Ophthalmoplegia with skin necrosis after a hyaluronic acid filler injection.

Hyaluronic acid filler injection is commonly used for aesthetic purposes. However, many clinicians neglect the possibility of developing vascular occlusion and its devastating sequelae. Besides visual loss after iatrogenic ophthalmic artery occlusion, ophthalmoplegia without blindness is rare but may occur. Here, we report a 23-year-old woman with ptosis, lateral deviation of the right eye, and skin necrosis after hyaluronic acid filler injection. After hyaluronidase injection and steroid pulse therapy, ptosis and eye movement were completely restored. Skin necrosis was treated with a human epithelial growth factor ointment, followed by Nd:YAG laser. Complete healing with minimal scar was achieved.

Nasolabial fold correction through cheek volume loss restoration versus thread lifting: a comparative study.

Nasolabial folds are caused by loss of deep fat and subsequent loss of muscle contour in the midface, leading to sagging which forms cosmetic issues in some cases when they are otherwise overly pronounced. Various treatment procedures have been developed to reduce their appearance. The objective of this study is to compare the efficacy of hyaluronic acid (HA) cheek fillers injection and thread lifting in improving the nasolabail folds. Twenty cases presenting with prominent nasolabial folds were randomly divided into two groups; group A underwent HA fillers for cheek lifting and group B underwent thread lifting for the cheek. Only one session was done for each case, and then they were followed up after 1 and 2 months. Statistical significant difference after treatment for both groups was detected using the wrinkle severity rating scale (WSRS) and the modified Fitzpatrick wrinkle scale (MFWS). The average global aesthetic improvement scale (GAIS) was 2.2 ± 0.79 for the fillers group and 3.2 ± 0.92 for the threads group, showing a statistical significant improvement with a p value less than 0.05 favoring the fillers group. 70% of fillers cases were satisfied and only 30% of threads cases. Fillers cheek injection is recommended for patients with sagged thin face to improve the nasolabial folds as well as giving volume and contour. Threads would do better for patients desiring an oval, less wide face shape. Combining threads with other cosmetic procedure would give a better holistic appearance.

A mini review on the common methods of pain reduction before filler and botulinum toxin injection.

BACKGROUND: As the desire for beauty and youthful appearance has increased in recent years, cosmetic injections are getting more attention. However, patients discomfort during these injections is a challenging issue. AIM: This review explores common approaches to reduce pain and discomfort during cosmetic injections through the available literature. METHODS: The eligible studies through searching in PubMed have been entered to evaluate the common methods of pain reduction for cosmetic injections. RESULTS: According to reviewed studies, vibration, local anesthesia, and vapocoolant anesthesia are common methods applied in order to reduce pain and discomfort in patients. All of these methods are able to reduce pain through their affects on neuron fibers. CONCLUSION: It seems that all common approaches can result in some amount of pain reduction. Using a combination of these methods during injections, practitioners can successfully reduce the pain of injection.

Combination Therapy of Microneedle Fractional Radiofrequency and Topical Poly-Lactic Acid for Acne Scars: A Randomized Controlled Split-Face Study.

BACKGROUND: Acne scarring occurs at a young age and causes distress for many patients. Various treatment modalities have been tried. OBJECTIVE: This study investigated the efficacy of combination therapy with topical poly-lactic acid and microneedle fractional radiofrequency (MFRF) for acne scars. MATERIALS AND METHODS: Patients with acne scars on both the cheeks were included. Poly-lactic acid was applied to the acne scars on one side of the face before MFRF treatment. The other side of the face was treated with MFRF and normal saline. Patients received 3 treatment sessions and were evaluated based on visual assessment and patient satisfaction. After the last treatment, objective scar assessment of scar smoothness, size, brightness, and overall improvement was performed. RESULTS: Both acne scar assessment scores and patient satisfaction were better with combination therapy (p = .036 and p = .009, respectively) than with monotherapy. Combination therapy resulted in significantly better efficacy for scar smoothness (p < .001), scar size (p = .003), and overall improvement (p < .001), but not for brightness (p = .151). CONCLUSION: Combination therapy resulted in significantly better clinical outcomes, including better scar smoothness and smaller scar size. Therefore, we believe this combination therapy is a safe and effective treatment for acne scars.

