Soft Tissue Filler Injections Research Articles

Nasal dorsum augmentation using soft tissue filler injection.

Soft tissue filler injection is a common procedure for augmentation rhinoplasty. Various techniques for augmenting the nasal dorsum using a soft tissue filler have been attempted considering the size of the needle, the anatomical layer where the filler is injected, and the vascular distribution. The purpose of this paper was to evaluate the course of the dorsal nasal artery in patients scheduled for nasal augmentation using a soft tissue filler and to propose a method of nasal augmentation that minimizes vessel damage during soft tissue filler injection by confirming the distribution pattern of blood vessels through ultrasound. Patients underwent augmentation rhinoplasty using a soft tissue filler. All patients underwent ultrasound examination before the filler injections. From July to September 2018, ultrasound studies were conducted before augmentation rhinoplasty in 50 consecutive patients. Forty patients (80%) had a well-known lateral arterial pathway, while in 10 patients (20%), the dorsal nasal artery was found at the midline of the nose. In four cases (8%), the artery travelled just beneath the preperiosteal layer, which is under the nasalis muscle. Additionally, in seven cases (14%), the dorsal nasal artery coursed superficially, just beneath the subdermal layer. Injecting the filler into the preperiosteal layer either via a needle or cannula is considered relatively safe but there remains the possibility of vascular compromise. Using a large diameter cannula and injecting the filler into the preperiosteal layer using a gentle approach may be the safest approach.

The Surface-Volume Coefficient of the Superficial and Deep Facial Fat Compartments: A Cadaveric Three-Dimensional Volumetric Analysis.

Soft-tissue filler injections for the treatment of facial aging can result in different skin surface effects depending on the targeted facial fat compartment and fascial plane. This work investigates the tissue response of defined amounts of soft-tissue filler material injected into superficial and deep facial fat compartments by means of the calculation of the surface-volume coefficient. Four fresh frozen cephalic specimens obtained from human donors (three female and one male; mean age, 74.96 ± 22.6 years; mean body mass index, 21.82 ± 6.3 kg/m) were studied. The superficial and deep lateral forehead compartments, deep temporal fat pad, sub-orbicularis oculi fat compartment, and deep medial cheek fat compartment were injected with aliquots of 0.1 cc of contrast-enhanced material and scanned using three-dimensional surface imaging, resulting in a total of 226 injection and scanning procedures. The sub-orbicularis oculi fat compartment revealed the highest correlation coefficient (rp = 0.992; p < 0.001) and the highest surface-volume coefficient (0.94). The compartment with the lowest tissue response was the deep medial cheek fat compartment (rp = 0.745; p < 0.001; surface-volume coefficient = 0.29), followed by the deep lateral forehead compartment (rp = 0.814; p < 0.001; surface-volume coefficient = 0.68), superficial lateral forehead compartment (rp = 0.824; p < 0.001; surface-volume coefficient = 0.74), and deep temporal fat pad (rp = 0.947; p < 0.001; overall surface-volume coefficient = 0.64). These results, confirmatory in their nature to current injection strategies, provide evidence for the validity and reliability of the surface-volume coefficient. Injection procedures should be targeted in terms of facial fat compartments and fascial planes for a desired aesthetic outcome, as each fat compartment and fascial plane has unique tissue responses to injected soft-tissue fillers.

Treatment of late bacterial infections resulting from soft-tissue filler injections.

PurposeLate bacterial infections (LBIs) after esthetic facial augmentation using hyaluronic acid (HA) fillers are relatively rare yet severe complications that are difficult to treat. No adequate treatment standards have hitherto been formulated. We have bridged this gap by formulating a treatment scheme based on the principles of treating foreign-body implantation-related infections and treating bacterial growth in the form of biofilm. The objective of this study was to evaluate the efficacy of a comprehensive scheme for treating LBI complications after facial augmentation using cross-linked HA fillers.MethodsA total of 22 patients with LBI symptoms at a site of cross-linked HA injection underwent treatment and observation. The comprehensive treatment scheme formulated by Marusza and Netsvyetayeva (M&N scheme) comprised draining the lesion, dissolution of cross-linked HA with hyaluronidase, broad-spectrum antibiotic combination therapy, and use of probiotics. While 17 patients underwent the M&N scheme, the remaining five were treated with other schemes. Statistical analysis of the data was performed using Mann–Whitney U and χ2 nonparametric tests with SAS 9.4 software.ResultsAll 17 patients who underwent the M&N scheme experienced resolution of symptoms, with no recurrence of infection at the HA-injection sites.ConclusionTo treat LBI at a site of cross-linked HA administration, the principles applicable to infections resulting from implantation of a foreign body must be followed. The treatment period should be sufficiently long for complete resolution of symptoms. The efficacy of treatment is considered proven if 2 months have elapsed without recurrence since the symptoms resolved. The M&N scheme is recommended for use as the first therapeutic option for treating LBI related to soft-tissue fillers.

