Eye-Tracking Insights into the Perception of Buttocks.

BACKGROUND: Aesthetic enhancements to the buttock region have grown in demand due to media influence and evolving beauty standards. Using eye-tracking technology, we sought to uncover subconscious visual preferences regarding the buttock aesthetic. The objective of this investigation was to assess visual gaze patterns in assessing female buttocks among Caucasian and Asians through eye-tracking technology. MATERIALS AND METHODS: 67 participants viewed photographs of buttocks from various angles, and eye movements were analyzed using the Tobii Pro Nano eye-tracker. RESULTS: Males fixated on the intergluteal cleft for 0.96 ± 1.1 s and the thigh gap for 0.07 ± 0.2 s; while, females fixated for 0.81 ± 0.9 s and 0.06 ± 0.2 s on the same regions, respectively. Significant gender differences were observed in the intergluteal cleft (p = 0.002) and upper lateral buttock (p < 0.001). CONCLUSION: This study offers new insights into the observation of buttocks. The consistent attention toward the intergluteal cleft across demographics could be of potential significance in the aesthetic perception of buttocks. However, diverse gaze patterns also underscore the multifaceted nature of human attraction. These findings hold implications for plastic surgery, aesthetic medicine, and the sociocultural understanding of beauty. A deeper dive into aesthetic preferences is pivotal for a holistic understanding of human perceptions of attractive buttocks. 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 Table of Contents or the online instructions to Authors www.springer.com/00266 .

Evaluation of a Plastic and Reconstructive Surgery Resident Non-surgical Cosmetic Clinic Experience.

INTRODUCTION: An important component of plastic surgery residency training is independent cosmetic patient management. A resident cosmetic clinic was created at Oregon Health & Science University in 2007 to expand this experience. The cosmetic clinic has traditionally been most successful in offering nonsurgical facial rejuvenation with neuromodulators and soft tissue fillers. This study focuses on the demographics of the patient population and the treatments provided over a 5-year period and compares this experience to those of the same program's attending cosmetic clinics. METHODS: A retrospective chart review of all patients seen at Oregon Health & Science University's Plastic and Reconstructive Surgery Resident Cosmetic Clinic between January 1, 2017, and December 31, 2021 was performed. Patient demographics, type of injectable received (neuromodulator versus soft tissue filler), location of injection, and additional cosmetic procedures were evaluated. RESULTS: Two hundred patients met the study criteria, which included 114 seen in the resident clinic (RC), 31 seen in attending clinic (AC), and 55 patients seen in both. A primary analysis compared the two groups seen in the resident and attending only clinics. The average age of patients seen in the RC was younger, 45 versus 51.5 (P ≤ 0.05). There was a trend toward more patients in the RC being involved in healthcare as compared to those patients seen in the AC, but this difference was not found to be statistically significant. The median number of neuromodulator visits in the RC was 2 (1, 4) versus 1 (1, 2) in the AC (P ≤ 0.05) The most common location for neuromodulator injections in both clinics was the corrugators. CONCLUSIONS: Patients in the resident cosmetic clinic were younger females, most receiving neuromodulator injections. No statistically significant differences were identified in patient population, injections received, and location of injections between the two clinics, indicating a similar trainee skill set and patient care plan between the two clinics.

Safety and Efficiency of Minimally Invasive Buttock Augmentation: A Review.

