LC-OCT as a tool to visualize in vivo location of dermal fillers.

BACKGROUND: Dermal fillers have emerged as a popular non-surgical solution for facial rejuvenation and enhancement. Apart from botulinum toxin injections, they are the most common non-surgical procedure performed in the US. Line-field optical coherence tomography (LC-OCT; deepLive system Damae Medical, France) represents one of the most recent developments in non-invasive skin imaging technologies. MATERIALS AND METHODS: We performed LC-OCT image acquisition on six patients that were treated with hyaluronic acid (HA) dermal fillers in various locations on the face. The images were acquired before the application of the fillers (T0), immediately after (T1), and at a 6- to 8-week (T2) follow-up visit. RESULTS: At T0, we were able to appreciate a normal-appearing epidermis, dermoepithelial junction, and dermis. At T1, the intradermal filler deposits appeared as homogeneously hyporeflective areas, clearly discernible from surrounding vessels and other structures. At T2, the deposits were distinguishable as hyporeflective areas, although they were diminished in size compared to T1. On enface view, collagen fibers had increased thickness and were more homogeneously organized and hyperreflective. CONCLUSIONS: We established the usefulness of LC-OCT in the non-invasive evaluation of dermal HA fillers to visualize both short-term and medium-term effects. LC-OCT may be a valuable tool in evaluating the precise location of filler placement and follow-up of resulting in vivo changes.

New Aesthetic Unit (NAU) Method: A Comprehensive Method Based on Accurate Anatomical Assessment and Precise Multilayering Panfacial Treatment for Hyaluronic Acid Fillers.

BACKGROUND: Recent progress in anatomy enables a more sophisticated approach to treat patients with facial aesthetic concerns (PFAC) with HA fillers. Furthermore, advances in rheology have offered a range of HA fillers with different biomechanical properties adapted to different indications. METHODS: Based on recent anatomical and rheological progresses, the author has developed a new methodology that couples an accurate patient assessment tool and a panfacial precise treatment instrument. In the presented method, the face is divided into 6 units called New Aesthetic Units (NAU). NAUs are classified on the extent of volume deficiency and asymmetry, ranging from none to moderate to severe deficiencies. After discussion with the patient regarding the assessment findings, a customized treatment plan, including timelines and number of sessions, is recommended. The modalities of the treatment are exhaustively described for each NAU based on multilayering, best practice medicine, and expert consensus available in the literature. RESULTS: Before-and after-case studies are presented to illustrate how the NAU method is used in routine practice for the treatment of two patients with HA fillers. CONCLUSION: The NAU method is not only a practical and accurate roadmap for the assessment and treatment of PFAC with HA fillers, but also facilitates communication between injectors and patients and data analysis. 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 .

Advancing the Era of Liquid Rhinoplasty: A Methodological Approach to Injection Protocols.

BACKGROUND: Liquid rhinoplasty, a non-surgical procedure using hyaluronic acid (HA) to reshape and refine the nose, has gained in popularity as an alternative to traditional surgical rhinoplasty although its results are not definitive. However, the lack of standardized injection protocols has raised concerns about treatment consistency and patient safety. OBJECTIVES: In this article, the authors propose a systematic protocol for the most common indications of liquid rhinoplasty. METHODS: By adopting a standardized methodology, healthcare professionals can enhance patient safety, improve treatment consistency, and optimize patient satisfaction. RESULTS: The protocol includes standardized injection sites categorized as dorsal, paramedian, tip and endonasal injections. Specific injection areas are recommended for different nasal shapes such as droopy noses, dorsal humps, nasal saddle deformity, inverted V deformity, tip shape abnormalities, twisted noses, revision cases with dorsal irregularities, and internal nasal valve dysfunction. While variations in filler dosages may be necessary based on individual patient needs, a conservative approach is recommended to maintain natural-looking results and reduce the risk of complications. CONCLUSIONS: The increase in non-surgical techniques for nasal refinement offers patients more options, and systematized injection protocols based on different nasal types provide a structured framework for liquid rhinoplasty. 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 .

Combination Administration of Heparin and Nitroglycerin for the Treatment of Polycaprolactone-Induced Intravascular Embolism: A Preclinical Investigation.