Arteries of the Face and Their Relevance for Minimally Invasive Facial Procedures: An Anatomical Review.

The purpose of this article is to provide a comprehensive review based on images and discussion of the current understanding of the arterial supply of the face to facilitate safe minimally invasive antiaging procedures. Contrast-enhanced computed tomographic scans of 40 fresh frozen heads from 17 male and 23 female Caucasian body donors with a mean age of 76.9 ± 13.1 years and a mean body mass index of 23.6 ± 5.3 kg/m(2) were retrospectively analyzed and compared to cadaveric dissections performed in more than 400 fresh cephalic specimens. This review presents the current understanding of the facial arteries based on existing literature, direct observation from cadaveric dissection, and the dissection experience of the two authors of the study. It reveals the constant three-dimensional locations of the facial and angular arteries: mandible, modiolus, and medial canthus as compared to their unpredictable course in other facial regions. In addition, the anatomy of the ophthalmic and central retinal arteries is discussed in the context of current treatment strategies in cases of blindness following facial soft-tissue filler injections. The arterial supply of the face exhibits high variability in branching patterns, course (two-dimensional), and depth (three-dimensional). Because of the lack of predictability of the vascular anatomy, it is impossible to absolutely guarantee safety when performing minimally invasive injectable procedures. Injectors should understand the potential for adverse vascular events, communicate this risk appropriately to patients, and be properly trained and equipped to treat any such complication.

Hyaluronic Acid Filler Emergency Kit

Widespread use of facial filler has led to a rise in reports of associated complications. The aim of this kit is to encompass all needed items to treat the patient and to be organized and prepared to provide correct treatment in urgent situations. A search was performed to gather information on the treatment of complications that occur after injection of soft tissue fillers. The search included reports published in English up to June 2018. We focused on reports of complications arising from emergent/urgent situations following the use of hyaluronic acid injectables; these included filler embolization resulting in impending skin necrosis, blindness or partial loss of vision, and anaphylaxis. We collated treatment of emergent complications from our search of published articles. There were 2 described protocols for filler complications in the literature. One protocol, the “old” protocol, was based on a low dose of hyaluronidase with longer intervals of injections and ancillary treatment. This protocol did not show good results in comparison with the “new” protocol, which was needed to improve these results. The new protocol demonstrated that a high dose of hyaluronidase had better efficacy; this protocol involves hourly injections with no ancillary treatment required except for aspirin. We propose a filler emergency kit (FEK) to deal with complications of hyaluronic acid fillers according to the new protocol to manage the stresses caused by these situations. Every physician needs to be prepared for any potential complication; therefore, there is a need to have a FEK as a crash kit in the clinic to avoid distressing the physician and the patient.

The Functional Anatomy of the Deep Facial Fat Compartments: A Detailed Imaging-Based Investigation.

Injection of soft-tissue fillers into the facial fat compartments is frequently performed to ameliorate the signs of facial aging. This study was designed to investigate the functional anatomy of the deep facial fat compartments and to provide information on the effects of injected material in relation to age and gender differences. Forty fresh frozen cephalic specimens of 17 male and 23 female Caucasian body donors (mean age, 76.9 ± 13.1 years; mean body mass index, 23.6 ± 5.3 kg/m(2)) were investigated. Computed tomographic and magnetic resonance imaging procedures were carried out using colored contrast-enhanced materials with rheologic properties similar to commercially available soft-tissue fillers. Anatomical dissections were performed to guide conclusions. No statistically significant influences of age or gender were detected in the investigated sample. Increased amounts of injected contrast agent did not correlate with inferior displacement of the material in any of the investigated compartments: deep pyriform, deep medial cheek, deep lateral cheek, deep nasolabial (located within the premaxillary space), and the medial and lateral sub-orbicularis oculi fat. Increasing volume in the deep midfacial fat compartments did not cause inferior displacement of the injected material. This underscores the role of deep soft-tissue filler injections (i.e., in contact with the bone) in providing support for overlying structures and resulting in anterior projection.

