Keratin hydrolysate as a chrome exhaust aid and keratin filler in leather processing: A cleaner technology approach for tannery solid waste management and leather manufacturing.

Hair burning unhairing and dampening of tannery wastes during the hair-saving unhairing process are becoming significant problems in the tanning industry. Therefore, this research article focuses on the extraction of keratin hydrolysate (KH) and its application as a chrome exhaust aid and keratin filler in leather manufacturing process. The structure, morphology and functional groups of the extract were examined using X-Ray Diffractometer (XRD), scanning electron microscopy (SEM) and Fourier transform infrared spectrometer (FTIR), respectively. To study and contrast the degree of improvement in chromium uptake, the KH solution was applied both before tanning on the pickled pelt and after tanning during basification. The thermal stability, physical strength characteristics and organoleptic properties of the leathers obtained were characterized. Furthermore, the environmental impact of the tanning system was assessed through a comparative analysis of the spent liquors. Finally, experimental retanning process was conducted to replace the commercial protein filler (Celatan F: 50, 75, and 100 %) with KH solution, with concurrent processing of control leather using conventional chrome tanning agent at 6 % dosage of chromium. The FTIR analysis of the extract confirmed the presence of alkyl side chains of amino acids as well as carboxylic, amide, carboxyl group and aldehyde functional groups at 1400-1700 cm-1,3,303.46 cm-1,3270 cm-1 and 2752 cm-1, respectively. XRD spectrum showed two diffraction peaks at 2 theta values of 9.36° and 21.16°, respectively. Leathers with improved mechanical strength, organoleptic properties and thermal stability were obtained with 100 % substitution of Celatan F at pH 6 and 10 % chromium dosage. It was also discovered that the shrinkage temperature of the experimental leather was enhanced to more than 105 °C. Environmental impact evaluation on the spent liquor showed that the complete replacement of Celatan F with KH solution brought about a notable decrease in COD and TDS in the spent liquor. The extraction and application of tannery hair waste-based keratin hydrolysate as an efficient, environmentally friendly chrome exhaust aid and keratin filler has been attempted and established in this research article.

[Forehead injections: Anatomy, technics, products]. / Les injections du front : anatomie, techniques, produits.

Knowledge of anatomy not only allows optimal treatment and therefore full satisfaction of our patients, but is also fundamental in the prevention of complications. A thorough understanding of aging allows for effective treatments, as most patients demand a natural result, removing the inevitable signs of aging, which can only be understood by considering their aging. Facial aging is a natural but complex multifactorial process, particularly for the forehead. In this article, we will focus on botulinum toxin as well as fillers in aging.

Intracorporeal evaluation of hyaluronic acid fillers with varied rheological properties and correlations with aesthetic outcomes.

BACKGROUND: Understanding the differences in soft tissue filler rheology and how these properties can impact clinical results is a fundamental concepts for any injector. This study aimed to assess the tissue integration characteristics of hyaluronic acid (HA) fillers manufactured with different technologies (Non-Animal Stabilized HA [HA-N] or Optimal Balance Technology [HA-O]) using ultra-high-frequency ultrasound. METHODS: Twelve female participants with mild-to-moderate midface volume loss and temporal hollowing were enrolled and treated with HA-N and/or HA-O. Participants were seen at five visits (screening/baseline [treatment], and Weeks 1 [optional touch-up], 4, 6, and 8 [follow-up visits]). Ultrasound was used to evaluate the degree of product integration. RESULTS: On ultrasound, HA-N presented with distinct borders, minimal tissue integration, and a capacity to displace tissues. Conversely, HA-O tended to spread horizontally within the same tissue plane and integrated within tissues. The volumizing capacity of the HA-O fillers was dependent on particle size. CONCLUSION: HA-N is suited for deep injections in areas such as the upper lateral cheek and under the muscle of the temporal region when a lifting effect is desired; HA-O is best suited for subcutaneous injections, in areas of dynamic movement or for patients with thin skin; and can be injected subcutaneously or supraperiosteally when a volumizing effect is desired.

A Historical Perspective on Dental Composite Restorative Materials.