Psychopathology among individuals seeking minimally invasive cosmetic procedures.

OBJECTIVES: In recent years, so many people want to alter their physical appearance with the purpose of raising their social and psychological well-being and the demand for minimally invasive cosmetic procedures (MICPs) has continued to rise. Our study aims to investigate the psychological profile of people seeking cosmetic procedures. STUDY DESIGN: The present observational cross-sectional study was conducted with a sample of 54 participants seeking cosmetic procedures (botulinum toxin injections, soft tissue filler injection, mesotherapy, platelet-rich plasma, and dermaroller treatments). Those patients were compared to the control group, who did not have any kind of cosmetic procedure (including cosmetic surgery) before and who did not want to have any of these procedures. METHODS: The research volunteers were invited to complete the demographic questionnaire (e.g., age, gender and history of procedures) as well as psychological scales. Psychological scales includes the validated and reliable The Brief Symptom Inventory (BSI), Automatic Thoughts Scale (ATS), and Social Adaptation Self-Evaluation Scale (SASS). RESULTS: Users of MICP were mostly female (n = 46, 85%) and had some high school education or higher and showed higher scores on General Severity Index (P = .013), anxiety (P = .018), depression (P = .004), interpersonal sensitivity (P = .008) of BSI and also higher on ATS (P = .022) and lower on SASS (P = .001) scores that mean less social adaptation. There was a statistically positive correlation between age and GSI, anxiety, depression, interpersonal sensitivity, somatization scores of BSI, and negative correlations between SASS scores and age and number of past procedures. CONCLUSION: Our study findings highlight the importance of understanding individuals' psychological symptoms who are seeking cosmetic procedures.

Comparative study of rheological properties and preclinical data of porous polycaprolactone microsphere dermal fillers.

BACKGROUND: In this study, a physical properties test and preclinical evaluation were performed on two polycaprolactone (PCL)-based dermal filler formulas. OBJECTIVE: This study was performed to compare the rheological characteristics, preclinical efficacy, and safety of a new PCL filler, SF-01, with a licensed PCL filler. METHODS: First, the viscoelasticity of the PCL filler was evaluated. Next, hairless mice were injected with fillers and evaluated for efficacy with a folliscope and PRIMOSLITE . Histological evaluation was conducted for 6 months to evaluate safety. RESULTS: In this evaluation, SF-01 was superior to a licensed PCL filler in initial volume increase rate and in vivo durability, and the migration of the injected filler was not confirmed. The elasticity (G*, G') and viscosity (G'') are also expected to be lower than those of a licensed PCL filler, thereby resulting in less foreign body sensation in the living body. CONCLUSION: SF-01 (porous PCL microsphere-based dermal filler) has been confirmed to be superior in durability and shape retention compared to the licensed PCL filler (nonporous PCL microsphere-based dermal filler), and the in vivo safety is equivalent.

Retention Rates Among Patients Undergoing Multimodal Facial Rejuvenation Treatment Versus a Single Monotherapy in Cosmetic Dermatology Practices.

BACKGROUND: Facial aging is a multifactorial process. Accordingly, expert opinion has largely been unanimous in that multimodal treatment targeting various aspects of the aging face provides superior results. However, there is a lack of studies exploring patient response. OBJECTIVE: To compare patient retention between triple multimodal facial rejuvenation treatment (neuromodulator, filler, and energy-based therapy) and monotherapy (neuromodulator alone). METHODS: A retrospective, multicenter (the United States, Canada, and Germany) study was performed. Cases were retrieved from July 2015 to June 2016. The study compared patients who had undergone monotherapy (neuromodulator), combined multimodal treatment (neuromodulator, filler, and energy-based therapy on the same day), and sequential multimodal treatment (neuromodulator, filler, and energy-based therapy over a 1-year period). Retention rates were calculated. RESULTS: A total of 509 patients were included: monotherapy (300), sequential multimodal treatment (93), and combined multimodal treatment (116). Patient retention was significantly higher in the combined multimodal treatment group compared with the monotherapy and sequential multimodal treatment groups (p < .001). Subgroup analysis revealed similar trends at all sites. CONCLUSION: Based on retention rates, patients are more likely to return to the clinic when multiple treatment modalities are used during 1 encounter. These data further solidify the importance of multimodal therapy for both the provider and the patient.

