Dermal Filler Injections Research Articles

Complications of toxins and fillers in facial aesthetics.

Dermal filler and botulinum toxin injections are among the most performed non-invasive procedures for rejuvenation and contouring, internationally. Although most dermal fillers and approved botulinum toxins are well tolerated with a high safety profile, adverse events and/or complications can happen. Injection-related sequelae and side effects are usually rare, mild, transient, and self-limiting in nature. However, devastating and life-changing complications, such as intravascular occlusion, skin necrosis, permanent visual impairment, and stroke, have been reported. Risk reduction measures include an in-depth knowledge of anatomy, physiology, and pharmacology, correct patient selection, correct identification of clinical indications, and, fundamentally, the importance of appropriate skill and training. In this paper, some of the complications are discussed and advice on how to minimise adverse events and complications from these injectables is provided.

Needleless laser injector versus needle injection for skin enhancement and rejuvenation effect of dermal filler.

A needleless laser-induced microjet injector is a novel transdermal drug delivery system that can rapidly inject a very small and precise drug dose into the skin with minimal pain and downtime. In this study, we aimed to compare the laser-induced microjet injection versus needle injection of polylactic acid/hyaluronic acid filler for skin enhancement and rejuvenation. A 24-week prospective, single-center,assessor-blinded,randomized, split-face study was conducted. The enrolled patients underwent one treatment session of dermal filler injection using a laser-induced microjet injector on one half of the face or a traditional needle injection on the other half of the face. Evaluation was conducted at baseline before treatment and at 4, 12, and 24 weeks after treatment. A single treatment of filler injection with a laser-induced microjet injector resulted in similar improvements in skin hydration and elasticity as a single treatment of filler injection by using manual needle injection, with reduced pain, side effects, and decreased treatment time. Laser-induced microjet injector enabled not only the application of a controlled dose and filler depth but also even distribution, improved clinical efficacy, reduced pain and side effects, and sufficient time for clinicians to perform treatment.

A Critical Literature Review Analysing the Evidence Base for the Efficacy of Aspiration Prior to Injection of Dermal Filler as A Safety Measure to Reduce the Risk of Vascular Complications

A Critical Literature Review Analysing the Evidence Base for the Efficacy of Aspiration Prior to Injection of Dermal Filler as A Safety Measure to Reduce the Risk of Vascular Complications

Filler Migration after Facial Injection—A Narrative Review

Background: The injection of dermal fillers for facial esthetics has become a very popular procedure. Although usually safe in the hands of the experienced user, filler injections may bear a risk of unwanted side effects. Material and Methods: This is a narrative review of dermal filler migration after facial injections. We performed research on the literature on Pubmed and Google Scholar. Inclusion criteria were observational studies, case reports, and clinical trials which investigated the association of facial filler injections to filler migration. Animal studies have not been considered. Intravascular injections were excluded. Results: We identified 28 reports that met the inclusion criteria. The age range of affected patients was 21 to 86 years (mean ± standard deviation: 47 ± 14.8 years). Women were 25 times more reported than males. Hyaluronic acid and polyalkylimide were the most commonly encountered filler substances. Injections into the nose, lips, nasolabial folds, and forehead (including glabella) are more often reported for filler migration than injections into the cheeks. Tear-trough correction bears a risk for orbital migration. The delay from injection to presentation of filler migration was highly variable. Very late filler migration was more commonly seen with permanent fillers than non-permanent products. Conclusions: Filler migration distant from the injection site can occur even several years after the primary treatment. All filler types can be involved. Permanent fillers bear a higher risk of very late filler migration. Migration of permanent fillers needs surgical treatment, while HA fillers respond to hyaluronidase injections. Detailed knowledge of facial anatomy, safer injection techniques, and filler qualities are preventive measures.

