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A review of dermal fillers in facial plastic surgery


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Purpose of review: Over the last decade, injectable soft tissue fillers have become an integral part of facial plastic surgery practice. The vast choice of new products being brought to the market, improved safety profile, lower costs in the current economic climate and high street availability mean that demand for nonsurgical rejuvenation treatments are increasing at an exponential rate and are no longer the preserve of the affluent. Recent findings: Recent published work has focused on the addition of local anaesthetic into fillers, widening their indications, reporting longer term results, avoidance of complications, regulation and future directions. Summary implications: The refinement of techniques to restore facial volume with dermal fillers, and widely available botulinum (BTX) injections to treat dynamic facial rhytids, fuelled by widespread mainstream advertising, has led to a surge in demand for nonsurgical rejuvenation procedures. An increasingly well informed and discerning patient population now seek better value procedures that require minimal downtime and have instant results. A thorough knowledge of the dermal fillers available for soft tissue facial augmentation is therefore essential to any clinician involved in facial plastic surgery.
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A review of dermal fillers in facial plastic surgery
Dominic Bray, Claire Hopkins and David N. Roberts
Nonsurgical rejuvenation procedures such as botulinum
toxin (BTX) and dermal filler injections are now the most
common aesthetic treatments performed worldwide. In
2008, the American Society of Aesthetic Plastic Surgeons
(ASAPS) published projected nationwide statistics of US
dermal filler practice [1]. Hyaluronic acid-based fillers
(Restylane, Juvederm, Hylaform) were the most com-
monly performed with over 1.26 million treatments.
Calcium hydroxylapatite (Radiesse) accounted for just
under 123 000 filler injections, collagen 58 000, and poly-
L-lactic acid (Sculptra) nearly 32 000 [standard error (SE)
3.21% at 95% confidence level (CI)]. These figures are
likely to be a conservative estimate as they are based on a
members’ survey that was projected to include only
board-certified plastic surgeons, otolaryngologists and
dermatologists. This article reviews the dermal fillers
available today in the USA and Europe, the injection
techniques, indications, avoidance of complications and
regulation of dermal fillers in facial plastic surgery.
Most injectable dermal fillers are supplied with a dis-
posable plastic syringe and Luer-Lok fitting, co-packaged
with a sterilized needle gauge appropriate for the filler
viscosity. Depth of the defect determines the depth of
injection, and generally speaking the deeper the defect,
the more viscous the filler. Superficial lines require
shallow correction in the upper dermis and cause blanch-
ing on delivery; deeper furrows and folds require place-
ment in the mid, deep or subdermis. Four techniques for
injection are reported: serial puncture, linear threading,
fanning and cross-hatching [2] (Fig. 1).
Serial puncture
The skin is pulled taught to stabilize the defect and
multiple boluses of filler are delivered along the defect
line. The injection sites should be close enough to form a
continuous smooth bead; however, small gaps can be
moulded with massage. This technique is useful for acne
scarring, shallow forehead rhytids, the glabella, philtrum
enhancement and nonsurgical rhinoplasty.
Linear threading
The full length of the needle is advanced along the
wrinkle or fold to create a tunnel for filler placement.
Injection can be anterograde ‘the push-ahead technique’
as the needle is advanced or retrograde as it is withdrawn.
Anterograde delivery may displace small blood vessels,
but retrograde delivery allows more uniform placement,
Department of Otolaryngology, Guy’s Hospital, London,
Correspondence to Mr Dominic Bray,
FRCS(ORL-HNS), Department of Otolaryngology,
Guy’s Hospital, Great Maze Pond, London SE1 9RT,
Tel: +44 207 188 2215; e-mail:
Current Opinion in Otolaryngology & Head and
Neck Surgery 2010, 18:295– 302
Purpose of review
Over the last decade, injectable soft tissue fillers have become an integral part of facial
plastic surgery practice. The vast choice of new products being brought to the market,
improved safety profile, lower costs in the current economic climate and high street
availability mean that demand for nonsurgical rejuvenation treatments are increasing at
an exponential rate and are no longer the preserve of the affluent.
Recent findings
Recent published work has focused on the addition of local anaesthetic into fillers,
widening their indications, reporting longer term results, avoidance of complications,
regulation and future directions.
Summary implications
The refinement of techniques to restore facial volume with dermal fillers, and widely
available botulinum (BTX) injections to treat dynamic facial rhytids, fuelled by
widespread mainstream advertising, has led to a surge in demand for nonsurgical
rejuvenation procedures. An increasingly well informed and discerning patient
population now seek better value procedures that require minimal downtime and have
instant results. A thorough knowledge of the dermal fillers available for soft tissue facial
augmentation is therefore essential to any clinician involved in facial plastic surgery.
dermal fillers, dermal implants, facial fillers, facial rejuvenation, soft tissue augmentation
Curr Opin Otolaryngol Head Neck Surg 18:295 –302
ß2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
1068-9508 ß2010 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI:10.1097/MOO.0b013e32833b5162
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
the preference being largely operator-dependent. Linear
threading is best for the nasolabial folds and vermillion
contour. Serial threading uses elements of both tech-
niques and is useful in wider folds.
