MRI Manifestations of Facial Paralysis Following Retroauricular Hyaluronic Acid Injection.

BackgroundHyaluronidase is used as an adjunct or main treatment to manage complications associated with cosmetic hyaluronic acid (HA) filler injections such as necrosis, blindness, hypersensitivity, delayed nodules, and poor aesthetic outcomes.ObjectiveTo systematically map the available evidence and identify the gaps in knowledge on the effectiveness of hyaluronidase use in managing the aesthetic complications associated with HA injections (vascular occlusion, blindness, nodules, delayed hypersensivity, granuloma, poor aesthetic outcome).MethodsPubMed, Medline, Embase and Cochrane databases were used up to May 2022, to look for randomized clinical trials (RCTs), clinical trials, and retrospective case-control studies reporting on the use of hyaluronidase for managing the HA filler injection complications.ResultsThe database search yielded 395 studies; of those 5 RCTs (all carried out in the USA) were selected (53 subjects), indicating the effectiveness of hyaluronidase for removal of un-complicated injected HA nodules (forearm, upper arm, or back skin). The follow-ups ranged from 14 days to 4 years. The amount of HA filler injected into each site varied from 0.2 to 0.4 mL. A dose dependent response was observed for most HA fillers. No major adverse reactions were reported. Overall, for removal of every 0.1 mL of HA filler they injected 1.25–37.5 units of hyaluronidase (single injections). When 3 consecutive weekly hyaluronidase injection was used much lower doses of 0.375–2.25 unit was utilised. There was no evidence in a form of RCTs, clinical trials, and retrospective case-control studies on the removal/reversal of HA injections in the facial skin, or management of over-corrections, inflammatory nodules, or tissue ischemia/necrosis associated with HA filler injection.ConclusionBased on studies on the forearm, upper arm and back skin, hyaluronidase can be used for the reversal of uncomplicated HA filler injection nodule. However, further adequately powered studies are warranted to establish the ideal treatment protocol/dose of hyaluronidase for reversal of HA filler injections in the facial region or management of complications associated with aesthetic HA injection.Level of Evidence IIIThis 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) filler injections have increased in popularity. They are usually performed in combination with other treatment modalities, including lasers and energy-based devices, to enhance cosmetic results. Theoretically, HA and other filler injections should be performed after laser- or energy-based device treatments. In some instances, however, practitioners are asked to administer laser- or energy-based device treatment after HA dermal filler injection. There is a concerning possibility of HA filler degradation as a result of bulk heating generated by lasers or energy-based devices, especially radiofrequency (RF). To evaluate the effect of RF treatment at different time points on HA degradation in vivo, using clinicohistological analysis. Fourteen volunteers were recruited and received intradermal HA filler injections in four sites on the abdomen. One site served as the control, and the other three sites were treated with monopolar RF on the same day after injection, at 14 and 28 days post-injection. Skin biopsies were performed at baseline and 56 days after HA injection. Histopathological sections were reviewed for residual filler in the tissue. The results showed that HA grading scores decreased in five (35.71%), one (7.14%), and one (7.14%) participants when RF was performed immediately, 14 and 28 days after injection, respectively. In conclusion, RF treatment after HA filler injection may affect the integrity of the HA filler in the tissue, especially if RF treatment was performed on the same day after HA injection.

Larger earlobes, which are a symbol of "richness" in traditional Chinese culture, are favored by Chinese patients. The objective of this paper is to investigate the application of earlobe augmentation with hyaluronic acid (HA) filler injection and its clinical effects in the Chinese population. A total of 19 patients (38 ears) who received earlobe augmentation with HA filler injections between March 2013 and March 2015 were included. The clinical effects, duration, and complications of these cases were investigated. All patients who received earlobe HA injections showed immediate postoperative effects with obvious morphological improvement of their earlobes. The volume of HA filler injected into each ear was 0.3-0.5ml. The duration of the effect was 6-9months. Two of the 19 cases (3 ears) demonstrated mild bruising at the injection site, but the bruising completely disappeared within 7days after the injection. No vascular embolism, infection, nodule, or granuloma complications were observed in the studied group. The application of earlobe augmentation with HA filler injection is a safe, effective, simple procedure for earlobe shaping. It has an easy clinical application with good clinical prospects. 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 .