Safety and efficacy of hyaluronic acid injectable filler in the treatment of nasolabial fold wrinkle: a randomized, double-blind, self-controlled clinical trial

IntroductionThe injectable skin fillers available for soft tissue augmentation are constantly growing, providing esthetic surgeons with more options in the treatment of scars, lines, and wrinkles. Hyaluronic acid (HA)-derived injectable fillers are ideal to reduce the appearance of nasolabial folding. This study investigated the efficacy and safety of the commercially available HA filler from Maxigen Biotech Inc. (MBI-FD) in the treatment of nasolabial folds (NLFs).MethodsWe analyzed 1,4-butanediol diglycidyl ether (BDDE) residues and injection force test and observed the protein content in MBI-FD, and then was cultured in fibroblast L929 cells and examined for cytotoxicity. Finally, 95 healthy participants underwent dermal filler injection therapy to evaluate the efficacy and safety for 24 and 52 weeks, respectively.ResultsBDDE residues in MBI-FD was <0.125 µg/mL. MBI-FD was fitted using 27- and 30-G injection needles with an average pushing force of 14.30 ± 2.07 and 36.43 ± 3.11 N, respectively. Sodium hyaluronate protein in MBI-FD was 7.19 µg/g. The cell viabilities of 1× and 0.5× MBI-FD were 83.25% ± 3.58% and 82.23% ± 1.85%, respectively, indicating MBI-FD had no cytotoxicity, and decreased NLF wrinkles with no serious adverse events.ConclusionMBI-FD is an effective filler for tissue augmentation of the NLFs and may be a suitable candidate as an injectable dermal filler for tissue augmentation in humans in the future.

Efficacy of Pegylated Hyaluronic Acid Filler Enriched with Calcium Hydroxyapatite: A 24-Week Post-Market, Observational, Prospective, Open-Label, Single-Center Study.

Recently, thanks to the greater discovery of the mechanisms of facial aging, an alternative to invasive plastic surgery has found space with less invasive aesthetic procedures, also based on an increasingly pressing request. We are specifically referring to dermal filler injection into or under the skin which leads to immediate rejuvenation and aesthetic improvements. In this study, we wanted to analyze the results obtained through the use of NEAUVIA Organic Stimulate, particularly with regard to its effectiveness, which is a cross-linked polymeric hydrogel, containing stabilized sodium hyaluronate 26 mg/mL and calcium hydroxyapatite (1%), glycine and L-proline in buffer pyrogen-free water, in its main indication, namely, the temporary correction of congenital and acquired deficiencies of the soft tissues of the face by intradermal injection. Initially, 70 patients were enrolled, but 10 did not complete the study due to non-observance of the investigation rules, so they were excluded from the protocol. The collected data demonstrate an efficient mechanical effect of the pegylated polymeric acid matrix enriched with low concertation of calcium hydroxyapatite and in accordance with other evidence in vitro and in vivo, and the mechanical support of the interstitial connective space improves the homestays of the anatomical layer rebalancing the physiological activity of the dermis cells.

TREATMENT OF POSTACNE USING THE COMBINATION OF TRICHLOROACETIC PEELING AND HYALURONIC IMPLANT: A CLINICAL CASE

Aim: to evaluate the efficiency of post-acne treatment using the combination of trichloroacetic peeling and a hyaluronic acid implant. Peeling with trichloroacetic acid belongs to the category of medium peels that penetrates the epidermis and reaches the basal membrane - the border between the epidermis and the dermis. Sometimes the papillary layer of the dermis is also burned out. Fillers are injectable dermal fillers that are widely used to correct cosmetic defects. The prescribed combination of peeling and hyaluronic acid gives a good therapeutic effect, since trichloacetic acid eliminates persistent defects (dyschromia, scars), creates a uniform color, and hyaluronic acid fills in atrophic changes and moisturizes the skin. Results: we present a clinical case where acne scars were corrected with a course of the systemic retinoids followed by TCA peeling and hyaluronic acid filler. The treatment enables to reduce the size of atrophic scars, makes skin smoother and evens the skin tone. Conclusion: This clinical case can be interesting for dermatologists, since it confirms the efficiency of using hyaluronic acid fillers and TCA peeling in post-acne therapy.

Adverse Events Reported From Hyaluronic Acid Dermal Filler Injections to the Facial Region: A Systematic Review and Meta-Analysis.