BACKGROUND: Volume restoration and enhancement of the gluteal region appearance has become nowadays a popular concern in particular for many women. Several options are available, none however are without complications and side effects. Volume enhancement with soft tissue fillers of the gluteal region is emerging as a highly attractive minimally invasive modality. It has led unfortunately to more unlicensed, nonmedical practitioners administering illicitly injections for buttock augmentation at relatively low costs. MATERIALS AND METHODS: To determine safety, efficacy, and cost effectiveness of mostly used soft-tissue fillers for buttock augmentation, a systematic literature search of PubMed, Medline, and Embase was conducted to identify the mostly used fillers for gluteal augmentation. It was complemented by searching for each of the identified filler material separately to retrieve any missed reports. References of clinical studies and trials, reviews, and consensus reports were reviewed as well for the same objective. RESULTS: In the final analysis 12, mostly strongly biased clinical reports providing a low level of evidence, were identified for inclusion in the review. Two studies involved Polymethylmethacrylate (PMMA), 5 Poly-L-lactic acid, 1 Calcium hydroxyapatite and 4 hyaluronic acid filler injection. No studies were identified involving liquid silicone or Polyacrylamide hydrogel. The little available evidence provided by this review indicates that a specific brand of PMMA in Brazil has a demonstrable relatively good safety, efficiency, and cost-effectiveness record superior to surgical alloplastic gluteal augmentation or to lipofilling only when injected by experts. CONCLUSION: Gluteal augmentation with soft tissue fillers is not as simple and innocuous as advertised. Serious complications may occur. Moreover, optimal buttock contouring entails not only volume augmentation but also volume removal; thus, volume augmentation with soft tissue fillers may not be ideal. Popularizing this modality must also be approached with great care. Serious complications do occur; they become inevitable when performed illegally by non-specialized, non-authorized, and unscrupulous practitioners in non-accredited facilities. Patients must be warned that adherence to regulations is critical and that only well-trained certified experts practicing legally in accredited facilities can address safely and efficiently their concerns. 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 .

Assessing the Practical Application of Rheological Properties of Hyaluronic Acid Fillers: A 1-Year Follow-Up Photographic Analysis.

BACKGROUND: A hyaluronic acid filler is a viscoelastic substance that can be evaluated by rheology. Rheological properties are important for the longevity of the filler, which can be deformed due to the various forces that exist on the face. This study aimed to evaluate the maintenance of the lifting capacity of hyaluronic acid filler injection. METHODS: Rheological evaluation of five different products was performed on nine patients who had undergone hyaluronic acid filler injection from Jan 18, 2021 to Jan 27, 2022. Photographs from different time points up to 1 year after filler injection were used to determine the maintenance of the lifting effect of the filler injection. RESULTS: After 1 year of follow-up, the filler on the forehead, temple area, nose, chin, nasojugal fold, and mid-cheek groove areas showed good maintenance, while the nasolabial fold slightly improved. CONCLUSIONS: Appropriate rheological parameters of hyaluronic acid fillers should be considered before injection into different facial areas. A good choice of filler can result in a good aesthetic effect 1 year after injection. 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 .

Multidose Hyaluronidase Administration as an Optimal Procedure to Degrade Resilient Hyaluronic Acid Soft Tissue Fillers.

Minimally invasive hyaluronan (HA) tissue fillers are routinely employed to provide tissue projection and correct age-related skin depressions. HA fillers can advantageously be degraded by hyaluronidase (HAase) administration in case of adverse events. However, clear guidelines regarding the optimal dosage and mode of administration of HAase are missing, leaving a scientific gap for practitioners in their daily practice. In this study, we implemented a novel rheological procedure to rationally evaluate soft tissue filler degradability and optimize their degradation kinetics. TEOSYAL RHA® filler degradation kinetics in contact with HAase was monitored in real-time by rheological time sweeps. Gels were shown to degrade as a function of enzymatic activity, HA concentration, and BDDE content, with a concomitant loss of their viscoelastic properties. We further demonstrated that repeated administration of small HAase doses improved HA degradation kinetics over large single doses. Mathematical analyses were developed to evaluate the degradation potential of an enzyme. Finally, we tuned the optimal time between injections and number of enzymatic units, maximizing degradation kinetics. In this study, we have established a scientific rationale for the degradation of HA fillers by multidose HAase administration that could serve as a basis for future clinical management of adverse events.

Standardized approach to treatment of retinal artery occlusion after intraarterial injection of soft tissue fillers: EYE-CODE.