The fanning and cross-hatching techniques are variations
of linear threading that allow filling of larger defects or
facial contouring. In the fanning technique a single
needle puncture allows ‘fan-like’ placement of successive
linear threads by radially changing the needle direction.
Cross-hatching delivers linear threads in a predetermined
grid by multiple punctures. Both techniques are useful in
the malar region and oral commissures.
Dermal fillers are licensed for injection into the mid to
deep dermis for the correction of moderate to severe
wrinkles and folds (such as the nasolabial lines). Some
have limited indication for correction of facial lipoatrophy
in HIV and acne scarring [3]. Dermal fillers are also used
‘off-label’ to treat facial rhytids, folds and depressions;
restore age-related facial soft tissue volume loss; augment
existing facial structures and improve nasal function. The
off-label use of medical devices was legalized by the US
Food and drug Administration (FDA) Modernization Act
of 1997. For ease of review indications are separated into
horizontal facial thirds [4
Upper face
The most commonly treated areas in the upper face are
the fine forehead lines created by the action of frontalis,
the vertical glabella furrows created by the depressor
corrugator complex and the crow’s feet formed by action
of orbicularis oculi. Whilst these dynamic lines are best
treated initially with BTX, in recalcitrant cases con-
comitant intradermal injection of hyaluronic acid filler
by serial puncture (e.g. Restylane Touch, Juvederm 18)
works well. Deeper furrows are best filled using Perlane
or Juvederm 24/30 by subdermal linear threading. Acne
scars can be elevated by needle subcision followed by
filler injection. Age-related temporal volume loss can be
replaced by subcutaneous injection of Restylane Sub-Q
(FDA approval pending) or Sculptra by cross-hatching.
Sinking or effacement of the malar eminence and hollow-
ing of the cheeks can be corrected with dermal fillers.
Restylane Sub-Q (the largest particle size in the hyaluro-
nic acid facial filler range at 1000 particles/ml) is an
effective alternative to fat transfer for mid-facial augmen-
tation and contouring [5]. Sculptra, whilst not a true
‘dermal filler’, stimulates collagen neogenesis. ‘Tear
296 Facial plastic surgery
Figure 1 Injection techniques
(a) Serial puncture; (b) linear threading; (c) fanning; (d) cross-hatching (from Rohrich et al. [2]).
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troughs’ formed by the naso-jugal fold can be corrected
with filler but achieving good results in this area is
challenging [6]. Accurate facial analysis, product choice,
injection technique and preparation are key to a good
outcome. The area should be anaesthetized with topical
cream to avoid distortion of the soft tissues and ice should
be used for vasoconstriction to reduce ecchymosis. The
patient should be seated upright to prevent gravitational
movement of the orbital fat pads and to best delineate the
area of correction. Preseptal injection of filler by linear
threading along the orbital rim avoids exacerbation of the
pseudoherniation of orbital fat that creates the original
deformity. Product choice depends upon degree of cor-
rection required but, in our experience, Restylane or
Juvederm give an excellent result. The area should be
gently massaged after injection to ensure even distri-
bution. If bruising becomes evident prompt pressure
and ice should be applied and injection postponed until
review at least 4 weeks later to allow time for dissociation
of water from the hyaluronic acid and oedema to settle.
Too superficial placement leads to bluish discoloration by
the Tyndall effect, which may improve with observation
but can be treated with hyaluronidase injection [7] or
Nd:YaG laser [8]. A good correction can last up to 2 years
owing to the relative immobility of the area.
A recent use of dermal filler is in nonsurgical ‘injection’
rhinoplasty [9]. Discreet volumetric changes in the
fronto-nasal angle, nasal dorsum and nasolabial angle
lead to significant differences in our perception of the
nasal aesthetic. These areas can be injected with dermal
filler to rejuvenate the nasal profile and correct asymme-
tries. In our experience the correction can last up to
2 years with Restylane [10], and 3 years with Radiesse,
probably because of the relative immobility of the mid-
Injection augmentation of a deep radix will soften the
fronto-nasal angle (Fig. 2c,d) and may disguise a promi-
nent rhinon and dorsal cartilaginous hump. Medial linear
subcutaneous threading of the bony and cartilaginous
dorsum will narrow a broad nose, and lengthen a shor-
tened nose. Saddle nose deformity and/or upper lateral
collapse may be disguised with injection superficial to
perichondrium. An underprojected tip may be built up by
supratip injection followed by moulding to the desired
aesthetic result. Nasal tip ptosis is addressed with single
puncture injection into the collumellar base to open the
nasolabial angle. This angle may be opened further with
injection of 2 units of Botox (Allergan Inc.) into the
depressor septi muscle.
Functional internal valve collapse may be addressed with
an endonasal ‘spreader’ injection of calcium hydroxyl-
apatite (Radiesse) into the apex of the internal nasal valve
[11] (Fig. 2a,b).
Lower face
The most commonly treated area is the lower face. Aging,
volume loss and gravity cause descent of facial soft tissue,
leading to down-turned oral commissures and develop-
ment of marionette lines exacerbated by the action of
depressor anguli oris. Descent of the malar fat pad leads
to deepened nasolabial folds and a prejowl sulcus and loss
of jawline definition is exacerbated by mandibular resorp-
tion. Selective correction with site appropriate filler can
restore volume and ‘lift’ the lower face nonsurgically
(Fig. 3a,b).