Dermal filler injections are one of the most popular cosmetic procedures in the United States. Of the many options available, hyaluronic acid (HA) dermal fillers like Juvederm or Restylane are often used. Despite their use and popularity, adverse events are known to occur from these procedures. Although most outcomes may be mild and resolve over time, rare instances of severe complications cannot be ignored, as these effects may be irreversible. Healthcare practitioners and patients must be aware of these risks, as these cosmetic procedures can affect the patient's quality of life. The aim of this study was to evaluate the incidence of adverse events (AEs) reported from the use of hyaluronic acid dermal fillers in the facial region. A systemized search of randomized controlled trials was conducted using Cochrane Central, Embase, Medical Literature Analysis and Retrieval System Online (MEDLINE), and the Web of Science databases. After screening for eligibility and conducting a critical appraisal of the articles, 19 studies were retained for the final review. The meta-analysis results included different side effects by facial location, i.e., nasolabial fold(NLF) vs. other (midface, perioral line, and lipregion). The midface includes the anteromedial cheek region, the zygomaticomalar region, and the submalar region. The adverse eventswere swelling, pain, erythema, bruising, lumps and bumps, firmness, tenderness, itching, and skin discoloration. A significant difference was found in the proportion of individuals experiencing swelling, lumps or bumps, and firmness at the nasolabial fold site versus the midface, perioral line, and lipregion. There was no significant difference in the proportion of individuals experiencing pain, erythema, bruising, tenderness, itching, or skin discoloration at the nasolabial fold site versus the other sites. The study highlights the prevalence of common AEs that can result from HA dermal fillers like Juvederm or Restylane, thus emphasizing the importance of healthcare professionals explaining the risk and benefits to patients.

Permanent fillers—What is their role

AbstractBackgroundWith the growing cosmetic industry, there have been numerous advancements in nonsurgical interventions including the use of permanent dermal filler injections. Permanent fillers are relatively novel in clinical use when compared to temporary and semi‐permanent fillers. The only FDA‐approved, non‐biodegradable permanent filler uses polymethylmethacrylate (PMMA) microspheres. PMMA is suspended in bovine collagen and lidocaine solution for injection, absorbed by the body, and replaced overtime by collagen. ArteFill® was the first FDA approved permanent filler in 2005 for correction of nasolabial folds, with studies demonstrating rejuvenation for up to five years, trumping its predecessors in longevity. A decade later with rebranding, Bellafill® was indicated for correction of nasolabial fold and atrophic acne scars.AimsTo review the development of permanent fillers, mechanism, and safety.Materials &amp; MethodsA qualitative systematic review was conducted on PMMA microspheres indications, contraindications, and off‐label use on benefits, risks, and adverse events.ResultsThe durability of permanent fillers has a strong appeal for both patients and practitioners, however, usage for certain patient populations demonstrates increased risk for both early and late complications compared to temporary and semi‐permanent fillers. A skin test composed of purified 3.5% bovine collagen gel administered in the volar forearm is recommended one month prior to injection, to identify any patients who may have a positive response. Bovine collagen demonstrates low immunogenicity with the incidence of preexisting hypersensitivity reported to be between 2‐4%. Bovine collagen in dermatologic formulations use pepsin‐solubilized formulations in which telopeptides are cleaved to further help reduce aberrant immunogenic responses.DiscussionEarly and late complications may outweigh the benefits in use of permanent fillers, however these complications are patient dependent.ConclusionPermanent fillers may be useful in volume replacement for nasolabial folds and atrophic acne scars, however a provider must use good clinical judgement in deciding which patients are ideal candidates.

Virtual Reality and Augmented Reality in Plastic and Craniomaxillofacial Surgery: A Scoping Review.