BACKGROUND: As a new-generation collagen stimulator, polycaprolactone (PCL) containing filler has been extensively applied in facial dermal fillers and other medical aesthetic fields. However, inadvertent intravascular injection of PCL may result in complications such as tissue edema, flap necrosis, and even blindness. To date, there is no effective treatment for PCL-induced intravascular embolism. OBJECTIVES: The aim of this study was to identify a viable resolution for the embolism resulting from intravascular administration of PCL-containing fillers. METHODS: Two different animal experiments were performed: (1) PCL-induced rat inferior epigastric arteries embolism, followed by gross observation, histological evaluation, and cytokines analysis from serum; and (2) PCL-induced rabbit auricular artery embolism, immediately treated with heparin and nitroglycerin. The ears were then evaluated by gross observation, Laser speckle imaging, in vivo imaging system (IVIS) imaging, and histological evaluation. Saline and hyaluronic acids (HA) were used as controls, hyaluronidase was used as a positive drug. RESULTS: In a rat model of inferior epigastric arteries embolism, both intravascular injection of HA and PCL resulted in flap necrosis, indicating that the filler-induced intravascular embolism can lead to serious complications. In a rabbit model of auricular artery embolism, the combination treatment of heparin and nitroglycerin resulted in a relative blood reperfusion recovery of 80% in the ischemic area of the PCL group on day 7 post-operation, which was comparable to that of the HA group treated with hyaluronidase. Histological analysis revealed that the administration of heparin and nitroglycerin significantly attenuated intravascular thrombosis formation and inflammatory cell aggregation. CONCLUSIONS: The combination of heparin and nitroglycerin effectively restores blood flow reperfusion in the intravascular embolization caused by PCL filler injection, alleviates local tissue edema and flap necrosis. These findings offer a novel approach for future clinical management of intravascular embolization with PCL-containing filler injection. NO LEVEL ASSIGNED: 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 www.springer.com/00266 .

Laser Speckle Contrast Imaging Guides Needling Treatment of Vascular Complications from Dermal Fillers.

BACKGROUND: Although laser Doppler imaging (LDI) accurately delineates a hypoperfused area to help target hyaluronidase treatment, laser speckle contrast imaging (LSCI) is more appropriate for assessing microvascular hemodynamics and has greater reproducibility than LDI. This study investigated the use of LSCI in the evaluation and treatment of six patients who developed vascular complications after facial dermal filler injections. METHODS: The areas of vascular occlusion were accurately defined in real time by LSCI and were more precise than visual inspections or photographic evidence for guiding needling and hyaluronidase treatment. RESULTS: All patients had achieved satisfactory outcomes as early as Day 2 of treatment and no procedure-related complications were reported after a median follow-up of 9.5 (7-37) days. CONCLUSION: LSCI accurately and noninvasively delineated vascular occlusions in real time among patients experiencing complications of facial dermal filler injections. Moreover, LSCI was more accurate than visual and photographic evaluations. Clinicians can use LSCI to reliably follow-up therapeutic outcomes after salvage interventions for vascular occlusions. 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 .

Are We Overlooking Harms of BDDE-Cross-Linked Dermal Fillers? A Scoping Review.

1,4-Butanediol ether (BDDE) is widely used as a cross-linker for hyaluronic acid in dermal fillers. The purpose of this scoping review was to determine the state of knowledge about the behaviour of cross-linked substances and safety of BDDE application. The rationale behind the review came from the clinical experience of one of the authors (KS), who noticed adverse reactions after BDDE-linked hyaluronan application. The scoping review was conducted according to PRISMA-ScR guidelines. Out of 399 articles, 52 met the inclusion criteria. Data on study design, sample/population, aims, methodology, outcomes and funding were extracted. Results were charted according to 6 subtopics: rheological properties, hydrogel stability, BDDE toxicity, immunogenicity, tissue interactions and clinical studies. In vitro, cross-linked hydrogels were characterized as effective fillers in terms of viscosity and elasticity; however, previously uncharacterized by-products of the cross-linking reaction were found. Most in vivo studies reported increased dermis regeneration, vascularization and anti-inflammatory cytokine release after implantation of BDDE-cross-linked substances. In clinical studies, BDDE was shown to sensitize subjects to 1,6-hexanediol ether and other substances found in epoxy resin systems. Occupational dermatitis and hypersensitivity reactions were documented. Our review shows that BDDE may have long-term adverse effects, which are overlooked in the safety assessment of fillers. Reviews on BDDE conducted so far have mostly been sponsored by the industry, potentially leading to incomplete reporting of adverse effects. A review of the occurrence of allergic reactions after commercial dermal filler use and analysis of possibly harmful by-products of BDDE hyaluronan degradation are needed.Level of Evidence III 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 .

