Facial Soft Tissue Augmentation Research Articles

Dynamic muscle discord in the context of non-surgical lip enhancement

Dynamic muscle discord (DMD) is a fundamental concept in facial soft tissue augmentation with dermal fillers, particularly in perioral rejuvenation and lip enhancement. It is frequently observed in patients with facial skeletal and soft tissue deficiencies. The lack of adequate structural support may result in compensatory muscle hypertonicity or confer a mechanical advantage in certain muscle groups over their antagonistic counterparts. This discord in activity between the various muscle groups can affect the posture and profile of mobile facial features both at rest and during facial expression. Unfortunately, despite being a condition that commonly presents to varying degrees in patients seeking lip enhancement, DMD is often poorly diagnosed and undertreated. The author describes the causes, consequences and treatment of this condition in relation to the perioral region, as illustrated by a case study discussion.

Basic Concept of Skull Base Reconstructive Surgery

In most cases of anterior cranial fossa defects, the cranial cavity and the nasal cavity are connected, and it is necessary to reconstruct the skull base in a narrow sense to separate both cavities. If the surgical purpose is only separation, reconstruction with a pedicled local flap is often possible. As other surgical purposes such as the reconstruction of surrounding tissues are added, the transplanted tissue volume becomes insufficient, and free tissue transfer is required. In the case of a defect in the middle cranial fossa, the cranial cavity is not always connected with the nasal cavity because it is far from the nasal cavity and oral cavity. In this case, it is skull base reconstruction in a broad sense whose purpose is other than separation. There are many factors such as facial soft tissue augmentation and facial nerve reconstruction as the surgical purpose, and the more the purposes, the more likely it is that free tissue transfer will be required. In patients with anterior and middle cranial fossa defects, both cavities are connected and the resected tissue volume is large, so free tissue transfer is selected in most cases, except for a few benign diseases.

1527 A Rare Case of Facial Skin Necrosis Following Subdermal Poly-L-Lactic Acid Injection

Abstract Introduction Non-surgical / minimally invasive aesthetic procedures are a growing trend in the UK. A range of devices are available for soft tissue augmentation, including injectable Poly-L-Lactic acid (PLLA). PLLA is used for soft tissue augmentation and is thought effective for the correction of contour deficiencies, facial wrinkles and in restoring subcutaneous volume in patients with HIV-associated lipoatrophy. Method In this case report, we present a rare but serious complication of subdermal injection of Poly-L-Lactic acid. A 45-year-old lady presented to our service approximately 24 hours after administration of self-sourced poly-L-Lactic acid. Results A 4cm ovaloid patch of full thickness skin necrosis over the zygomatic region was evident on presentation, with reactive/inflammatory changes in the adjacent skin. Vascular compromise is deemed the most likely cause, with loss of the transverse facial artery mapping to the area of necrosis. This patient was managed conservatively, with dressings and a prophylactic course of antibiotics. Conclusions Vascular compromise is a recognised and rare complication of subdermal injectable devices for facial soft tissue augmentation. The transverse facial artery branches from the superficial temporal artery within the substance of the parotid gland. Cadaveric and imaging studies alike demonstrate that the most common anatomical variant is a single TFA (70%), originating at the level of the temporofacial trunk of the facial nerve. It typically has a 5cm course, giving off on average 1.9 cutaneous perforators. This case highlights the importance of a detailed understanding of facial anatomy to ensure safe and effective placement of dermal fillers/devices.

Buccal Fat Pad Graft in Maxillofacial Surgery.

Despite the widespread use of pedicled buccal fat pad (BFP) flap in maxillofacial reconstruction, free nonvascular transfer of this fat is not widely used. Dermal fat transfer to the maxillofacial region is a known procedure with good results; however, it needs a skin incision in the donor site. Resorption of this graft is the other problem. Buccal fat with inherent resistance against resorption and ease of harvest is an interesting option. Six cases are reported in this article for the facial soft tissue augmentation in hemifacial microsomia, scar adhesion, temporal hallowing, and the release of TMJ bony ankylosis and check adhesion.

Lip Augmentation Using Post-Auricular Fibroareolar Tissue as a New Autogenous Filler.