This review article will discuss the origin of resin-based dental composite materials and their adoption as potentially useful adjuncts to the primary material used by most dentists for direct restorations. The evolution of the materials, largely driven by the industry's response to the needs of dentists, has produced materials that are esthetic, strong, and versatile enough to be used in most areas of the oral cavity to replace or restore missing tooth structures. Significant advancements, such as the transition from chemical to light-curing materials, refinements in reinforcing particles to produce optimum polishing and wear resistance, formulating pastes with altered viscosities to create highly flowable and highly stiff materials, and creating materials with enhanced depth of cure to facilitate placement, will be highlighted. Future advancements will likely reflect the movement away from simply being a biocompatible material to one that is designed to produce some type of beneficial effect upon interaction within the oral environment. These new materials have been called "bioactive" by virtue of their potential effects on bacterial biofilms and their ability to promote mineralization of adjacent tooth structures.

Nanocellulose-based conductive composites: A review of systems for electromagnetic interference shielding applications.

Electronic systems and telecommunications have grown in popularity, leading to increasing electromagnetic (EM) radiation pollution. Environmental protection from EM radiation demands the use of environmentally friendly products. The design of EM interference (EMI) shielding materials using resources like nanocellulose (NC) is gaining traction. Cellulose, owing to its biocompatibility, biodegradability, and excellent mechanical and thermal properties, has attracted significant interest for developing EMI shielding materials. Recent advancements in cellulose-based EMI shielding materials, particularly modified cellulosic composites, are highlighted in this study. By incorporating metallic coatings compounded with conductive fillers and modified with inherently conductive elements, conductivity and effectiveness of EMI shielding can be significantly improved. This review discusses the introduction of EMI shields, cellulose, and NC, assessing environmentally friendly EMI shield options and diverse NC-based composite EMI shields considering their low reflectivity. The study offers new insights into designing advanced NC-based conductive composites for EMI shielding applications.

Comparative analysis of in vivo bio-integration of three hyaluronic acid-based fillers for 26 weeks: a histological study.

Stabilized hyaluronic acid (HA), produced through diverse cross-linking technology and formulated as an injectable gel, has found widespread utilization in aesthetic industry. Cross-linked HA essentially constitutes a gel particle composition formed by numerous viscoelastic particulates. Various product formulations yield HA gels with distinct properties, including particle size, viscoelasticity, and interaction forces between particles. While previous studies have primarily concentrated on the biological safety and macroscopic expression of fillers, limited research exists on the internal mechanisms governing their macro-performance. This study selected three common dermal fillers for analysis, establishing an animal model to assess their in vivo interaction with surrounding tissues and explore their internal mechanisms. The findings revealed that particle size plays a crucial role in tissue integration.

Using dermal filler to camouflage forehead osteoma: A case report.

OBJECTIVE: To review the technique and outcomes of using dermal filler to camouflage forehead osteoma, providing a minimally invasive alternative to surgical excision. BACKGROUND: Forehead osteoma, commonly known as a forehead bump or bone spur, can be a cosmetic concern. Surgical excision, while effective, carries risks of scarring and postoperative complications. An innovative approach using dermal filler offers a potential solution. METHODS: A hyaluronic acid­based filler is injected into the deep subcutaneous plane over the bony prominence using a cannula. The fanning technique ensures even distribution of the filler. The procedure's safety, patient selection, and communication between the injector and patient are emphasized to achieve optimal results. RESULTS: The technique provides immediate aesthetic improvement with results that can last up to 12 months, depending on the filler used. While generally safe, potential complications include infections, swelling, asymmetry, and lumpiness. Proper technique, patient selection, and good communication between the injector and patient are critical to achieving optimal outcomes. CONCLUSION: Using dermal filler to camouflage forehead osteoma is a minimally invasive alternative to surgical excision, offering immediate and long­lasting results with minimal downtime and fewer risks. Further studies are needed to refine the technique and optimize outcomes.

Poly-L-lactic acid fillers for nasal alar retraction: safety and effectiveness in 13 cases.

OBJECTIVE: To assess the effectiveness and safety of poly-L-lactic acid (PLLA) fillers in treating nasal alar retraction. We conducted a series of case reports on 13 patients treated for nasal alar retraction at the Chengdu Ningyue FRESKIN Medicine Cosmology Clinic from September 2022 to July 2023. Patients ranged from 23 to 49 years, comprising 12 females and 1 male. Of these, 5 had no prior medical history, 7 had previously undergone rhinoplasty, and 1 had a history of nasal trauma. Treatment outcomes and adverse reactions were monitored following PLLA filler injections. The mean pre-treatment severity score was 1.62±0.65, improving to 0.54±0.66 post-treatment (t=4.19, df=23, P<0.001). All participants reported satisfaction with their results without adverse effects. PLLA facial fillers are a safe and effective treatment for nasal alar retraction, presenting no embolism risk. This treatment merits consideration for broader clinical application.

