El reposicionamiento malar. Presentación de una técnica original: punto MM / Malar repositioning. Presentation of an original technique: point MM

El envejecimiento facial es una sinergia compleja de cambios texturales de la piel, hiper- o hipoactividad muscular, reabsorción del tejido graso y resorción ósea. El déficit de volumen resultante, la deflación y la posterior caída del tercio medio facial produce una cara menos atractiva y juvenil. Los procedimientos inyectables en región malar son cada vez más populares y solicitados por los pacientes. El conocimiento de la anatomía de la cara media es fundamental para el inyector. La comprensión de la irrigación facial puede ayudar a disminuir la exposición a la aparición de hematomas y complicaciones vasculares severas. Existen múltiples técnicas de inyección propuestas para el tercio medio, en este artículo presentamos una técnica original, simple, segura y eficaz con resultados satisfactorios y riesgo reducido

Facial aging is a complex synergy of textural skin changes, muscle hyperactivity, fat dysmorphism, bone resorption. The resulting volume deficit and deflation of the mid face produces a less attractive and youthful face. Injectable midface procedures are becoming increasingly popular and requested by patients. Knowledge of the anatomy of the midface is critical for the injector. Understanding the irrigation of the face can help decrease the risk of hematoma and severe vascular complications. There are multiple injection techniques proposed for the middle third, in this article we present a simple, safe and effective technique with satisfactory results and lower risk

Optimizing Facial Aesthetics: Sequential Application of Botulinum Toxin A and Dermal Fillers for Enhanced Results.

In recent years, the field of aesthetic medicine has witnessed significant advancements, offering patients a plethora of options to rejuvenate their appearance. Among the most popular techniques are the administration of botulinum toxin A (BoNT-A) and dermal fillers. This article delves into the rationale and benefits of preparing the face with BoNT-A to weaken depressor muscles before proceeding with dermal filler injections. This sequential approach not only enhances patient outcomes but also improves procedural safety and patient satisfaction while reducing the chances of needing filler. This article reviews the anatomy, scientific evidence, and clinical implications supporting this innovative approach while shedding light on the potential for revolutionizing facial aesthetic procedures. With advanced applications of BoNT-A, it is possible to slim round faces, reduce jowling, create hollowing in some patients by obliterating masseters, slim the parotid, extend the chin, and more.

The Efficacy and Safety of Hyaluronic Acid Injection in Tear Trough Deformity: A Systematic Review and Meta-analysis.

BACKGROUND: Hyaluronic acid (HA) injection is an effective method to correct tear trough deformity. Nevertheless, the quantitative data of cosmetic results and complications of HA injection in tear troughs remained unemployed. The purpose of this meta-analysis was to synthesize the current quantitative data on the aesthetic outcomes and adverse effects of tear trough deformity correction with HA injection. METHODS: This meta-analysis consulted PubMed, Embase, Web of Science, Scopus and Cochrane databases based on the search terms published before September 2022. Data extracted was analyzed to evaluate the satisfaction rates and complications of HA injection. Meta-analysis was performed using the random-effect model for overall and subgroup analysis. RESULTS: This meta-analysis comprised 31 reports involving 2556 participants. The pooled overall satisfaction rate was 91.0% (95% CI 84.9-95.7%). The pooled rates of swelling/edema and bruising/ecchymosis were 19.2% (95% CI 10.4-29.9%) and 18.4% (95% CI 10.1-28.4%), respectively. The pooled rates of redness/erythema, contour irregularity/lump and blue discoloration/Tyndall effect were 7.1% (95% CI 1.5-15.6%), 5.3% (95% CI 1.8-10.2%) and 0.9% (95% CI 0.0-2.5%), respectively. CONCLUSIONS: The present meta-analysis manifested a low risk of complication rate and a high satisfaction rate in tear trough rejuvenation with HA injection. LEVEL OF EVIDENCE I: 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 .

Treatment of Atrophy of the Labia Majora: Calcium Hydroxyapatite or Hyaluronic Acid?