Deeper nasolabial folds can be softened with retrograde
subdermal linear threading of hyaluronic acid, Radiesse
or collagen derivatives, but finer nasolabial lines are best
effaced by intradermal injection of hyaluronic acid.
Superficial injection during needle withdrawal risks
nodularity and should be avoided.
The lip is a common ‘off-label’ area for injection.
Orbicularis oris action causes development of perioral
rhytids, and age-related atrophy leads to volume loss,
A review of dermal fillers in facial plastic surgery Bray et al. 297
Figure 2 Nonsurgical ‘injection’ rhinoplasty
Right upper lateral cartilage collapse causing right internal nasal valve
dysfunction (a); at 18 months corrected with endonasal Restylane
injection (b). Saddle nose deformity (c); at 18 months following sub-
dermal radix Restylane injection (d).
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flattening of the cupid’s bow, loss of vermillion contour
and convexity of the pout on profile view. These features
can be restored and our preference is to use Restylane
lidocaine as the gel is firm enough to provide support, can
be moulded into position, and rapidly softens. Treatment
in this area is painful and a local infraorbital and mental
block with 2% lidocaine and 1 : 100 000 epinephrine is
advised. Starting at the commissure, the needle is
advanced along the vermillion line. Retrograde linear
threading in the subdermis enables filler hydrodissection
and augmentation of the vermillio-cutaneous border. The
cupid’s bow can be sculpted and the commissures
upturned by selective filling of the upper and lower
lateral commissure vermillion. Perioral rhytids are filled
with mid-dermis serial puncture [2]. Lip volume is
enhanced by injection of filler at the junction of the
wet/dry mucosa in the middle third (Fig. 3c,d).
There are over 150 injectable fillers on the global market,
but at the time of writing only a dozen or so have FDA
approval. These include modifications (larger particle
size, addition of lidocaine) of existing fillers and fillers
no longer available [12]. Fillers can be permanent or
temporary and classified into three categories: collagens,
hyaluronic acids and biosynthetic polymers. Commonly
used FDA-approved/Conformite
´enne (CE)-
marked fillers available at the time of writing are sum-
marized in Table 1 [13].
Collagen is the major structural component of skin. Inject-
able forms consist of varying concentrations of bovine
(Zyderm 1&2, Zyplast), human bio-engineered or more
recently porcine (Evolence) collagen. Human collagens
are derived from cadaveric skin (Alloderm, Cymetra) or
laboratory culture of human fibroblasts (Cosmoderm 1&2,
Cosmoplast). They have a significantly reduced allergic
risk compared with their bovine counterparts. Autologous
collagen from punch skin sampling (Isolagen) was recently
in vogue but, owing to its cost, complexity and processing
time, did not realize the initial interest and is no longer
available. Despite FDAapproval in 2008, Evolence, which
is derived from porcine collagen, stopped distribution in
November 2009. Allergan, following their 2006 acquisition
of INAMED (manufacturers of Zyderm, Zyplast, Cosmo-
derm and Cosmoplast), have not actively marketed their
collagen dermal fillers – a reflection of the global move
towards hyaluronic acid injectables.
Hyaluronic acids
Since its 1934 discovery in the vitreous of cow’s eyes [14],
hyaluronic acid has become the most commonly used
298 Facial plastic surgery
Figure 3 Restylane– lidocaine for lower facial rejuvenation
Lower facial third volume loss characteristic of ageing (a); 3-month review following Restylane injection to the nasolabial folds, marionette lines, perioral
rhytids, commissures and vermillion contour (b). Ageing lips with decreased volume, loss of cupid’s bow and down-turned commissures (c); 3-month
review following injection augmentation (d).
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A review of dermal fillers in facial plastic surgery Bray et al. 299
Table 1 Summary of FDA-approved dermal fillers on the market
Filler type Subtype Name (manufacturer) Distributor Indication (off-label use) Durability Market status
Collagens Bovine Zyderm 1 Allergan Correction of dermal contour deficiencies
(superficial defects and rhytids, acne scars)
2– 4 months FDA-approved
Zyderm 2 Allergan Correction of dermal contour
deficiencies (moderate defects,
deep acne scars, lip volume)
2– 6 months FDA-approved
Zyplast Allergan Correction of dermal contour
deficiencies (deep defects,
lip volume)
2– 6 months FDA-approved
Cell-cultured Cosmoderm Allergan Superficial dermis for soft tissue contour
deficiencies, rhytids and acne scars
3– 4 months FDA-approved
Cosmoplast Allergan Mild to deep dermis for soft tissue
contour deficiencies, rhytids and
acne scars
3– 4 months FDA-approved
Cadaveric Alloderm Lifecell Corp.
Woodlands, TX
Deep rhytids, scars, lip volume 6– 12 months CE-marked
Cymetra micronized
injectable Alloderm
Lifecell Corp.
