radiofrequency rhytidectomy. Conclusions: Despite the difference in mechanisms of action, each technique can address facial aging involving the loss of collagen, displacement and enlargement of fat, and muscle relaxation. Combinations of these treatments can provide patients with reasonable, comprehensive, and personalized treatment plans.
... Skin aging is evidenced by a thinning of the dermis and epidermis, a decrease in collagen, dermal elastosis, and actinic damage, causing laxity, rhytids, and pigment irregularities. 13 Skin laxity is further thought to result from volume loss, both fat and bone, 5 and from attenuation of the facial retaining ligaments. The bony skeleton atrophies during aging in predictable patterns. ...
... 15 Resorption and posterior rotation of the maxilla including retrusion of the medial infraorbital area, 16 expansion of the pyriform aperture, 17 recession of the jaw, chin, and cheeks further result in the skin and soft-tissue laxity and discordance exhibited as nasolabial folds and jowls, among other characteristic age-related changes. 5 These dysmorphisms are thought to be further exacerbated by age-dependent increases in facial strain. ...
... cm 3 should be injected per pass, in a slow manner, irrespective of technique. 5,20,35 To avoid injury to neurovascular structures, anatomical knowledge is mandatory, and can be augmented by the use of cannulae and small-bore needles. 36 As another measure of safety, aspirating before injecting, for a minimum of 5 seconds per pass, may prevent intravascular injections, but this maneuver should never replace a thorough knowledge of anatomy. ...
Article
Full-text available
Facial rejuvenation is a rapidly advancing field in aesthetic medicine. Minimally invasive techniques represent a powerful tool for rejuvenation, and fillers are a popular modality with which to restore and optimize facial proportions. Currently, our filler armamentarium is characterized by products with an increasing variety of biochemical compositions warranting tailored injection approaches. An intimate knowledge of anatomy, product characteristics, and appropriate injection techniques is essential to achieve optimal results while maintaining patient safety. Here, we review facial anatomy, structural changes secondary to aging, appropriate filler selection, safe injection techniques, and complications.
... 16,17 Once on the market and routinely used by health-care practitioners, the product may end up being injected in diverse locations, with more variable indications and techniques than those evaluated through clinical investigations. 18 Therefore, specific postmarket study designs are needed to collect clinical evidence supporting routine practice. ...
Article
Full-text available
Background: Monitoring the effectiveness, safety and emerging uses of hyaluronic acid (HA) fillers in their wide range of indications requires a holistic approach. Purpose: To propose an observational study design aiming to gather real-world evidence (RWE) and continuously evaluate the performance and safety of marketed devices in routine practice. Materials and methods: A prospective, observational registry was initiated at six European sites. Investigators enrolled any subject receiving at least one injection with a target study device (TEOSYAL Deep Lines [HADL] and/or Global Action [HAGA]). They followed their routine practice regarding injection technique, volume, and subject follow-up. Effectiveness was evaluated at 3 months using the global aesthetic improvement scale (GAIS). Safety was assessed based on common treatment reactions (CTR) and adverse events (AE). Results: High quantity of RWE was collected following the initiation of this registry. In the first 158 subjects enrolled, 1220 injections were performed in more than 25 indications, including 679 with the target devices and 271 with devices of the same filler line. The primary objective was achieved, with 93.9% of treatments providing improvement at Month 3 according to the PI and subject. Post-injection CTR were mild to moderate and short-lived, and there was no clinically significant AE. More than 76% of treatments still provided some visible effect at month 12. Conclusion: Based on RWE, HADL and HAGL are effective and safe in their respective indications mostly distributed in the midface, perioral region, and lower face. Observational registries are a valuable asset in the context of post-market clinical follow-up.
... The level of placement of such products depends largely on the indication intended to be addressed and facial anatomy of the target area, as well as the type of product and its approved indications. Fillers are placed intradermally, immediately subdermally, or in the subcutaneous plane [12,13]. ...
Article
Full-text available
Recently, the use of noninvasive facial cosmetic procedures has been widely disseminated. In the face, cosmetic fillers, threads, and implants are used to reduce or delay the effects of aging or adjust facial defects caused by trauma or disease. The dentist or dental specialist may encounter these materials in the radiographic images of their patients. There are few reports in the dental literature describing the radiographic appearance of some materials along with the diseases they mimic. As the procedures and materials advance and evolve, dentists and dental specialists must be aware of their radiographic appearance to avoid errors in diagnosis. This is a report of two cases that include panoramic radiography and CBCT scan. Among these cases, there is an unusual appearance of a cosmetic filler due to a subperiosteal injection method. Moreover, it will discuss common types of cosmetic materials used in the face and their imaginological appearance. This is the key to dentists and dental specialists due to increasing use of facial cosmetic materials and a parallel increase in the use of cone beam CT and chances to encounter such findings.
... Hyaluronic acid (HA) dermal fillers are one of the most common nonsurgical modalities in aesthetic medicine due to their ease of administration, quick onset of action and minimal recovery time for patients. 1 Although HA fillers are useful for facial rejuvenation and soft-tissue augmentation, 2-4 complications such as delayed inflammatory reactions (DIRs) and aesthetically unpleasant outcomes can arise, in addition to common side effects like bruising, swelling and redness. 5,6 While there are discrepancies in the definition of DIRs in the literature, in this article, DIRs are defined as large, tender, erythematous nodules with surrounding edema presenting ≥14 days after filler placement. ...
Article
Full-text available
Complications such as delayed inflammatory reactions (DIRs) and unnatural outcomes can sometimes arise from hyaluronic acid (HA) dermal filler treatments and can be challenging to address. Given the popularity of HA dermal fillers for aesthetic procedures, there is a need for preventive strategies to minimize these complications. Two hundred practitioners from 10 regions in Asia Pacific who administer HA fillers completed a survey on prevention of DIRs and unnatural outcomes. Thirteen global experts convened to evaluate the current practices and propose practical approaches for safe and appropriate use of HA dermal fillers. From the survey, the top three measures used to reduce the risk of DIRs included choosing an appropriate HA filler, aseptic technique, and patient selection. Key strategies employed to achieve natural-looking outcomes were treatment customization, understanding the rheological properties and behavior of different HA fillers, and being conservative in treatment approach. The panel developed a concise reference guide aimed at minimizing the risk of DIRs while achieving natural aesthetic outcomes. Five practical considerations were recommended: patient assessment and individualization of treatment plan, choice of an appropriate HA filler, adequate knowledge of facial anatomy, strict adherence to aseptic methods, and proper injection technique. The panel highlighted the need for education efforts to increase awareness of differential immunogenicity between HA fillers and to improve understanding on the importance of preserving aesthetic individuality for optimal results. These practical insights from the global experts support practitioners in optimizing safety and quality of aesthetic treatment with HA fillers.
... These interventions have served as important alternatives to surgical procedures. At the forefront of these modalities is the use of dermal fillers and their evolving technique-based refinements [10,11]. Injectable fillers are treatment modalities with versatile applications that afford patients the opportunity to enhance or conceal a variety of particular features, delay or avoid surgery, and/or serve as adjuncts to surgery, all with the above-mentioned advantages including immediate, time-enduring results [12]. ...