The Treatment of Acne Scars, a 30-Year Journey.

Over the past 30 years, the treatment of acne scars has undergone changes that have been significantly influenced by the concurrent development of new devices. The advent of fractional resurfacing lasers was a watershed moment for acne scarring therapy. The author recounts a career history of considerations of acne scarring treatments as well as the literature supporting the experiences causing changes in practice. Fractional ablative and nonablative lasers, sublative radiofrequency, picosecond lasers, microneedling with and without radiofrequency and fillers are the bulk of the treatments covered, along with a discussion of combination therapy. A practical algorithm for acne scarring for selection of treatment modalities is presented.

Treatment of skin soft tissue embolism after hyaluronic acid injection for injection rhinoplasty in Asian patients.

INTRODUCTION: The purpose of this manuscript is to investigate the treatment of skin soft tissue embolization or vascular occlusion after the injection of hyaluronic acid (HA) for Injection Rhinoplasty (IR) in Asians with a special interest in the time occurrence of the occlusion. METHODS: A total of 35 cases were evaluated after receiving HA injections for IR who presented with a vascular occlusive event. They were divided into three stages based on the time to embolization. Immediate, ≤5 hours; early, ≤3 days; and late, >3 days. There were two cases of immediate, 28 deemed early, and five late. Methods to prevent tissue necrosis are reviewed in the manuscript based on these stages. RESULTS: Skin color gradually recovered to normal after 11 treatments in 11 patients with mild embolization. No ischemic aggravation or skin necrosis was observed in 19 patients with moderate embolization; red scarring was seen in two and hypertrophic scar with uneven skin color in one patient. The five patients in the severe category had longer healing, more red scars, and more hypertrophic scarring. CONCLUSION: The treatment of skin soft tissue embolization or vascular occlusion after HA IR in Asians can be effected by identifying the stage and degree of embolization and treating appropriately with the outlines presented in this manuscript.

Concomitant Use of Hyaluronic Acid and Laser in Facial Rejuvenation.

BACKGROUND: Facial aging is a process that involves many different changes. Therefore, in many patients, it may be necessary to perform a combined treatment. Botulinum toxin A and dermal fillers are the two most popular nonsurgical cosmetic procedures performed globally to treat age-associated changes. However, there are not many studies reporting the concomitant use of dermal fillers and laser technology for facial rejuvenation. This review aims to assess the concomitant use of dermal hyaluronic acid (HA) fillers and laser technology for facial rejuvenation. METHODS: The present updated consensus recommendations are based on the experience and opinions of the authors and on a literature search. RESULTS: If a combined procedure (HA and light treatments) is to be performed, on the same day, the panel recommends starting always with the light treatments, avoiding skin manipulations after having injected HA. To customize the therapeutic management, it is crucial to establish a precise diagnosis of the photodamage and loss of volumes suffered by the patients. CONCLUSIONS: The currently available scientific evidence about the combined use of HA fillers and laser-radiofrequency-intense pulsed light (laser/RF/IPL) is limited and encompasses mainly small and nonrandomized studies. Nevertheless, most of these studies found that, on average, the concomitant use (same day) of laser and HA fillers for facial rejuvenation represents an effective and safe strategy which improves clinical results and patient's satisfaction. Future well-designed clinical studies are needed regarding the effectiveness and safety of combination filler/laser treatments. 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 .

Biostimulatory effects of polydioxanone, poly-d, l lactic acid, and polycaprolactone fillers in mouse model.