Woodlands, TX
Deep rhytids, scars, lip volume 3– 6 months CE-marked
Hyaluronic acids Avian derived Hylaform (Genzyme) Allergan, CA Mild to deep dermis for mod-
severe folds (superficial
rhytids, glabella, nose and lips)
3– 4 months FDA-approved
Prevelle Silk (Genzyme) Mentor, Irving, TX Moderate to deep dermis for
mod-severe folds, for example
nasolabial folds (superficial
rhytids, glabella, nose and lips)
3– 4 months FDA-approved
Bacterial-cultured Perlane (Qmed) Qmed Deep dermis to superficial subcutis
for mod-severe folds, for example
nasolabial folds
6– 12 months FDA-approved
Perlane lidocaine (Qmed) Qmed 6– 12 months FDA-approved
touch (Qmed)
Qmed Mild to deep dermis for mod-severe
folds, for example nasolabial
(superficial rhytids, glabella,
nose and lips)
6– 12 months FDA-approved
Restylane lidocaine (Qmed) Qmed 6– 12 months FDA-approved
Elevess (Annika Therapeutics) Annika Therapeutics
Woburn, MA
Mild to deep dermis for mod-severe
folds, for example nasolabial
(superficial rhytids, glabella,
nose and lips)
6– 12 months FDA-approved
Captique (Genzyme) Allergan, CA Mild to deep dermis for mod-severe
folds (superficial rhytids, glabella,
nose and lips)
3– 6 months FDA-approved
Juvederm (Corneal, Paris) Allergan, CA Mild to deep dermis for mod-severe
folds, for example nasolabial
(superficial rhytids, glabella,
nose and lips)
6– 12 months FDA-approved
Juvederm lidocaine
(Corneal, Paris)
Allergan, CA 6– 12 months FDA-approved
Synthetic polymers Poly-L-lactic acid Sculptra Sanofi Aventis Facial lipoartophy in HIV (facial
contouring and volumetric
1– 2 years FDA-approved
Calcium hydroxylapatite Radiesse Bioform medical Moderate to severe folds, for example
nasolabial, facial lipoatrophy in
HIV (nose)
1– 2 years FDA-approved
4% Polyalkylimide Bio-alcamid Ascente Medical Deep defects Permanent CE-marked
Polyacrylamide hydrogel Aquamid Contura International Deep defects Permanent CE-marked
Adapted and updated from Buck et al. [13].
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dermal filler worldwide. It has been identified as the main
polysaccharide in the extracellular matrix of human con-
nective tissue. Hyaluronic acid stabilizes intercellular
structures, and produces a viscoelastic framework for
collagen and elastin to bind; it potently binds water
and when injected, volumizes, softens and hydrates
the skin. As the skin ages, hyaluronic acid content
decreases leading to decreased cell hydration, elasticity
and movement. The half-life of hyaluronic acid in the
dermis is 1 day as it degraded by hyaluronidase. The
hyaluronic acid molecule can be stabilized by bio-
chemical reticulation (cross-linking) with butanediol
diglycidyl ether (BDDE Restylane, Juvederm), or
divinyl sulfone (DVS Prevelle Silk, Captique, Hyla-
form) conferring resistance to degradation by heat or
enzymatic action [15
]. Hyaluronic acid implants can
be divided depending upon their reticulation character-
istics into biphasic (reticulated chains in fluid suspension
that is resorbed after implantation) and monophasic (con-
tinuous polysaccharide reticulated chain) implants. The
former enables even distribution of hyaluronic acid HA
macromolecules, the latter is more homogeneous with
theoretically easier delivery [16]. The cross-linking pro-
cess can be further engineered to produce particulate or
nonparticulate forms. The jury is currently out as to
which form delivers a better outcome the particulates
depend on particle size to increase volumetric lift and
longevity, the nonparticulates (of which Juvederm is the
only FDA-approved product) depend on greater cross-
linking to produce volume. The ideal degree of cross-
linking is unknown, as significant cross-linking may
reduce the hydrophilic properties of hyaluronic acid
and therefore reduce lift or could affect biocompatibility
and cause rejection or encapsulation [17].
Restylane was the first hyaluronic acid to gain FDA
approval in December 2003 and remains the market
leader today. A recent advance is the addition of 0.3%
lidocaine to the filler (Restylane-L, Juvederm XC). In a
multicentre, double-blind, randomized clinical trial, 72
patients received Juvederm XC and Juvederm in separate
nasolabial folds. Ninety-three per cent of patients
reported less procedural pain when treated with the
lidocaine-containing dermal filler compared with the
original version. The safety profile and outcomes were
similar [18]. Another multicentre study of 3566 patients
in 16 European countries reported greater than 95%
patient and injector satisfaction with the lidocaine-con-
taining filler [19]. Within a week of writing, Restylane-L
and Juvederm XC have gained FDA approval and await
US market release.
Biosynthetic polymers
Synthetic facial fillers are composed of a biosynthetic
polymer (poly-L-lactic acid, calcium hydroxylapatite,
polymethylmethacrylate) combined with differing inject-
able carriers including hydrogels, beads and liquids [13].
Concerns remain about the long-term effects of the
permanent synthetic compounds Bio-Alcamid and
Aquamid [2024] and, in our opinion, cannot be justified
when other fillers with more predictable outcomes and
safety profiles exist.