Article
Background Dermal fillers are increasingly popular for facial rejuvenation and enhancement, including effacement of nasolabial folds (NLFs) and marionette lines and lip augmentation. This study aimed to evaluate casual observer perception of physical and interpersonal traits of subjects who receive filler treatment. Methods An anonymous survey of 8 before/after treatment photographical sets was administered in Likert scale format (1–7) using online crowdsourcing. Three sets of photographs were before/after NLF/ marionette line treatment, three of lip augmentation, and two internal controls. Respondents were surveyed on personal demographics, as well as perceptions of subject photographs across nine domains (facial symmetry, confidence, likeability, youthfulness, trustworthiness, attractiveness, intelligence, approachability, happiness).ResultsIn total, 260 respondents completed the survey. The majority were male (63.1%), Caucasian (58.1%), 18–34 years old (58.1%), and college graduates (66.2%). Respondents rated photographs with line filler treatment and lip filler treatment as significantly improved compared to the pre-treatment photographs across all nine trait domains [p < 0.001, for all]. No differences were found between the control photosets [p > 0.05, for all]. Middle-aged respondents (35–55 years) were more likely to perceive treated filler photographs as more youthful than younger respondents (18–34 years) [p < 0.006] Additionally, respondents with lower educational attainment (high-school graduate or less) were more likely to perceive treated patients as less intelligent compared to higher-educated respondents (college/postgraduates) [p < 0.05, for both].Conclusion The use of dermal fillers for treatment of NLF/marionette lines and lip augmentation have significant associations with the perception of improved attractiveness and several personality traits. Additionally, casual observer demographic subgroups may influence perceptions.Level of Evidence IVThis 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.
... Hyaluronic acid (HA) is a ubiquitous glycosaminoglycan that has been used for temporary restoration of volume in the face, resulting in the appearance of rejuvenation. Reasons for its popularity include a good safety profile and reproducible results [1]. Despite the safety of HA-based applications, side effects can occur [2,3]. ...
Article
Background: Despite the favorable safety profile of hyaluronic acid (HA) dermal fillers, side effects can occur. Skin necrosis is one of the most severe early-occurring complications resulting from accidental vascular impairment. Hyaluronidase (HYAL) is commonly used to degrade HA chains, allowing the degraded product to pass through vessels, and thus relieving the vascular obstruction. Objective: The purpose of this study is to evaluate, in an ex vivo setting, the capability of HYAL to degrade crosslinked HA that was injected into human vessels. Materials and methods: During a neck dissection, a portion of the anterior jugular vein and facial artery was harvested. The vein and artery specimens were filled with 25 mg/mL of crosslinked HA filler. Each specimen was soaked in 0.5 mL of HYAL (300 IU/mL), in its own test tube, for 4 hours, after which the remaining HA was quantified. Results: The remaining HA volume was found to be 0.02 mL in the vein segment and 0.002 mL in the artery segment. Conclusion: A single administration of HYAL may not be adequate to restore blood flow in the event of embolism, and relatively high doses of this enzyme must be injected hourly into the affected tissue until resolution is complete.
... These results are related to the temporary effect of hyaluronic acid-based filler, the most used worldwide in the last years. [20][21][22][23] Hyaluronic acid-based fillers represent in fact the safest option since the availability of hyaluronidase, if properly administered, is able to solve even severe vascular complications. [24][25][26][27] Nevertheless, this solution is not permanent, and patients need to repeat the injections over time to maintain the desired result. 1 Several attempts to obtain permanent lip enhancement have been described, such as the use of silicone lip implants or the offlabel use of permanent fillers. ...
Article
Over the years, several techniques have been introduced to obtain permanent lip enhancement, such as the use of silicone lip implants or the off-label use of permanent fillers. Although some reports indicate that permanent lip filler is safe, many others describe early- and late-onset complications. The main issue with permanent lip fillers is the lack of a standard technique to correct undesirable results. The aim of this scoping review was to list and evaluate the surgical pathways described in literature to correct lip deformity resulted from the injection of permanent fillers. The methods and the inclusion criteria of this work were specified in advance and documented in a protocol, according to the PRISMA 2009 checklist. The research was carried out on electronic databases PubMed, Cochrane Library, and Scopus databases identifying articles from March 1991 to December 2020 and conducted up to December 23rd, 2020. Articles language was limited to English. The selection process identified 3 retrospective studies eligible for inclusion. 73 patients and a total of 111 lips (72 upper and 39 lower) were considered. Two early complications were identified, 1 suture dehiscence and 1 total lip mucosa necrosis. Surgical lip remodeling following permanent filler injection seems to be an effective approach although the surgical pathway needs to be customized per each patient. Complication rate seems to be coherent to lip surgery performed with reconstructive purposes. To confirm these data case-control studies with much wider cohorts are needed to reach statistical significance.
Article
Filler injections have become very popular in recent decades. Of the various injection procedures, lip injection is an important aspect of filler injection, especially for Caucasian patients. Asians tend to have fuller lips than Caucasians, necessitating a different approach to lip injection. Classification systems for the lip for aesthetic treatment purposes can help a physician assess a patient accordingly, and a simple classification of Asian lips into four types for injection approaches is proposed in this paper. Each patient type is discussed in terms of trait and categorization, injection area, injection techniques, injection goals, and sample patients with treatment results.
Article
Background: The malar augmentation injection has gained popularity in recent years, but the exact location of each injection site has not been clearly identified. Objective: To discover ideal injection sites by comprehensively considering the distributions of ligaments, muscles, and vessels. Materials and methods: Eighteen cadaver heads were dissected to investigate the zygomatic ligamentous system and to measure the position of muscles. Sixty-six cadaver heads were subjected to computed tomographic scanning and three-dimensional vessel reconstruction. Radiological evaluation of the fillers was performed before and after experimental injection in one hemiface and dissected to confirm safe delivery. Five patients were enrolled in a prospective clinical study. 2D and 3D photographs were taken before and after the injections for comparison. Results: Site 1 was defined along the zygomatic arch, except the first 1/4 length and the midline of the arch. Site 2 was on the body of the zygoma, superior to the level of the infraorbital foramen and medial to the jugale. Site 3 was defined in the anteromedial midface approximately 30 mm below the lateral canthus. Conclusion: Injections at these 3 sites can be performed within the range of the ligaments to achieve effective lifting effects and minimize potential complications.
Article
Background Facial aging is a multifactorial process characterized by structural changes to the dermis and ligaments, lipoatrophy in the fat pads and hypodermis, remodeling of the bony skeleton, change in muscle tonicity and tissue descent. Aims The purpose of this study is to evaluate the efficacy of a hyaluronic acid‐based treatment for the aging face that addresses all its causes in a caudal to cranial and medial to lateral direction: the centrifugal technique. Methods Between March 2015 and January 2018, 187 patients were treated with a high G’ hyaluronic acid in two sessions, one/two weeks apart, to improve signs of facial aging, starting from the lower centrofacial area and progressing laterally and cranially. Results were assessed using a Global Aesthetic Improvement Scale (GAIS) judging pre‐ and post‐treatment (32 weeks) pictures. Results The technique effectively treated the aging face. The investigator and all patients evaluated the results improved or very much improved and agreed that the results were very natural looking. Conclusion Use of a systematic centrifugal technique to address the signs of facial aging resulted in significant and long‐lasting improvement, as judged by the investigator and high patient acceptance and satisfaction.
Article
Background: As one of the most commonly used soft-tissue fillers, hyaluronic acid is generally considered safe and efficacious. However, evident bone resorption in mentum was observed. In this study, the authors analyzed the impact of hyaluronic acid on bone resorption in mentum and the influencing factors. Methods: The authors retrospectively compared the computed tomographic scans of patients with or without mentum augmentation using hyaluronic acid. The body mass index- and sex-matched control group was selected randomly. Semimandibular bone resorption index was calculated as the ratio of bone thickness in the incisive fossa to that in the mandibular symphysis. Injection volume, injection interval, the number of injections, product, complication were also recorded. Results: From January of 2014 to June of 2019, 80 patients (160 cases) and 80 controls were recruited. The bone resorption index in the hyaluronic acid injection cohort was significantly lower than in the controls (75.25 ± 10.02 versus 82.86 ± 6.38; p = 0.000). Patients injected with greater than or equal to 1 ml per time were more susceptible to bone erosion compared with patients injected with less (68.89 ± 10.84 versus 76.49 ± 9.42; p = 0.000). There was no significant difference between one- versus multiple-injection groups and short-injection-interval versus long-injection-interval (≥6 months) groups. Furthermore, no reduced aesthetics were realized. Conclusions: Hyaluronic acid injection could induce bone resorption in the mentum; nevertheless, the aesthetics were not impaired. The severity of the bone loss was positively correlated with the injection volume per time; therefore, large-volume injection of hyaluronic acid should be performed with caution. The patients should be fully informed about this complication preoperatively. Clinical question/level of evidence: Therapeutic, III.
