Current Landscape of Hyaluronic Acid Filler Use in the United States.

BACKGROUND: Hyaluronic acid (HA) fillers are among the most used fillers for soft-tissue augmentation. There are now many FDA-approved HA products, and the successful use of injectable HA fillers requires an understanding of the available options.  Objective: The purpose of this manuscript is to provide a comprehensive list of HA fillers and their indications. An overview of their biochemical properties and formulations will aid dermatologists in appropriate use. METHODS: A comprehensive search of all the FDA-approved dermal fillers was conducted via the FDA "pre-market approval" (PMA) site. Additional details regarding filler properties were obtained using the respective agent's package inserts.  Results: A total of 28 HA dermal fillers were identified and key pharmaceutical properties were discussed. These findings will help the physician match the appropriate HA filler with the area that is to be treated.  Conclusion: Understanding the available fillers and their properties can help physicians select the appropriate fillers for more predictable and sustainable results.  J Drugs Dermatol. 2024;23(1):1247-1252.    doi:10.36849/JDD.7858.

Injectable and topical neurotoxins in dermatology: Basic science, anatomy, and therapeutic agents.

Botulinum toxin is a potentially deadly anaerobic bacterial toxin that acts by inhibiting release of acetylcholine at the neuromuscular junction, thereby inhibiting contraction of the exposed striated muscle. There are currently 4 botulinum toxin preparations approved by the US Food and Drug Administration (FDA): onabotulinumtoxin, abobotulinumtoxin, incobotulinumtoxin and rimabotulinumtoxin. While significant overlap exists, each product has unique properties and specifications, including dosing, diffusion, and storage. Extensive physician knowledge of facial anatomy, coupled with key differences of the various neurotoxin types, is essential for safe and successful treatments. The first article in this continuing medical education series reviews key characteristics of each neurotoxin, including new and upcoming agents, and provides an anatomic overview of the most commonly injected cosmetic sites.

Injectable and topical neurotoxins in dermatology: Indications, adverse events, and controversies.

The use of neuromodulators for therapeutic and cosmetic indications has proven to be remarkably safe. While aesthetic and functional adverse events are uncommon, each anatomic region has its own set of risks of which the physician and patient must be aware before treatment. The therapeutic usages of botulinum toxins now include multiple specialties and multiple indications. New aesthetic indications have also developed, and there has been an increased utilization of combination therapies to combat the effects of global aging. In the second article in this continuing medical education series, we review the prevention and treatment of adverse events, therapeutic and novel aesthetic indications, controversies, and a brief overview of combination therapies.

Hypersensitivity reaction to nonanimal stabilized hyaluronic acid.

Soft tissue augmentation has become a cornerstone of facial rejuvenation. The bovine collagens were historically considered the "gold standard" as they had an extensive safety history and were effective. However, because of their brief duration and the approximate 1.0% to 3.0% incidence of hypersensitivity, alternatives were sought. A new class of agents, the hyaluronans, was recently granted approval by the Food and Drug Administration. The hyaluronans are indicated for injection into the mid to deep dermis for correction of moderate to severe facial wrinkles and folds (eg, the nasolabial folds). The hyaluronans have two derivations: nonanimal stabilized hyaluronic acid (NASHA) and an additional formulation of avian origin. Both are considered major advancements as they are not species specific and therefore theoretically do not elicit humoral or cell-mediated immune reactions. To date there have been a few reports of allergic reactions to the NASHA hyaluronans, primarily to Restylane. We report what to our knowledge is the first hypersensitivity reaction to the second brand of NASHA, Captique.

The use of injectable collagens for aesthetic rejuvenation.

Bovine collagen was approved by the Food and Drug Administration in 1982 and since that time has remained a primary filler of choice for soft-tissue augmentation of dermal defects. During the past decade, however, perhaps mirroring the growth and overwhelming acceptance of botulinum toxin for wrinkle reduction, there has been an increase in demand and availability of new injectable filler products. A partial list includes the ever-expanding class of hyaluronans (hyaluronic acids), calcium hydroxylapatite, polymethylmethacrylate, poly-L-lactic acid, and silicone oil. There are many more on the immediate horizon that are under investigation both abroad and in the United States. Nevertheless, the collagen family of agents, regardless of their source of derivation, remain a reliable and useful alternative. They have an unparalleled record of safety and efficacy; they have different formulations, which makes them amenable to many indications and user friendly for the physician. And, for patient, the admixture of local anesthesia reduces the discomfort of the injection procedure.