Correction of Tear Trough Deformity Using Autologous Fibroblast Combined with Keratin: New Soft Tissue Filler.

To evaluate the effectiveness and safety of autologous fibroblasts combined with keratin gel for tear trough deformity rectification as injectable soft tissue filler. The new injectable soft tissue filler was derived from autologous fibroblasts and keratin gel. A total of 35 patients received treatment of this filler injection for tear trough deformity rectification. All the patients were followed up, and the clinical features including photographs and satisfaction were collected and assessed at 1, 3, 6, 12 and 24months after injection. The efficacy of each patient was evaluated independently by blinded evaluators at different time points. All patients consented to publish identifiable photographs in this study. Tear trough deformity was improved even at 18-24months post-injection. No severe adverse effects were observed resulting from the filler injection. Combination of autologous fibroblasts and keratin is efficient and safe for correction of the tear trough deformity with long-term satisfaction and desirable result. 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 .

Body Image, Personality Traits, and Quality of Life in Botulinum Toxin A and Dermal Filler Patients.

The demand for minimally invasive cosmetic procedures has continued to rise, especially in Germany, yet few studies have examined this patient population. The literature in Germany has repeatedly voiced the speculation that users of minimally invasive, skin-rejuvenating procedures displayed a higher tendency toward dysmorphic behavior patterns or, respectively, other abnormal personality traits. The aim of this study was to investigate body image, personality traits, quality of life, and socioeconomic parameters in users of botulinum toxin and/or facial fillers. One hundred forty-five females presented for botulinum toxin and/or soft tissue filler injections completed demographic and standardized psychometric questionnaires such as the World-Health-Organization Quality of Life-Short Form, Big Five Inventory-10, Body Dysmorphic Disorder Questionnaire before treatment. Patients undergoing injectable aesthetic treatments in an urban dermatology practice were women, middle-aged, highly educated, and mostly employed. Furthermore, participants showed higher quality of life, especially health-related quality of life, and a lower body mass index than controls. Concerning personality traits, our participants scored significantly higher on extraversion, agreeableness, openness to experience, and neuroticism. This study helps to better understand the psychosocial factors characterizing this patient population. Patients differ from controls by having a higher level of quality of life. No signs of body dysmorphic patterns or problematic personality traits were found. 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 .

The treatment of hyaluronic acid aesthetic interventional induced visual loss (AIIVL): A consensus on practical guidance.

SummaryBackgroundVisual loss (blindness) caused by injection of soft tissue fillers is a rare but devastating issue to both patient and practitioner. There is a lack of any structured protocol in the management of this problemAimsTo produce a pathway for the management of hyaluronic acid aesthetic interventional induced visual loss that was based on the current available literature and guidelines. evidence proposed guidance for the practical management of this problem. was evaluated and a pathway has been developed for patient management and specialist adviceMethodA consensus group experts involved in aesthetic intervention, visual loss research and with experience in dealing with visual loss assessed the current literature and proposed guidelines available. Using the protocols available a pathway for the treatment of aesthetic interventional induced visual loss was proposed.ResultsThe group produce a set of guidelines for the practitioner to use as an emergency situation and for use in a delayed presentation. The group also produced guidelines for specialists to use in a secondary care setting.ConclusionsThese recommendations are based on current publications and or consensus view as there is still a lack of robust Level I data to support any particular intervention therapy.

Enhancing Facelift With Simultaneous Submalar Implant Augmentation.

The midface is particularly prone to the senescent changes of soft tissue ptosis and volume loss, which in individuals with aging or low adiposity can manifest as submalar hollowing. Facelift alone in those with submalar hollowing inadequately addresses the volume loss and may result in a gaunt appearance postoperatively. Submalar implant augmentation is a powerful tool for permanent midface volume restoration for a more youthful and natural contour, as opposed to soft tissue fillers that diminish over time. When performed together, submalar augmentation and facelift synergistically enhance facial rejuvenation results. Determine the long-term safety and efficacy of submalar implant augmentation as an adjunct to facelift. Retrospective review evaluating results and complications in all consecutive patients who had submalar implant augmentation with SMAS-plication facelift in a single surgeon private practice setting from January 1, 1991, to December 31, 2017. Forty-eight patients underwent submalar augmentation with simultaneous facelift with an overall satisfaction rate of 95.7%. Complications included 2.1%transient infraorbital hypoesthesia, 1.1% prolonged swelling, and 1.1% capsular contraction that required a minor adjustment under local anesthesia. No infection, implant migration, or extrusion or facial nerve injury occurred. Submalar implant augmentation is a safe and effective means of enhancing facelift results through midface volume restoration, subperiosteal release, and improved soft tissue suspension in a more favorable vector. Submalar implant augmentation performed simultaneously with facelift may be an attractive alternative to repeated soft tissue filler or fat injections for patients with submalar hollowing who are interested in facial rejuvenation surgery.