Microfocused ultrasound (MFU) and hyaluronic acid (HA) filler injection are increasingly popular aesthetic procedures. HA filler injection is generally recommended after MFU if combined treatment is required in a single visit. However, data regarding the safe and optimal time of MFU treatment after HA injection is still limited. The purpose of this study was to evaluate the degree of HA loss when performing MFU treatment after dermal filler injection. Fourteen subjects were recruited in this pilot study. HA was injected intradermally on four 2 × 2cm areas at the abdomen (0.25 ml/site). Site A was served as control whereas site B, C, D were treated with MFU using 1.5 mm transducer at 60 min, Day 14, and Day 28 after the injection, respectively. All experimental sites were biopsied using a 3-mm punch biopsy to evaluate the histopathological profile at baseline and Day 56. Grading of the quantity of retained HA was evaluated by a blinded experienced dermatopathologist. All 14 subjects completed the study. One subject has been excluded due to the poor quality of histopathologic slides. Seven subjects (53.9%) at site B and 6 subjects (46.2%) at site C had HA loss at Day 56 compared with baseline. The mean HA grading at baseline and Day 56 was 3.7 vs. 2.8 (p < 0.001) at site B and 3.7 vs. 3.0 (p=0.001) at site C, respectively. There was no statistical difference between the mean HA grading at baseline and Day 56 at site D (3.7 vs. 3.3, p=0.073). No inflammation or granuloma was observed on Day 56 of the study. MFU treatment after HA injection appears to be safe. However, some degree of HA loss was observed if MFU treatment was done within 2 weeks after HA injection.

Injection of hyaluronic acid (HA) filler for nasolabial fold (NLF) correction is a popular aesthetic procedure. In relation to HA filler injections, effective pain control for patient comfort is an important concern. We compared the pain relief achieved by HA filler with 0.3% lidocaine (HAF-Lidocaine) with that achieved by HA filler without lidocaine (HAF) for NLF correction. A total of 62 subjects with visible NLFs were enrolled in this double-blind study at two university hospitals and injected with HAF-Lidocaine and HAF, randomly assigned to the each NLFs. Subjects assessed pain using the visual analog scale (VAS). Blinded independent dermatologists assessed the Wrinkle Severity Rating Scale (WSRS) and subjects assessed the Global Aesthetic Improvement Scale (GAIS) for the evaluation of effectiveness. All adverse events during the follow-up period were recorded. Immediately after treatment, 95.2% of subjects who were treated with HAF-Lidocaine reported reduced pain when compared with those who were treated with HAF and the mean VAS score difference was 38.6mm. At 15, 30, 45, and 60minutes after treatment, respectively, 67.7%, 41.9%, 32.3%, and 21.0% of subjects experienced reduced pain. Based on the mean WSRS and GAIS scores and the incidence of local injection site reactions, the clinical effectiveness and safety profile of HAF-Lidocaine were comparable to those of HAF. We conclude that HA filler containing pre-incorporated lidocaine could reduce pain in Korean patients for NLF correction, and the addition of lidocaine does not affect the effectiveness and safety of HA filler.

Submental fullness, commonly referred to as a double chin, is a frequent aesthetic concern influenced by subcutaneous fat accumulation and underlying skeletal structure. High-intensity focused ultrasound (HIFU) and hyaluronic acid (HA) filler injection have each been used as minimally invasive treatment options; however, reports on their combined use remain limited. We report two Asian female patients with mild to moderate submental fullness who were treated with a sequential combination of linear HIFU and HA filler injection in routine clinical practice. One patient underwent HIFU followed by HA injection, whereas the other received HA injection prior to HIFU treatment. Both patients demonstrated improvement in submental contour, cervicomental angle, and chin projection during follow-up, with results maintained at 24weeks. Patient satisfaction was high, treatment-related discomfort was minimal, and no immediate or delayed adverse events were observed. Although limited by the small number of cases, these observations suggest that a combined approach using HIFU and HA filler may represent a well-tolerated, minimally invasive option for selected patients with submental fullness.