Nonsurgical Rhinoplasty: Results from a Retrospective Study of Rino-4-Puntos Technique with Hyaluronic Acid.

BACKGROUND: Nonsurgical rhinoplasty (NSR) utilizing hyaluronic acid (HA) filler injections is increasingly used to address nose shape issues. While refinements have been proposed, the technique lacks standardization. OBJECTIVES: Our study aimed to evaluate the aesthetic outcome, longevity of results, safety, and patient satisfaction with the novel Rino-4-Puntos (R4P) NSR technique. METHODS: This is a retrospective study of consecutive individuals treated with R4P between January 2021 and July 2023. All participants had one of the four indications: rectification of the dorsum (21%), triangulation of the tip (32%), projection (25%), and strengthening of the columella (22%). Each patient received two hyaluronic acid (HA) fillers: one with intermediate G prime (G') at Points 1-3 and another with high G' at Point 4, which is further divided into Points 4.1, 4.2, 4.3, and 4.4. The injection points were as follows: P1 (radix, 0.05-0.15 mL, supraperiosteal), P2 (supratip, 0.025 mL, suprachondrial), P3 (tip, 0.15 mL, deep fat), P4 (columella, 0.30 mL, supraperiosteal [4.1], or deep fat [4.2, 4.3, and 4.4]). RESULTS: Four hundred individuals (n = 284 [71%] females) are included. The mean filler volume used was 0.65 ± 0.17 mL. Injecting small boluses (≤ 0.05 mL) in the midline at deep planes minimized the risk of adverse effects, as no vascular complications occurred. Ninety-three percent of participants considered the overall outcome at least satisfactory ("good," "very good," or "excellent"). The treatment effect was maintained for a median of 11 months. CONCLUSIONS: The R4P technique refines NSR by combining enhanced aesthetic outcome, longevity, and safety. 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 .

Foreign body reactions related to orofacial esthetic fillers: A systematic review.

The aim of this study was to systematically review the clinicopathological data regarding foreign body reactions (FBR) related to esthetic procedures in the orofacial region. Electronic searches were performed in six databases and in gray literature using PEO acronym for the review question. Case series and case reports describing FBR related to esthetic procedures in the orofacial region were included. The JBI Critical Appraisal Checklist-University of Adelaide tool was used for measuring the risk of bias. Eighty-six studies reporting 139 cases of FBR were identified. The mean age at diagnosis was 54.12 years (14-85 years), with most of the cases reported in America, North America (n = 42/30.70%) and Latin America (n = 33/23.60%), mainly occurring in women (n = 131/94.40%). Asymptomatic (n = 60/43.40%) nodules (n = 71/50.60%) were the main clinical characteristics. The lower lip represented the most affected anatomical location (n = 28/22.20%), followed by the upper lip (n = 27/21.60%). Surgical removal was the treatment of choice (n = 53/35.70%). Twelve different dermal fillers were reported in the study, and the microscopic characteristics of the cases varied according to the material used. The results based on case series and case reports showed that nodule and swelling were the main clinical characteristics of FBR related to orofacial esthetic fillers. The histological characteristics depended on the type of the filler material used.

Polymethylmethacrylate-induced foreign body reaction presenting as bilateral parotid lesions: A case report of dermal filler adverse reaction diagnosed on fine needle aspiration.

BACKGROUND: Dermal filler injections are being increasingly used as a non-surgical option for facial cosmetic procedures. However, their use has been implicated in multiple adverse events including immediate, early onset, and late onset complications. AIM: We present a case of dermal filler-induced foreign body reaction presenting as bilateral parotid lesions and diagnosed using fine needle aspiration. CONCLUSION: This case elucidate the risk of delayed adverse events in patients with dermal filler injections and stresses the importance of awareness by patients and providers for such events.

Laser treatment for adverse reactions to injectable facial filling: a systematic review.