BACKGROUND: Inadvertent intraarterial injection of soft tissue fillers during facial aesthetic procedures can result in serious adverse events including visual impairment and blindness. Once the retinal artery has been occluded, only a short window of opportunity exists before blindness becomes irreversible. All physicians should be prepared for the eventuality of intraarterial injection, despite its rarity. OBJECTIVE: The aim of this document is to provide a simple and evidence-based protocol using the easy to remember acronym EYE-CODE: EYE (I call retinal referral center), C (check vision), O (optic nerve function), D (decrease intraocular pressure), and E (erase filler). METHODS: The EYE-CODE acronym incorporates 2 key components: (1) a systematic office-based protocol to first determine whether vision loss is present and to what extent and (2) a treatment strategy that can be started in the acute office setting and continued by an emergency ophthalmologist. RESULTS: The protocol incorporates a crash kit of treatments readily available to an aesthetic physician combining measures to rapidly reduce intraocular pressure to allow the emboli to dislodge downstream with measures to improve retinal perfusion. CONCLUSION: EYE-CODE provides an up-to-date, one-stop reference for appropriate management of retinal artery occlusion induced by injection of soft tissue fillers.

Soft Tissue Filler Therapy and Informed Consent: A Canadian Review.

Soft Tissue Filler (STF) Therapy for cosmetic facial rejuvenation is associated with known complications. The manifestation of these known complications can lead to patients commencing civil litigation actions or making complaints to provincial regulatory authorities and alleging that the practitioner failed to obtain the patient's informed consent to the therapy. Data provided by the Canadian Medical Protective Association (CMPA) on medical-legal cases arising from the provision of STF therapy between 2005 and 2019 are presented. Select reported case law decisions from Canadian courts and regulatory bodies addressing the concept of informed consent are reviewed. Insights about the risk factors pertaining to the process of obtaining informed consent for STF therapy are presented to increase an understanding of the elements of communication and documentation needed to ensure patients are aware of the consequences of this treatment.

High-Frequency Ultrasound Imaging Findings of Different Mental Injectable Soft Tissue Fillers.

BACKGROUND: In recent years, the use of mental injectable soft tissue fillers is popular. However, some fillers are difficult to distinguish from pathological tissue, and some non-absorbable fillers need to be removed in time. Therefore, identification of different fillers is important. In this study, we summarized the ultrasonic manifestations of different mental injectable soft tissue fillers to provide references for clinical practice. METHODS: We screened the mental ultrasound images from November 2014 to November 2021 in the Plastic Surgery Hospital of Chinese Academy of Medical Sciences, identified different filling injection materials, and summarized and classified the ultrasonic characteristics of each filling material. RESULTS: A total of 244 cases were included, involving 62 cases of hyaluronic acid, 126 cases of polyacrylamide hydrogel, 19 cases of growth factor, 16 cases of calcium hydroxyapatite, 15 cases of silicone oil and 6 cases of fat. The ultrasonic manifestation of hyaluronic acid was anechoic area, which could be divided into six types according to the distribution characteristics. The ultrasonography of polyacrylamide hydrogel showed fine punctate echo, which could be divided into nine types. The ultrasonographic appearance of growth factor was similar to the echo of the surrounding tissue, and the boundary was not clear. Calcium hydroxyapatite was characterized by uneven hyperechoic area, which was spread in the tissue space, with unclear boundary with surrounding tissues. Sonographic patterns of silicone oil were hyperechoic and cloudy on high-frequency ultrasound. The deep tissue and periosteum layer were not clear. Transplanted fat showed isoechoic area or uneven low-echo area, with clear boundary and peripheral adipose tissue acoustic enhancement. CONCLUSIONS: High-frequency ultrasound is safe and reliable for identification and typing of chin filling injection materials, which can be applied in clinical practice. 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 .

A prospective, multi-centre, follow-up clinical study evaluating the safety and effectiveness of a 24mg/ml sodium hyaluronate soft tissue filler.