Wedge-shaped polydioxanone threads in a folded configuration ("Solid fillers"): A treatment option for deep static wrinkles on the upper face.

Facial wrinkles are key signs of aging which affect one's quality of life and psychological well-being. Absorbable wedge-shaped polydioxanone (PDO) sutures are popular in the esthetic clinics of Korea and may be a treatment option for static wrinkles on the upper face. To describe a novel technique applicable to deep static wrinkles on the upper face and to assess its safety and efficacy. A retrospective chart review was performed on the static wrinkle cases which were treated with folded, wedge-shaped PDO threads. A total of 33 Korean patients with glabellar and forehead wrinkles were included. All participants underwent a single treatment session. The results were assessed objectively using serial photography and subjectively based on the patients' satisfaction scores. Complications were also recorded. Our patients displayed moderate (15.2%), severe (39.4%), and very severe (45.4%) static wrinkles at baseline. The majority of patients (81.8%) considered the results satisfactory. Consensus ratings by two independent dermatologists showed that the objective outcomes at 2-month follow-up were very much improved (30.3%), much improved (30.3%), and improved (24.2%). The incidence of complications was low, and the complications were minor. Wedge-shaped PDO sutures in a folded configuration ("solid fillers") are a promising treatment option for deep static wrinkles on the upper face. They may be applied as an adjunct, or as an alternative to conventional therapies such as botulinum toxin and soft tissue filler injection.

Clinical Implication of the Arterial Supplies and Their Anastomotic Territories of the Nasolabial Region for Avoiding Arterial Devastation and Complications during Soft Tissue Filler injection

BackgroundThe nasolabial fold is one of the most concerning aging property in the middle face region. This fold initially appears when people are coming age‐wise to their 20s. To correct this fold, the aesthetic nonsurgical procedure, known as filler injection, has been popularly and increasingly performed. However, the arterial complications occurring as a consequence of nasolabial fold filler injection have been continually reported in a recent year. Therefore, the objective of this study was to investigate the arterial location related to nasolabial fold filler injection sites and their anastomotic pathways.MethodsThirty hemi‐faces of 15 Thai embalmed cadavers were performed by dissection method. The nasolabial folds (NLF) were used as the anatomical landmarks: at the inferior margin of NLF (NLF1), at the level of the mid philtral horizontal line of NLF (NLF2), and at the inferior alar level of NLF (NLF3). Additionally, the 5 cadavers were underwent the modified Sihler's staining procedure to investigate the arterial anastomoses.ResultsThe main artery nearby of NLF1 and NLF2 was the facial artery. The facial artery located inferior and medial to NLF1 (Type I, 7 of 25 cases); moreover, the mean distance was 3.53 ± 2.11 mm along the X‐axis and 3.53 ± 1.75 mm along the Y‐axis. The facial artery located medial (Type V, 12 of 22 cases) to NLF2 and the distance was 4.93 ± 1.53 mm along the X‐axis. For the NLF3, there were several accurate arteries including the facial artery (10 of 30 cases), the infraorbital artery (9 of 30 cases) and the lateral nasal artery (10 of 30 cases). The anastomosis of the nasolabial arteries was served both as the connection of external‐external carotid system and the connection of internal‐external carotid system. The communication between the facial artery and the transverse facial artery was found in all specimen. Similarly, the communication between the facial artery and the infraorbital artery was seen in all cases. Finally, the anastomosis between the dorsal nasal artery and the lateral nasal artery was found in 5 of 10 (50%) cases.ConclusionAt the lower part of NLF, the facial artery must be concerned. The filler injection should not over approximately 1.5 mm medial to NLF1 and 1 mm inferior to NLF1. For the NLF2, the safe injection point should less than 2.5 mm in the medial direction. In order to prevent injury of the facial artery and the infraorbital artery, the injection tools must not be exceeded 2 mm lateral to NLF3, while the injection less than 2 mm medial to NLF3 is the harmless point for the lateral nasal artery. The possibility of blindness might be caused by the anastomosis between the lateral nasal artery and the dorsal nasal artery.Support or Funding Information The 100th Anniversary Chulalongkorn University Fund for Doctoral Scholarship from the Graduate School, Chulalongkorn University Overseas Academic Presentation Scholarship for Graduate Students from the Graduate School, Chulalongkorn University This abstract is from the Experimental Biology 2018 Meeting. There is no full text article associated with this abstract published in The FASEB Journal.