Virtual reality (VR) and augmented reality (AR) have evolved since their introduction to medicine in the 1990s. More powerful software, the miniaturization of hardware, and greater accessibility and affordability enabled novel applications of such virtual tools in surgical practice. This scoping review aims to conduct a comprehensive analysis of the literature by including all articles between 2018 and 2021 pertaining to VR and AR and their use by plastic and craniofacial surgeons in a clinician-as-user, patient-specific manner. From the initial 1637 articles, 10 were eligible for final review. These discussed a variety of clinical applications: perforator flaps reconstruction, mastectomy reconstruction, lymphovenous anastomosis, metopic craniosynostosis, dermal filler injection, auricular reconstruction, facial vascularized composite allotransplantation, and facial artery mapping. More than half (60%) involved VR/AR use intraoperatively with the remainder (40%) examining preoperative use. The hardware used predominantly comprised HoloLens (40%) and smartphones (40%). In total, 9/10 Studies utilized an AR platform. This review found consensus that VR/AR in plastic and craniomaxillofacial surgery has been used to enhance surgeons' knowledge of patient-specific anatomy and potentially facilitated decreased intraoperative time via preoperative planning. However, further outcome-focused research is required to better establish the usability of this technology in everyday practice.

Lawsuits after dermal filler injection registered in the state Court of São Paulo

The search for aesthetic procedures in the health sector have increased in the last years. The increase in the number of procedures brought together a higher number of lawsuits, especially when it comes to the injection of dermal fillers. This study aimed to revisit the jurisprudence of the State Court of São Paulo, Brazil, to investigate the risk factors behind the lawsuits and convictions of health care professionals after the injection of dermal fillers. The sample consisted of 46 lawsuits published between 2000 and 2022 in the State Court of São Paulo, Brazil. Data extracted from each lawsuit were: the year of publication, the reason behind the lawsuit, the defendant (individual or legal entity), sex of the plaintiff, type of dermal filler, whether there was a technical legal/forensic examination of the case and conviction. Most of the lawsuits were published between 2020 and 2022 (n = 26, 56.52%). The presence of intercurrences was the most common reason behind the lawsuits (n = 27, 58.69%). The defendants were mostly health care providers (n = 16, 34.78%), individually, and their combination with legal entities (n = 16, 34.78%), separately (the rest was legal entities alone). Female plaintiffs were predominant (n = 36, 78.26%), as well as the use of hyaluronic acid as dermal filler (n = 35, 76.08%). Technical legal/forensic examination was registered in 34 lawsuits (73.91%). Most of the defendants were convicted (n = 25, 54.34%). The chance of conviction was 3,9 times higher if the case was judged between 2017-2019 compared to 2020-2022 (p = 0.05); and 3,4 times higher if the case was based on intercurrences (p = 0.05). It is estimated that convictions in lawsuits after dermal filler injections might decrease in more recent cases. However, higher chances of conviction might be expected in the presence of intercurrences (e.g. accidents or complications) in the State São Paulo, Brazil.

How an Automated Patient Education Module Improves Patient Outcomes and Informs Quality-of-Care Measures for Providers Within a Minimally Invasive Aesthetic Practice.

I conducted a quality improvement project to determine whether providing patient education before consultation and treatment would help meet the needs of aesthetic patients and providers. The project objective was to create an automated patient education module that provided consistent, accurate information to each patient who viewed it and would give the providers additional time to treat the patient and generate revenue. Before and during the 6-week study period, I administered three surveys and reviewed electronic health records metrics indicating patient check-in and check-out times and facility revenue. I used descriptive statistics to examine the demographics of the patients included in the study. I analyzed check-in and check-out times and facility revenue by conducting two-tailed Mann-Whitney U tests. There were a total of 201 patient visits in the 6-week period before the study and a total of 316 patient visits during the study period. Most patients were White, married women, 50- to 59-years-old, with at least some college education. The most common treatments administered were neurotoxin and dermal filler injections. After implementing the preappointment education, I found a significant reduction in the length of patient appointments (p < .001) and a significant increase in facility revenue (p < .037). I concluded that after implementing the education program, patient understanding about the intended treatment was improved. To better correlate how preappointment automated education impacts the amount of time the provider spends with patients and influences practice revenue, I recommend conducting a longer study with a greater number of patients.

Treatment of Striae Distensae with Filler Injection: A Systematic Review.

