Dermal Filler Injections Research Articles

Anatomical Considerations for Injectable Fillers in the Face: How to Reduce Complications and Optimize Aesthetic Results.

The popularity of minimally invasive injectable aesthetic treatments has grown exponentially with over thirteen million neurotoxin and dermal filler injections being performed in 2014. While aesthetic results can be dramatic and convalescence minimal, significant complications including vascular compromise, neuropraxia, and blindness have been reported. Thorough knowledge of the complex anatomy in this area and the use of anatomic landmarks can help the physician obtain improved aesthetic results by deploying fillers in the appropriate anatomic plane and avoiding inadvertent injury to important neurovascular structures in this area. J Drugs Dermatol. 2022;21(4):354-362. doi:10.36849/JDD.6642.

Characterizing Ocular Adverse Events After Facial Dermal Filler Injection-Reviewing the MAUDE Database.

Juhász, Margit MD, MSc*; Sharma, Ajay Nair MD, MBA†; Cohen, Joel L. MD*,‡ Author Information

FDA Warns Against Using Needle-Free Injection Devices For Dermal Fillers.

The Food and Drug Administration (FDA) has issued a safety communication to warn the public and health care professionals not to use needle-free devices for injection of dermal fillers. These devices are not approved by the FDA. FDA-approved dermal fillers are for prescription use only with a syringe and either a needle or cannula.Nurses should inform patients not to purchase any needle-free devices or products over the internet. Adverse effects from these devices should be reported to the FDA's MedWatch system.

Human dermal fibroblast response to hyaluronic acid-based injectable dermal fillers: an in vitro study.

Hyaluronic acid (HA)-based injectable dermal fillers (IDFs) used in aesthetic procedures may increase fibroblast activity and ultimately improve subcutaneous tissue quality. To further our understanding of fibroblast response to different commercial HA-based IDFs. Normal human dermal fibroblasts (NHDFs) were cultured with four different commercially available HA-based IDFs to assess their effects on the synthesis of extracellular matrix components and regulators (type I collagen, type III collagen, elastin, and transforming growth factor (TGF)-β1) as well as pro-inflammatory and oxidative DNA damage markers (interleukin (IL)-1β and 8-hydroxy-2'-deoxyguanosine (8-OHdG)). The six biomarkers were measured in supernatants from NHDF cultures after 24 h, 48 h, and 72 h of exposure to HA-based IDFs. All tested IDFs elicited a higher release of type I collagen in NHDF culture supernatants, although Juvederm Voluma was found to induce the most pronounced increase. Agex Fill Ultra induced the highest production of type III collagen and elastin. Levels of TGF-β1 and type I collagen in cell culture supernatants were positively correlated to each other (r = 0.57, p < 0.05). Conversely, 8-OHdG concentrations were inversely associated with both type III collagen (r = -0.41, p < 0.05) and elastin (r = -0.46, p < 0.05). Commercially available HA-based IDFs may elicit different in vitro fibroblast responses - a finding with potential implications in the prediction of their effects in aesthetic procedures. Our results also confirm that in vitro experiments may be viable tools for testing the effects of HA-based IDFs without resorting to animal studies.

Visual loss after aesthetic facial filler injection: a literature review on an ophthalmologic issue.

Dermal filler injection is among facial rejuvenation treatments that have been increasingly used. Despite being a minimally invasive procedure, it can lead to severe complications such as blindness. A review of all cases of filler- -induced visual loss in the world literature was conducted to summarize the mechanisms, anatomical considerations, and clinical ophthalmologic course, current strategies of prevention and management, and trends over the years. We identified 233 cases of filler-induced visual loss, and 172 patients had a severe visual impairment in at least one eye. The typical patients are young women who received injections of hyaluronic acid or autologous fat in the glabella or nose, and the typical presentations were sudden ocular pain, ptosis, and ophthalmoplegia due to vascular occlusion. The findings of this study also suggest an increase in the number of unlicensed professionals performing the procedure. Even though the continued development of dermal fillers has improved the treatment options available, further studies and strategies are necessary to reduce the incidence and minimize the consequences of filler-induced visual loss.

Insight into women with dermal fillers perceptions in Riyadh to uptake the Coronavirus vaccine.