Treatment of facial chromhidrosis with botulinum toxin type A.

BACKGROUND: Hyperhidrosis is an idiopathic condition of exaggerated sweat production by the eccrine glands that affects approximately 1% of the population. There are many viable therapeutic options and the use of botulinum toxin has become an important treatment option and received FDA approval for this disorder in July 2004. The other forms of aberrant sweating; bromhidrosis (malodorous) and chromhidrosis (pigmented) are much rarer and more recalcitrant to treatment. METHOD: This is the first case report of dark-colored facial sweat in a young woman that was adequately controlled with botulinum toxin. CONCLUSION: Chromhidrosis is an unusual clinical entity with an ill-defined glandular etiology. The successful response to botulinum toxin supports the eccrine gland as a source of the sweat production and, furthermore, that the administration of this toxin should be considered as a form of therapy.

Comparison of botulinum toxins A and B in the treatment of facial rhytides.

Facial rhytides of the upper one third of the face are common aesthetic concerns, and are caused principally by overactivity of the underlying facial musculature. Botulinum toxin, which acts by causing flaccid paralysis of facial mimetic muscles, has become a treatment of choice for the management of these hyperfunctional facial lines. Two antigenically distinct serotypes have been developed and are currently available for commercial use in the United States. There are major differences between the two toxins in terms of pharmacology and formulation that account for clinical differences, and precise interconversion is not well-established. Nevertheless, in these preliminary studies, Myobloc seems to have a faster onset of action and potentially a more even and smoother paralysis. The shorter duration of action of Myobloc seems to be dose-related. It is clear that both agents safely and effectively reduce dynamic facial rhytides. Based on individual efficacy, safety, diffusion pattern, onset, and duration, ultimately, with further trials and clinical experience, it is conceivable that each toxin will have its own set of indications.

Understanding and using hyaluronic acid.

Injectable synthetic hyaluronic acid is biodegradable and biocompatible with human hyaluronic acid. Soft tissue augmentation with this product does not require prior skin testing and provides robust augmentation. Its ability to attract and maintain significant amounts of water accounts for the volume and duration of correction that persists until the stabilized gel is completely metabolized.

Injectable collagens: lost but not forgotten--a review of products, indications, and injection techniques.

Soft-tissue augmentation and three-dimensional volume replacement remain a cornerstone of facial rejuvenation. There has been an exponential increase in interest in dermal fillers. Science and technology have kept pace with this demand, and currently there is a wide range of options from which to choose. This is especially well illustrated by the recent introduction of an entirely new class of agents--the hyaluronans. The temporary fillers (the collagens and the Zyderm and CosmoDerm families), however, remain an excellent alternative, as they have a well-documented safety record, there are multiple formulations that make them very versatile, and the admixture of local anesthetic decreases the discomfort of injection.

Consensus recommendations for soft-tissue augmentation with nonanimal stabilized hyaluronic acid (Restylane).

The American Society for Aesthetic Plastic Surgery recently reported that there were nearly 12 million cosmetic procedures (2.1 million surgical and 9.7 million nonsurgical) performed in the United States in 2004. Almost 900,000 of the nonsurgical procedures were soft-tissue augmentation procedures using hyaluronic acid fillers. Restylane (Medicis Aesthetics, Inc., Scottsdale, Ariz.), nonanimal stabilized hyaluronic acid, was approved for use in the United States in December of 2003. Although the use of all fillers increased from 2003 to 2004, use of hyaluronic acid fillers increased nearly 700 percent. The dramatic increase in all cosmetic procedures reflects the growing trend, especially with increasing job competition, to maintain a youthful lifestyle and appearance. Basic recommendations for aesthetic use of Restylane were established based on short- and long-term efficacy and safety studies (Medicis Aesthetics, package insert). With the widespread and growing use of Restylane, a cross-sectional panel of experts with extensive clinical experience, including cosmetic dermatologists and surgical specialists (cosmetic, plastic, and ocular), convened to develop consensus guidelines for the use of Restylane. This supplement reviews the aesthetic affects of aging on the face, the role of fillers in facial soft-tissue volume replacement, and general principles for the use of Restylane, including patient comfort and assessment techniques. Specific recommendations for Restylane use in each potential target area, including type of anesthesia, injection techniques, volume for injection, use in combination with other procedures, and expected longevity of corrections, are provided. Techniques for optimizing patient outcomes and satisfaction and for minimizing and managing expected problems and potential complications are described.