The use of hyaluronic acid (HA) fillers in oncology patients undergoing PET-CT scans is a topic of debate due to potential interference with imaging accuracy. A 54-year-old female, postmelanoma metastasectomy in the parotid region with subsequent facial nerve palsy (FNP), received HA filler injections for facial symmetry and functional restoration. Follow-up PET-CT scans showed no interference or artifacts attributable to HA injection, allowing for accurate imaging results. This case suggests that HA fillers administered in oncology patients may not universally pose challenges or disrupt PET-CT imaging interpretation. Due to the possible false positives induced by fillers, the inclusion of aesthetic treatments in patients' anamnesis is a crucial step to accurately interpret PET-CT images. Although maintaining high level of caution in interpreting PET-CT results after filler injection is essential, our case emphasizes the safety of this procedure in oncology patients undergoing follow-up PET-CT scans.

(232) A Novel Dual-Zone Injection Protocol Using Hyaluronic Acid for the Treatment of Premature Ejaculation

Vascular embolism is a severe complication following hyaluronic acid (HA) filler injections, with hyaluronidase injection being the most effective treatment. The nasal region, including the nose and nasolabial fold, is the most common site of vascular embolism after facial HA injections. Currently, there is insufficient clinical evidence regarding the benefits of facial artery thrombolysis. This article aimed to evaluate the efficacy of hyaluronidase injection via the facial artery as an emergency treatment for vascular embolism induced by facial aesthetic HA fillers. We reviewed 14 patients who experienced nasal vascular embolism following facial HA filler injections. All 14 patients underwent percutaneous facial artery thrombolysis with a combination of hyaluronidase and urokinase administered intravascularly. For patients with longer occlusion duration and severe necrosis, femoral artery interventional thrombolysis was performed, with local injection of platelet-rich plasma to promote recovery. Follow-up ranged from 1 month to 1 year. Following facial artery hyaluronidase injection, all cases showed improvement in nasal skin lesions. Twelve patients fully recovered, while 2 patients were left with minor superficial scars and defects in the nasal wings. Early thrombolysis postnasal embolism is crucial, and percutaneous facial artery puncture is an effective emergency treatment. Arterial intervention targeting the facial artery in the nasolabial fold may offer more precise thrombolysis. The combined use of hyaluronidase and urokinase is both safe and effective.

Vision loss is a serious complication of hyaluronic acid (HA) filler injections, and long-term observations regarding the prognosis, particularly with angiography, are rare. This study aimed to investigate the long-term prognosis and living status of patients with visual defects due to HA filler injections. Nine patients with vision loss caused by HA filler injections and receiving different treatments were included and followed up for 2 to 6 years after their accident. Follow-ups, including outpatient ophthalmologic examinations, were performed. In the follow-up observation, all patients had reintegrated into society and work. The prognosis was similar for all hyaluronidase treatments, including retrobulbar injections and superselective ophthalmic artery thrombolysis. The facial appearance was not remarkably affected, and only 3 patients reported slight scarring. Ptosis disappeared in all the patients, and slight strabismus was found in 5 patients. However, vision improvement was very limited, even in the patients whose occluded retinal central artery received reperfusion. This long-term follow-up showed that the patients with vision loss caused by HA filler injections could reintegrate into society after treatment. Although the embolization of the retinal central artery led to reperfusion, vision was not restored, which further demonstrated the difficulty of recovering vision with the current treatment and the importance of prophylaxis. Autohydrolysis of HA by incorporating hyaluronidase-containing stimuli-responsive nanoparticles and a dual-pipe syringe are potential future approaches to address this catastrophic event.