Vaccination is considered to be the ideal way for population immunity, and willingness in taking the COVID-19 vaccine has been a controversial issue worldwide. The commonly reported adverse events of the COVID-19 vaccination have made people question the safety of the vaccine, especially for women with dermal filler and using cosmetics injections. It has been reported that some COVID-19 vaccines can cause side effects in women with dermal filler injections. In this study, we aimed to assess the perception and attitude of females with dermal fillers in Riyadh towards the COVID-19 vaccine using a self-answered questionnaire. A total of 352 females participated in the study of different ages and nationalities. our study findings indicate that the mean knowledge and attitude scores of females with dermal fillers regarding the COVID-19 vaccine are sub-optimal. Knowledge is significantly related to factors such as educational level, and chronic disease status, while attitude scores are significantly associated with nationality, educational level, COVID-19 vaccination status, previous history of taking the seasonal flu vaccine, and source of information related to COVID-19. These findings suggest the need to increase awareness regarding the COVID-19 vaccine and improve the attitude toward it.

Visualizing the Individual Arterial Anatomy of the Face Through Augmented Reality- A Useful and Accurate Tool During Dermal Filler Injections.

BackgroundThe arterial anatomy of the face is extremely variable. Despite numerous cadaver dissections and anatomical descriptions, the exact location of the superficial facial arteries remains unpredictable. This ignorance is a determining factor in the pathophysiology of intravascular filler injections, potentially causing skin necrosis and blindness.ObjectivesThe main objective of this study is to evaluate the accuracy of an augmented reality (AR) application that visualizes the individual arterial anatomy of the face.MethodsA workflow was developed during which a magnetic resonance angiography (MRA) mapped the superficial arteries of the face. The images were further processed into an AR image that was visualized on the patient’s face using a specifically designed smartphone application. The accuracy of the AR image and the position of each individual artery were analyzed using duplex ultrasound (US).ResultsA total of 216 facial arteries were visualized in 20 patients. The superficial temporal (100%), supratrochlear (92.5%), facial (75%), and angular (82.5%) arteries were visualized the most. The inferior labial (17.5%), dorsal nasal (22.5%), and supraorbital (42.5%) arteries were the most difficult to visualize through MRA. The average deviation between the artery visible on the AR image and the location assessed by US was 0.30 mm (standard deviation = +/− 0.66 mm). There were no complications reported.ConclusionsThe combination of a risk-free MRA to map the individual arteries of the face and the processing into an AR image may be considered as a useful and accurate tool during dermal filler injections to potentially minimize the risk of intravascular filler injections.

Midface Rejuvenation Using Juvederm Fillers in Male Patients.

In the recent years, there has been a significant rise in the number of men seeking rejuvenating procedures. The development of minimally invasive, non-surgical, office-based procedures without minimal downtime has stimulated a fresh interest among men who may seek cosmetic treatment to increase competitiveness and appear youthful in the workplace. It is important to understanding the differences in facial features in men and women to achieve more natural results and to reduce the risk of feminizing the male's face. The purpose of this study was to present our experience of midface rejuvenation using hyaluronic acid (HA) fillers in men. The authors discuss the anatomical considerations, pathophysiology of aging, gender considerations, and their injection technique for midface rejuvenation in male patients. Midface rejuvenation was successful in male patients using HA dermal fillers while maintaining the masculine features. The treatment was well tolerated and resulted in high level of satisfaction. Use of injectable HA dermal fillers is a safe, effective, and well-tolerated non-surgical treatment modality for midface rejuvenation in men. A thorough knowledge of the midface anatomy, injection techniques, and properties of individual fillers along with an understanding of the considerations in facial features of men can make injectable dermal fillers a rewarding treatment even in male patients.

452 Dermal Filler Injection Leading to Facial Cellulitis: A Case Report

Abstract Background Aesthetic medicine is a rapidly expanding field that is progressively becoming a normal part of society’s health and beauty regime. Hyaluronic Acid dermal filler injections are the second most widely performed aesthetic procedure, following Botulinum Toxin type A. Although serious complications are rare, they can have a detrimental impact on aesthetic outcome and general health. Infections following dermal fillers can be difficult to treat and have the potential to require hospital admission, intravenous antibiotics and surgical intervention. Case description We present a case of a 41-year-old female who suffered from facial cellulitis as a consequence of palpebro-malar groove dermal filler injections. The patient had 0.1ml of Monalisa dermal filler injected over her right malar prominence and suffered complications 6 days later, which eventually lead to the need for hospital admission on day 12 following the procedure for intravenous antibiotics. The management of this aesthetic procedure complication is outlined to highlight the risks and serious complications of these procedures. Conclusions Facial cellulitis is a rare adverse event following facial filler injection; however, it is an important risk factor to discuss during the consent process for these procedures. In addition, it is important that a highly trained and skilled professional performs these injections using a sterile non-touch technique due to the potential for serious complications and the anatomical proximity to vital structures.

