Simplifying the injector's armamentarium: An international consensus regarding the use of gel science to differentiate hyaluronic acid fillers and guide treatment recommendations.

BACKGROUND: The Restylane portfolio of soft tissue fillers spans a wide range of indications, due in part to their complementary manufacturing technologies [non-animal stabilized hyaluronic acid (NASHA) and Optimal Balance Technology (OBT/XpresHAn)]. Using an array of products, injectors can achieve a holistic, natural looking effect for their patients. However, with a wide range of products it may be difficult to choose an optimal combination. AIM: Simplify and align global use recommendations for NASHA versus OBT products. METHODS: Two pre-meeting surveys were completed by 11 key opinion leaders with international representation, with the goal of collecting information regarding their current injection practices for various anatomical regions of the face (i.e., temporal region, forehead, tear trough, lateral zygoma, anteromedial cheek, nose, pyriform aperture, nasolabial fold, perioral area, lips, labiomental crease, marionette lines, chin, and jawline). The data collected from these surveys was subsequently discussed in a consensus group meeting involving 11 voting members and 3 nonvoting members. RESULTS: Top product recommendations were identified for each anatomical area, along with secondary and tertiary recommendations that can also be used under defined circumstances. Recommendations were provided based on a consideration of elements such as patient features (e.g., skin thickness, bone structure), the desired aesthetic outcome, experience of the injector, and the preferred injection technique. CONCLUSION: A majority consensus regarding the top NASHA versus OBT product choice for each anatomical region of the face was reached. These recommendations represent international agreement regarding the use of Restylane products.

Safety of infraorbital hyaluronic acid injections: Outcomes of a meta-analysis on prospective clinical trials.

BACKGROUND: Hollowing of the infraorbital region represents a common concern among aesthetic patients. In the past decade, an increasing number of patients have resorted to noninvasive aesthetic procedures to treat these concerns. The objective of this study was to evaluate the safety profile of infraorbital hyaluronic acid injections for aesthetic rejuvenation. METHODS: Through a systematic review and meta-analysis of prospective clinical trials, investigators sought to answer the research question "Does the use of needle versus cannula during infraorbital HA injections result in the same incidence rate of adverse events?" The primary outcomes of interest were the incidence rates of ecchymosis and edema in subject groups treated with a needle or cannula. RESULTS: Subjects treated with needles had a statistically significant greater incidence rate of ecchymosis, compared to those treated with cannula. Conversely, subjects treated with cannula had a statistically significant greater incidence rate of edema, compared to those treated with needles. CONCLUSIONS: The incidence rates of adverse events following the administration of hyaluronic acid injections in the infraorbital region vary depending on whether a needle or cannula is used; with needles being associated with a greater risk of ecchymosis and cannulas being associated with a greater risk of edema. These findings should be discussed with patients prior to treatment consultation. Finally, as with most techniques, it is usually prudent to develop expertise with one technique before using a second, especially in cases where both approaches can be used and have different adverse event profiles.

Novel Treatment Protocol for Combined Tear Trough Ligament Stretching and Injection.

BACKGROUND: Complex anatomical changes have been the main challenges for optimal treatment results of tear trough deformities through hyaluronic acid (HA) injections. The authors present a novel technique consisting of a preinjection tear trough ligament stretching (TTLS-I) leading to its release, and compared its efficacy, safety, and patient satisfaction to tear trough deformity injection (TTDI). METHODS: This was a 4-year, retrospective, single-center cohort study of 83 TTLS-I patients, with a follow-up period of 1 year. One hundred thirty-five TTDI patients served as a comparison group. Outcome analyses included the analysis of possible risk factors for adverse outcome and comparative statistics between the complication and satisfaction rates of the two groups. RESULTS: TTLS-I patients received significantly less HA (0.3 cc; range, 0.2 to 0.3 cc) than TTDI patients did (0.6 cc; range, 0.6 to 0.8 cc; P < 0.001). The injected HA amount was a significant predictive factor for complications ( P < 0.05). Complication rates assessed during the follow-up visit for hematomas, edema, and the need for corrective hyaluronidase injection were low in both groups, with no significant differences between the groups. TTDI patients had significantly higher rates (5.1%) of lump surface irregularities during follow-up, compared with 0% in the TTLS-I group ( P < 0.05). After 1 year of follow-up, 98.8% of TTLS-I patients were satisfied, whereas 95.6% of TTDI patients were satisfied, with no significant difference between groups. CONCLUSIONS: TTLS-I is a novel, safe, and effective treatment method, necessitating significantly less HA compared with TTDI. Moreover, it leads to very high satisfaction rates and very low complication rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Expert Recommendations on the Use of Hyaluronic Acid Filler for Tear Trough Rejuvenation.