PURPOSE: The study aimed to evaluate and compare the efficacy and safety of treating atrophied labia majora with hyaluronic acid (HA) and calcium hydroxyapatite (CaHA). METHODS: Ten participants complaining of sagging or loss of volume in the labia majora were evaluated and randomly assigned to two groups-treated with CaHA or AH. Photographic documentation was taken and appreciated by the participants and by blind observers. RESULTS: The study showed an improvement in labia majora regarding volumization and flaccidity that was more significant after 90 days of treatment in both treatments. Besides flaccidity, volume replacement resulted in better balance and proportion between the labia majora and labia minora. The evaluators, independent and blind, judged that in 80% of the cases of the HA group and in 50% of cases of the CaHA group, there was an excellent improvement. CONCLUSION: CaHA and HA are both effective and safe for treating the intimate region, and this study cannot prove the superiority of one over the other. An appropriate assessment involving the analysis of sagging and/or volume loss and the creation of a sequential treatment protocol, involving CaHA and HA, seems to be the best solution. LEVEL OF EVIDENCE I: Evidence obtained from at least one properly designed randomized controlled trial. 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 .

Volumizing Fillers for Skin: Selection Strategies.

The normal processes of aging in the face are accompanied by facial volume loss. Aesthetic treatments have been developed to restore lost volume to and below the skin. Understanding the properties and appropriate usages of those volumizing fillers is vital to achieving the best outcomes for patients. Gel firmness, cohesivity, hydrophilicity, tissue integration, and collagen stimulatory properties are attributes to take into consideration when deciding on a volumizing filler. Beyond filler properties, a clinician's understanding of facial harmony and natural aging changes help in understanding how to visualize a holistic response to the use of fillers for youthful restoration.

Hyaluronic Acid Basics and Rheology.

Hyaluronic acid (HA) is the most common dermal filler in use. It improves wrinkles and volume loss not only by filling and volumizing but also by hydrating the injected area with its water affinity. It is a naturally occurring component of skin, and there is a negligible risk of immunologic or allergic reaction with injection. It is rapidly degraded by the injection of hyaluronidase, thus creating an ideal injectable material that is low risk and reversible. Its duration of effect may be longer than expected based on bioavailability of the HA product due to collagen synthesis or fibroblast stimulation.

Employing hyaluronic acid-based mesotherapy for facial rejuvenation.

BACKGROUND: Mesotherapy is a method of treatment in which biocompatible substances are injected in small aliquots into different levels of skin. This technique can be used for facial rejuvenation. AIM: To comprehensively evaluate efficacy of different hyaluronic acid (HA) materials for skin rejuvenation, and discuss longevity of these products, potential adverse effects, and different injection techniques. MATERIAL AND METHODS: We searched Pubmed, Scopus, Web of science, Google Scholar, Embase, Cochrane Library, and Science direct until April of 2022. Thirty-four articles were selected including 23 articles about non-cross-linked HA and 11 articles about cross-linked HA. RESULTS: Eleven and five different non-cross-linked HA and cross-linked HA materials were utilized, respectively. Treatment sessions for non-cross-linked HA were between 1 and 6 at weekly-to-bimonthly interval, and for cross-linked HA were 1-3 at 4-36 weeks apart. In most of the studies, serial micropuncture technique with 23-32 gauge needles was used for injection. Other injection techniques were Nappage (picotage), depot and micro-linear. CONCLUSION: Mesotherapy with HA-based fillers is a favorable method for restoring youthful appearance, rejuvenation, and revitalization of skin. Proper selection and precise placement of HA in desired level of dermis is an essential key to optimize improvement and minimize side effects including skin irregularities and Tyndall effect. Adjuvant therapy with additional rejuvenation procedures to enhance esthetic results is required especially in elderly individuals with severe photodamaged skin. Moreover, preservation of esthetic results requires maintenance therapy every few months.

Quantitative Evaluation of Volume Augmentation and Durational Changes in the Anteromedial Cheek with Hyaluronic Acid Fillers Using Three-Dimensional Measurement: 2-Year Results from a Comparative Split-Face Study.