Laser Doppler Imaging for Treating Vascular Complications from Procedures Involving Dermal Fillers: Case Series and Literature Review

Vascular occlusion is a rare but severe complication of dermal filler injections. Early treatment of this complication produces better outcomes. Current diagnostic methods for vascular occlusion in the skin are subjective and imprecise; these include capillary refill time, skin color, and reports of pain. This study aimed to assess the use of laser Doppler imaging (LDI) in the evaluation and treatment of vascular complications caused by dermal filler injections. This retrospective study used laser Doppler imaging (LDI) in 13 patients who developed vascular occlusion after facial dermal filler injections, with subsequent follow-up. The precise areas of perfusion observed on LDI were compared with the findings of clinical and photographic evaluation. The results showed that LDI accurately identified areas of vascular occlusion and improved treatment precision among these thirteen patients. The procedure was more precise than visual inspection or photographic evidence. Satisfactory outcomes were achieved for all patients, and no procedure-related complications were reported. Collectively, LDI provides fast, noninvasive, and accurate delineation of areas of vascular occlusion caused by complications of dermal filler injections and avoids several subjective shortcomings of visual and photographic evaluations. Thus, LDI effectively tracks treatment outcomes. However, large-scale studies are required to confirm the present findings.

Hydroxyapatite-embedded levan composite hydrogel as an injectable dermal filler for considerable enhancement of biological efficacy

We previously developed an injectable levan-based hydrogel as a temporary dermal filler. However, the longevity and collagen stimulation effect of the levan-based hydrogel were limited. Herein, we prepared hydroxyapatite (HAp)-embedded levan composite hydrogel as a long-acting dermal filler for enhancing in vivo collagen production and anti-wrinkle efficacy. HAp amount (0.1–5 wt%) in the levan hydrogel was optimized for stability, safety, and efficacy. Increasing the HAp amount decreased the in vitro stability and elastic modulus, but the composite hydrogel structure was still maintained. Furthermore, the composite hydrogel showed improved cell proliferation stimulation compared to the bare levan hydrogel in human dermal fibroblast cells. In vivo stability of the composite hydrogel was enhanced in contrast to the in vitro result, showing stable residence of the composite hydrogels with 0.5 or 1 wt% HAp over 8 weeks. Moreover, the excellent anti-wrinkle efficacy of composite hydrogel with 1 wt% HAp was maintained during 8 weeks and it showed the highest collagen production. Thus, HAp-embedded levan composite hydrogel showed potential as a dermal filler with easy injectability, biocompatibility, and long-acting anti-wrinkle efficacy.

Survey of Dermatologic Procedures in Transgender Adults.

Dermatologists have the opportunity to provide medically necessary procedures, including laser hair removal, to transgender patients for gender affirmation. Further research is required to better assess the unique dermatologic needs of this population. To examine the prevalence of dermatologic procedures among transgender people in the context of gender-affirming treatment. This cross-sectional study examined survey responses from 696 transgender persons enrolled in the Study of Transition, Outcomes, and Gender cohort. Prevalence of self-reported dermatologic procedures was examined and compared across participant subgroups. Electrolysis was the most commonly reported procedure (32.9%). Transfeminine patients were more likely to use dermatologic procedures compared with transmasculine patients. Only 19 participants (2.8%) reported the use of dermal filler injections. Differences in utilization of dermatologic procedures were noted in transgender populations. Motivations, barriers, and optimal timing for gender-affirming dermatologic procedures among transgender persons should be examined in future studies.

Combination of hyaluronic acid fillers and personalized skincare as a perfect tool in aesthetic medicine.

Nowadays the desire to look younger has increased. The most popular noninvasive rejuvenation method is hyaluronic acid (HA) filler injection. However, aging of the skin involves multiple pathological processes, which can be managed by using topical formulations with sophisticated active agents addressing problems such as extracellular matrix degradation, textural variances, and dyschromias. A single site experience trial was conducted to assess the efficacy of HA dermal filler injections combined with personally prepared, bespoke formulations on epidermis and dermis condition. A total of 15 female participated in the study. Mid and lower face were treated with Saypha® HA fillers injection with volume chosen by the investigator performed with 25G/50mm cannula. The formulations for topical skincare consisted of substances chosen from 19 active agents, which were scientifically proven. The subjects were supposed to use them for 6 weeks. Fourteen subjects completed the study, and one subject was lost to follow-up. The age of the study population ranged from 36 to 58 years. The average amounts of Saypha volume plus, Saypha volume, and Saypha filler used per subject were 2.8ml, 2.25 ml and 1.7ml, respectively. The most typical skin dysfunctions were loss of elasticity (12 subjects), hyperpigmentation (nine subjects), erythema (eight subjects), and hyperseborrhea with enlarged pores (five subjects). After completing the study all subjects were satisfied. Combined therapies based on HA fillers and personalized skincare with Universkin™ products show promising results in patients with skin problems due to aging.