BACKGROUNDAugmentation of facial components is an acceptable approach in facial aesthetics. The best filler material and the optimal technique for facial soft tissue augmentation still remain to be determined. This study has assessed the lip augmentation using post-auricular fibroareolar tissue as a new autogenous filler.METHODSThis prospective study enrolled patients who were candidate for lip augmentation. Loose fibroareolar tissue was harvested from post-auricular region and was inserted in the prepared lip pocket. Standard digital photography was used for lip analysis in each patient before and 6 months after surgery (the height and projection of the upper lip and lower lip).RESULTSAt a mean follow-up period of 6 months, average upper and lower lip height increased from 5.27 to 8.72 mm (p<0.001), and the average upper and lower lip projection increased from 3.97 to 7.75 mm (p<0.001).CONCLUSIONOur technique was minimally invasive and a safe method, in which post-auricular loose fibroareolar tissue was applied for lip augmentation with minimum donor site morbidity and long-term results. On the follow-up, all patients were satisfied with the results and no patients required any revision operation. Moreover, the complication rate was negligible.

Facial Soft Tissue Augmentation With Bellafill: A Review of 4 Years of Clinical Experience in 212 Patients.

Bellafill (Suneva Medical Inc) is a semipermanent injectable soft tissue filler composed of smooth and uniform polymethylmetacrylate (PMMA) microspheres suspended in a bovine collagen gel. It is a third generation PMMA filler, with more uniform shapes and sizes of the PMMA microspheres, which has been purported to decrease the incidence of granuloma formation. We performed a retrospective review of our clinical experience from 2014 to 2017 with Bellafill as a soft tissue injectable filler in the following clinical scenarios: deep nasolabial folds, depressed facial acne scars, malar volume loss, temporal wasting, tear trough deformity, chin augmentation, angle of jaw augmentation, and lip augmentation. The primary outcome is the rate of adverse events, and the secondary outcome is subjective patient satisfaction. From 2014 to 2017, 842 syringes of Bellafill were administered to 212 patients, for a total of 417 procedures. Of the 417 procedures, 96 (23.0%) were for acne scars, 82 (19.7%) malar volume restorations, 65 (15.6%) nasolabial fold augmentations, 45 (10.8%) chin augmentations, 42 (10.1%) tear trough volume restorations, 28 (6.7%) temple volume restorations, 25 (6.0%) rhinoplasty touch-ups for small areas of nasal depression, 22 (5.3%) lip augmentations, and 12 (2.9%) jaw angle augmentations were performed. A range of 1 to 12 syringes were injected into each patient, over 1 to 3 sessions; 6 cases of adverse events occurred (1.4%). There were 4 cases of solitary nodules in the injection site, 1 case of lower eyelid oedema which persisted for 3 months and 1 case of lower lip oedema which resolved within hours. Patient satisfaction rates ranged from 83.3% for angle of jaw augmentation to 99.0% for improvement of acne scars. Bellafill is a safe and effective option for a semipermanent soft tissue filler, with high patient satisfaction and a good safety profile.

Micro-Autologous Fat Transplantation Combined With Platelet-Rich Plasma for Facial Filling and Regeneration: A Clinical Perspective in the Shadow of Evidence-Based Medicine.

Despite the popularity of lipofilling procedures in recent years, the presence of older habits still in fat graft harvesting and processing seems to be the biggest obstacle to the final better outcome of fat grafting. Our study is aimed to highlight some strategies what should be done in fat grafting in the shadow of evidence-based medicine and patient-reported outcomes which might be of interest to the clinicians. Between 2015 and 2017, 14 patients were included who underwent facial micro-autologous fat transplantation with platelet-rich plasma injection. The outcome was determined by the difference in presurgery and postsurgery FACE-Q modules, which were designed as patient-reported outcome instrument to evaluate the unique outcomes of patients undergoing facial cosmetic procedures. Surveys conducted were modules of satisfaction with facial appearance, satisfaction with cheeks, satisfaction with skin, psychological function, social function, aging appearance appraisal, and satisfaction with the outcome. All patients were followed up minimum 9 months. No major complications were recorded. The patient-reported FACE-Q satisfaction and FACE-Q quality-of-life presurgery and postsurgery results showed statistically significant improvement (<0.001). Overall satisfaction with the outcome was 87.6 ± 16.8 (range 55-100). A combination of platelet-rich plasma and micro-fat grafting with soft harvesting and processing could be seen a good surgical technique to restore volume and enhance skin quality in facial soft tissue augmentation. The authors believe that with minimum detrimental effect on fat grafting while harvesting, processing, and with the addition of platelet-rich plasma while applying may increase the surgeon's and patient's satisfaction with the outcome.