Calcium hydroxylapatite (Radiesse) consists of a 30%
concentration of 25 –45 mm spherical particles suspended
in sodium carboxymethylcellulose gel. It is FDA-approved
for facial soft tissue augmentation,specifically correction of
moderate to severe facial lines and folds and correction of
soft tissue loss from HIV lipoatrophy, vocal cord augmen-
tation and as a radiological tissue marker. In addition, the
off-label use of Radiesse has been reported for the infra-
orbital rim [25], nose [26], internal nasal valve [11] and
malar/submalar augmentation [27]. Following injection,
the gel is phagocytized and the calcium hydroxylapatite
microspheres displace surrounding soft tissue. Collagen
proliferation and slow degradation of the microspheres
lead to a prolonged duration of effect up to 2 years.
Poly-L-lactic acid (PLA) is not designed as a filling
agent per se. It is indicated for HIV-associated lipoa-
trophy but is widely used off-label for cosmetic facial
volumization. It is given by subdermal injection and
activates collagen neogenesis by granulomatous inflam-
mation [28]. This process takes at least 6 weeks but
the ‘filling’ effect is noticeable for up to 2 years. Serial
treatments are often necessary. Sculptra, like Radiesse,
contains sodium carboxymethylcellulose gel to aid
particle displacement.
Adverse events from dermal fillers are classified into
immediate (pain, hypersensitivity, anaphylaxis), early
(swelling, erythema, infection, overcorrection, necrosis),
late (activation of HSV, nodules, granuloma formation)
and permanent (scarring) [29
Patients’ expectations should be addressed prior to treat-
ment and they should be informed of the risks, altern-
atives, and aftercare instructions. Fillers have FDA
approval for soft tissue augmentation in the nasolabial
fold; all other sites are off-label and the patient should be
informed of this. Injectors should be aware of facial
danger zones, specifically embolization of the supra-
trochlear (glabella), facial (alar facial angle) and dorsal
nasal (nasal dorsum) arteries [30,31].
International regulations vary with regard to who can
inject fillers. In the USA, fillers must be FDA-approved
and prescribed as medicine. However, in the UK and
300 Facial plastic surgery
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Europe they require only CE marking (pertaining to
production standards not efficacy) and are classed as non-
prescription medical devices [32]. Over 140 injectable
fillers are therefore available to the UK/European market
compared with only six in the USA. The massive growthof
the industry, fuelled by exponential demand, demedica-
lization through advertising, and lack of regulation, has led
to dentists, nurses and beauticians offering filler injections
on the high street. There is currently no requirement for
certified training or background in facial plastic surgery.
An international report in 2008 by the FDA of adverse
events highlighted the potential for serious complications
resulting from filler injection, especially from inexperi-
enced practitioners [2]. Of the 823 adverse events
reported, 638 (78%) responded to medication (from
topical steroid cream to systemic steroids, antibiotics,
anti-inflammatories and antihistamines), 94 (11%)
required surgical intervention (abscess drainage and/or
nodule excision) and 19 (2%) required emergency admis-
sion for hypersensitivity reaction.
Despite widespread variation in injector experience, per-
manent complications are fortunately rare. In the UK,
these most commonly arise with permanent fillers (e.g.
Bio-Alcamid/Aquamid) and no permanent filler is cur-
rently FDA-approved after Artes Medical, manufacturers
of Artefill, went into administration in late 2008 [29
A quarter of British Association of Aesthetic Plastic
Surgeons (BAAPS) members have reported surgery for
complications following their use and 96% of BAAPS
members want regulation and UK adoption of FDA
approval for dermal fillers [33].
Dermal fillers are now an essential part of any facial
plastic and aesthetic surgical practice. The field is moving
so quickly, with new fillers being manufactured at an
ever-increasing rate, that published reviews less than a
year old at the time of writing include products no longer
available [4
,13]. The FDA is responding to this by
streamlining the approval process and improving safety
testing, event reporting and product labelling.
We echo the call by the BAAPS for tighter regulation in
the UK [33]. The increased choice of products available
in the UK and Europe has not conferred better outcomes
as the literature is full of adverse events from fillers now
withdrawn from the market [34]. The FDA approval
process has in some way protected American patients
from these products.
Lastly, despite perceived demedicalization of fillers,
it is essential that the injector remains their patients’
advocate. They should understand the differences,
indications and safety profiles of available products to
achieve a mutually desired outcome.
References and recommended reading
Papers of particular interest, published within the annual period of review, have
been highlighted as:
of special interest
 of outstanding interest
Additional references related to this topic can also be found in the Current
World Literature section in this issue (p. 346).
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lers.pdf] accessed 19th February 2010.
Alam M, Hayes G, Kramer E, et al. ASDS guidelines of care for injectable
fillers. Dermatol Surg 2008; 34:S115– 148.
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... Поставянето на хиалуронидаза е със степен по-важно и отговорно, отколкото поставянето на самия филър. Познанията за това как да избегнат въпросните усложнения, са с първостепенно значение [3,4,5,6]. ...