Highly concentrated hyaluronic acid dermal fillers commonly contain 20 mg/ml sodium hyaluronate. The soft tissue filler SF 24 contains 24 mg/ml sodium hyaluronate. It is a viscoelastic gel, which is moderately cross-linked and specifically designed to correct moderate to deep wrinkles and folds of facial skin.To evaluate the long-term safety and effectiveness of the SF 24 for facial augmentation.The primary endpoints were effectiveness and safety, which were measured by investigators' assessment of wrinkle/ fold/ defect severity and reaction severity, respectively. The Global Esthetic Improvement Scale (GAIS) evaluated secondary endpoints, such as patient and physician satisfaction. Data collection occurred at treatment date (day 0) and at each visit set at an interval of 21 days, 121 days, 213 days, and 395 days. A total of 74 individuals (3 male and 71 female) received treatment with SF 24 across five sites. The baseline value (2. 70) of wrinkle and fold severity was reduced to 1.22 directly after treatment and remained improved even after 273 days at 1.59. The improvements compared to baseline were all significant (p < .001). The injection-related reactions were mainly short-term (1-7 days), mild to moderate in severity, and resolved without intervention. SF 24 is safe and effective for facial volume augmentation. It shows long-lasting (9 months) results in treated patients.

The Aetiopathogenesis of Late Inflammatory Reactions (LIRs) After Soft Tissue Filler Use: A Systematic Review of the Literature.

BACKGROUND: Late inflammatory reactions (LIRs) are the most challenging complications after filler use. The immune system plays a prominent role in its etiology, albeit to an unknown extent. Bacterial contamination in situ has been hypothesized to be causative for LIRs. How this relates to the immunological processes involved is unknown. This article aims to provide an overview of immunological and bacterial factors involved in development of LIRs. METHODS: We undertook a systematic literature review focused on immunological factors and microbiota in relation to LIRs after filler use. This systematic review was performed in accordance with the PRISMA guidelines. PubMed, EMBASE and the Cochrane databases were searched from inception up to August 2019. Included studies were assessed for the following variables: subject characteristics, number of patients, primary indication for filler injection, implant type/amount and injection site, type of complication, follow-up or injection duration, study methods, type of antibiotics or medical therapies and outcomes related to microbiota and immunological factors. RESULTS: Data on immunological factors and bacterial contamination were retrieved from 21 included studies. Notably, the presence of histocytes, giant cells and Staphylococcus epidermidis within biopsies were often associated with LIRs. CONCLUSION: This review provides a clear overview of the immunological factors associated with LIRs and provides a hypothetical immunological model for development of the disease. Furthermore, an overview of bacterial contamination and associations with LIRs has been provided. Follow-up research may result in clinical recommendations to prevent LIRs. 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. .

Granulomatous Reaction to Cosmetic Soft Tissue Filler with Late-onset Inflammatory Response.

is missing (Short communication).

Calcitriol-mediated hypercalcemia secondary to granulomatous disease caused by soft-tissue filler injection: a case report.

Soft-tissue filler (STF) injections have been used worldwide for cosmetic reasons. In most cases, they are not approved by the United States Food and Drug Administration (FDA). Regulatory boards in Latin American countries do not allow the medical use of STF injections; however, these injections are still widely used. A case of calcitriol-mediated hypercalcemia with ectopic calcifications, chronic kidney disease, nephrolithiasis and calcinosis is presented. The reported case highlights the consequences of STF use, including calcitriol-mediated hypercalcemia secondary to granulomatous reactions years after an esthetic procedure.

Treatment of glabella skin necrosis following injection of hyaluronic acid filler using platelet-rich plasma.

Hyaluronic acid (HA) fillers have been widely used for soft-tissue augmentation. However, there can be various complications following HA filler injection. Skin necrosis is rare but one of the most disastrous side effects that, if not treated promptly and effectively, can result in permanent and potentially disfiguring scarring. Thus, early proper management is important. Herein we report a patient who experienced tissue necrosis of the glabellar area after receiving filler injections that was successfully treated using platelet-rich plasma and provide full follow-up clinical photographs.

Why some of the dermatologists choose to avoid carrying out minimally invasive cosmetic procedures?