Facial filling is widespread in society, albeit associated with inherent risks. This review analyzes clinical studies using laser therapy for filler complications to assess its safety and efficacy as an alternative treatment. A literature search was conducted up until April 2023, encompassing five different databases: PubMed, Scopus, Embase, Web of Science, and Medline, to find clinical trials addressing patients who underwent laser treatment for adverse reactions to injectable facial filling. The outcome variables were the clinical assessment of the lesion and the occurrence of post-intervention complications/sequelae. The risk of bias was assessed using the ROBINS-I tool. In total, six studies were included, all classified as having a "moderate risk" of bias. A total of 533 patients underwent laser treatment for adverse reactions to injectable facial fillers. The diode laser was the most frequently utilized equipment, with positive results reported in five studies. Among all treated patients, 96.24% achieved partial or complete resolution, 0.22% experienced some sequelae or complications, and only 0.01% showed no improvement. Laser treatment can eliminate the necessity for surgical intervention for adverse reactions to injectable facial fillers, resulting in partial or complete improvement of the condition.

Myomodulation with Facial Fillers: A Comprehensive Technical Guide and Retrospective Case Series.

The article titled "Myomodulation with Facial Fillers: A Comprehensive Technical Guide and Retrospective Case Series" by Coimbra et al. in Aesthetic Plastic Surgery presents a technical guide for holistic facial treatment using hyaluronic acid (HA) fillers and a map for addressing individual facial units through myomodulation. The authors' approach is appreciated for its value. However, concerns arise about the employed methodologies. Understanding HA's properties is vital for treatment standardization. The significance of HA's rheological properties, encompassing viscosity, elasticity, and cohesiveness, is critical for optimal dermal filler selection. The authors' insights are acknowledged, yet further analysis considering these factors is recommended. LEVEL OF EVIDENCE V: 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 .

Laser Speckle Contrast Imaging Guides Needling Treatment of Vascular Complications from Dermal Fillers.

We have read the article titled "Laser Speckle Contrast Imaging Guides Needling Treatment of Vascular Complications from Dermal Fillers" by Tsai et al. in Aesthetic Plastic Surgery, and we are deeply interested in their research. The study explores the use of laser speckle contrast imaging (LSCI) for evaluating and treating vascular complications in six patients who experienced issues after facial dermal filler injections. The authors found that LSCI accurately and noninvasively identified vascular occlusions in real time, surpassing the accuracy of visual and photographic assessments. This suggests that LSCI can be a valuable tool for clinicians to monitor therapeutic outcomes following interventions for vascular occlusions. While we appreciate the study's significance and quality, we have specific concerns regarding the methodologies employed to prevent complications related to hyaluronic acid (HA). Understanding the properties of the active substance is crucial for standardization in medical treatments. A comprehensive understanding of HA's essential characteristics is vital to determine if correlations exist between these properties, treatment outcomes, and the risk of complications. Key considerations include rheology, which studies how matter flows and deforms under strain, viscosity, elasticity, cohesiveness, and gel texture. These factors play a vital role in the safety and efficacy of dermal filler treatments.Level of Evidence V 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 .

Myomodulation with Facial Fillers: A Comprehensive Technical Guide and Retrospective Case Series.

BACKGROUND: Placement of fillers in close proximity to the mimetic or sphincter muscles of the face appears to enhance or suppress muscle action in a relatively predictable way. METHODS: From June 2016 to June 2021, patients who underwent the first author's technique of myomodulation with dermal fillers to address aesthetic concerns or to manage facial spasms or synkinesis were evaluated in a retrospective case series. Additionally, the authors provide a technical guide for a whole-face approach to treatment with fillers and a conceptual map for treatment of each facial subunit with a focus on myomodulation. RESULTS: A total of 1352 patients (1108 women, 244 men; mean age, 51 years) underwent at least 1 treatment session during the 5-year study period. The treatment patterns of the study population and details of 2 representative cases are presented. CONCLUSIONS: Although not well understood mechanistically, myomodulation with injectable fillers shows promise for significant and reliable results of facial rejuvenation. 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 .

Broken Dermal Filler Cannula in Post-Radiated Décolleté.