Granuloma formation after injection of polycaprolactone dermal filler (case report)

A case of clinical observation of a patient with a granulomatous reaction developing in the region of both nasolacrimal grooves after the injection of a filler based on polycaprolactone (PCL) is presented. PCL is used in cosmetology as a filler and collagen synthesis stimulator. It is a biocompatible and biodegradable polymer with a proven safety profile. However, as with the introduction of other types of fillers, in some cases it can cause a granulomatous reaction of varying severity. The clinical observation of this case is of interest to practicing dermatologists, cosmetologists and plastic surgeons.

Effects of basic fibroblast growth factor combined with an injectable in situ crosslinked hyaluronic acid hydrogel for a dermal filler

Hyaluronic acid (HA) has been applied as a biomaterial for injectable dermal filler due to the unique viscoelastic property. Although HA derivatives are promising dermal filler materials, poor durability by degradation is the limitation of HA dermal filler. The chemical crosslinking of HA hydrogel is necessary to restrain the degradation rate. Herein, we present an injectable in situ HA hydrogel containing basic fibroblast growth factor (bFGF) crosslinked via a visible light-induced thiol-ene reaction. The thiol-ene reaction between thiolated HA (SH-HA) and methacrylated HA (MA-HA) is triggered by riboflavin phosphate with blue light (BL) exposure. The mechanical property, matrix degradation, and protein release of HA hydrogels were evaluated regarding SH-HA and MA-HA ratio. The HA hydrogels improve NIH/3T3 fibroblast proliferation and migration, and the bFGFs incorporated in HA hydrogel additionally induce the cell proliferation and scratch closure rate. In addition, the HA hydrogel precursor solution under a porcine skin forms hydrogel by transmitted BL through the skin, so the gelation can occur under the skin after injection. According to the results, the in situ crosslinked HA hydrogel is a promising injectable and long-lasting dermal filler that can deliver therapeutic factors.

Hand Rejuvenation With A Hyaluronic Acid-Based Dermal Filler: A 12-Month Clinical Follow-Up Case Series.

Requests for hand rejuvenation, in particular with nonsurgical aesthetic procedures, are increasing. Several injectable dermal fillers are currently used to restore soft tissue volume; however, the anatomic complexity of the hand and extreme mobility of its underlying tissues involve the use of specific implants and adapted injection technique. We report a case series demonstrating the efficacy, durability, and safety of a hyaluronic acid-based dermal filler (HA-filler) for hand rejuvenation. Five female subjects aged 56 to 67 with moderate to severe hand aging were treated by one physician (PM) at his private office. The HA-filler was injected in the hypodermis using a retrograde injection technique. A massage performed at the site of injection ensured optimal cosmetic results. Four subjects had a touch-up 3 months later. The aesthetic effect was evaluated on each hand, by 5 evaluators and the subjects, up to 12 months following the last injection. Adverse events, including pain, were collected. Merz Aesthetic Hand Aging Scale (MAS) and the Global Aesthetic Improvement Scale (GAIS) scores indicated stable and significant improvement in hand aging up to 12 months following the last injection. Despite a slight decrease over time, there was a durable enhancement of skin glow, quality, and hydration on the GAIS. The retrograde injection of the HA-filler, which was usually described as painless, was well tolerated by all subjects. Hand rejuvenation using a HA-filler and a retrograde injection technique was associated with subjects&rsquo; satisfaction and was proved safe for the 5 subjects of this case-series. J Drugs Dermatol. 20(4):451-459. doi:10.36849/JDD.5154.

Commentary on: The Change of Plane of the Supratrochlear and Supraorbital Arteries in the Forehead—An Ultrasound-Based Investigation

When considering dermal filler injections, the brow and low forehead have been considered an area of high reward but also high risk for intravascular injection and therefore a relative “no-fly zone” especially for the inexperienced. The supraorbital (SOA) and supratrochlear artery (STA) as well as the less consistent superficial paracentral and central arteries are implicated in intravascular injection. Details relating to the transition of the SOA and STA from the orbit to subcutaneous fat and the precise location with respect to discrete ligamentous structures and fascial planes have not been well described and are confusing, in part due to the complexity of the fascial planes in this zone. The authors of this study have set out to clarify the 2- and 3-dimensional (3D) relation of the SOA and STA to these anatomic planes as they pass from deep to superficial.1 Key to understanding their findings and visualizing a potential clinical application is a thorough comprehension of the anatomy.

