An Innovative Treatment Using Calcium Hydroxyapatite for Non-Surgical Facial Rejuvenation: The Vectorial-Lift Technique.

BACKGROUND: The facial aging process entails alterations in the volume, shape, and texture of all skin layers over time. Calcium hydroxyapatite (CaHA) is a well-established safe skin filler with unique properties to resolve some skin alterations by stimulating neocollagenesis. The vectoral-lift (V-lift) technique targets the global repositioning of facial structures by addressing distinct anatomical injection planes. It includes deep facial augmentation with Radiesse PlusTM to retain ligament restructuring and superficial subcutaneous enhancement with diluted Radiesse DuoTM. Herein, we present cases that illustrate the use of this approach. METHODS: This pilot study enrolled 36 participants (33 women and three men; ages 37-68 years) in a Brazilian clinical setting, and all patients underwent a single treatment. Photographs were taken at rest, in frontal and oblique views, before injection, and 90 days after treatment. RESULTS: Treatment resulted in elevation of the upper and middle face, notable improvements in the infraorbital hollow, and adjustment of the mean facial volume. CONCLUSIONS: The V-lift technique is a three-dimensional pan-facial treatment that relies on ligament support and face vectoring to obtain a lifting effect and facial contour restoration. It encompasses deep facial augmentation involving the use of Radiesse PlusTM for restructuring and retaining ligaments and Radiesse DuoTM for superficial subcutaneous enhancement. This approach targets a global repositioning of the facial structures by addressing distinct anatomical injection planes. It achieves a repositioning of the overall facial anatomy without requiring a substantial volumetric expansion. LEVEL OF EVIDENCE IV: 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 .

High-Resolution Ultrasound of Odontogenic Cutaneous Sinus Tract: An International Multicentric Experience and a Review of the Literature.

OBJECTIVES: To investigate the role of high-resolution ultrasound (HR-US) in the initial and differential diagnosis of the Odontogenic Cutaneous Sinus Tract (OCST) in a multicentric setting. METHODS: Skin HR-US examinations of OCSTs performed between January 2019 and June 2023 at different Institutions were retrospectively reviewed. Epidemiological and clinical data (age, gender, location of the skin lesion, causative tooth, and the clinical suspicion) as well as HR-US imaging findings (morphology and length of the sinus tract, Doppler signal, and cortical bone interruption of maxilla or mandible) were collected. US examinations were performed by expert radiologists using a high-performance US scanner, employing a high-frequency linear probe (15 MHz or higher frequencies). In only one patient the HR-US exam was integrated with strain elastography (SE). RESULTS: Sixteen patients were enrolled with a median age of 37.6 years (range 16-70 years). The most frequent clinical suspicion was epidermal cyst, while OCST was suspected in only two cases. In all cases, HR-US depicted the sinus tract as a nodular, triangular or "champignon-shaped" lesion in the subcutaneous layer, which continued with a slightly tortuous band structure, up to the focally interrupted cortical bone plate. Furthermore, color Doppler evaluation showed color signals around and/or within the lesion, expression of inflammation. On SE, the sinus tract showed a hard pattern, due to fibrous and granulomatous tissue. CONCLUSIONS: HR-US, thanks to its high spatial resolution, allows the evaluation of OCST, and play a crucial diagnostic role, mainly when the clinical suspicious is different.

Ultrasound in Aesthetics: Filler and Non-Filler Applications.

Ultrasound in aesthetics presents multiple applications in several areas, including diagnosing fillers and non-fillers complications, the performance of ultrasound-guided injections in real-time, and identifying the most common types of cosmetic fillers. Furthermore, this application of ultrasound in aesthetics has become a must for managing aesthetic patients because, to date, this modality is the one that provides the higher resolution among imaging techniques, detailed anatomical information, and blood flow detection, besides showing worldwide availability. This paper aims to review the current applications of ultrasound in aesthetics based on publications from scientific literature and the authors' experience.

Rationale and Guidelines for the Use of Hyaluronidase: A Practical Guide for Complications Caused by Hyaluronic Acid.