We present a case of 72-year-old that arrived at our emergency department following breaking of a dermal cannula used to inject a poly-L-lactic acid (PLLA) to the décolleté by an aesthetic practitioner. She had a history of previous radiation to the breast after a lumpectomy. The cannula was removed using fluoroscopy guidance. This case emphasizes several key messages. First is the extreme caution needed when using a cannula to inject dermal fillers in a previously radiated area. Second, the importance of properly trained practitioners. Last, one should consider the use of bio-stimulants in a previously cancerous area. Please confirm if the author names are presented accurately and in the correct sequence (given name, middle name/initial, family name). Author 1 Given name: [Yoav Yechezkel] Last name [Pikkel], Author 1 Given name: [Assaf Aviram] Last name [Zeltzer] Also, kindly confirm the details in the metadata are correct.confirmedPlease check and confirm the organization division and organization name is correctly identified for the affiliation 2.yesLevel of Evidence V 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 .

Evaluating hyaluronic acid dermal fillers: A critique of current characterization methods.

Soft-tissue augmentation has gained much popularity in recent years. Hyaluronic acid (HA) based dermal fillers; a non-permanent injectable device, can restore volume loss, fill fine lines and wrinkles and add curves and contours. HA based dermal fillers entered the non-surgical treatment market in the late 1990s, however there is a lack of data and literature comparing the range of products and detailing the complexities of these products and how it relates to tissue performance. Measuring the physico-chemical properties of these dermal fillers provide key parameters to predict their performance after injection into the body. This article reviews the currently reported methods and parameters used to characterize dermal fillers. The review of these methods and data from the literature provides a useful guide to clinicians and injectors in selecting the optimal product suitable for the needs of each patient.

Treatment of Human Immunodeficiency Virus-Associated Facial Lipoatrophy With Hyaluronic Acid Filler Mixed With Micronized Cross-Linked Acellular Dermal Matrix.

BACKGROUND: Human immunodeficiency virus (HIV)-associated facial lipoatrophy (FLA) is a stigmatizing side effect associated with the use of highly active antiretroviral therapy. We sought to evaluate the safety and efficacy of the hyaluronic acid filler mixed with micronized cross-linked acellular dermal matrix (HA/MADM) in HIV-associated FLA. METHODS: We conducted an open-label safety and efficacy study in patients with HIV-associated FLA. Fourteen patients received single injection of the HA/MADM, and 13 patients completed the 24-week follow-up evaluation. Treatment efficacy, safety, and patient and physician satisfaction were evaluated. Repeated measure analysis of variance with post-hoc analysis with the Wilcoxon signed rank test was performed to compare and incorporate parameters at each time point. RESULTS: All 13 patients maintained a significant improvement of the Carruthers Lipoatrophy Severity Scale grade throughout the study period, along with improvement of the depressed volume due to lipoatrophy measured using a three-dimensional camera system. More than 80% of patients and physicians were satisfied with the treatment, and no treatment-related adverse events were reported, except for one case of transient subcutaneous nodule formation. CONCLUSION: Our study findings suggest that injectable HA/MADM is a potentially effective and safe treatment option for treating HIV-positive patients with FLA.

Liquid Spreader Grafts: Internal Nasal Valve Opening with Hyaluronic Acid.

BACKGROUND: Nasal valve disorders frequently give rise to nasal obstruction. Dermal fillers could be used in the internal valve area to generate valve widening. The goal of this study was to report our "liquid spreader" procedure consisting in the injection of hyaluronic acid (HA) at the internal nasal valve in patients complaining of nasal obstruction. METHODS: The procedure described in this paper is suitable for patients with unilateral or bilateral nasal obstruction related to architectural features resulting in narrowing of the internal nasal valve. HA is injected along the internal valve from a single entry point located at the anterior part of the internal valve, thus creating a volume which will induce nasal valve widening. Rhinomanometries and visual analog scales (VAS) regarding nasal obstruction were collected before and after the procedure. RESULTS: Sixteen patients were enrolled (7 females). Mean age was 44 years (min=24 y-o, max=65 y-o). Thirteen presented nasal valve narrowing without septal deviation while 3 patients had high septal deviation. Before injection, mean nasal resistances were 3.4±5.6 sPa/mL (min=0.55, max=19.8). One month after injection, mean nasal resistances were 0.38±0.26 sPa/mL (min = 0.20, max = 0.85). The difference was statistically significant (p=0.049). VAS scores were improved with a trend back to baseline after 12 months. CONCLUSIONS: The liquid spreader is a useful procedure that can be combined with non-surgical esthetic rhinoplasties. 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 .

Transcriptomic Analysis in Human 3D Skin Model Injected with Resorbable Hyaluronic Acid Fillers Reveals Foreign Body Response.