Hyaluronic acid (HA) filler is an important dermatological procedure. Although many studies have reported clinical improvement with this procedure, histology with morphometric evidence is not well documented. To evaluate the clinical and histological results of a HA filler injection and to quantify dermis remodeling at 3 and 9 months after HA injections into aged faces. Twenty patients were enrolled in this study. Hyaluronic acid filler was injected into the nasolabial folds and preauricular regions of the patients. Skin biopsies of the preauricular regions were performed before the procedure and at 3 and 9 months after the procedure. Sixteen women (aged 40-50 years) completed the clinical study and demonstrated improvement for 12 months. Twenty patients completed the histologic studies. Morphologic evaluation showed increases in the epidermal layers. The morphometric study showed a statistically significant increase in collagen fibers at 3 and 9 months after the procedure (34.2% ± 31.5% and 39.5% ± 39.7%, respectively, p < .05). Sustained clinical results for HA filler can be explained not only by the presence of HA gel on the dermis but also by the dermal remodeling induced by HA filler injected into the face.

Large and long ears are regarded as symbols of wealth and health in East Asian culture, and people with lying ears often want their ears to be more exposed and prominent. Surgeries to correct lying ears have been documented. The aim of this study was to report the correction of lying ears and the aesthetic modification of helix and ear lobule with hyaluronic acid (HA) injections. HA injections were performed at the auriculocephalic sulcus to increase the cranioauricular angle (CA) and correct lying ears. The injections at helix and lobule were case specific. The CA was measured and photographs were taken at baseline and at 1-, 3-, 6-, and 10-month follow-ups. Efficacy was assessed with the 5-point Global Aesthetic Improvement Scale (GAIS). Adverse events were recorded. Forty-six patients (92 ears) received HA injections and completed follow-ups. Instant correction outcomes were observed. Sixteen (34.8%) patients received 1 touch-up injection, the clinical efficacy of which persisted for 1 to 1.5 years. For over 90% of cases with touch-up treatment the GAIS was "very much improved" or "much improved" at all follow-ups. The GAIS for over 70% of cases without touch-up treatment was "very much improved" or "much improved" at 1-, 3-, and 6-month follow-ups. CA increased significantly compared with the baseline. Patients also reported "more V-shaped face shape" and "lifted jawline" effects. No serious adverse events occurred. As an alternative technique to surgeries, HA filler injections at the auriculocephalic sulcus effectively corrected lying ears. This technique produced immediate, long-lasting, and aesthetically pleasing results. The side effects and downtime were minimal.

A Comparison Between Hyaluronic Acid and Polylactic Acid Filler Injections for Temporary Penile Augmentation in Patients with Small Penis Syndrome: A Multicenter, Patient/Evaluator-Blind, Comparative, Randomized Trial

PENILE GIRTH ENHANCEMENT WITH HYALURONIC ACID INJECTION: A SINGLE-CENTER STUDY

Background:Initial and early swelling post injection of hyaluronic acid (HA) filler are considered to affect outcomes and complications in patients; however, the contribution of HA filler type to swelling postinjection remains undetermined. Here, initial and early swelling post injection of HA fillers manufactured via different crosslinking technologies was evaluated in mice.Methods:Mice received injections of HA fillers or controls: High Concentration Equalized (HICE), Stabilized High Concentration Equalized (S-HICE), High molecular Ideal, VYCROSS, NASHA, HICE control, non-HICE control, or no HA control. Initial and early swelling were evaluated via magnetic resonance imaging and collagen deposition via histological evaluation over 28 days.Results:Mice (N = 65) were allocated to 13 groups (per group, n = 5) to receive subcutaneous injections of HA filler or control. Maximum swelling in descending order was High molecular Ideal, 290%; non-HICE control, 256%; VYCROSS 1, 249%; S-HICE 2, 248%; S-HICE 1, 238%; S-HICE 3, 226%; VYCROSS 2, 210%; HICE 1, 203%; HICE 2, 184%; NASHA 1, 174%; HICE control, 159%; NASHA 2, 148%; and no HA control, 100.0%. The mean (SD) collagen area in the residual substance ranged from 2525 (3612) µm2/HPF (high-power field [×400]) for NASHA 2 to 18,870 (4544) µm2/HPF for S-HICE 2. The mean (SD) collagen area around the substance ranged from 9879 (2923) µm2/HPF for VYCROSS 1 to 15,248 (7005) µm2/HPF for S-HICE 3.Conclusions:HA fillers manufactured via different crosslinking technologies may lead to different levels of initial and early swelling and collagen stimulation over 28 days.