The use of enzyme hyaluronidase to treat the complications of different brands of hyaluronic acid (HA) dermal fillers is increasing in the same proportion as the number of nonsurgical cosmetic procedures. Guidelines for diagnosing and treating complications remain controversial and are primarily based on anecdotal reports and small case series. We proposed approaching HA-related complications based on our clinical research and observations of treating more than 200 patients and providing a practical guide for the thoughtful use of hyaluronidase according to adverse events. Standardization of hyaluronidase dose and concentration is beneficial for better outcomes and future comparative analyses of the results of this treatment worldwide. The use of hyaluronidase is increasing for the reversal of the clinical manifestations of complications caused by HA fillers, although a consensus is lacking. We propose using different doses and concentrations of hyaluronidase to focus on selected anatomic areas considering properties of the product and pathogenesis of each complication.

Ultrasound Assessment of Skin Tumors Local Recurrence.

Skin cancer may recur at or around the surgical site despite wide excisions. Prompt clinical and sonographic detection of local recurrence is important since subjects with relapsing melanomas or nonmelanoma malignancies can be managed efficaciously, with a relevant impact on morbidity and survival. Ultrasound is being employed with increasing frequency in the assessment of skin tumors, but most of the published articles relate to initial pretherapeutic diagnosis and staging. This review aims to offer an illustrated guide to the sonographic evaluation of locally recurring skin cancer. We introduce the topic, then we provide some sonographic tips for patient follow-up, then we describe the ultrasound findings in case of local recurrence, illustrating the main mimickers, and finally, we mention the role of ultrasound in guiding diagnostic and therapeutic percutaneous procedures.

Recalcitrant Sterile Abscesses by Volux®: A New Therapeutic Approach.

The number of patients developing sterile abscesses because of hyaluronic acid (HA) filler procedures has increased for unknown reasons. We described this adverse reaction after filling with Juvederm Volux®, the latest innovative product in the Vycross range of technology. We presented five patients with recalcitrant sterile abscesses after filling with Juvederm Volux® who did not respond to the traditional therapy but whose lesions were resolved with the "Munhoz-Cavallieri lavage protocol" developed and recently published by the present authors. (SKINmed. 2023;21:27-33).

Ultrasonographic Patterns of Calcium Hydroxyapatite According to Dilution and Mix With Hyaluronic Acid.

OBJECTIVES: To assess the ultrasonographic patterns of different calcium hydroxyapatite (CaHA) formulations, including the undiluted, diluted, and mixed with hyaluronic acid (HA) compounds. METHODS: To review the ultrasonographic images of patients ≥18 years with confirmed injections of CaHA clinically and ultrasonographically, and without different concomitant types of fillers in the same region or other systemic or localized cutaneous diseases. RESULTS: Twenty-one patients met the criteria (90% female; 10% male; mean age: 52 years ± 12.8). Of these, 33.3% have been injected with an undiluted formulation, 33.3% with diluted, and 33.3% with a mixed formulation. All cases were studied with devices presenting frequencies that ranged from 18 to 24 MHz. Twelve cases (57%) were also studied with the 70 MHz. The ultrasonographic patterns of CaHA presented differences in the presence and intensity of PAS and the degree of inflammation according to the dilution and mix with HA. Diluted formulations show a milder intensity posterior acoustic shadowing (PAS) artifact than undiluted at 18-24 MHz. In mixed formulations, 57% showed mild PAS, and 43% demonstrated no PAS artifact at 18-24 MHz, besides fewer inflammatory changes in the periphery of the deposits. CONCLUSIONS: The ultrasonographic patterns of CaHA show differences in the presence and intensity of PAS and the degree of inflammation according to the dilution and mix with HA. Awareness of these ultrasonographic variations can support better discrimination of CaHA.