... Първи стъпки при подобни състояния, като аспирация преди всяка инжекция, инжекции с ниско налягане на минимални обеми от пълнителя (< 0.1 ml), използване на незахабени канюли, разреждане на пълнителя с лидокаин биха могли да предотвратят или да минимализират подобни усложнения [6,7,8,9]. ...
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The use of injectable hyaluronic acid in wrinkle fi lling and soft tissue augmentation is one of the most commonly performed procedures in cosmetic and aesthetic medical practice. The use of these fi llers is increasing, as is the expectation of possible complications. The presence of the hyaluronidase enzyme in contemporary aesthetic medical practices is of a primary need. On the one hand, for immediate injection and on the other, for delayed injection, in order to prevent posttraumatic necrosis and other complications. Most often, vascular occlusion is accompanied by persistent pain, sensitivity and progressive discoloration of the injected area. This condition accentuates the importance of the immediate establishment and treatment of vascular occlusion in order to improve patient status and reduce the risk of persistent complications. The purpose of this article is to describe the main steps of vascular obstruction behavior after applying a hyaluronic fi ller. The presence of the hyaluronidase enzyme is of primary need, when undertaking cosmetic procedures with a hyaluronic acid based fi ller. Timely diagnosis and immediate application at high doses of hyaluronidase (at least 200 U), in vascular obstruction after injection of hyaluronic acid fi ller successfully prevents possible necrosis and is from primary importance. Key words: hyaluronic acid fi ller; hyaluronidase, soft tissue fi ller, vascular complications
... Injection correction also eliminates the manifestations of deep adipose tissue atrophy and atrophy/redistribution of superficial (subcutaneous) tissue. Correction of various facial folds and wrinkles is also performed by injections of fillers [6]. ...
Full-text available
The relevance of aesthetic treatments with dermal fillers, botulinum toxin, energy-based devices, and cometic threads to improve the appearance of the patient and, as a result, the quality of life, is confirmed by several studies in recent years. Protocols for their use, considering the multi-level impact in different areas of the face, are becoming increasingly widespread and in demand in clinical practice. To date, there is insufficient data on the algorithm for choosing a treatment strategy in combined programs from the point of view of the efficacy and safety of procedures for patients of various types of aging. Analysis of published studies and recommendations of the authors, based on personal experience, will enable wider use of combined programs with a good profile of efficacy and safety. A combination of fillers and thread lifting is possible in one treatment session, but the methods should be used in different areas of the face. To make the combined effect safer, it is advisable to separate the time of these procedures. It is not recommended to treat the upper face with botulinum toxin and thread lifting within one session due to the anesthesia that accompanies thread implantation. When planning combined treatment protocol, the period of rehabilitation after implantation of the threads with the possible prescription of antibiotic therapy should be taken into account. The sequence or synergy of the methods is determined individually, considering aesthetic indications, anatomical and age characteristics, and individual preferences of the physician and the patient.
... Soft tissue llers are often used in facial rejuvenation. With this technique it is possible to remodel the aged face, to increase the volume and to decrease accidity with 10,11 minimal side effects . Using polymethyl methacrylate (PMMA) lling presents the advantage of a non-absorbable material which 10 therefore has a denitive effect stimulating collagen neogenesis at 12 the implant sites . ...
Introduction: The use of associated less invasive techniques can be an alternative skin rejuvenation treatment. Objective: To demonstrate the efcacy and safety of the 4T treatment. Methods: Retrospective study of patients that underwent rejuvenation treatment using 4 different techniques simultaneously: polymethylmethacrylate (PMMA) lling, fractional CO laser, 2 radiofrequency, and botulinum toxin. More than 1,400 patients who underwent this treatment between December 2009 and July 2019 were analyzed. Results were very good in all patients submitted to the 4T technique as documented by pic Results: tures, assessment of the medical team and by the patients. Follow-up was similar to the single use of CO2 laser with edema for 2-3 days, additional 3-4 days until complete skin scaling and decrease of the swelling (downtime 5-7 days). It was possible to reestablish the natural volumetric loss caused by ageing and there were no complications in any patient. Conclusion: Treatment with the 4T technique is effective and safe for facial rejuvenation and can enhance a good aesthetic result as assessed by physicians and patients.
... The additional indications are to correct the facial and the body lipoatrophy in HIV patients, acne scarring, nasal reconstruction. 7,8 Dermal fillers have the risk of complications, namely short-term and long-term. Short-term complications occur immediately up to several days. ...
... Decades of research have produced polymers that may be fine-tuned to match nearly any desired application [6]. Some polymers may form hydrogels, three-dimensional systems which are able to retain large quantities of water due to either chemical or physical crosslinking, rendering these polymers attractive platforms for dermal fillers or for the delivery of hydrophilic drugs [7,8]. The ability to inject a polymeric material through a syringe and form a hydrogel post-injection is advantageous, as formation of a hydrogel depot may afford localized release of therapeutic agents or provide tissue augmentation [9,10]. ...