In Vitro Evaluation of the Sensitivity of a Hyaluronic Acid PEG Cross-Linked to Bovine Testes Hyaluronidase.

Neauvia Intense is biocompatible, injectable hyaluronic acid (HA) filler PEG cross-linked for facial soft-tissue augmentation that provides volume to tissues. The aim of the present study is to evaluate the sensitivity of Neauvia Intense in hyaluronidase from bovine testes in a time-course analysis. The test is based on the colourimetric determination of the N-acetyl – D - glucosamine (NAG) released by the hyaluronidase in standardised conditions. The in vitro conditions involve the treatment of Neauvia Intense with a known concentration of the enzyme (6080U/ml). The NAG content was determined at different times to assess the kinetics of the degradation (1h, 3h, 6h, 24h, 48h, 72h, 120h, and 168h); the Ehrlich’s reagent was used for the colourimetric quantification, by the method described by Reissing and colleagues. The intensity of the violet colour developed after the chemical reaction was proportional to the NAG present in each sample. A microplate reader at 585 nm read the absorbance. The amount of NAG released by the product was proportional to the time of incubation with bovine hyaluronidase, reaching a plateau after 168 hours.

In Vitro Evaluation of the Biosafety of Hyaluronic Acid PEG Cross-Linked with Micromolecules of Calcium Hydroxyapatite in Low Concentration.

OBJECTIVE:Neauvia Stimulate is biocompatible, injectable hyaluronic acid (HA) filler (26 mg/ml) PEG cross-linked with 1% of calcium hydroxyapatite (CaHA) for facial soft-tissue augmentation that provides volume to tissues, followed by process of neocollagenesis for improving skin quality.AIM:The aim of the present study is to evaluate the biosafety of the product (Lot. 160517-26-1/2 PEG) on human keratinocytes cultured in vitro.MATERIAL AND METHODS:The experimental model proposed, despite being an in vitro system, allows the derivation of useful information to predict the possible activity of the product in further in vivo application. Human keratinocytes (HaCaT cells) were treated with the product for 24h at increasing concentrations of product respect to control (untreated cells).RESULTS:The biosafety of the product to be tested has been evaluated performing different methods: MTT test, NRU test, Kenacid Blue assay. Moreover, any possible effect on the structure, morphology, and viability of cells has been evaluated.CONCLUSION:In conclusion, the results obtained by the different methods show that the product Neauvia Stimulate® does not cause any cytotoxic effect and does not affect the correct structure and morphology of cells cultures.

Calcium hydroxylapatite treatment of human skin: evidence of collagen turnover through picrosirius red staining and circularly polarized microscopy.

BackgroundCalcium hydroxylapatite (CaHA, Radiesse®) is a biocompatible, injectable filler for facial soft-tissue augmentation that provides volume to tissues, followed by a process of neocollagenesis for improved skin quality.ObjectiveTo examine the effects of CaHA treatment on the molecular organization of collagen using a combination of picrosirius red staining and circularly polarized light microscopy.MethodsFive subjects received subdermal injection of 0.3 mL of CaHA in tissues scheduled for removal during abdominoplasty 2 months later. Tissue specimens from the CaHA injection site and a control untreated area were obtained from excised skin at the time of surgery. Processed tissue sections were stained with picrosirius red solution 0.1% and visualized under circularly polarized light microscopy for identification of thick mature (type I) and thin newly formed (type III) collagen fibers. Pixel signals from both the control and CaHA-treated areas were extracted from the images, and morphometric computerized hue analysis was performed to provide a quantitative evaluation of mature and newly formed collagen fibers.ResultsUnder picrosirius red staining and circularly polarized light microscopy, green/yellow areas (thin newly formed collagen type III) were visible among the collagen fibers in tissue sections from the area of CaHA injection. In contrast, the majority of the collagen fibers appeared red (thick mature collagen type I) in control tissues. Morphometric analysis confirmed that, following CaHA treatment, the proportion of fibers represented by thin newly formed collagen type III increased significantly (p<0.01) in comparison with the proportion of thick mature collagen type I fibers. In contrast, collagen content of control tissues consisted almost exclusively of thick mature collagen type I fibers.ConclusionThe use of picrosirius red staining and circularly polarized light microscopy provides evidence that subdermal injection of CaHA stimulates the formation of new collagen and dermal remodeling.