SUMMARY: Hyaluronic acid fillers are widely used for the augmentation of facial soft tissues. Hyaluronic acid fillers can be monophasic or biphasic and have different characteristics, especially regarding volumetric effects and maintenance potential. However, there is paucity of long-term quantitative and objective data on clinical outcomes following hyaluronic acid injection. In this study, the authors evaluated volumetric changes over 2 years and the maintenance potentials of both types of fillers on the anteromedial cheek using objective three-dimensional measurements. This comparative split-face study enrolled participants aged 30 to 50 years who received a midfacial injection of the test filler (Belotero Volume) on one side and a random control filler (Juvéderm, Restylane SubQ, or Yvoire Contour) on the contralateral side. The authors conducted three-dimensional scanning assessments at baseline and after 30 minutes; 3 days; 2, 4, 12, and 24 weeks; and 2 years. The volume augmentation effects for the anteromedial cheek of two monophasic fillers (Belotero Volume and Juvéderm Voluma) were maintained for at least 2 years (81 percent and 66 percent, respectively, compared to the volume at 4 weeks). Two biphasic fillers (Yvoire Contour and Restylane SubQ) maintained over 50 percent volume compared to the volume 4 weeks after injection. Monophasic fillers showed better outcomes than biphasic fillers; however, both types of hyaluronic acid fillers demonstrated superior efficacy, safety, and durability for volumetric augmentation in the anteromedial cheek. Objective data obtained using three-dimensional imaging analysis will enable dermatologists to better demonstrate the results of the procedure to patients, through the provision of visual aids. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Cutaneous Vascular Compromise and Resolution of Skin Barrier Breakdown After Dermal Filler Occlusion-Implementation of Evidence-Based Recommendations Into Real-World Clinical Practice.

BACKGROUND: Vascular occlusions that threaten skin integrity, although not an emergency like those that threaten a patient's vision, is an urgent situation. Accurately interpreting physical examination findings is paramount. The use of high-dose, pulsed hyaluronidase is the mainstay of therapy; however, adjunctive measures that may optimize clearance of an occlusion and/or skin barrier repair such as the use of image guidance and hyperbaric oxygen should be considered. OBJECTIVE: To provide a review of the literature on the treatment of vascular occlusions threatening skin barrier integrity and develop a step-wise treatment guide. MATERIALS AND METHODS: The authors searched PubMed for peer-reviewed studies, consensus statements, case series, and case reports using a variety of keywords. RESULTS: Twenty-six articles focusing on vascular occlusions threatening the skin barrier were reviewed. The authors collectively agreed on treatments to reverse vascular occlusions and restore the skin barrier. The importance of high-dose, pulsed hyaluronidase was clear. Therapies that lacked evidence such as sodium thiosulfate were also revealed. CONCLUSION: A vascular occlusion that threatens skin integrity is an urgent matter which requires accurate interpretation of physical examination findings that will help guide intervention. High-dose, pulsed hyaluronidase along with adjunctive measures performed in a step-wise manner is key to an optimal outcome.

The 7-point Shape and The 9-point Shape: An Innovative Nonsurgical Approach to Improve the Facial Shape.

Treatment with injectable fillers is considered to be intrinsically associated with the understanding of facial anatomy and appropriate techniques. However, a more comprehensive understanding of facial structure is critical to improving facial shape. This article presents two Nonsurgical approaches developed from the MD Codes system denominated "The 7-point Shape" and "The 9-point Shape." Both techniques were designed to help create a more feminine and masculine look, respectively. The aim is to provide foundation for the midface (cheek) and contour for the lower face (chin and jawline) and indirectly improve the facial signs that patients usually focus on when looking for aesthetic treatment (lines, folds, jowls, double chin, etc.). The MD Codes platform aims to deliver an alternative to surgery with injectables. The 7-point Shape and The 9-point Shape may provide visible results immediately after treatment.

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.

Dermal Fillers for Tear Trough Rejuvenation: A Systematic Review.

There is significant variation in treatment parameters when treating the infraorbital region. Thorough knowledge of these pertinent factors, choice of the optimal filling material, and proper understanding of the anatomy of this unforgiving region will contribute to a safe, effective, and natural result. We aim to conduct a systematic review of published literature related to soft tissue fillers of the tear trough and infraorbital region. A search of published literature was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and included PubMed, Embase, and Science Direct databases. The Medical Subject Headings (MeSH) terms used were "tear trough" OR "infraorbital" AND "dermal filler" OR "hyaluronic acid" OR "poly-L-lactic acid" OR "calcium hydroxyapatite" OR "Restylane" OR "Radiesse" OR "Perlane" OR "Juvéderm" OR "Belotero." Different combinations of these key terms were used. The initial search identified 526 articles. Six additional articles were identified through references. Two-hundred twenty-five duplicates were removed. A total of 307 studies were screened by title and abstract and 258 studies were eliminated based on inclusion and exclusion criteria. Forty-nine articles underwent full-text review. The final analysis included 23 articles. Patient satisfaction was high, and duration of effect ranged from 8 to 12 months. Restylane was most commonly used. Injection technique varied, but generally involved placing filler pre-periosteally, deep to orbicularis oculi muscle, anterior to the inferior orbital rim via serial puncture or retrograde linear threading with a 30-gauge needle. Topical anesthetic was most commonly used. Side effects were generally mild and included bruising, edema, blue-gray dyschromia, and contour irregularities. Nonsurgical correction of the tear trough deformity with soft tissue filler is a minimally invasive procedure with excellent patient satisfaction with long-lasting effects. It is essential to have a fundamental understanding of the relevant anatomy and ideal injection technique to provide excellent patient outcomes and prevent serious complications.