BACKGROUND: Some dermatologists choose to avoid carrying out cosmetic dermatology procedures. The aim of this study is to reveal the knowledge and daily outpatient clinic applications of dermatologists in Turkey, and their problems concerning minimally invasive cosmetic procedures (MICPs). MATERIALS AND METHODS: This study was designed as a descriptive cross-sectional study. Between December 2014 and July 2015, a questionnaire was sent to dermatologists by e-mail. RESULTS: Of the 318 participant dermatologists, 233 (73.3%) were female. It was determined that 63.8% of the participants had sufficient knowledge on MICP (very good, good, and medium) while 36.2% had insufficient knowledge (little, very little, and none). About 19.9% of the patients required MICP during outpatient clinic service. The 120 dermatologists who do not apply MICP gave the following reasons: not having adequate training (50%), MICP not being profitable (28.3), not having enough time (25%), being worried about side effects and complications (14.2%), and legal problems (9.2%). CONCLUSION: It was observed that many dermatologists are interested in cosmetic dermatology, received their training on the subject through courses, have sufficient knowledge, and apply these procedures. However, it was also found out that some dermatologists do not apply MICP due to inadequate training, time, and physical constraints.

Identification of a soft tissue filler by ex vivo confocal microscopy and Raman spectroscopy in a case of adverse reaction to the filler.

BACKGROUND: Soft tissue fillers are usually identified in the skin using the conventional histopathologic examination. Ex vivo RCM has been used in one case and Raman spectroscopy (RS), which has been recently applied for the identification of skin foreign bodies, has never been employed for fillers. We report the use of both these new techniques, ex vivo RCM and RS, to confirm the diagnosis of adverse reaction to a soft tissue filler and to identify its composition. METHODS: We excised a skin nodule suspicious of adverse reaction to soft tissue filler, and we performed an ex vivo reflectance confocal microscopy (RCM) and an histopathologic examination, followed by a RS analysis. RESULTS: Ex vivo RCM showed numerous hypo-reflective microspheres in the dermis that corresponded to rounded vacuoles at histopathologic examination, suggestive of polymethylmethacrylate (PMMA). RS showed a series of peaks at 600, 813, 970 1252, 1450, 1728, and 2951 cm(-1) in correspondence to the microspheres, confirming the presence of PMMA. CONCLUSION: These results suggest that ex vivo RCM and RS are additional tools to conventional histopathologic examination to characterize soft tissue fillers in case of adverse reaction. RCM has the advantage compared with the histopathologic examination that can be extemporaneously performed on a fresh surgical specimen. RS allow a precise chemical identification of the filler.

Treatment algorithm of complications after filler injection: based on wound healing process.

Soft tissue filler injection has been a very common procedure worldwide since filler injection was first introduced for soft tissue augmentation. Currently, filler is used in various medical fields with satisfactory results, but the number of complications is increasing due to the increased use of filler. The complications after filler injection can occur at any time after the procedure, early and delayed, and they range from minor to severe. In this review, based on our experience and previously published other articles, we suggest a treatment algorithm to help wound healing and tissue regeneration and generate good aesthetic results with early treatment in response to the side effects of filler. Familiarity with the treatment of these rare complications is essential for achieving the best possible outcome.

Complications of injectable fillers, part 2: vascular complications.

Accidental intra-arterial filler injection may cause significant tissue injury and necrosis. Hyaluronic acid (HA) fillers, currently the most popular, are the focus of this article, which highlights complications and their symptoms, risk factors, and possible treatment strategies. Although ischemic events do happen and are therefore important to discuss, they seem to be exceptionally rare and represent a small percentage of complications in individual clinical practices. However, the true incidence of this complication is unknown because of underreporting by clinicians. Typical clinical findings include skin blanching, livedo reticularis, slow capillary refill, and dusky blue-red discoloration, followed a few days later by blister formation and finally tissue slough. Mainstays of treatment (apart from avoidance by meticulous technique) are prompt recognition, immediate treatment with hyaluronidase, topical nitropaste under occlusion, oral acetylsalicylic acid (aspirin), warm compresses, and vigorous massage. Secondary lines of treatment may involve intra-arterial hyaluronidase, hyperbaric oxygen therapy, and ancillary vasodilating agents such as prostaglandin E1. Emergency preparedness (a "filler crash cart") is emphasized, since early intervention is likely to significantly reduce morbidity. A clinical summary chart is provided, organized by complication presentation.

"Cohesiveness of Hyaluronic Acid Fillers": Evaluation Using Multiple Cohesion Tests.