Injectable Soft-Tissue Augmentation for the Treatment of Tracheoesophageal Puncture Enlargement

This study reports on the use of injectable soft-tissue fillers for the treatment of tracheoesophageal prosthesis enlargement and periprosthetic leakage.

Body Image and Self-esteem in Botulinumtoxin A and Dermal Filler Patients

Background: The demand for minimally invasive cosmetic procedures has continued to rise especially in Germany, yet few studies have examined this patient population. The literature in Germany has repeatedly voiced the speculation that users of minimally invasive, skin-rejuvenating procedures displayed a higher tendency toward dysmorphic behavior patterns or respectively less self-esteem. Objectives: Aim of this study was to investigate body image, self-esteem and socioeconomic parameters in users of BoNTA and/or facial fillers. Methods: One hundred forty five females presented for botulinum toxin and/or soft tissue filler injections, completed demographic and standardized psychometric questionnaires such as Rosenberg Self-Esteem Scale and Body Dysmorphic Disorder Questionnaire before treatment. Results: Patients undergoing injectable aesthetic treatments in an urban dermatology practice were woman, middle-aged, highly educated and mostly employed. Furthermore, patients who undergo minimally facial rejuvenation procedures showed a normal sense of self-esteem, and have a lower body mass index than controls. Participants also had a normal body image and no signs for a body image disturbance were found. Conclusions: This study helps to better understand the psychosocial factors characterizing this patient population. No signs of body dysmorphic pattern or less self-esteem were found.

Commentary on Intracranial Penetration During Temporal Soft Tissue Filler Injection.

Commentary on Intracranial Penetration During Temporal Soft Tissue Filler Injection.

Sensitivity of aspiration as a safety test before injection of soft tissue fillers.

Embolism due to accidental intra-arterial injection of a soft tissue filler (STF) can lead to serious complications. Physicians practice aspiration as a safety test before injection to rule out intra-arterial placement of the needle tip. The value of aspiration as a safety test is evaluated in this study, which also considered the rheological properties of different STFs and their needle dimensions. Aspiration with eleven different needle sizes and 24 different STFs was performed using Ringer's lactate (RL) colored with blue skin marking ink and secondly an empty saline bag containing anticoagulated blood, both pressurized to 150mmHg to mimic arterial blood pressure. Time between the start of aspiration and liquid in the needle hub was recorded. A total of 340 individual aspiration tests with different STFs and needles were performed, of which 112 yielded true-positive results within 1-s and 128 yielded false-negative results after 10s. Positive results between one and ten seconds were seen in 101 aspiration tests. True-positive results were seen in 33% of the tests performed with STFs within 1s of aspiration. Aspiration test results are influenced by needle diameter, needle length, and rheological properties of STFs. Additional safety measures are necessary to further reduce risk of inadvertent intravascular injection of STFs.

The Role of Injectables in Aesthetic Surgery: Financial Implications.

The plastic surgeon competes with both core and noncore physicians and surgeons for traditional cosmetic procedures. In 2007, the American Society for Aesthetic Plastic Surgery (ASAPS) and the American Society of Plastic Surgeons (ASPS) joined efforts to form a Cosmetic Medicine Task Force to further analyze this trend. Our objective is to document and quantify the patient capture and total collections generated in a single surgeon's practice exclusive from Botulinum Toxin A and filler injections over a 10-year period. We subsequently identified the effect and importance that fillers and Botulinum Toxin A have on an active cosmetic practice. A retrospective chart review of all male and female patients who received Botulinum Toxin A or soft tissue filler injections (noninvasive aesthetic treatment) in a single surgeons practice from January 2004 to December 2013 was undertaken. Only those patients new to the practice and who were exclusively seeking out Botulinum Toxin A or fillers were included in the study. Chart review then identified which of these selected patients ultimately underwent invasive aesthetic surgery during this 10-year period. Noninvasive and invasive aesthetic surgery total collections were calculated using billing records. From January 2004 to December 2013, 375 patients entered the senior surgeon's practice specifically requesting and receiving noninvasive aesthetic treatments. Of these 375 patients, 59 patients (15.7%) subsequently underwent an aesthetic surgery procedure at an average of 19 months following initial noninvasive aesthetic treatment. Of these 375 patients, 369 were female and 6 were male. The most common initial invasive aesthetic procedure performed after injectable treatment included 22 facelifts (18.5%), 21 upper eyelid blepharoplasties (17.6%), and 15 endoscopic brow lifts (12.6%). Total collections from noninvasive aesthetic sessions and invasive surgery combined represented US$762,470 over this 10-year span. This represented US$524,771 and US$396,166 in total collections for injectables and surgery respectively. Noninvasive aesthetic surgery is a critical part of a plastic surgery practice. A measurable and significant number of patients who sought out a single plastic surgeon exclusively for noninvasive treatment ultimately underwent traditional invasive cosmetic surgical procedures.