Facial Soft Tissue Augmentation in Males: An Anatomical and Practical Approach.

Soft tissue augmentation is increasingly being performed to treat male facial aging. To review anatomical consideration specific for the male face and define an approach to male soft tissue augmentation that creates harmonious and natural results. Addressing aesthetic concerns in the upper face, midface, and lower face should be performed in concert with a combinatorial and pan facial approach. Correct filler placement at different areas of concern is important to achieve desired and natural results. Dermal and subcutaneous fillers can be used successfully in the male patient to enhance facial features, correct volume loss, and improve features of aging.

Minimal recovery time needed to return to social engagement following nasolabial fold correction with hyaluronic acid fillers produced with XpresHAn technology.

IntroductionThe appeal of hyaluronic acid fillers for facial soft tissue augmentation is attributable to both an immediate aesthetic effect and relatively short recovery time. Although recovery time is an important posttreatment variable, as it impacts comfort with appearance and perceived treatment benefit, it is not routinely evaluated. Natural-looking aesthetic outcomes are also a primary concern for many patients.Materials and methodsA single-center, noncomparative study evaluated the time (in hours) until subjects return to social engagement (RtSE) following correction of moderate and severe nasolabial folds (NLFs) with RR (Restylane® Refyne)® and RD (Restylane Defyne), respectively. Twenty subjects (aged 35–57 years) who received bilateral NLF correction documented their RtSE and injection-related events posttreatment. Treatment efficacy was evaluated by improvements in Wrinkle Severity Rating Scale (WSRS) and subject satisfaction questionnaire at days 14 and 30, and by Global Aesthetic Improvement Scale (GAIS) at day 30. Safety was evaluated by injection-related events and treatment-emergent adverse events.ResultsFifty percent of subjects reported RtSE within 2 hours posttreatment. WSRS for the RR group improved significantly from baseline at day 14 (–1.45±0.42) and day 30 (–1.68±0.46) (P<0.001), respectively. WSRS for the RD group improved significantly from baseline at day 14 (–2.22±0.44) and day 30 (–2.50±0.50) (P<0.004), respectively. All GAIS improvements were clinically significant at day 30. The majority of injection-related events were mild or moderate. Two subjects experienced 3 related treatment-emergent adverse events; 1 RR subject experienced severe bruising, and 1 RD subject experienced severe erythema and mild telangiectasia. Subject satisfaction was high regarding aesthetic outcomes and natural-looking results.ConclusionOptimal correction of moderate NLFs with RR and severe NLFs with RD involved minimal time to RtSE for most subjects. Treatments that significantly improved WSRS and GAIS, were generally well-tolerated, and provided natural-looking aesthetic outcomes.

The role of fillers in the management of acne scars.

Acne scars are present in 95% of patients with acne, and can cause profound psychosocial morbidity. Fillers are commonly used for facial soft tissue augmentation, and there is increasing interest in their use for the treatment of acne scars, particularly for the atrophic subtype. We review the evidence for the use of temporary, semi-permanent and permanent fillers for acne scars. The use of permanent methylmethacrylate fillers for acne scarring is supported by a randomized controlled trial, and is approved by the United States Food and Drug Administration. There is initial evidence supporting the use of poly-L-lactic acid and hyaluronic acid fillers, but evidence is still lacking about the use of polyacrylamide and polyalkylimide fillers.

The use of expanded polytetrafluoroethylene in depressed deformities of the face.