An Anatomical Guide to the Terminal Facial Artery: Lumen Diameter and Associated Anatomy Relevant to Dermatologic Procedures.

Dermal filler injection in the vicinity of the terminal facial artery (FA) can lead to vascular compromise with devastating consequences, including tissue necrosis, blindness, and stroke. The purpose of this study was to examine lumen diameter and other anatomical features of the terminal FA relevant to dermal filler injection. Eighteen embalmed adult cadavers were dissected along the distribution of the terminal FA. Gross and microscopic measurements were taken at predetermined points in its course. Mean lumen diameter was largest at the midpoint between the oral commissure and the lateral supra-alar crease (0.81 ± 0.36 mm; point P1) and smallest at the midpoint between the lateral supra-alar crease and the medial canthus (0.43 ± 0.23 mm; point P3). Mean cutaneous depth was deepest at the lateral supra-alar crease (5.06 ± 1.84 mm; point P2) and most superficial at the midpoint between the lateral supra-alar crease and the medial canthus (3.13 ± 2.07 mm; point P3). The large-caliber lumen diameter of the terminal FA creates the potential for intra-arterial injection with commonly used filler needles and blunt-tipped cannulas at all points in its course in the nasolabial fold and midface.

Hand Rejuvenation With A Hyaluronic Acid-Based Dermal Filler: A 12-Month Clinical Follow-Up Case Series

Background: Requests for hand rejuvenation, in particular with nonsurgical aesthetic procedures, are increasing. Several injectable dermal fillers are currently used to restore soft tissue volume; however, the anatomic complexity of the hand and extreme mobility of its underlying tissues involve the use of specific implants and adapted injection technique. We report a case series demonstrating the efficacy, durability, and safety of a hyaluronic acid-based dermal filler (HA-filler) for hand rejuvenation. Methods: Five female subjects aged 56 to 67 with moderate to severe hand aging were treated by one physician (PM) at his private office. The HA-filler was injected in the hypodermis using a retrograde injection technique. A massage performed at the site of injection ensured optimal cosmetic results. Four subjects had a touch-up 3 months later. The aesthetic effect was evaluated on each hand, by 5 evaluators and the subjects, up to 12 months following the last injection. Adverse events, including pain, were collected. Results: Merz Aesthetic Hand Aging Scale (MAS) and the Global Aesthetic Improvement Scale (GAIS) scores indicated stable and significant improvement in hand aging up to 12 months following the last injection. Despite a slight decrease over time, there was a durable enhancement of skin glow, quality, and hydration on the GAIS. The retrograde injection of the HA-filler, which was usually described as painless, was well tolerated by all subjects. Conclusions: Hand rejuvenation using a HA-filler and a retrograde injection technique was associated with subjects’ satisfaction and was proved safe for the 5 subjects of this case-series. J Drugs Dermatol. 20(4):451-459. doi:10.36849/JDD.5154

Comparative Analysis of Hyaluronidase-Mediated Degradation Among Seven Hyaluronic Acid Fillers in Hairless Mice.

PurposeHyaluronic acid (HA) is the most common injectable dermal filler used for soft-tissue augmentation, and can be removed non-surgically by directly injecting hyaluronidase. In this study, the hyaluronidase-mediated degradation of different types of HA fillers implanted subcutaneously at the back of hairless mice having filler residence time of four days or three months were compared.MethodsTwo sites at the back of female hairless mice were subcutaneously implanted with 0.1-mL of one of the seven HA fillers (NLL, NL, NDL, NVL, and ND, JUVX+, and RESLYFT) and injected with 30 IU or 60 IU hyaluronidase per 0.1-mL filler after reaching a filler residence time of 4 or 91 days, respectively. Filler bolus projection was measured using three-dimensional optical imaging over a 72 h period, and the implantation sites were histologically examined 2 weeks after hyaluronidase injection.ResultsFollowing hyaluronidase injection, all seven HA fillers showed a rapid decrease of filler volume within 24 h, and complete degradation was confirmed by histological examination after 2 weeks. There was no significant difference in filler volume reduction rate among the seven HA fillers, and no evidence of macroscopic or microscopic adverse effects were observed at the implantation sites.ConclusionAll seven HA fillers show comparable susceptibility to hyaluronidase-mediated degradation. HA fillers with prolonged filler residence time may require a higher dose of hyaluronidase to achieve efficient degradation owing to tissue integration.