Stretch marks, also known as striae cutis distensae (SD), are visible linear scars that occur in regions of dermal damage due to skin stretching. Stretch marks are not serious health issues, but they may have a major psychological effect on patients. Due to poor skin color improvement or prolonged skin atrophy, there is no standard treatment for SD. Fillers have been studied for their effectiveness in the treatment of SD. This systematic review aims to determine the efficacy of fillers onSD. This systematic review is reported following PRISMA guidance. We included all relevant articles published up to November 2022 in the following electronic databases: Science Direct, Midline, the Web of Science, CINAHL, and Google Scholar. The initial search yielded 119, of which seven were included after applying inclusion and exclusion criteria. The systematic review included a total of 184 female participants who were over the age of 18 years old. Three studies used jet volumetric remodeling (JVR) to inject HA pneumatically. One study injected polycaprolactone filler. One study used calcium hydroxylapatite, micro-needling, and ascorbic acid. MFU-V and CaHA were given in one study. One study delivered MFU-V using micro-focused ultrasound. All studies showed that it reduces SD with only mild, temporary side effects. More favor was given to combining CaHA and MFU-V, which had the fewest side effects compared to other dermal fillers. As monotherapy or combination therapy, injectable dermal fillers may treat SD with minimal adverse effects. We suggest that more RCTs look into injectable dermal filler to find out what is best for patients with SD and compare it to other treatment methods in terms of results, costs, and side effects to provide satisfactory practice and basic guideline interventions for these cases.

Vascular occlusion

Adverse vascular events (AVEs) are unequivocally the most feared complication resulting from injection of dermal filler. The potentially life-changing consequences, which include tissue necrosis, scarring, blindness, stroke and even death, are not always understood by clients seeking aesthetic intervention; however, these events can occur, even in the most experienced hands and injectors must acknowledge that the risk is impossible to eliminate completely. Detailed history taking, careful patient selection, in -depth understanding of vascular anatomy (and its variability) and safe injection technique should be practi sed in order to minimi se risks; early diagnosis and immediate action taken when an AVE occur s and clients should be appropriately counselled as part of the informed consent process of this possibility in advance of their procedure.

Algorithmic Approach to Management of Complications of Permanent Facial Filler: A Saudi Experience.

Twelve participants were presented to the service through emergency or as outpatient from November 2015 to May 2021. Demographic characteristics such as age, sex, date of injection, time of onset, and types of complications were collected. After examination, all cases were managed based on an algorithm established. FACE-Q was used to measure overall satisfaction and psychological well-being. An algorithm to diagnose and manage these patients effectively with high satisfaction rate was established in this study. All participants were non-smoking women, with no known medical comorbidities. The algorithm determined the treatment plan when faced with complications. Results revealed high appearance-related psychosocial distress before surgery, which significantly dropped after surgery. FACE-Q was able to establish evidence of satisfactory rating among patients before and after surgery. This treatment algorithm can guide the surgeon in formulating a suitable plan with less complications and high satisfaction rate.

Precision diagnosis and treatment of vaso-occlusive complications from injectable dermal fillers: Evolving role for ultrasound guidance

Precision diagnosis and treatment of vaso-occlusive complications from injectable dermal fillers: Evolving role for ultrasound guidance

Revitalizing Hands: A Comprehensive Review of Anatomy and Treatment Options for Hand Rejuvenation.

Dorsal hand rejuvenation is gaining popularity as a solitary procedure and adjunct to face and neck rejuvenation treatments. As the hands age, the skin loses elasticity and becomes more translucent, the veins, joints, and tendons appear more prominent, and the bones become more noticeable. These changes are due to intrinsic and extrinsic factors. Current treatment methods include the injection of dermal fillers and autologous fat grafting. Anatomic studies to ensure the successful implementation of rejuvenation procedures identified three separate fascial layers in the dorsum, from superficial to deep. More recent re-evaluations revealed a less distinct, inseparable, sponge-like fascial layer. All authors agree that the superficial dermal layer is probably the optimal location for the injection of volumizing materials because it is free of anatomical structures. Many methods for harvesting, preparing, and injecting fat grafts to the dorsum of the hand have been described in the past three decades. Both filler and fat-graft procedures are performed on an ambulatory basis under local anesthesia. Good results with low postoperative and long-term complication rates and high patient satisfaction have been reported.