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Hydrogels based on poly(caprolactone)–b-poly(ethylene glycol)–b-poly(caprolactone) (PCL–PEG–PCL) have been evaluated extensively as potential injectable fillers or depots for controlled release of drugs. Common drawbacks of these copolymer systems include instability of aqueous solutions and low mechanical strength of gels, issues which are commonly overcome by adding pendant groups to the end of the copolymer chains. Here, a systematic study of the effects of increasing polymer molecular weight (MW) is presented, utilizing PEG blocks of MW 2, 4 or 8 kDa. Triblock copolymers were prepared by the ring-opening polymerization of Ɛ-caprolactone by PEG. Copolymers prepared with PEG MW 2 kDa did not form hydrogels at any copolymer molecular weight. Copolymers prepared with PEG MW 4 kDa formed gels at MW between 11 and 13.5 kDa, and copolymers prepared with PEG MW 8 kDa formed gels at MW between 16 and 18 kDa. Copolymers with PEG block 8 kDa formed hydrogels with high viscosity (17,000 Pa·s) and mechanical strength (G′ = 14,000 Pa). The increased gel strength afforded by increased molecular weight represents a simple modification of the reactants used in the reaction feed without added synthetic or purification steps. Shear-thinning of PCL-PEG-PCL triblock copolymer hydrogels allowed for injection through a standard 23G syringe, allowing for potential use as dermal fillers or drug delivery depots.
Aging is associated with edentulism, resorbed alveolar ridge, reduced muscle activity, and sunken cheeks. When there is not enough muscle mass between zygomatic and mandibular bone, slumping of cheeks occurs. Sunken cheeks lead to facial disfigurement and unesthetic appearance resulting in a negative psychological impact on the patient. The use of conventional complete dentures can rehabilitate the loss to some extent, but excellent denture esthetics can be achieved by providing additional support to the slumped tissues. This clinical case series describes different techniques to provide support for sunken cheeks using detachable maxillary cheek plumper prosthesis in completely edentulous geriatric patients.
Rhinoplasty is one of the most requested aesthetic procedures performed by plastic surgeons world-wide and nonsurgical rhinoplasty is becoming the gold standard in aesthetic nasal treatment. Follow-up clinical examinations were performed on all 107 patients, being a safe and predictable technique with a high degree of satisfaction for the patients. Nonsurgical rhinoplasty using hyaluronic acid is an effective, fast, and safe nasal reshaping procedure with a high degree of patient satisfaction. Generally, due to the gradual reabsorption of the filler, the results last up to 8 to 12 months after treatment, making it a valid minimally invasive alternative to surgical rhinoplasty. Consequently, to maintain the effects it is necessary to repeat the treatment once a year.
Study design: A prospective clinical study. Background: To the best of our knowledge, there is no study in the literature that addresses the effect of showing comparative photographs in the follow-up period to patients who had undergone nonsurgical rhinoplasty on patient satisfaction. Objectives: To examine the effect of showing preprocedure and postprocedure photographs to patients in the follow-up period on patient satisfaction. Methods: It was a nonsimultaneous prospective study that included patients suitable for nonsurgical rhinoplasty. Photographs were taken during routine follow-up after 1 month of the procedure, and patients were asked to fill the Derriford Appearance Scale 24 (DAS24) and Rhinoplasty Outcome Evaluation (ROE) questionnaires. Next, after the preprocedure and postprocedure photographs were shown to the patients, they were asked to complete the DAS24 and ROE questionnaires again. Results: The study included 265 female patients. The mean age of the patients was 35.11 ± 8 (18-61 years). Before the preprocedure and postprocedure photographs were shown, the DAS24 score was 52.2 ± 14.26 and the ROE score was 75.91 ± 11.91. After the photographs were shown, the DAS24 score was found to be 40.80 ± 13.25 and the ROE score as 87.722 ± 8.56. Therefore, significant improvement in DAS24 and ROE scores and an increase in patient satisfaction were observed after the preprocedure and postprocedure photographs were shown (p = 0.01, p < 0.05). Conclusion: Showing preprocedure and postprocedure photographs in the follow-up period to patients who underwent nonsurgical rhinoplasty leads to greater patient satisfaction with the surgery and their self-image.
Regulations to which dermal filler manufacturers must adhere so as to bring a product to market vary across the world. It is recognised that standards of the EU Medical Device Directive were inadequate, and, as a result of this, it is due to be replaced by the EU Medical Device Regulation (MDR) ( EU 2017 /745) on 26 May 2021. The EU CE mark will continue to be recognised in the UK until 30 June 2023. Typically, the more rigorous US Food and Drug Administration (FDA) process has been more trusted, but will this still be the case when the MDR comes into force? This piece contrasts and compares the new EU MDR and FDA regulation from an injector perspective.
Facial aging involves volumetric change, alteration of tissue quality, and the effects of long-standing facial muscular animation. These factors lead to soft tissue ptosis and static and dynamic rhytids. The traditional conept of beauty involves the “triangle of beauty” with high cheekbones and a defined jaw, whereas the “reverse triangle” or pyramid with flattened cheeks, drooping eyes, and jowling is considered unattractive. Facial rhytids can be classified as dynamic or static. Dynamic rhytids occur with muscle action and are best treated by specifically targeting facial muscles with botulinum toxin.