Delayed Complications following Dermal Filler for Tear Trough Augmentation: A Systematic Review.

Tear trough deformity is a popular target for the treatment with filler injections. The side effects are generally mild and transient. However, delayed complications may occur. We aim to perform a thorough systematic review of the published literature related to delayed complications after tear trough filler injections. A search of published literature was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in June 2021 and included PubMed, ScienceDirect, and Embase databases. The Medical Subject Headings (MeSH) terms used included the following terms: delayed complications, nodules, granulomas, swelling, discoloration, dermal filler, hyaluronic acid (HA), polyacrylamide, calcium hydroxyapatite (CaHA), poly-L-lactic acid (PLLA), eyelid, periorbital, periocular, and tear trough. Twenty-eight articles consisting of 52 individual cases were included in the final analysis. 98% (51/52) of patients were female and had an average age of 48.3 years. HA was the most reported product (71.2%, 37/52), followed by PLLA (4/52, 7.7%), and CaHA (4/52, 7.7%). The most common delayed complication with any dermal filler was swelling (42.3%, 22/52) followed by lumps or nodules (25.0%, 13/52). Xanthelasma-like reaction (17.3%, 9/52), migration (7.7%, 4/52), discoloration (3%, 3/52) also occurred. The average time of onset of any complication was 16.8 months with xanthelasma-like reaction appearing soonest (mean: 10 months) and discoloration appearing latest (mean: 52 months). Most swelling cases were caused by HA. Semi-permanent fillers such as PMMA and synthetic fillers such as PLLA were more likely to be associated with lumps and nodules than other complications. It is important that clinicians who perform tear trough augmentation with dermal fillers have a thorough understanding of the risks of the procedure to diagnose and manage them promptly as well as provide patients with accurate information regarding the potential adverse effects.

A prospective open-label, multicentre study evaluating a non-cross-linked hyaluronic acid based soft-tissue filler in the correction of lateral canthal and perioral lines.

OBJECTIVE: The aim of this investigation was to assess the effectiveness of a non-cross-linked hyaluronic acid based soft-tissue filler in the correction of lateral canthal lines and periorbital lines. MATERIAL AND METHODS: A total of 59 female Caucasian patients with a mean age of 52.6 ± 9.0 years were enrolled in this prospective open-label, multicentre study and received intradermal injections of a soft-tissue filler at baseline, after 3 and 6 weeks. Aesthetic improvement and patient satisfaction, skin hydration, skin firmness and skin elasticity, as well as adverse events were assessed at 3, 6, 8, 12 and 16 weeks. RESULTS: At baseline, the lateral canthal skin firmness was 0.206 ± 0.07 mm and increased after 8 weeks to 0.087 ± 0.08 mm with p < 0.001, while the perioral skin firmness was 0.205 ± 0.09 mm and increased after 8 weeks to 0.116 ± 0.08 mm with p < 0.001. Increases in skin hydration were observed after 8 weeks in both areas, however, did not reach statistical significance at any point. At week 8, 12 and 16 a majority (93.1%, 91.1% and 73.7% respectively) of the patients stated that they were 'satisfied' or 'very satisfied' with the treatment. CONCLUSION: Overall, the skin firmness and skin visco-elasticity showed significant increases in the lateral canthal and perioral region. Moreover, albeit not statistically significant, skin hydration increased in both areas after 8 weeks. The procedure has been shown to be safe and satisfactory for the treated patients; however, emergence of oral herpes should be added to the safety profile of intradermally applied hyaluronic acid treatments.