Article
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Skin necrosis is the most severe complication arising from hyaluronic acid injection. To avoid skin necrosis, hyaluronidase should be injected along the course of the involved artery, to allow blood flow restoration. We evaluated the ability of hyaluronidase to degrade a hyaluronic acid (HA) filler in two simulated clinical situations—a compression case and an embolization case—to identify differences in the hyaluronidase injection. In the compression case, a bolus of HA filler was directly soaked in hyaluronidase solution; in the embolization case, a vein harvested from a living patient was filled with the same HA filler and then soaked in hyaluronidase. We then evaluated the quantity of HA remaining after 2 hours. While we found hydrolysis of hyaluronic acid in both cases, in the compression case, we detected almost complete hydrolysis, whereas in the embolization case we observed a reduction of the 60%. Our results support the hypothesis that vessel compression can be resolved with only one injection of hyaluronidase, while in the case of vascular embolization, repeated perivascular injections should be performed owing to the reduction of hyaluronidase activity. This article is protected by copyright. All rights reserved.
Article
Background Strengthening weakened ligament tissues with injectable fillers to improve their supportive effect may achieve the aesthetic goal of face lifting. Objectives The aim of our study was to design an injectable technique for enhancing the true facial ligaments and dissect the ligaments to provide anatomical guidance for effective injection. Methods Six true facial ligaments were chosen as target anatomical sites for injection. Specimens were dissected, and three-dimensional images were reconstructed to confirm the exact location of each injection site and to confirm that the proposed injection routes will not cause dangerous vascular damage. A total of five patients received the injections; three-dimensional images were taken before and after the injections for comparison and clinical outcome assessments. Results The injection technique was designed to target six true facial ligaments, as follows. Site 1 targeted the temporal ligamentous adhesion region to lift the lateral ends of the eyebrows. Site 2 targeted the region of the lateral orbital thickening to lift the lateral canthus. Site 3 and site 4 targeted the zygomatic retaining ligaments and zygomatic cutaneous ligaments, respectively, to augment the soft tissues of the midface. Site 5 targeted the region of the maxillary ligament to lessen the nasolabial folds, and site 6 targeted the mandibular ligament to reduce the marionette line. Conclusions This site-specific injection technique targeting the true ligaments may lead to increased efficiency and accuracy of face rejuvenation and exert a lifting effect.
Article
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Hyaluronic acid fillers indisputably represent an important tool for face rejuvenation and volume restoration. The temporal area has recently been considered as a potential site of injection. As it happens in the middle face and in other regions of the face, the temporal fossa changes according to the aging process. In a young person, the temple profile has a fullness aspect, and this contributes to giving the face a beautiful and healthy appearance. With age, the loss of volume leads the bone prominences to be visible. The aim of this article is to classify the temporal fossa atrophy and get better into the anatomy, identifying the ideal plane to inject in, through the use of a safe and reliable technique. Cadaver dissections have been performed to specifically describe the anatomy of the temple layer by layer. The authors' preferred technique, called interfascial by cannula implantation, is discussed. All the treated patients reported a good improvement by survey according to the Global Aesthetic Improvement Scale scale. No major complications were detected. No ecchymosis neither swelling were documented. Although further studies are necessary to broaden the casuistry and better verify the potentiality of this technique, the authors do believe that it could be considered a very reliable procedure with pretty consistent results, if supported by an adequate and imperative anatomical knowledge.
Article
Background Laser treatments for facial rejuvenation are common, with ablative modalities being of more common use for this indication. Efficient nonablative modalities are of rising demand. Aim Our aim was to determine the safety and efficacy of high‐fluence, nonablative 1540‐nm fractional Erbium:glass laser for facial rejuvenation. Patients and Methods A retrospective study of patients treated with 3‐4 treatments using the 1540‐nm fractional Erbium:glass laser for facial rejuvenation, using 2500‐3000 mJ/stacked pulses (51‐61 mJ per pixel). Patients were followed‐up for 3 months following their last treatment. Before and after photos were independently blindly evaluated by 2 dermatologists, who graded them using a scale from 0 (exacerbation) to 4 (76%‐100% improvement) for 2 different facial regions (frontal face region and lateral canthal region). Pain perception and adverse effects as well as patient satisfaction were documented throughout the study. Results Sixteen patients completed both treatment and follow‐up period. At the 3‐months posttreatment follow‐up visit, moderate‐to‐significant improvement in rhytids appearance (mean grade of improvement: 2.93 for frontal face and 3 for lateral canthal region) was observed. Patients’ satisfaction was high (4.25). Patients reported mild and transient erythema posttreatment with no other adverse effects. Conclusion The high‐fluence 1540‐nm fractional Erbium:glass laser is a safe and effective nonablative modality for facial rejuvenation.
Article
Background Periocular melanosis (POM) due to shadow effect of tear trough deformity (TT )does not respond to the conventional treatment modalities. Hyaluronic acid(HA) fillers are a favourable treatment modality . This area is a high-risk for injectables due to its unique anatomy . Aims To find role of HA fillers in treatment POM due to TT deformity with special emphasis on practical anatomy, patient satisfaction rate and management of complications. A correlation of the grade of TT, age of the patient and patient satisfaction was done. A follow up at 1 year was done to assess longevity of results. Methods Retrospective study of 60 cases of clinically diagnosed POM(120 TT) due to TT deformity, was performed. Each patient was injected with 1ml, cross linked HA 22.5 mg/ml in under eye area using 30 G needle or a 25 G cannula. Follow up was done at 2 weeks, 4 weeks and 1 year. Results Mean age of patients was 36.4 years. Majority of patients i.e. 31 (52%) were in the age group of 30-40 . As per Hirmand’s classification, 46.6% (28/60) had grade 2 TT which was most common . We graded results in form of VAS and 80% patients had VAS>7. There were no major side effects. Conclusion HA fillers are promising treatment modality without any major side effects. Both needle and cannula can be used effectively. Patient satisfaction is higher in younger patients with low grade of TT and results persisted in all cases for a minimum of 1 year.
Article
Background: Lips play an important role in facial aesthetics. Hyaluronic acid fillers have been widely used for lip augmentation in females but very few men seek this treatment due to the fear of feminization of lips. However, there are very few case reports published for correction of lips using fillers in men. Objective: To assess the effectiveness of Hyaluronic acid dermal fillers for enhancement of lips in males. Method: A 52 year old male underwent two sessions of treatment for inturned lips. In the first session 2 ml hyaluronic acid dermal filler (Juvederm Ultra Plus - JUP) with 27Gx8mm needle via bolus and retrograde linear thread technique was used. Assessment of lips was done after one week. Second session of treatment was done after 30 months of first treatment with 1 ml of filler. Results: Injection of filler not only led to a significant improvement in vermillion show, but also improved the overall facial appearance. The results of this treatment were long lasting and even after 30 months from the first treatment the patients vermillion body still showed ten percent improvement from the original. Conclusion: Dermal lip filler treatment in men can be a very satisfying and rewarding procedure. Its awareness should be spread afar to increase its acceptability.
Article
A novel image-guided treatment of postseptal intraorbital complications of dermal filler injection may help to avoid oculoplastic surgery. This article describes three patients who had postseptal hyaluronic acid confirmed by magnetic resonance imaging. All three patients underwent hyaluronidase treatment using a "magnetic resonance imaging road map" and ultrasound-guided dissolution.