Introduction Pain is a common patient complaint during dermal filler injections. The primary objective of this study was to compare a new formulation of Juvéderm® injectable gel with lidocaine (denoted as JUV + L) to commercially-available Juvéderm® injectable gel without lidocaine (denoted as JUV) with respect to procedural pain scores in subjects desiring nasolabial fold (NLF) correction. Methods Subjects received randomized treatment with the lidocaine filler in one NLF and the filler without lidocaine in the other NLF. Investigators determined the appropriate formulation (Ultra or Ultra Plus) and volume of material to inject but were blinded as to which syringe contained lidocaine. Subjects rated procedural pain (pain during injection) using an 11-point scale within 30 min after receiving treatment in both NLFs and compared procedural pain between right and left NLFs using a 5-point scale. NLF severity was rated by both subjects and investigators before and 2 weeks after treatment. Results The mean difference on the procedural pain scale was 3.4 (P < 0.0001), and 93% of subjects found JUV + L to be less or slightly less painful than JUV. Improvement in NLF severity was comparable for both products. Common treatment site reactions (CTRs) of pain and tenderness were considerably less frequent for JUV + L than JUV while all other CTRs showed no statistically significant differences. Conclusion The dermal filler formulated with lidocaine is effective in reducing procedural pain during correction of facial wrinkles and folds while maintaining a similar safety and effectiveness profile to the filler without lidocaine.
Polyalkylimide is a nonresorbable, biocompatible polymeric filler that has been used for several years to treat soft tissue deficits. The literature has shown a minor complication rate. We noticed that complications typically appear several years after injection. To evaluate the complications reported after treatment with polyalkylimide. We describe a retrospective evaluation, reported by members and candidate members of the Dutch Society of Cosmetic Medicine, of complications after use of polyalkylimide. In total, 3,196 patients were treated, and 4,738 treatments were performed, from which 154 complications (patient complication rate 4.8%, treatment complication rate 3.3%) were reported. The most common complication was inflammation; other complications were hardening, migration, and accumulation of the product. In some patients, skin biopsy followed by histologic examination was performed. Treatments with polyalkylimide have been reported to give rise to complications years after treatment. Even though the study described is a retrospective evaluation, we consider an overall complication rate of 4.8%, the severity of the complications, and the difficulty in treating them too high a risk for a cosmetic treatment. The Dutch Society of Cosmetic Medicine advises against the use of polyalkylimide.
SUMMARY: The development of dark circles under the eyes is one of the early signs of periorbital aging, lending a fatigued and aged appearance to the face. Loeb, in 1961, used the term "nasojugal groove" to describe the concavity at the border of the eyelid and the cheek medially. Flowers, in 1969, first named this groove the "tear trough." In the present article, the author presents a detailed description of the anatomy and nonsurgical correction of this deformity. Nonsurgical correction of the tear trough deformity with hyaluronic acid is effective and safe and is associated with high patient satisfaction. The procedure offers both an adjunct to surgery and an alternative to it in some patients. It also provides an opportunity for global midfacial volume correction. Careful patient selection and attention to technique will minimize side effects.
To review our experience with the long-term orbitofacial complications of polyalkylimide 4% (Bio-Alcamid), including migration, infection, and recurrent swelling. A retrospective case series of 4 patients who received preperiosteal polyalkylimide 4% filler treatment: 3 patients received treatment to cheeks and/or nasolabial folds and 1 received treatment to the tear-trough region. All 4 patients were referred with delayed complications. Four patients presented with the unusual delayed complications of infection including abscess formation, migration of filler, recurrent swelling, and inflammatory nodules. Because of the hydrophilic and endoprosthetic nature of polyalkylimide 4%, migration of the product is unexpected. We hypothesise that in our patients, filler migration occurred after bimanual expression and/or manipulation of the product with disruption of the surrounding collagen capsule. Because removal of polyalkylimide 4% is only achieved via aspiration and bimanual expression, which itself may precipitate long-term migration of the product, it is vital that clinicians are mindful of these complications and the pitfalls of overfill and misplacement of the product, for informed patient consent.
Given the recent boom of the cosmetic industry, there is a wealth of new products available to patients and physicians, including soft-tissue fillers. Bio-Alcamid polyacrylamide gel (Polymekon, Milan, Italy) is a filler that has potential to cause adverse reactions. Two patients who had previously been treated with Bio-Alcamid outside of the United States presented with different manifestations of inflammatory responses to the product. These reactions were challenging to treat. Despite claims of safety, Bio-Alcamid and possibly other soft-tissue fillers available worldwide have the potential to cause adverse reactions. Physicians should be aware of the various presentations and treatment options for these reactions.
Bio-alcamid is one of the newest agents on the market for soft tissue augmentation. Seven studies were documented in the medical literature that examined the safety of Bio-alcamid (Polymekon, Brindisy, Italy); all reported no cases of tissue migration, foreign body granulomas, allergenicity, or interference with the control of cell proliferation. On 2 separate occasions, a woman who had recently undergone lip augmentation presented at our hospital with submucosal nodules of the lip. Histologic examination revealed multiple foreign body-type granulomas composed of giant cells, epithelioid cells, and chronic inflammation of the lip. Efforts to produce a cosmetic material that fulfills all the criteria as an "ideal" agent has not yet been found because all injectable foreign agents have the potential to induce adverse reactions. Caution must be exercised in all cases and the risks explained to the patient before its use.