Usage of injectable dermal fillers applied for aesthetic purposes has extensively increased over the years. As such, the number of related adverse reactions has increased, including patients showing severe complications such as product migration, topical swelling and inflammatory reactions of the skin. In order to understand the underlying molecular events of these adverse reactions we performed a genome-wide gene expression study on the multi-cell type human Phenion® Full-Thickness Skin Model exposed to five experimental hyaluronic acid (HA) preparations with increasing cross-linking degree, four commercial fillers from Perfectha®, and non-resorbable filler Bio-Alcamid®. In addition, we evaluated whether cross-linking degree or particle size of the HA-based fillers could be associated with the occurrence of adverse effects. In all cases, exposure to different HA fillers resulted in a clearly elevated gene expression of cytokines and chemokines related to acute inflammation as part of the foreign body response. Furthermore, for one experimental filler genes of OXPHOS complexes I-V were significantly down-regulated (adjusted p-value < 0.05), resulting in mitochondrial dysfunction which can be linked to over-expression of pro-inflammatory cytokines TNFα and IL-1ß and chemokine CCL2. Our hypothesis that cross-linking degree or particle size of the HA-based fillers is related to the biological responses induced by these fillers could only partially be confirmed for particle size. In conclusion, our innovative approach resulted in gene expression changes from a human 3D skin model exposed to dermal fillers that mechanistically substantiate aforementioned adverse reactions, and thereby adds to the weight of evidence that these fillers may induce inflammatory and fibrotic responses.

Bridging a Century-Old Problem: The Pathophysiology and Molecular Mechanisms of HA Filler-Induced Vascular Occlusion (FIVO)-Implications for Therapeutic Interventions.

Biocompatible hyaluronic acid (HA, hyaluronan) gel implants have altered the therapeutic landscape of surgery and medicine, fostering an array of innovative products that include viscosurgical aids, synovial supplements, and drug-eluting nanomaterials. However, it is perhaps the explosive growth in the cosmetic applications of injectable dermal fillers that has captured the brightest spotlight, emerging as the dominant modality in plastic surgery and aesthetic medicine. The popularity surge with which injectable HA fillers have risen to in vogue status has also brought a concomitant increase in the incidence of once-rare iatrogenic vaso-occlusive injuries ranging from disfiguring facial skin necrosis to disabling neuro-ophthalmological sequelae. As our understanding of the pathophysiology of these injuries has evolved, supplemented by more than a century of astute observations, the formulation of novel therapeutic and preventative strategies has permitted the amelioration of this burdensome complication. In this special issue article, we review the relevant mechanisms underlying HA filler-induced vascular occlusion (FIVO), with particular emphasis on the rheo-mechanical aspects of vascular blockade; the thromboembolic potential of HA mixtures; and the tissue-specific ischemic susceptibility of microvascular networks, which leads to underperfusion, hypoxia, and ultimate injury. In addition, recent therapeutic advances and novel considerations on the prevention and management of muco-cutaneous and neuro-ophthalmological complications are examined.

Upscaling the pharmacy profession: Knowledge and willingness of the Lebanese pharmacists to practice the administration of dermal fillers.

Background: The rapid global development of the pharmacy profession has led pharmacists to enter the cosmetic industry by administering injectable dermal fillers (DFs) to those in need. However, there is no clear indication that the Lebanese pharmacists are familiar with these procedures or are willing to do so. Objectives: We aimed to investigate the Lebanese community pharmacists' knowledge about DFs and their willingness to administer them. Methods: A self-administered questionnaire was sent to 461 randomly selected pharmacists who agreed to participate in the study after a phone call. A scoring system for the knowledge about DFs was employed. Results: Only 31.4 % of participants reported formal education as the source of knowledge about DFs, and 3.7 % of them reported practicing them on patients. The mean score of knowledge was 5.9 ± 2.5 (out of 14). High level of knowledge was observed in only 25 % of the participants, where females, older and experienced pharmacists, and those working in Beirut region were more significantly knowledgeable. Around 67 % of participants were willing to be trained in this field to expand their field of practice and improve their income. Conclusions: Lebanese community pharmacists are not yet ready for this new dimension in the career. Legislative procedures, training, licensing, and developed pharmacy curriculum must precede the practice of DFs by pharmacists in Lebanon.