Article
Background Hyaluronic acid (HA) fillers are known to be effective for the correction of facial wrinkles and folds, but there is no clinical study that compares the efficacy of small-to-medium-particle HA fillers and large-particle HA fillers for the correction of nasolabial folds (NLFs). Moreover, injection depth also plays an important role in the correction of NLFs as well as improvement of facial aesthetics. Objectives To assess the efficacy, safety, and durability of a small-to-medium-particle HA filler, Restylane, and a large-particle HA filler, Yishumei, as well as the effect of injection depth in the correction of moderate-to-severe NLFs and facial aesthetics in a Chinese population. Methods This 52-week, prospective, randomized, double-blind study enrolled 100 participants with moderate-to-severe NLFs. The participants were randomized to receive either Restylane (Group A) or Yishumei (Group B). Group A and Group B were further randomly divided into a superficial injection group (Group A1 & B1) and a deep injection group (Group A2&B2) according to injection depth. Improvement in the Wrinkle Severity Rating Scale (WSRS) score and Global Aesthetic Improvement Scale (GAIS) and participants’ satisfaction were evaluated as endpoints. All adverse events were monitored throughout the study. Results The treatments were well tolerated by all the participants. All four groups showed a reduction in their mean WSRS scores and GAIS scores by week 12. At week 24, the WSRS and GAIS scores did not change in Group A1 and A2, while participants in Group B1 and Group B2 had higher WSRS and GAIS scores than those in the previous weeks. By week 52, the WSRS scores in all the groups returned to almost baseline levels. The mean FACE-Q scores increased compared with the baseline scores in all groups through week 24. Most participants were satisfied with their treatment, and no meaningful differences were found between the fillers in terms of participant satisfaction. The most common adverse events were swelling, redness, and tenderness at the injection site, but they resolved spontaneously without treatment. Conclusion The two HA fillers had good therapeutic effect on NLFs in the early stage of treatment, but Restylane had a more prolonged effect. Moreover, compared with the superficial injection, the deep injection provided slight midface lifting and improved facial aesthetics.
Article
Background: Nasolabial sulcus rejuvenation is steadily gaining popularity among Asians. Though many treatment options using synthetic grafts and autografts have been introduced, none of them has yet been accepted as an ideal technique. This study describes the operative procedure and evidence-based clinical outcomes of paranasal augmentation using dermal grafts. Methods: From March 2015 to August 2019, 56 patients underwent paranasal augmentation. The dermal graft, harvested from the buttock, was folded into 4 to 6 layers and inserted into the supraperiosteal pocket through a gingivobuccal incision. Ultrasonographic evaluation was performed at postoperative months 1, 6, 12, and 18 to appraise the change in the thickness of the graft. Results: No major complications, including foreign body sensation and graft extrusion, occurred. The average dermal thickness was 10.31 mm at postoperative month 1 and 6.30 mm, 5.21 mm, and 5.17 mm at postoperative months 6, 12 and 18, respectively. The average absorption rates were 38.72%, 49.36%, and 49.92% at postoperative months 6, 12, and 18, respectively. Conclusions: Paranasal augmentation using a folded dermal graft serves as a useful method to rejuvenate the midface with durable and aesthetically satisfactory outcomes. By virtue of biocompatibility, complications occurred rarely compared with the artificial implants. 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.
Article
Background: Non-surgical, minimally invasive techniques are an effective way to bring a facelift with long lasting results; and minimal downtime and side effects. Due to an increased awareness and growing social acceptability, a large number of patients have been seeking these treatments to maintain a youthful appearance. Objective: To assess the efficacy of combined use of PDO threads and hyaluronic acid fillers for non-surgical facelift in a male patient. Method: A 39-year-old male patient underwent a non-surgical facelift using a combination of PDO threads and hyaluronic acid dermal fillers. Treatment was done in two sessions at an interval of one week using 4 pair mint PDO cog threads in the first session followed by injection of 5ml of hyaluronic acid dermal filler (4 ml JuvedermVoluma and 1 ml Juvederm Ultra Plus). Results: Combined use of PDO threads and dermal fillers is an effective technique for face lift and to correct sagging. Significant improvement is seen within a week of procedure which ensures high degree of patient satisfaction. Conclusion: Facial rejuvenation and lifting using PDO cog threads and hyaluronic acid dermal fillers are effective in providing immediate, long lasting results with minimal downtime.
Chapter
Botulinum toxin and soft tissue filler injections are the most common minimally invasive cosmetic procedures with growing use every year, given their relatively quick effects, short procedure time, and fast recovery. Botulinum toxins result in temporary paralysis of the facial muscles injected by blocking the release of acetylcholine from nerve terminals. The use of botulinum toxins has expanded from ophthalmic medical indications such as blepharospasm, hemifacial spasm, torticollis, and strabismus to growing cosmetic indications to treat facial rhytids at the glabella, forehead, eyelids, perioral areas, and cervical region. Soft tissue fillers combat facial aging by providing volume supplementation. The substances injected in dermal fillers include hyaluronic acid, polylactic acid, calcium hydroxyapatite, polymethylmethacrylate, and autologous fat. Complications from both procedures are infrequent but can have devastating consequences if the procedures are performed incorrectly. Administration by an experienced injector and appropriate understanding of the facial anatomy are essential to obtain an acceptable cosmetic outcome and minimize complication risks. This chapter will focus on the available botulinum toxin and soft tissue filler products and their uses, as well as appropriate injection techniques and potential complications.
Article
Facial fat grafting is increasing worldwide. Although there are few reports in the literature on complications following facial lipofilling, rare but serious complications include embolic risk to local end organs such as the skin and eye, and the central nervous system. Treatment strategies are outlined. The key to prevention of complications is understanding the regional anatomy. It is imperative to adhere to the safe and efficacious techniques to minimize risk. Every surgeon who performs facial fat grafting should establish a systematic method to deliver safe, consistent, and long-term results for their patients.
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Surgical and non-surgical aesthetic treatments are very popular throughout Asia and in particular in China. With the globalisation and immigration of Chinese people to other countries where many seek treatment from Western-trained doctors, it is important to understand the ideals of beauty amongst Chinese people so as to achieve optimal results. We conducted an online survey to understand the preference of Han Chinese laypersons for facial shape, profile (straight, convex, concave), jaw angle and shape, and shape of the chin, nose, and lips. In addition, the participants were asked about their educational level, geographic location, likelihood to have cosmetic surgery, preference for surgical or non-surgical cosmetic procedures and whether "being beautiful" would affect their daily life. A total of 1417 responses were collected from 599 male and 818 female participants, the majority of them who were 25-35 years old (58.93%). The responses showed that the majority of participants preferred an oval face shape, with a smoothly tapered jaw angle for both men and women, round and pointy chin for both genders, straight to concave nose profile and full lips with well-defined cupid's bow. Most responders indicated they were not willing to undergo cosmetic surgery; however, when given a choice between surgical and non-surgical cosmetic procedures, 82.22% of the participants preferred non-surgical procedures. The majority of respondents (83%) thought that being beautiful has an effect on daily life and improves quality of life. Level of evidence v: 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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Clarification is needed regarding the definitions and classification of groove and hollowness of the infraorbital region depending on the cause, anatomical characteristics, and appearance. Grooves in the infraorbital region can be classified as nasojugal grooves (or folds), tear trough deformities, and palpebromalar grooves; these can be differentiated based on anatomical characteristics. They are caused by the herniation of intraorbital fat, atrophy of the skin and subcutaneous fat, contraction of the orbital part of the orbicularis oculi muscle or squinting, and malar bone resorption. Safe and successful treatment requires an optimal choice of filler and treatment method. The choice between a cannula and needle depends on various factors; a needle is better for injections into a subdermal area in a relatively safe plane, while a cannula is recommended for avoiding vascular compromise when injecting filler into a deep fat layer and releasing fibrotic ligamentous structures. The injection of a soft-tissue filler into the subcutaneous fat tissue is recommended for treating mild indentations around the orbital rim and nasojugal region. Reducing the tethering effect of ligamentous structures by undermining using a cannula prior to the filler injection is recommended for treating relatively deep and fine indentations. The treatment of mild prolapse of the intraorbital septal fat or broad flattening of the infraorbital region can be improved by restoring the volume deficiency using a relatively firm filler.