Cross-linked Sodium Hyaluronate Gel with PLLA-b-PEG Microsphere for Facial Contouring in Chinese: A Retrospective Study.

BACKGROUND: In Asia, the demand for cosmetic facial treatments has surged due to technological advancements, increased social acceptability, and affordability. Poly-L-lactic acid (PLLA) fillers, known for their biocompatibility and biodegradability, have emerged as a popular choice for facial contouring, yet studies specifically addressing their use in Asian populations are scarce. METHODS: This retrospective study examined 30 Chinese patients who underwent facial contouring with PLLA fillers, focusing on product composition, injection techniques, and safety measures. A comprehensive clinical evaluation was performed, including the Global Aesthetic Improvement Scale (GAIS) and Global Impression of Change Scale (GICS) for effectiveness and patient satisfaction, respectively. RESULTS: No significant difference in GAIS scores was observed between injectors and blinded evaluators over a 12-month period, indicating consistent effectiveness. Patient satisfaction remained high, with GICS scores reflecting positive outcomes. The safety profile was favorable, with no serious adverse events reported. The study highlighted the importance of anatomical knowledge to avoid complications, particularly in areas prone to blindness. CONCLUSIONS: PLLA fillers offer a safe, effective option for facial contour correction in the Asian population, achieving high patient satisfaction and maintaining results over time. The study underscores the need for tailored approaches in cosmetic procedures for Asians, considering their unique facial structures and aesthetic goals. Further research with larger, multicenter cohorts is recommended to validate these findings and explore long-term effects. 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 .

"Filler-Associated Acute Stroke Syndrome": Classification, Predictive Modelling of Hyaluronidase Efficacy, and Updated Case Review on Neurological and Visual Complications.

INTRODUCTION: The rising use of soft tissue fillers for aesthetic procedures has seen an increase in complications, including vascular occlusions and neurological symptoms that resemble stroke. This study synthesizes information on central nervous system (CNS) complications post-filler injections and evaluates the effectiveness of hyaluronidase (HYAL) treatment. METHODS: A thorough search of multiple databases, including PubMed, EMBASE, Scopus, Web of Science, Google Scholar, and Cochrane, focused on publications from January 2014 to January 2024. Criteria for inclusion covered reviews and case reports that documented CNS complications related to soft tissue fillers. Advanced statistical and computational techniques, including logistic regression, machine learning, and Bayesian analysis, were utilized to dissect the factors influencing therapeutic outcomes. RESULTS: The analysis integrated findings from 20 reviews and systematic analyses, with 379 cases reported since 2018. Hyaluronic acid (HA) was the most commonly used filler, particularly in nasal region injections. The average age of patients was 38, with a notable increase in case reports in 2020. Initial presentation data revealed that 60.9% of patients experienced no light perception, while ptosis and ophthalmoplegia were present in 54.3 and 42.7% of cases, respectively. The statistical and machine learning analyses did not establish a significant linkage between the HYAL dosage and patient recovery; however, the injection site emerged as a critical determinant. CONCLUSION: The study concludes that HYAL treatment, while vital for managing complications, varies in effectiveness based on the injection site and the timing of administration. The non-Newtonian characteristics of HA fillers may also affect the incidence of complications. The findings advocate for tailored treatment strategies incorporating individual patient variables, emphasizing prompt and precise intervention to mitigate the adverse effects of soft tissue fillers. 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 .

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 .

Exploring the Future of Polyhydroxyalkanoate Composites with Organic Fillers: A Review of Challenges and Opportunities.

Biopolymers from renewable materials are promising alternatives to the traditional petroleum-based plastics used today, although they face limitations in terms of performance and processability. Natural fillers have been identified as a strategic route to create sustainable composites, and natural fillers in the form of waste by-products have received particular attention. Consequently, the primary focus of this article is to offer a broad overview of recent breakthroughs in environmentally friendly Polhydroxyalkanoate (PHA) polymers and their composites. PHAs are aliphatic polyesters obtained by bacterial fermentation of sugars and fatty acids and are considered to play a key role in addressing sustainability challenges to replace traditional plastics in various industrial sectors. Moreover, the article examines the potential of biodegradable polymers and polymer composites, with a specific emphasis on natural composite materials, current trends, and future market prospects. Increased environmental concerns are driving discussions on the importance of integrating biodegradable materials with natural fillers in our daily use, emphasizing the need for clear frameworks and economic incentives to support the use of these materials. Finally, it highlights the indispensable need for ongoing research and development efforts to address environmental challenges in the polymer sector, reflecting a growing interest in sustainable materials across all industries.