BACKGROUND: Numerous fillers are increasingly used for augmentation of volume loss and relaxation of facial wrinkles. Collagen stimulators are the latest next-generation dermal fillers that can induce neocollagenesis. To investigate biophysical characteristics, safety, and efficacy of newly developed polydioxanone (PDO) filler in comparison with poly-l lactic acid (PLLA) and polycaprolactone (PCL) fillers. METHODS: In vitro assay, morphology of particles, and rheological property of fillers were measured. A total of 24 female hairless mice (SKH1-Hrhr ) were randomly divided into three groups and injected with PDO, PLLA, or PCL fillers. Durability of fillers was assessed at 0, 3 days, and 1, 4, 8, 12 weeks after injection using folliscope and PRIMOS. To determine biocompatibility and neocollagenesis, histologic evaluation was performed at 1, 4, 8, and 12 weeks after injection. Efficacy was also evaluated based on skin surface roughness changes using PRIMOS in a hairless mouse photoaging model. RESULTS: In the particle morphology test, PDO microspheres had an irregular surface and were spherical and uniformly sized. PDO filler demonstrated similar neocollagenesis and inflammatory response to other collagen stimulators. PDO filler showed better biodegradability than PLLA and PCL fillers. In the hairless mouse photoaging model, there was a statistically significant decrease in skin surface roughness after PDO filler injection. CONCLUSIONS: Our data suggest that newly developed collagen stimulating PDO filler might be a safe and effective option for correction of volume loss and rejuvenation of photoaging skin.

Randomized, single-blinded, crossover study of a novel wound dressing vs current clinical practice after percutaneous collagen induction therapy.

INTRODUCTION: Skin rejuvenation procedures have become common with sophisticated technologies with reduced downtime and related risks. Recently, microneedling has been paired with radiofrequency to create Fractional Radiofrequency Microneedling (FRFM) to induce neocollagenesis. Frequently, topical products are applied immediately after the needling. This procedure is known as percutaneous collagen induction therapy (PCIT). Postoperative topical wound care is critical for prompt rapid and safe healing, with moist wound healing deemed of primary importance for fast and correct scarring process. An ideal dressing enables a moist environment while reducing postprocedural inflammatory responses in the first stages of wound healing. OBJECTIVE: To evaluate whether an innovative silicone-based wound dressing is superior than standard of care therapy in decreasing severity and duration of treatment-site acute inflammatory reactions post PCIT. MATERIALS AND METHODS: Endymed PRO Intensif Handpiece (Endymed, Israel) was used for the full-face FRFM procedure. Subjects (n = 20) applied treatment (Stratacel® -Stratpharma SG, Switzerland) and control (Aquaphor® -Beiersdorf Inc, USA) immediately after the procedure and daily; they were evaluated immediately postprocedure (baseline assessment), at 2, 3 and 7 days postprocedure. Digital and 3D pictures (Antera 3D Camera for Skin Analysis-Miravex, Ireland) were taken at each assessment. RESULTS: All patients healed properly without reporting adverse reactions to any of the studied products. Erythema at each study visit was significantly reduced with the use of the novel wound dressing (P < 0.001). A statistically significant difference in favor of the innovative wound dressing also emerged with respect to the patient-rated product properties (P = 0.008), such as feel on skin, drying time and stickiness. CONCLUSIONS: The novel wound dressing reduced signs of acute inflammation following PCIT when compared to standard of care, without reporting adverse events and resulting in a more favorable outcome from a patient perspective.

Post Filler Ecchymosis Resolution With Intense Pulsed Light

Bruising after dermal filler and neuromodulator injections is a common side effect and can have durations of 1 to 2 weeks. While it ultimately resolves, faster resolution can produce better outcomes for patients and also make patients more likely to return for future treatments. We report the successful reduction in bruising following injections of fillers with an intense pulsed light source. We also documented the onset of action of bruising resolution with serial photographs. Resolution started within the first hour of treatment and continued rapidly over 48 hours. This is the first-time reported study of resolution of bruising from injectables with intense pulsed light. Patient satisfaction is improved when such adverse events are minimized.

Pulsed-dye laser as a novel therapeutic approach for post-filler bruises.

Fillers have become popular worldwide as the demand for enhancements in rejuvenating effects and esthetic improvements is continually increasing. With broader applications and the increasing number of cosmetic procedures using fillers, more filler-related complications are being reported. These filler-related complications range from mild bruising to severe vascular complications. Because of the severe and irreversible outcomes of vascular complications, treatment protocols for such complications are being investigated and updated actively. However, not much attention is paid to mild bruises that develop after filler injections. Simple observation is the treatment of choice for bruises in current filler complication protocols. In the present study, the possible effect of a pulsed-dye laser (PDL) on bruises is reported, with a case report of a female patient who received PDL treatment for a bruise that developed after a filler injection.