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Consideration of facial muscle dynamics is underappreciated among clinicians who provide injectable filler treatment. Injectable fillers are customarily used to fill static wrinkles, folds, and localized areas of volume loss, whereas neuromodulators are used to address excessive muscle movement. However, a more comprehensive understanding of the role of muscle function in facial appearance, taking into account biomechanical concepts such as the balance of activity among synergistic and antagonistic muscle groups, is critical to restoring facial appearance to that of a typical youthful individual with facial esthetic treatments. Failure to fully understand the effects of loss of support (due to aging or congenital structural deficiency) on muscle stability and interaction can result in inadequate or inappropriate treatment, producing an unnatural appearance. This article outlines these concepts to provide an innovative framework for an understanding of the role of muscle movement on facial appearance and presents cases that illustrate how modulation of muscle movement with injectable fillers can address structural deficiencies, rebalance abnormal muscle activity, and restore facial appearance. Level of Evidence V 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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Background: There is increasing interest among patients and plastic surgeons for alternatives to rhinoplasty, a common surgical procedure performed in Asia. Objectives: To evaluate the safety, efficacy, and longevity of a hyaluronic acid filler in the correction of aesthetically detracting or deficient features of the Asian nose. Methods: Twenty-nine carefully screened Asian patients had their noses corrected with the study filler (Juvéderm VOLUMA [Allergan plc, Dublin, Ireland] with lidocaine injectable gel), reflecting individualized treatment goals and utilizing a standardized injection procedure, and were followed for over 12 months. Results: A clinically meaningful correction (≥1 grade improvement on the Assessment of Aesthetic Improvement Scale) was achieved in 27 (93.1%) patients at the first follow-up visit. This was maintained in 28 (96.6%) patients at the final visit, based on the independent assessments of a central non-injecting physician and the patients. At this final visit, 23 (79.3%) patients were satisfied or very satisfied with the study filler and 25 (86.2%) would recommend it to others. In this small series of patients, there were no serious adverse events (AEs), with all treatment-related AEs being mild to moderate, transient injection site reactions, unrelated to the study filler. Conclusions: Using specific eligibility criteria, individualized treatment goals, and a standardized injection procedure, the study filler corrected aesthetically detracting or deficient features of the Asian nose, with the therapeutic effects lasting for over 12 months, consistent with a high degree of patient satisfaction. This study supports the safety and efficacy of this HA filler for specific nose augmentation procedures in selected Asian patients. Level of evidence: 3 Therapeutic.
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Background The desire for and use of nonsurgical injectable esthetic facial treatments are increasing in Asia. The structural and anatomical features specific to the Asian face, and differences from Western populations in facial aging, necessitate unique esthetic treatment strategies, but published recommendations and clinical evidence for injectable treatments in Asians are scarce. Method The Asian Facial Aesthetics Expert Consensus Group met to discuss current practices and consensus opinions on the cosmetic use of botulinum toxin and hyaluronic acid (HA) fillers, alone and in combination, for facial applications in Southeastern and Eastern Asians. Consensus opinions and statements on treatment aims and current practice were developed following discussions regarding pre-meeting and meeting survey outcomes, peer-reviewed literature, and the experts’ clinical experience. Results The indications and patterns of use of injectable treatments vary among patients of different ages, and among Asian countries. The combination use of botulinum toxin and fillers increases as patients age. Treatment aims in Asians and current practice regarding the use of botulinum toxin and HA fillers in the upper, middle, and lower face of patients aged 18 to >55 years are presented. Conclusions In younger Asian patients, addressing proportion and structural features and deficiencies are important to achieve desired esthetic outcomes. In older patients, maintaining facial structure and volume and addressing lines and folds are essential to reduce the appearance of aging. This paper provides guidance on treatment strategies to address the complex esthetic requirements in Asian patients of all ages. Level of Evidence V This journal requires that the 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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Background Asians increasingly seek non-surgical facial esthetic treatments, especially at younger ages. Published recommendations and clinical evidence mostly reference Western populations, but Asians differ from them in terms of attitudes to beauty, structural facial anatomy, and signs and rates of aging. A thorough knowledge of the key esthetic concerns and requirements for the Asian face is required to strategize appropriate facial esthetic treatments with botulinum toxin and hyaluronic acid (HA) fillers. Methods The Asian Facial Aesthetics Expert Consensus Group met to develop consensus statements on concepts of facial beauty, key esthetic concerns, facial anatomy, and aging in Southeastern and Eastern Asians, as a prelude to developing consensus opinions on the cosmetic facial use of botulinum toxin and HA fillers in these populations. Results Beautiful and esthetically attractive people of all races share similarities in appearance while retaining distinct ethnic features. Asians between the third and sixth decades age well compared with age-matched Caucasians. Younger Asians’ increasing requests for injectable treatments to improve facial shape and three-dimensionality often reflect a desire to correct underlying facial structural deficiencies or weaknesses that detract from ideals of facial beauty. Conclusions Facial esthetic treatments in Asians are not aimed at Westernization, but rather the optimization of intrinsic Asian ethnic features, or correction of specific underlying structural features that are perceived as deficiencies. Thus, overall facial attractiveness is enhanced while retaining esthetic characteristics of Asian ethnicity. Because Asian patients age differently than Western patients, different management and treatment planning strategies are utilized. Level of Evidence V 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 Table of Contents or the online Instructions to Authors www. springer. com/ 00266.
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Injection-induced necrosis is a rare but dreaded consequence of soft tissue augmentation with filler agents. It usually occurs as a result of injection of filler directly into an artery, but can also result from compression or injury. We provide recommendations on the use of hyaluronidase when vascular compromise is suspected. Consensus recommendations were developed by thorough discussion and debate amongst the authors at a roundtable meeting on Wednesday June 18, 2014 in Las Vegas, NV as well as significant ongoing written and verbal communications amongst the authors in the months prior to journal submission. All authors are experienced tertiary care providers. A prompt diagnosis and immediate treatment with high doses of hyaluronidase (at least 200 U) are critically important. It is not felt necessary to do a skin test in cases of impending necrosis. Some experts recommend dilution with saline to increase dispersion or lidocaine to aid vasodilation. Additional hyaluronidase should be injected if improvement is not seen within 60 minutes. A warm compress also aids vasodilation, and massage has been shown to help. Some experts advocate the use of nitroglycerin paste, although this area is controversial. Introducing an oral aspirin regimen should help prevent further clot formation due to vascular compromise. In our experience, patients who are diagnosed promptly and treated within 24 hours will usually have the best outcomes. © 2015 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.
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Background There are few studies that evaluate the differences in the perception of beauty and attractiveness of different races or ethnicities. The purpose of this study was to determine whether there are any actual differences in the configuration of beautiful eyes among different races. Methods Using seven composite faces of different races or ethnicities, photogrammetric measurements were performed to determine the relative differences in the average and attractive configuration of the eyes. Fourteen distance measurements and five angular measurements were performed for analyzing the morphological differences in the configuration of attractive and average faces. Results The results of our study found that attractive Korean faces have relatively wide-set eyes and that the medial and lateral eye fissure height is greater than that in average Korean faces. Attractive Korean faces have larger but not ptotic eyes than those in average Korean faces and they have a narrow double fold line; however, attractive Asian faces have a slightly higher double fold line. Attractive Korean or Asian faces do not have an epicanthus and there is a lot of exposure of white in the medial and lateral area of the eyes. Attractive Caucasian and African faces have an acute or keen shape to the eyes like the jaguar’s eye. Attractive Asian faces have a less steep slant of the palpebral fissure compared to that of the average Asian face, but attractive Caucasian and African faces have a steeper palpebral slant than that of average Caucasian and African faces. Attractive Caucasian and African faces have a relatively narrower palpebral fissure height and width than average Caucasian and African faces. Regardless of race, attractive faces have wide-set eyes and a lower brow position than average faces. Conclusions “Beautiful eyes” can be defined as youthful, brilliant, vivid, and attractive. We found that there are some common and some different characteristics in the configuration of beautiful eyes according to racial background. Level of Evidence I 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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The exact anatomical cause of the tear trough remains undefined. This study was performed to identify the anatomical basis for the tear trough deformity. Forty-eight cadaveric hemifaces were dissected. With the skin over the midcheek intact, the tear trough area was approached through the preseptal space above and prezygomatic space below. The origins of the palpebral and orbital parts of the orbicularis oculi (which sandwich the ligament) were released meticulously from the maxilla, and the tear trough ligament was isolated intact and in continuity with the orbicularis retaining ligament. The ligaments were submitted for histologic analysis. A true osteocutaneous ligament called the tear trough ligament was consistently found on the maxilla, between the palpebral and orbital parts of the orbicularis oculi, cephalad and caudal to the ligament, respectively. It commences medially, at the level of the insertion of the medial canthal tendon, just inferior to the anterior lacrimal crest, to approximately the medial-pupil line, where it continues laterally as the bilayered orbicularis retaining ligament. Histologic evaluation confirmed the ligamentous nature of the tear trough ligament, with features identical to those of the zygomatic ligament. This study clearly demonstrated that the prominence of the tear trough has its anatomical origin in the tear trough ligament. This ligament has not been isolated previously using standard dissection, but using the approach described, the tear trough ligament is clearly seen. The description of this ligament sheds new light on considerations when designing procedures to address the tear trough and the midcheek.