Research Progress of Natural Rubber Wet Mixing Technology.

The performance of natural rubber (NR), a naturally occurring and sustainable material, can be greatly enhanced by adding different fillers to the NR matrix. The homogeneous dispersion of fillers in the NR matrix is a key factor in their ability to reinforce. As a novel method, wet mixing technology may effectively provide good filler dispersion in the NR matrix while overcoming the drawbacks of conventional dry mixing. This study examines the literature on wet mixing fillers, such as graphene, carbon nanotubes, silica, carbon black, and others, to prepare natural rubber composites. It also focuses on the wet preparation techniques and key characteristics of these fillers. Furthermore, the mechanism of filler reinforcement is also examined. To give guidance for the future development of wet mixing technology, this study also highlights the shortcomings of the current system and the urgent need to address them.

Synergy of Hybrid Fillers for Emerging Composite and Nanocomposite Materials-A Review.

Nanocomposites with polymer matrix provide tremendous opportunities to investigate new functions beyond those of traditional materials. The global community is gradually tending toward the use of composite and nanocomposite materials. This review is aimed at reporting the recent developments and understanding revolving around hybridizing fillers for composite materials. The influence of various analyses, characterizations, and mechanical properties of the hybrid filler are considered. The introduction of hybrid fillers to polymer matrices enhances the macro and micro properties of the composites and nanocomposites resulting from the synergistic interactions between the hybrid fillers and the polymers. In this review, the synergistic impact of using hybrid fillers in the production of developing composite and nanocomposite materials is highlighted. The use of hybrid fillers offers a viable way to improve the mechanical, thermal, and electrical properties of these sophisticated materials. This study explains the many tactics and methodologies used to install hybrid fillers into composite and nanocomposite matrices by conducting a thorough analysis of recent research. Furthermore, the synergistic interactions of several types of fillers, including organic-inorganic, nano-micro, and bio-based fillers, are fully investigated. The performance benefits obtained from the synergistic combination of various fillers are examined, as well as their prospective applications in a variety of disciplines. Furthermore, the difficulties and opportunities related to the use of hybrid fillers are critically reviewed, presenting perspectives on future research paths in this rapidly expanding area of materials science.

A Study on the Aesthetic Parameters and Proportions of the External Contour for Minimally Invasive Facial Injection.

OBJECTIVE: The aim of this study was to further guide the diagnosis and treatment programs for clinical facial contouring with injectable fillers by studying the facial contour parameters and proportion preferences consistent with Asian aesthetics. METHODS: A total of 89 subjects (42 males and 47 females aged 20-60 years) who met the inclusion criteria were enrolled in this study. The subjects were grouped by age, sex, and external contour attractiveness score, and the external contour aesthetic parameters and proportions of the subjects in different groups were measured and analysed. RESULTS: The upper facial breadth and lower facial breadth decreased with age, with significant differences between the 50-60-year age group and other age groups (P < 0.01). The nasomental angle showed a decreasing trend with age, with significant differences between the 40-49-year age group and the 20-29-year and 30-39-year age groups (P < 0.05). Males and females were significantly different in calva height, total head height, lower facial height, and calva height to total head height ratio (P < 0.05). With increasing age, the external contour attractiveness scores of males and females both showed decreasing trends, with significant differences between the 50-60-year age group and other age groups (P < 0.05). CONCLUSION: The calva height and the cranioauricular angle have a significant impact on external contour attractiveness. In general, temporal depression, cheek sagging, lateral cheek depression, and an ill-defined mandibular border will occur due to ageing, collagen loss, ligament laxity and sagging, and soft tissue atrophy and sagging, reducing the attractiveness of the external contour. 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 .

Botulinum Toxin Type A and Hyaluronic Acid Dermal Fillers in Dentistry: A Systematic Review of Clinical Application and Indications.