K.I.S.S. technique: sistematização para um preenchimento labial simples e seguro / K.I.S.S. Lip Filler Technique - keeping injections simple and safe when filling lips

Para tornar o preenchimento labial mais simples e seguro, desenvolvemos a técnica de preenchimento labial K.I.S.S. - Keep Injection Simple and Safe. Para ser simples, a técnica recomenda apenas a avaliação de quatro parâmetros anatômicos e o preenchimento de cinco áreas labiais. Por segurança, a injeção é realizada apenas no plano supramuscular, por meio de cânulas de ponta romba, inseridas a partir de quatro portas de entrada, duas no lábio superior e duas no lábio inferior. O preenchimento é realizado em vetores anatômicos específicos para volumização, projeção, melhora do contorno e sustentação do arco do cupido e comissuras labiais

To simplify the procedure and increase lip augmentation safety, we have developed the KISS - Keep Injection Simple and Safe lip filler technique. To be simple, the method recommends only the evaluation of four anatomical parameters and the filling of five labial areas. To be safe, the injection is performed only in the supramuscular plane, using cannulas with a blunt tip, inserted in four entries: two in the upper lip and two in the lower lip. Fillers are injected in specific anatomical vectors for lips volumization, projection, contour improvement, and support of cupid's bow and lip corners

NOT SO "HAPPY BUMP": A complication due to hyaluronic acid.

INTRODUCTION: The use of hyaluronic acid (HA) as a dermal filler is considered safe. However, as new brands come to the market, reports of adverse events are becoming more and more common. OBJECTIVE: To describe a particular type of adverse effect that, unlike the erythematous, indurated, and painful nodules described in the literature as "angry red bumps," is characterized by noninflammatory, stony-like nodules that appear in sites previously treated with HA. METHODS: The report of four patients who presented this complication, and the occurrence of two HA syringes from the same batch that had hardened the product inside at the time of filling. CONCLUSION: The authors propose the nomenclature "happy bump" to group adverse reactions to HA that translate into noninflammatory nodules, with a stony consistency, appearing up to 4 weeks (recent) or after one month (late) in sites previously treated with AH.

Sterile abscess due to hyaluronic acid: A new diagnosis and a proposal for treatment-A series of eight cases.

BACKGROUND: In recent years, fillers procedures with hyaluronic acid (HA) have grown significantly. Despite HA relative safety, the number of cases of complications after injections has grown, and in many of which, we are not aware of or have little control over. AIMS: In this article, the authors describe a new adverse reaction after filling with HA injection, the sterile abscess. PATIENTS/METHODS: We present eight patients with similar clinical, laboratory, and ultrasound characteristics for sterile abscess and report a new therapeutic modality for it. RESULTS: All cases were treated with "Munhoz-Cavallieri Lavage Protocol" procedure with complete resolution. CONCLUSIONS: "Munhoz-Cavallieri Lavage Protocol" serves as a guideline in diagnosis and management of sterile abscess.

Management of Patients Seeking Surgical Rhinoplasty with Previous Nasal Injections of Hyaluronic Acid.

BACKGROUND: Patients are looking for procedures which are minimally invasive and consequently incur minimal downtime. However, these procedures are not usually long lasting and have limited outcomes both esthetically and functionally. For these reasons, the number of patients seeking surgical rhinoplasty and who have previous nasally injected hyaluronic acid is increasing. METHODS: The aim of this article is to provide the surgeon with information for both the identification and surgical approach for those patients who seek nasal cosmetic surgery, and who have previously been treated with nasal injections of hyaluronic acid filler. RESULTS: We present cases that illustrate the use of this approach and suggest three possible patient management. CONCLUSIONS: There are three possible approaches: wait HA to be naturally reabsorbed; apply hyaluronidase before the surgery or proceed to rhinoplasty with no prior application of hyaluronidase. The physician must be aware of this progression and know how to manage each case to optimize the surgical outcome. LEVEL OF EVIDENCE IV: 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 Table of Contents or online Instructions to Authors www.springer.com/00266 .