Background Hyaluronic acid fillers can be manufactured using various processes. They have multiple properties, including their concentration, degree of modification, and rheological data. Cohesion is one such property to evaluate gel integrity; however, there is no standardized method for calculating this parameter. This study aimed to evaluate different tests for calculating hyaluronic acid cohesion and discuss the importance of hyaluronic acid cohesion as a consideration when selecting fillers. Methods The cohesion levels of five different hyaluronic acid fillers with different rheological properties were evaluated and compared using the drop weight, compression, tack, and dispersion time tests. Results The cohesion tests yielded different results in the samples. Samples 2 and 4 showed approximately two times the number of droplets when compared with Sample 5 in drop weight test. Samples 1, 2, 3, and 4 were superior to Sample 5 in tack test. Samples 1, 2, and 3 showed cohesive appearances at 95 seconds in most cases in dispersion test. Rheological test results did not reflect the measures of cohesion. Conclusion Although there are no definite standardized tests to evaluate the cohesion of hyaluronic acid fillers, our proposed tests showed similar results for different hyaluronic acid filler products. Further studies are needed to evaluate the cohesion of hyaluronic acid fillers and determine the clinical use of this distinguishing characteristic for clinicians selecting the product of choice. Level of evidence statement: These data are Level IV evidence.

HIV-associated facial lipoatrophy treated with injectable silicone oil: a pilot study.

BACKGROUND: Facial lipoatrophy (FLA) is associated with HIV infection and is part of the lipodystrophy syndrome. Temporary filler treatments do not meet the need of the patient, as there is a lack of permanence, and excessive cost. OBJECTIVE: We sought to evaluate the safety and efficacy of a highly purified medical-grade 1000-cst liquid injectable silicone in the treatment of HIV-associated FLA using the serial microdroplet injection technique. METHODS: Twenty patients with HIV-associated lipoatrophy were treated with liquid injectable silicone with a maximum of 6 treatment sessions (2.0 mL each session maximum). Patients were evaluated at 9-, 12-, and 18-month follow-up sessions. Safety, efficacy, injection volumes, and patient satisfaction were evaluated. RESULTS: No persistent adverse effects were reported throughout the study. Most of the patients achieved complete correction of their HIV-associated FLA after 6 treatments and maintained this correction to the 18-month follow-up. LIMITATIONS: This is a noncomparative, nonblinded study. Study patient population size is small. CONCLUSION: Given our small sample size of 20 patients, our results suggest that, if administered correctly, liquid injectable silicone is potentially a safe, effective, and natural-feeling treatment option for HIV-associated FLA. Larger studies may be needed to confirm safety, efficacy, and permanence.

Clinical validation of the upper face first principle-A clinical, prospective, interventional split-face study.

BACKGROUND: Previous clinical and anatomic investigations have identified the clinical relevance of facial biomechanics. Based on this new understanding, principles for facial aesthetic procedures were established: Lateral Face First, Deep Layers First, and Upper Face First. OBJECTIVE: To test the upper face first principle by showing that an injection sequence, starting in the upper face is superior to an injection sequence starting in the lower face. METHODS: This study was designed as an interventional split-face study administering the same amount and type of soft tissue filler for the upper, middle, and lower face but in a different sequence: upper, middle, lower face versus lower, middle, and upper face. A total of 15 patients (5 males and 10 females) with a mean age of 39.4 years (9.6) and a mean BMI of 23.4 kg/m2 (1.7) were studied. Follow-up at D0, D30, and D90 was conducted utilizing semiquantitative scores and objective 3D imaging. RESULTS: Despite not reaching statistical significance, midfacial volume and jawline contouring were rated better at every follow-up visit (D0, D30, D90) when treated with the upper versus the lower face first injection algorithm. The global aesthetic improvement scale showed statistically significantly better values for the upper face first algorithm when compared to the lower face first algorithm at all evaluated time points with all p < 0.001. CONCLUSION: Applying the upper face first injection algorithm seems to result in better aesthetic outcomes when directly compared to the lower face first algorithm. Semiquantitative and objective outcome measurements confirm its clinical effectiveness.