Highlights of Skin Disease Education Foundation's 41st Annual Hawaii Dermatology Seminar™.

New therapies, recent pathophysiological findings, and updated guidelines combined to create compelling presentations at the Skin Disease Education Foundation's 41st Annual Hawaii Dermatology Seminar™. This educational supplement summarizes the highlights of clinical sessions presented during this CME/CE conference. A growing understanding of the biology of psoriasis has facilitated the development of increasingly efficacious medications. Skin clearance used to be regarded as an impractical goal for psoriasis therapy. Now, some clinical trials of newer medications report more than half of participants attaining Psoriasis Area and Severity Index (PASI) scores of 90. Two leading investigators review the latest findings about the treatment of this condition. Recent evidence demonstrates that psoriasis and psoriatic arthritis share multiple pathological underpinnings. A T helper type 17 (Th17) lymphocyte-based pathogenesis, genes, and microbiome changes have been identified in both conditions. Many therapeutics used in psoriasis care are efficacious in psoriatic arthritis. An expert in psoriatic arthritis updates readers about this condition. Cutaneous fungal infections, including onychomycosis, pose diagnostic and treatment challenges. New topical therapies and an investigational oral agent offer expanded options for management. The American Academy of Dermatology has issued new guidelines for the treatment of acne. Appropriate antibiotic use is a prominent theme. The US Food and Drug Administration has issued a communication about the risk of unintentional injection of soft tissue fillers into facial blood vessels-including blindness. The lead author of a recent review about this topic discusses how to prevent this serious outcome. The volume of new information about pathophysiology, diagnosis, therapy, and safety challenges our ability to keep current while enabling us to improve patient care. We hope that the highlights of this seminar offer you information that can be applied to your busy practices.

Nonsurgical Facial Rejuvenation: Outcomes and Safety of Neuromodulator and Soft-Tissue Filler Procedures Performed in a Resident Cosmetic Clinic.

The ability to perform nonsurgical facial rejuvenation procedures is a core competency requirement for plastic surgery residents. However, limited data exist on training models to achieve competency in nonsurgical facial rejuvenation and on outcomes of these procedures performed by residents. The purpose here is to evaluate patient-reported outcomes and safety of nonsurgical facial rejuvenation procedures performed by plastic surgery residents. We prospectively enrolled 50 patients undergoing neuromodulator and/or soft-tissue filler injections in a resident cosmetic clinic between April and August 2016. Patients completed FACE-Q modules pre-procedure, and at 1week and 1month post-procedure. Paired t-tests were used to calculate statistical significance of changes between pre- and post-procedure scores. Effect sizes were calculated to assess clinical improvement from pre- to post-procedure. The magnitude of change was interpreted using Cohen's arbitrary criteria (small 0.20, moderate 0.50, large 0.80). Forty-five patients completed the study. Patients experienced significant improvements (p<0.001) in all FACE-Q domains, including aging appearance appraisal (improved from 49.7±29.4 to 70.1±21.6, effect size 0.79), psychological well-being (44.0±14.6-78.6±20.7, effect size 1.93), social functioning (48.6±16.6-75.5±21.7, effect size 1.20), and satisfaction with facial appearance (50.1±13.7-66.2±19.7, effect size 0.95). At 1month, overall satisfaction with outcome and decision were 75.8±20.7 and 81.1±20.4, respectively. No patients experienced complications. Nonsurgical facial rejuvenation procedures performed by residents can improve patients' quality of life and provide high satisfaction without compromising safety. This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Ischemical Problems after Filler Injections: Anatomical Details and Practical Guide Lines to Avoid Disasters

Introduction: Soft-tissue fi ller injection is a very common procedure all around the world. Although the safety profi le for these products is favorable, adverse events can occur, ranging from mild to severe in intensity.