Edema tardio intermitente e persistente ETIP: reação adversa tardia ao preenchedor de ácido hialurônico / Persistent, Intermitent Delayed Swelling PIDS: late adverse reaction to Hyaluronic Acid fillers

Introdução: O uso do ácido hialurônico para correções estéticas cresceu exponencialmente nos últimos anos. O ultrassom de pele mostra-se método eficaz para identificação do preenchedor e suas complicações. Um tipo particular de efeito adverso, caracterizado por edema tardio e persistente, de caráter intermitente, vem sendo observado ultimamente. Objetivo: Caracterizar uma complicação tardia após preenchimento facial com ácido hialurônico. Métodos: Selecionaram-se exames de ultrassom da pele realizados em clínica privada de outubro de 2016 a julho de 2017, encaminhados para avaliação de complicação após preenchedores. Questionários foram enviados aos médicos solicitantes para coleta de dados clínicos. Resultados: Em 108 exames foram identificados 33 casos de edema local associado à presença de ácido hialurônico. Episódios de edema foram referidos como recorrentes, na área previamente afetada ou em outro sítio de injeção. Conclusão: Os autores propõem nomenclatura específica: edema tardio intermitente e persistente para agrupar as reações adversas tardias ao ácido hialurônico, que se traduzem por edema local tardio, de caráter intermitente, deflagrado por gatilhos específicos e que persiste enquanto houver a presença do ácido hialurônico no tecido.

Introduction: The use of hyaluronic acid fillers (HA) for esthetic corrections has exponentially grown in recent years. Skin ultrasound (US) is an effective method to identify the filler and its complications. A particular type of adverse effect, characterized by late, persistent edema of an intermittent nature, has been lately observed. Objective: To describe a delayed complication due to easy HA fillers, named by the authors as Persistent, Intermitent Delayed Swelling (PIDS). Methods: From October 2016 to July 2017, US examinations performed at Cavallieri Clinic were selected and referred for evaluation of post-filler complications. Questionnaires were sent to requesting physicians for clinical data collection. Results: Of 108 exams, 33 cases of local subcutaneous edema associated with the presence of HA fillers were identified. Episodes of edema were referred to as recurrent, in the previously affected area, or at another injection site. Conclusion: The authors propose a specific nomenclature: PIDS to refer to this late adverse reaction to HA fillers, which includes delayed and intermittent local swelling, triggered by specific conditions, that persists for as long the HA remains in the subcutaneous tissue.

Marcação pré-operatória com carvão nas metástases linfonodais não palpáveis da região cervical, guiada pela ultrassonografia / Preoperative marking with activated charcoal suspension for the ultrasound-guided localization of nonpalpable metastatic lymph nodes

Introdução: A incidência de recorrência não palpável delinfonodos cervicais detectada por ultrassonografia no pósoperatóriode tireoidectomia tem aumentado com uso do examede ultrassom no seguimento desses pacientes. Desta forma,uma eficiente e segura marcação pré-operatória da lesão énecessária a fim de colaborar para o sucesso da segunda cirurgia,reduzindo as complicações. Objetivo: Estudar a segurança e aeficácia da marcação pré-cirúrgica com carvão ativado guiadapor ultrassonografia para a localização de linfonodos cervicaisnão palpáveis durante o ato cirúrgico. Método: Entre agosto de2010 e maio de 2011 foram avaliados 18 pacientes com 24 lesõescervicais não palpáveis que foram submetidas à marcação cominjeção de carvão ativado guiada por ultrassonografia. Todosos pacientes foram submetidos à ressecção cirúrgica logo apósa marcação. A eficácia e as complicações da marcação e dadetecção cirúrgica foram avaliadas através de ultrassonografia,cirurgia e estudo histopatológico. Resultados: Todas as 24lesões foram evidenciadas no ato cirúrgico e posteriormenteenviadas para avaliação histopatológica. O tamanho médio daslesões localizadas foi de 0,9 cm. Linfonodos cervicais foram aslesões mais marcadas, nos níveis IV, VI e VII. A taxa de sucessotécnico da marcação e da detecção ultrassonográfica para aslesões suspeitas foi de 100% (24/24). Não se observou nenhumacomplicação. Conclusão: O uso da marcação pré-operatóriacom carvão ativado mostrou ser um método seguro e eficaz noscasos de lesões não palpáveis da região cervical, em pacientespreviamente submetidos à cirurgia.