Background: Botulinum toxin type A (BoNT-A) and hyaluronic acid (HA) dermal fillers are increasingly utilized in dentistry for therapeutic and aesthetic purposes. However, a comprehensive synthesis of their clinical applications and indications in dentistry is lacking. This systematic review aimed to analyze the clinical application and indications of BoNT-A and HA dermal fillers in dentistry, providing insights into their efficacy, safety profiles, and limitations. Methods: A systematic search was conducted in PubMed/MEDLINE databases to identify relevant studies published between 2018 and 2024. Medical Subject Headings (MeSH) terms and keywords related to BoNT-A, HA dermal fillers, dentistry, clinical applications, and indications were used. Study selection criteria included randomized controlled trials (RCTs) and non-RCTs involving human participants of any age group. Data extraction and synthesis followed established guidelines, focusing on study characteristics, participant demographics, intervention details, outcome measures, and key findings related to BoNT-A and HA dermal fillers' clinical application in dentistry. Results: Systematic searches across electronic databases and grey literature identified 857 records, with an additional 73 from hand searches. After screening titles and abstracts, 542 records were excluded, leaving 374 full-text publications for evaluation. Ultimately, 12 RCTs and 13 non-RCTs were included. The systematic review encompassed diverse geographic locations: Brazil, Italy, Spain, Syria, India, Egypt, Korea, and the Netherlands, involving samples sizes ranging from 14 to 143 participants. The review synthesized findings on HA's efficacy in various areas, including bone repair, gingivitis management, temporomandibular joint disorders, postoperative swelling reduction, periodontal defect treatment, chin and check projection and lips augmentation. BoNT-A exhibited promising efficacy in managing orofacial pain conditions, gummy smile treatment and neuromodulation of the lower third muscles. Safety profiles varied among studies, with some reporting minimal adverse effects while others noted dose-related concerns. Conclusion: BoNT-A and HA dermal fillers offer a wide array of clinical applications in dentistry, ranging from therapeutic interventions to aesthetic enhancements. Despite promising efficacy, careful consideration and monitoring of safety outcomes are essential when integrating these interventions into clinical practice. Further research addressing methodological limitations and safety concerns is warranted to optimize their utilization and improve patient care in dentistry.

Impact of lipid droplet characteristics on the rheology of plant protein emulsion gels: Droplet size, concentration, and interfacial properties.

Plant-based meat analogs are being developed to address environmental, sustainability, health, and animal welfare concerns associated with real meat products. However, it is challenging to mimic the desirable physicochemical, functional, and sensory properties of real meat products using plant-based ingredients. Emulsion gels consisting of lipid droplets embedded in biopolymer matrices are commonly used to create products with appearances, textures, and sensory attributes like meat products. In this study, the impact of soybean oil droplet characteristics (concentration, size, and charge) on the physicochemical properties of potato protein gels was studied. The oil droplets were either coated by a non-ionic surfactant (Tween 20) or a plant protein (patatin) to obtain different surface properties. The introduction of the oil droplets caused the protein gels to change from mauve to off-white, which was attributed to increased light scattering. Increasing the oil droplet concentration in the emulsion gels decreased their shear modulus and Young's modulus, which was mainly attributed to the fact that the oil droplets were less rigid than the surrounding protein network. Moreover, increasing the oil droplet size made this effect more pronounced, which was attributed to their greater deformability. Competitive adsorption of proteins and surfactants at the oi-water interface in the Tween emulsion promoted emulsion instability. This research highlights the complexity of the interactions between oil droplets and protein networks in emulsion gels. These insights are important for the utilization of emulsion gels in the formulation of plant-based foods with improved quality attributes.

Adverse Effects Associated with Dermal Filler Treatments: Part II Vascular Complication.

Vascular complications arising from dermal filler treatments pose significant risks, including ischemia, tissue necrosis, and severe outcomes like blindness and pulmonary embolism. This study investigates the mechanisms of vascular complications, categorizing them into extravascular compression and intravascular emboli. Extravascular compression occurs when injected fillers compress adjacent blood vessels, leading to ischemia and potential necrosis, while intravascular emboli result from fillers entering blood vessels, causing blockages. The study emphasizes the importance of anatomical knowledge, careful injection techniques, and early intervention. Management strategies include the use of hyaluronidase to dissolve HA fillers, vasodilators to improve blood circulation, and hyperbaric oxygen therapy. The regions most susceptible to complications align with major arterial pathways, particularly the nasolabial folds and nasal region. The study also highlights the need for meticulous injection techniques, the use of cannulas over needles in high-risk areas, and the aspiration test to detect vessel penetration. Early detection and immediate intervention are crucial to mitigate adverse outcomes. Continuous education and training for practitioners, along with advancements in filler materials and injection methods, are essential for improving the safety of cosmetic procedures. This comprehensive understanding aids in preventing and managing vascular complications, ensuring better patient outcomes. The field of dermal filler treatments is advancing with new techniques and technologies, such as High-Resolution Ultrasound, Infrared Imaging, self-crossing hyaluronic acid filler, biodegradable microspheres, and microinjection.

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 .