Iatrogenic ophthalmic artery occlusion after platelet-rich plasma dermal filler documented with ultra-widefield imaging.

To report a case of iatrogenic ophthalmic artery occlusion (OAO) secondary to platelet-rich plasma (PRP) dermal filler injection for facial rejuvenation documented with ultra-widefield imaging. Case report. A 45-year-old woman developed a sudden and painful vision loss in the left eye (LE) after a dermal filler injection of PRP in the left glabellar region. She immediately received intravenous corticosteroids with no improvements. Two weeks later a complete ophthalmological examination including visual acuity (VA), fundus examination, ultra-widefield fundus autofluorescence and fluorescein angiography, and optical coherence tomography was performed. A diagnosis of iatrogenic OAO in the LE with profound ocular ischemia was made and VA remained no light perception. Monthly follow-up visits were scheduled to ascertain the onset of any ocular complication. Dermal filler injections of PRP can lead to rare but devastating side effects with permanent visual loss. Considering that there is currently no validated treatment strategy, prevention could be the real key of iatrogenic OAO management.

Anatomic evaluation of the normal variants of the arteries of face using color Doppler ultrasonography: Implications for facial aesthetic procedures.

Knowledge of normal facial vascular variations could prevent catastrophic complications of cosmetic procedures as well as providing a guide for surgical planning. Color Doppler ultrasound is a safe and noninvasive method for real time vascular evaluation. The aim of this study was to evaluate the normal variations of the facial, angular, transverse facial, supratrochlear and supraorbital arteries in a sample of normal individuals. Normal individuals referred for dermal filler injection to the tertiary dermatologic center, were selected. Patients who were smoker or had a history of facial filler injection, facial surgery, or trauma were excluded from the study. Facial artery at three levels as well as angular, supratrochlear, supraorbital, and transverse facial arteries were evaluated by an 18 MHz ultrasound linear probe regarding their distance from facial reference lines and landmarks, and also their depths in various regions of face. A total number of 43 individuals were evaluated in this study. Thirty-one (72.1%) were women. The number of absent facial artery was zero in level one, three (3.48%) in level two, and nine (10.46%) in level three. The angular artery was absent in 10 (11.62%) participants. The transverse facial artery was absent in 27 (31.39%) assessed individuals. Distance from reference lines at level 2 and 3 of facial artery and its depth at level 2 were significantly different between left and right side (p-values: <0.001, 0.01, and 0.03, respectively). No significant difference was seen between depth and distance of two sides for angular and transverse facial arteries. The comparison of the depths and distances from the reference lines of the assessed arteries between two sexes revealed only a significantly greater value of facial artery distance in level 1 in males (p-value: 0.001). BMI was also significantly correlated with the depth of facial artery in level 2 (Pearson correlation coefficient=0.471, p-value=0.002) and level 3 (Pearson correlation coefficient=0.357, p-value=0.03) and the distance of the facial artery in level 1 (Pearson correlation coefficient=0.333, p-value=0.029). Color Doppler ultrasound could be used to map the arteries of face to prevent vascular complications and safely guide cosmetic procedures.

Infraorbital mass long after dermal filler injection: A report of two cases.

Hyaluronic acid fillers have been increasingly used throughout the world in the management of aging skin in the periocular region and other areas. To evaluate very late-term orbital mass formation secondary to Hyaluronic acid filler injection into the inferior eyelid. We report two cases that presented with a subcutaneous palpable mass localized at the right medial lower infraorbital area. Following clinical and radiological examination, surgical excision was required for the differential diagnosis of tumor. After pathologic examination and the finding of a foreign-body granulomatous reaction, both patients recalled that hyaluronic acid filler had once been injected into their lower eyelids approximately 10 years prior. This is consistent with the fact that dermal-filler-related granuloma formation may occur even years later in the differential diagnosis of mass lesions. It is suggested that patients be informed about the possible but rare mass effect in the infraorbital region. Clinicians should also attend to delayed hypersensitivity reactions, since patients may not recall details due to the length of time since injection.