Expanded polytetrafluoroethylene (ePTFE) has been extensively used for facial soft tissue augmentation procedures, and is regarded as safe and reliable and suitable as a permanent implant. This implant is generally used in the lower third of the face for lips filling, nasal augmentation, nasolabial folds and chin augmentation, and rarely for congenital or acquired depressed deformities of the face. The aim of the present study was to assess the effects of ePTFE in congenital or acquired depressed deformities of the face. From September, 2008 to January, 2014, 26 patients were implanted with the material ePTFE to correct depressed deformities of the face. The average age at operation was 23.2 years, with a range of 17–45 years. The depressed deformities were lateralized. The follow-up period was 6–18 months (average 9 months). The etiologies of the depressed deformities included stable hemifacial atrophy (3 cases), craniofacial microsomia (13 cases), bony depression after trauma (8 cases), and other unclear reasons (2 cases). The operations were performed under local anesthesia. ePTFE was inserted in different tissue planes that varied among the different subanatomical areas in the face: beneath the superficial temporal fascia in the temporal area, and on the surface of the superficial musculoaponeurotic system in the zygomatic area, cheek and mandibular area. All of the patients were followed up. Most of the patients [25 of 26 patients (96.2%)] were satisfied with the results, while 1 patient (3.8%) was not satisfied for incomplete correction of the depressed deformity. In conclusion, aside from lipofilling and a free flap transfer, the results showed that ePTFE was an alternative treatment for facial depressed deformity.

Clinical Experiences with the Scapular Fascial Free Flap.

BackgroundThe goal of reconstruction is to provide coverage of exposed vital structures with well-vascularized tissue for optimal restoration of form and function. Here, we present our clinical experience with the use of the scapular fascial free flap to correct facial asymmetry and to reconstruct soft tissue defects of the extremities.MethodsWe used a scapular fascial free flap in 12 cases for soft tissue coverage of the extremities or facial soft tissue augmentation.ResultsThe flaps ranged in size from 3×12 to 13×23 cm. No cases of total loss of the flap occurred. Partial loss of the flap occurred in 1 patient, who was treated with a turnover flap using the adjacent scapular fascial flap and a skin graft. Partial loss of the skin graft occurred in 4 patients due to infection or hematoma beneath the graft, and these patients underwent another skin graft. Four cases of seroma at the donor site occurred, and these cases were treated with conservative management or capsulectomy and quilting sutures.ConclusionsThe scapular fascial free flap has many advantages, including a durable surface for restoration of form and contours, a large size with a constant pedicle, adequate surface for tendon gliding, and minimal donor-site scarring. We conclude that despite the occurrence of a small number of complications, the scapular fascial free flap should be considered to be a viable option for soft tissue coverage of the extremities and facial soft tissue augmentation.

Complications from Nasolabial Fold Injection of Calcium Hydroxylapatite for Facial Soft-Tissue Augmentation: A Systematic Review and Meta-Analysis

Despite its increasing usage of facial applications, there is a paucity of objective data regarding calcium hydroxylapatite (CaHA). To systematically evaluate the complications from CaHA injection for facial soft tissue augmentation. Published studies on CaHA injection for facial soft tissue enhancement were identified through searches of the PubMed, EMBASE, and Cochrane Controlled Trial databases. Only randomized, controlled trials comparing CaHA injection to either placebo or an active comparator for facial cosmetic use were included. The outcome measures were the count (n) and frequency (%) of each complication, including edema (swelling), erythema (redness), ecchymosis (bruising), pain, pruritus (itching), hematomas, nodules, and extrusions. Four studies on nasolabial fold (NLF) injection of CaHA consisting of two subgroups were included: (i) a CaHA-lidocaine vs CaHA subgroup and (ii) a CaHA vs hyaluronic acid (HA) subgroup. The addition of lidocaine to CaHA therapy displayed no significant effect on edema (RR (95% CI): 1.07 (0.94-1.21), P = .311), erythema (RR (95% CI): 0.91 (0.66-1.24), P = .544), ecchymosis (RR (95% CI): 1.04 (0.71-1.52), P = .843), pain (RR (95% CI): 0.88 (0.58-1.33), P = .553), or pruritus (RR (95% CI): 0.82 (0.45-1.50), P = .515). There was no significant difference between CaHA vs HA for hematomas (RR (95% CI): 0.24 (0.01-4.31), P = .332) or nodules (RR (95% CI): 0.18 (0.01-6.62), P = .353). There was no significant publication bias detected in either subgroup (Begg's test P > 0.05). These findings support the addition of lidocaine to NLF injection of CaHA and suggest an equivalence between CaHA and HA with respect to hematoma and nodule formation. LEVEL OF EVIDENCE 2: Risk.