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Hollow temples are a common sign of aging, contributing to the upper face appearing "pinched" and the brows appearing short and ptotic. Many treatments have been described for this area, including fat injections and implants. However, traditional injection techniques have not proven entirely satisfactory in correcting the problem without resulting irregularities. The author describes a technical refinement wherein diluted hyaluronic acid (HA) fillers are injected into the temple. Thus far, a series of 40 patients has been treated over 18 months with the author's technique, which involves diluting the HA filler by a ratio of approximately two to one (diluent to filler) and injecting the temple as evenly as possible. As the saline component absorbs, the filling material is distributed more evenly in the temple than with undiluted filler. Patients experienced improved results, with a smoother appearance to the brow. There were no instances of complications requiring dissolution of the product with hyaluronidase. Irregularities proved minor and easily correctable; no intravascular complications were noted in this series of patients. Clinical photographs demonstrate improvement in the "pinched" upper face and an apparent elongation of the brows. The author estimates, based on prior experience, that duration of effect will be approximately two to three years. Dilution of the HA fillers administered for brow treatment results in a more even distribution of the product and a lower morbidity than previously described techniques, making temple treatment far easier than in the past.
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In the aging process, upper periorbits can be divided broadly into two groups. Group 1 is characterized primarily by soft tissue ptosis of the upper eyelid, which requires surgical excision. The patients in group 2, show volume depletion of the soft tissue and bony resorption of the orbit, characterized by deflation of the upper eyelid as well as sunken, hollow, and skeletonized orbits. Currently, structural fat grafting is the only means for adding volume the depleted upper periorbit. It is, however, an invasive procedure associated with fairly significant morbidities, long downtime, and hence poor patient acceptance. The advent of safe hyaluronic acid (HA)-based dermal filler has, in the authors' opinion, revolutionized treatment for this group of oculoplastic patients. In the current series, 36 patients with volume depletion of the periorbit were treated with HA dermal fillers to restore the smooth arc of the upper periorbit. The average volume required ranged from 0.2 to 0.6 ml of filler. Despite the relatively small volume required, the upper periorbital aesthetics of the patients were successfully and dramatically transformed. At this writing, the longest follow-up period has been 3.5 years, with the patient still maintaining periorbital volume. No significant morbidities occurred. Given the multiple risks and the resistance of patients to structural fat grafting compared with HA dermal fillers, the authors believe that this nonsurgical technique for adding volume to the periorbit should become the method of choice for this group of oculoplastic patients.
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Despite plastic surgeons' best efforts, deformities can be seen following a face lift. One of the most obvious signs of face-lift surgery is the cross-cheek depression or "joker line," which begins as an indentation in the region of the oral commissure and extends laterally and superiorly toward the ear. When this depression develops postoperatively, the face can appear harsh, pulled, and abnormal, creating a visual illusion that the corner of the mouth extends laterally onto the cheek. There is a relationship between the preoperative contours of a patient and the postoperative ones. Most patients who develop cross-cheek depressions postoperatively exhibit a version of the problem preoperatively. Inspection and light finger traction on the cheeks identifies and intensifies the abnormal configuration. The clinician needs to be aware of the propensity for this complication preoperatively, as anticipation is the first step toward prevention and treatment. The most specific treatment for the surgical accentuation of cross-cheek depressions is the use of volume to fill the areas of unnatural depression, either intraoperatively or postoperatively.
Article
This third article of a three-part series addresses techniques and recommendations for aesthetic treatment of the lower face. The lower face is considered an advanced area for facial aesthetic treatment. In this region, soft-tissue fillers play a more important role than neuromodulators and should be used first to provide structure and support before neuromodulators are considered for treatment of dynamic lines. Treatment of the lip, perioral region, and chin, in addition to maintaining balance of the lower face with the face overall, is challenging. Procedures on the lip should avoid overcorrection while respecting the projection of the lips on the profile view and the ratio of lip size to chin. The chin is often neglected, but reshaping the jawline can provide dramatic improvement in facial aesthetics. Both profile and anterior views are critical in assessment and treatment of the lower face. Finally, rejuvenation of the neck region requires fillers for structural support of the chin and jawline and neuromodulators for treatment of the masseter and platysma.
Article
This second article of a three-part series addresses techniques and recommendations for aesthetic treatment of the midface. Injectable fillers are important for rejuvenation of the midface by replacing lost volume and providing structural support; neuromodulators play a smaller role in this facial region. Fillers are used for volumization and contouring of the midface regions, including the upper cheek and lid-cheek junction and the submalar and preauricular areas. Also, treatment of the frontonasal angle, the dorsum, the nasolabial angle, and the columella may be used to shape and contour the nose. Neuromodulators may be used to treat bunny lines and for elevation of the nasal tip. The midface is considered an advanced area for treatment, and injectors are advised to obtain specific training, particularly when injecting fillers near the nose, because of the risk of serious complications, including blindness and necrosis. Injections made in the midcheek must be performed with caution to avoid the infraorbital artery.
Article
Techniques for the administration of injectable fillers and neuromodulators for facial aesthetic rejuvenation and enhancement continue to evolve. As the number of physicians with limited experience in providing aesthetic treatments expands, the need for guidance and training from more experienced injectors has become apparent. The use of a slow, careful, and methodical injection technique is imperative in all treatment settings and for all facial areas. Constant attention to local anatomy, particularly arteries, veins, and nerve bundles, is critical for minimizing complications. This first article of a three-part series addresses techniques and recommendations for aesthetic treatment of the upper face. Traditionally, the upper face has been considered a basic area for treatment with neuromodulators but an advanced area for treatment with fillers. Injectable fillers may be used for temple volumization, eyebrow shaping, and forehead contouring. Neuromodulators are well suited for diminishing the appearance of dynamic facial lines such as forehead, glabellar, and crow's feet lines, and eyebrow lifting and eye-aperture widening. These techniques may be used independently or together, sequentially or concurrently, to address rejuvenation of individual or multiple facial regions. Overall, this series provides a practical framework of techniques for physicians who desire to perform safe and effective aesthetic treatments using a multimodal approach.
Article
Given the short recovery and immediate results, facial fillers have become a popular alternative to surgical rejuvenation of the face. Reported complications arising from facial filler injections include erythema, tissue loss, blindness, stroke, and even death. In this article, the authors describe their anatomically based techniques to minimize risk and maximize safety when injecting in the facial danger zones, including the glabella/brow, temporal region, perioral region, nasolabial fold, nose, and infraorbital region. Complications generally arise secondary to vasculature injury and/or cannulation with filler. The authors have outlined their preferred injection techniques in the facial danger zones with respect to the pertinent anatomy in an attempt to minimize risk and maximize results. Most importantly, the practitioner should be able to recognize complications and address them immediately.