Nonthrombotic Pulmonary Embolism: A Potential Complication of Polyacrylamide Hydrogel Cosmetic Injection.

Context. Polyacrylamide hydrogel (PAAG) has gained importance as a synthetic soft tissue filling agent. It has been commonly employed by physicians in Europe for facial contouring and soft tissue augmentation. Previously, PAAG is considered nontoxic and well tolerated with a few mild procedural complications. Case Presentation. A 26-year-old female was hospitalized for dry cough, worsening dyspnea, and chest discomfort after 3 hours of multiple PAAG injections in buttocks. The patient's condition deteriorated and rapidly advanced to acute respiratory failure. Therein, the diagnosis of nonthrombotic pulmonary embolism (NTPE) was established on standard set of investigations. She was intubated; corticosteroid and empiric antibiotic therapy was initiated resulting in improvement of her condition. Subsequently, extubation was done, and she was discharged from the hospital after an uneventful recovery. On 1-month follow-up, the patient had no previous symptoms. Conclusion. This report implicates clinicians to maintain a high index of suspicion for NTPE in patients presenting with respiratory symptoms following PAAG usage.

Cell-assisted lipotransfer in the clinical treatment of facial soft tissue deformity

Cosmetic surgeons have experimented with a variety of substances to improve soft tissue deformities of the face. Autologous fat grafting provides significant advantages over other modalities because it leaves no scar, is easy to use and is well tolerated by most patients. Autologous fat grafting has become one of the most popular techniques in the field of facial plastic surgery. Unfortunately, there are still two major problems affecting survival rate and development: revascularization after transplantion; and cell reservation proliferation and survival. Since Zuk and Yosra developed a technology based on adipose-derived stem cells and cell-assisted lipotrophy, researchers have hoped that this technology would promote the survival and reduce the absorption of grafted fat cells. Autologous adipose-derived stem cells may have great potential in skin repair applications, aged skin rejuvenation and other aging-related skin lesion treatments. Recently, the study of adipose-derived stem cells has gained increased attention. More researchers have started to adopt this technology in the clinical treatment of facial soft tissue deformity. The present article reviews the history of facial soft tissue augmentation and the advent of adipose-derived stem cells in the area of the clinical treatment of facial soft tissue deformity.

Comparison of the Matrix Synthesizing Abilities of Human Adipose-Derived Stromal Vascular Fraction Cells and Fibroblasts.

For facial soft tissue augmentation or wound coverage using tissue-engineering technology, cultured fibroblasts have been most commonly used as key cells and their properties have been extensively studied. Clinical strategies based on human cultured fibroblasts, however, require Food and Drug Administration (FDA) approval for the facilities and the procedures used and time-consuming culture. Adipose tissue-derived stromal vascular fraction (SVF) cells may be a reliable alternative to fibroblasts because they are easily harvested by liposuction and do not require culture or FDA approval. No quantitative standard governing their use has, however, been issued. The purpose of this study was to quantitatively compare matrix-forming abilities of SVF cells and fibroblasts. Human dermal fibroblasts were obtained from the dermis of 10 healthy adults and cultured, and SVF cells were obtained from 10 patients who underwent liposuction. Monolayer and suspension cell cultures were performed using both cell types for 3 days. Cell proliferations, collagen synthesis levels, and glycosaminoglycan levels were compared using a 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide assay, a collagen type I carboxy-terminal propeptide enzyme immunoassay, and the Blyscan Dye method, respectively. Cell proliferation ratios (fibroblasts versus SVF cells) in monolayer and suspension cultures were 1:0.75 and 1:0.99, respectively; collagen synthesis ratios in monolayer and suspension cultures were 1:0.50 and 1:0.52, respectively; and glycosaminoglycan production ratios were 1:0.70 and 1:0.74, respectively. The results of this in vitro study indicate that SVF cells have 50-74% of the matrix-forming ability of fibroblasts.

Facial soft tissue augmentation using filler focused on Filler augmentation rhinoplasty

Facial soft tissue augmentation using filler focused on Filler augmentation rhinoplasty