Article
The purpose of this article is to update the changes to the author’s protocols used to manage acute filler related vascular events from those previously published in this journal. For lack of a better term, this new protocol has been called the High Dose Pulsed Hyaluronidase (HDPH) protocol for vascular embolic events with hyaluronic acid (HA) fillers. The initial protocol used involved many different modalities of treatment. The current protocol is exceedingly simple and involves solely the use of hyaluronidase in repeated high doses. Despite the simplicity of the treatment, it has proven itself to be very successful over the past two years of clinical use. There has been no partial or complete skin loss associated with this protocol since its implementation if the protocol was implemented within 2 days of the ischemic event onset. The protocol involves diagnosis and repeated administration of relatively high doses hyaluronidase (HYAL) into the ischemic tissue repeated hourly until resolution (as detected clinically through capillary refill, skin color, and absence of pain). The dosage of HYAL varies as the amount of ischemic tissue, consistent with the new underlying hypothesis that we must flood the occluded vessels with a sufficient concentration of HYAL for a sufficient period of time in order to dissolve the HA obstruction to the point where the products of hydrolysis can pass through the capillary beds. Although vascular embolic events are rare, it is important to note that the face has higher risk and lower risk areas for filler treatment, but there are no “zero risk” areas with respect to filler treatments. Even with good anatomic knowledge and correct technique, there is still some nonzero risk of vascular embolic events (including highly skilled, experienced injectors). However, with careful low pressure, low volume injection technique, and adequate preparation for treatment of acute vascular events, the risk is quite manageable and the vast majority of adverse events are very treatable with an excellent prognosis, with a few exceptions. This new protocol offers excellent results, but requires further research to determine optimal parameters for various HA fillers.
Article
With limited downtime and immediate results, facial filler injections are becoming an ever more popular alternative to surgical rejuvenation of the face. The results, and the complications, can be impressive. To maximize safety during injections, the authors have outlined general injection principles followed by pertinent anatomy within six different facial danger zones. Bearing in mind the depth and the location of the vasculature within each zone, practitioners can tailor their injection techniques to prevent vessel injury and avoid cannulation.
Article
Learning objectives: After reading this article and watching the accompanying videos, the participant should be able to: 1. Assess patients seeking facial volumization and correlate volume deficiencies anatomically. 2. Identify appropriate fillers based on rheologic properties and anatomical needs. 3. Recognize poor candidates for facial volumization. 4. Recognize and treat filler-related side effects and complications. Summary: Facial volumization is widely applied for minimally invasive facial rejuvenation both as a solitary means and in conjunction with surgical correction. Appropriate facial volumization is dependent on patient characteristics, consistent longitudinal anatomical changes, and qualities of fillers available. In this article, anatomical changes seen with aging are illustrated, appropriate techniques for facial volumization are described in the setting of correct filler selection, and potential complications are addressed.
Article
The use of injectable fillers enables facial sculpting through treatment of volume depletion and modeling of facial contours. Injectable fillers are among the most frequently performed minimally invasive cosmetic procedures.However, treatment of the lower third of the face can be challenging and requires expertise in facial anatomy. In this article, the authors provide a comprehensive review of the anatomy of the lower third of the face, highlighting danger zones. In addition, the authors describe their preferred approach and detailed technique used in the treatment of each specific area, namely the jawline, prejowl sulcus, melomental folds, and lips.
Article
Loss of viscoelasticity is one of the primarily signs of skin aging, followed by appearance of visible wrinkles. Hyaluronic acid (HA)-based fillers are widely used to fill wrinkles and compensate for volume loss. Recent clinical observations demonstrate persistence of the filling effect longer than the biological availability of the filler. Stimulation of new collagen by cross-linked HA and up-regulation of elastin have been suggested as possible explanation to this observation and have been supported experimentally. Cross-linked HA substitutes for fragmented collagen in restoring extracellular matrix required for normal activity of fibroblasts, such as collagen and elastin production. To restore extracellular matrix efficiently, serial monthly treatments are required. Boosting of facial and nonfacial skin through fibroblast activation is a new indication for HA-based products. Injectable HA has also been recently registered in Europe as agents specific for the improvement of skin quality (Restylane Skinboosters). Further explanation of the possible mechanisms supported by long-term clinical examples is presented herein.
Article
Background: The use of facial fillers has been rapidly increased as the range of injectable products and indications continues to expand. Complications may arise from improper placement or technique. This article highlights the importance of anatomic knowledge when using injectable fillers in the face. Methods: A detailed review of the clinical anatomy of the upper face is performed. Regional approaches are described using the applied anatomy to efficiently and safely augment the different subunits of the upper face. Results: Key aspects of safe and successful injection of fillers in the upper face include a thorough knowledge of the location of fat compartments and neurovascular structures. Awareness of these structures enables the practitioner to maximize injections, while avoiding damage to important nerves and vessels. Conclusion: A detailed knowledge of the anatomy and properties of the product is paramount to maximize the efficacy while minimizing the risk of complications.
Article
The clinical approach towards the midface is one of the most important interventions for practitioners when treating age-related changes of the face. Currently a plethora of procedures are used and presented. However, few of these approaches have been validated or passed review board assigned evaluations. Therefore, it is the aim of this work to establish a guideline manual for practitioners for a safe and effective mid-face treatment based on the most current concepts of facial anatomy. The latter is based on the 5-layered structural arrangement and its understanding is the key towards the favoured outcome and for minimizing complications.
Article
BACKGROUND As the popularity of soft tissue fillers increases, so do the reports of adverse events. The most serious complications are vascular in nature and include blindness.OBJECTIVE To review the cases of blindness after filler injection, to highlight key aspects of the vascular anatomy, and to discuss prevention and management strategies.METHODSA literature review was performed to identify all the cases of vision changes from filler in the world literature.RESULTSNinety-eight cases of vision changes from filler were identified. The sites that were high risk for complications were the glabella (38.8%), nasal region (25.5%), nasolabial fold (13.3%), and forehead (12.2%). Autologous fat (47.9%) was the most common filler type to cause this complication, followed by hyaluronic acid (23.5%). The most common symptoms were immediate vision loss and pain. Most cases of vision loss did not recover. Central nervous system complications were seen in 23.5% of the cases. No treatments were found to be consistently successful in treating blindness.CONCLUSION Although the risk of blindness from fillers is rare, it is critical for injecting physicians to have a firm knowledge of the vascular anatomy and to understand key prevention and management strategies.
Article
Background: Hyaluronidase (HYAL) has been recommended in the emergency treatment of ischemia caused by accidental intra-arterial injection of hyaluronic acid (HA) dermal fillers. To date, there have been no published studies showing that HYAL can pass through intact arterial wall to hydrolyze HA emboli. Objective: The goal of this study was to study whether or not HYAL could cross intact human facial arterial wall to hydrolyze HA filler. Materials and methods: Short tied-off segments of fresh human cadaver-sourced facial artery specimens, overfilled with a monophasic dermal filler (dermal filler "sausages"), were immersed in either HYAL or normal saline as controls. At 4 and 24 hours, the vessels were removed from the preparations, and one end of each vessel was cut open. Results: Only the HYAL-immersed specimens showed degradation of filler gel. Conclusion: In conclusion, cross-linked HA is susceptible to hydrolysis by HYAL when contained within the intact facial artery in a cadaver model, indicating that direct intra-arterial injection of HYAL is likely not necessary to help restore the circulation of ischemic tissues. This bench study provides support for the current recommended treatment of accidental intra-arterial injection with HYAL injection diffusely into ischemic tissues.
Article
Accidental intra-arterial filler injection may cause significant tissue injury and necrosis. Hyaluronic acid (HA) fillers, currently the most popular, are the focus of this article, which highlights complications and their symptoms, risk factors, and possible treatment strategies. Although ischemic events do happen and are therefore important to discuss, they seem to be exceptionally rare and represent a small percentage of complications in individual clinical practices. However, the true incidence of this complication is unknown because of underreporting by clinicians. Typical clinical findings include skin blanching, livedo reticularis, slow capillary refill, and dusky blue-red discoloration, followed a few days later by blister formation and finally tissue slough. Mainstays of treatment (apart from avoidance by meticulous technique) are prompt recognition, immediate treatment with hyaluronidase, topical nitropaste under occlusion, oral acetylsalicylic acid (aspirin), warm compresses, and vigorous massage. Secondary lines of treatment may involve intra-arterial hyaluronidase, hyperbaric oxygen therapy, and ancillary vasodilating agents such as prostaglandin E1. Emergency preparedness (a "filler crash cart") is emphasized, since early intervention is likely to significantly reduce morbidity. A clinical summary chart is provided, organized by complication presentation.
Article
Background: Light and electron microscopy have not identified a distinct anatomical structure associated with either skin wrinkles or creases, and a histological difference between wrinkled and adjacent skin has not been identified. Objectives: The authors investigate whether facial wrinkles are related to underlying lymphatic vessels and perilymphatic fat. Methods: Lymphatic vessels with a specialized tube of perilymphatic fat were identified beneath palmar creases. Sections of skin, adipose tissue, and muscle were harvested from each of 13 cadavers. Three sites were investigated: the transverse forehead crease, lateral orbicularis oculi wrinkle (crow's feet), and the nasojugal crease. The tissue was paraffin embedded and processed. Two-step indirect immunohistochemistry was performed, and images were examined using laser confocal microscopy. Measurements were taken with software. Results: Every wrinkle examined was found above and within ±1 mm of a major lymphatic vessel and its surrounding tube of adipose tissue. The results satisfied our null hypothesis and were statistically significant. Lymphatic vessels were identified by positive immunofluorescence as well as histological criteria. These findings have been further validated by fluorochrome tracer studies. Conclusions: An anatomical basis for wrinkles was identified among the specimens studied. Lymphatic vessels, along with the surrounding distinct perilymphatic fat, traveled directly beneath wrinkles and creases. Lymphatic dysregulation leads to inflammation, scarring, and fibrosis, but inadvertent injection of these vessels can be avoided with anatomical knowledge.
Article
Dermal filling has rapidly become one of the most common procedures performed by clinicians worldwide. The vast majority of treatments are successful and patient satisfaction is high. However, complications, both mild and severe, have been reported and result from injection of many different types of dermal fillers. In this Continuing Medical Education review article, the author describes common technical errors, the signs and symptoms of both common and rare complications, and management of sequelae in clear, easily adaptable treatment algorithms.
Article
Learning objectives: Learning Objectives: After reading this article, the participant should be able to: 1. Examine a nasal defect to determine its true dimension and outline and plan the appropriate timing of reconstruction. 2. Develop a surgical plan to restore normal dimension, volume, symmetry, and outline. 3. Determine the need for local versus regional flap repair. 4. Understand and apply aesthetic principles of nasal reconstruction. 5. Use exact surgical templates to determine the position, dimension, and outline transferred tissues. 6. Distinguish the indications for a two- or three-stage forehead flap. 7. Use the modified folded forehead flap technique with primary and delayed primary support replacement. 8. Understand an approach to the late revision. Summary: This article and accompanying video discuss a step-by-step approach to the reconstruction of a full-thickness heminasal defect in a demanding attractive woman who developed necrosis after cosmetic rejuvenation of the nasolabial fold by filler injection. Aesthetic principles were applied to develop a surgical plan to define the timing of reconstruction and true defect for repair with a full-thickness folded forehead flap transferred in three stages using a modified folded forehead flap for lining and primary and delayed primary support with a late revision to further refine nasal landmarks.
Article
The recent availability of safe volumizing fillers has provided cosmetic physicians with the tools necessary to contour facial features non-surgically and cost-effectively. This review focuses on outlining objective parameters necessary for creating a template to maximize each individual's facial beauty. Phi relationships can be approached for all facial features and rely on the establishment of smooth ogee curves in all dimensions. Once goals have been determined and a budget established, a logical syntax is used to create an algorithm for selecting products and procedures. The methodology leads to consistent and pleasing results with a high rate of patient satisfaction.
Article
Aging eyes often are treated by excision of apparent excess skin and fat and, in some instances, by elevation of the brow. The result of these traditional approaches is increased definition of the orbit, which is not of benefit for all patients. In some cases, the addition of volume in the periorbital area may provide a better-looking result than traditional surgical alternatives. The author describes the use of hyaluronic acid (HA) fillers for improvement of the periorbital region. Using local anesthetic, patients are provided with a preview of the aesthetic result of treatment with HA fillers to add volume to the brow. Most treatments are performed using HA fillers, which have the benefit of results that are both reversible and long-lasting. The author uses a fanning technique to inject small quantities of material. The use of these techniques results in a high degree of patient satisfaction. Occasional minor irregularities may occur, but these can be smoothed out by massage or blended by further injection. Results lasting two years are common and we have observed longevity of three years or more in some patients. Some brow configurations that falsely project emotional states, such as anxiety, may also be corrected. As in other types of cosmetic surgery, patient selection is key. In properly selected patients, increased fullness of the upper lids is preferable to the greater definition of the lids resulting from traditional surgical techniques. The longevity of treatment and reversibility of changes to the upper lids with HA fillers render this approach both cost-effective and safe.
Article
The face loses volume as the soft-tissue structures age. In this study, the authors demonstrate how specific bony aspects of the face change with age in both men and women and what impact this may have on the techniques used in facial cosmetic surgery. Facial bone computed tomographic scans were obtained from 60 Caucasian patients (30 women and 30 men). The authors' study population consisted of 10 male and 10 female subjects in each of three age categories. Each computed tomographic scan underwent three-dimensional reconstruction with volume rendering, and the following measurements were obtained: glabellar angle (maximal prominence of glabella to nasofrontal suture), pyriform angle (nasal bone to lateral inferior pyriform aperture), and maxillary angle (superior to inferior maxilla at the articulation of the inferior maxillary wing and alveolar arch). The pyriform aperture area was also obtained. The t test was used to identify any trends between age groups. The glabellar and maxillary angle in both the male and female subjects showed a significant decrease with increasing age. The pyriform angle did not show a significant change between age groups for either sex. There was a significant increase in pyriform aperture area from the young to the middle age group for both sexes. These results suggest that the bony elements of the midface change dramatically with age and, coupled with soft-tissue changes, lead to the appearance of the aged face.
Article
Because the concept of subcutaneous fat compartments has many significant implications for cosmetic and reconstructive surgery, it is important to verify the original findings and validate the concept. The authors studied the histology of the septal boundaries between several adjacent fat compartments. Eighteen hemifacial cadaver specimens were used (five male and four female cadavers; age range, 39 to 87 years). Tissue marking dye was injected into the central forehead and the medial, middle, and lateral temporal cheek compartments. Dye was allowed to diffuse for 4 hours until a skin blush was noted, at which point dye-setting solution was injected to fix the dye. En bloc transverse specimens were harvested and stored in formalin overnight. Standard histologic processing was performed. Each compartment partitioned dye in a consistent and reproducible manner. A fibrous condensation of connective tissue formed the diffusion barriers. These septa originated from underlying fascia and inserted into the dermis of the skin. A septal barrier originated from the fascia of the frontalis muscle, so these septal barriers are not necessarily related to the superficial musculoaponeurotic system but can occur anywhere between superficial fascia and skin. These findings support the concept that subcutaneous fat is compartmentalized, specifically by fascial condensations that travel from superficial fascia to dermis. These septa form an interconnecting framework that limits shearing forces on the face. This framework provides a "retaining system" for the human face. Implicit in this concept is the suggestion that the face ages three dimensionally, with separate compartments changing relative to one another by both position and volume.