Restylane® Lidocaine is one of the most widely used hyaluronic acid (HA) fillers to replace lost or displaced volume during tear trough correction. Patient goals for tear trough correction include looking less tired or removing dark circles and this may be achieved by administering HA filler into the infraorbital region to correct the lower eyelid relative to the volume deficit, thereby smoothing the transition from the lower eyelid to the cheek. To achieve patient satisfaction and consistent results with Restylane, optimal application is essential; however, clinical guidance based on experience is limited. This paper reflects the recommendations of an interdisciplinary expert panel for the use of Restylane in correcting tear trough deformity, including patient selection, dosing, injection technique, and post-treatment care. Recommendations were discussed and agreed as a consensus, according to cross-sectional expertise and clinical experience. J Drugs Dermatol. 2022;21(4):387-392. doi:10.36849/JDD.6597.

A Randomized, Crossover-Controlled Evaluator-Blinded Trial Evaluating Cannula- vs Needle-Assisted Hyaluronic Acid Injections for Infraorbital Deformities.

BACKGROUND: Periorbital deformities can be corrected utilizing hyaluronic acid injections. However, previous studies have not evaluated the effect of utilizing different injection techniques (eg, a needle vs cannula) on efficacy and safety. OBJECTIVES: The authors sought to investigate the efficacy and safety of HA for the correction of periorbital deformities when utilizing either needle or cannula-assisted injections. METHODS: This was a prospective, randomized-controlled (with crossover), evaluator-blinded study. Forty-two patients with a mean age of 44.82 ± 11.62 years were recruited. Patients underwent 2 treatment sessions, spaced 2 weeks apart, and attended 1 follow-up visit at Week 4, following the last treatment. Patients were randomized in a 3:3:1 ratio, whereby 18 patients received injections by needle, 18 received injections by cannula, and 6 were randomized to act as their own control at baseline. Those in the control group were randomized (n = 3) to needle or cannula injections at Week 4 and proceeded with the same visit schedule as those treated at baseline. At Weeks 2 and 4 posttreatment, patient satisfaction was evaluated and information on adverse effects was collected. A blinded reviewer assessed patient imagery utilizing standardized efficacy scales. RESULTS: Chi-square tests did not reveal any associations between treatment group and efficacy, safety, or patient satisfaction scores (P ≥ 0.05). Adverse effects reported in patient diaries were mild to moderate in nature and expected. CONCLUSIONS: For the treatment of infraorbital deformities, hyaluronic acid injections performed utilizing either a cannula or needle result in similarly high efficacy and safety ratios.

Hyalurostructure treatment: superior clinical outcome through a new protocol-a 4-year comparative study of two methods for tear trough treatment.

BACKGROUND: The tear trough represents a main aesthetic characteristic of the aging process, which leads many patients to the wish for a safe and efficient rejuvenation method to fill their eye rings. The authors analyzed results and complication rates of two methods for hollow eye ring treatment. METHODS: The authors used two methods on two patient collectives. Group A was treated using hyaluronic acid gel (Restylane; Q-Med, Uppsala, Sweden) and a reinforced 25-gauge Pix'l+ micro cannula. The authors developed a modified method for group B that included a combination of cooling of the periorbital area, no local anesthesia, preincision displacement of malar fat 10 mm below the orbital border, and postintervention corticoid therapy for 48 hours. RESULTS: Protocol B was associated with significantly lower complication rates. The authors also analyzed in how smoking, age, and skin properties might affect the clinical outcome. They found that choice of treatment and a history of blepharoplasty were significant predictive factors that correlated with complications. CONCLUSIONS: Tear trough treatment by hyalurostructure shows satisfying and efficient results with few complications. The revised technique used in group B combines multiple peri-interventional procedures including preinjection cooling of the periorbital area, preincision with displacement of the malar fat 10 mm below the orbital border, applying gentle back-and-forth movements while injecting, and oral corticosteroid therapy 48 hours after intervention. This technique makes hyalurostructure a competent and promising treatment for tear trough management. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Evolution in technique: use of hyalurostructure for lips rejuvenation as an alternative to needle injection without troncular anesthesia.

PURPOSE: To enhance lips ageing rejuvenation with specific microcannula and hyaluronic acid. METHOD: Clinical review was conducted from December 2010 to December 2011 among 46 patients complaining of predictable changes on lips and perioral region such as deficiency in contour definition, volume and projection. Lips rejuvenation injections were made using the hyalurostructure technique. RESULTS: Forty-two patients (92%) with a 6-month follow-up were satisfied or very satisfied with the aesthetic results after the hyalurostructure of the lips and the perioral region rejuvenation. The use of the specially designed cannula led to fewer complications. We noticed 40 oedemas (87%) that appeared 24-48 h after the injection and seven patients (15.2%) with haematomas. We noted fewer surface irregularities and a better distribution of the product. Patients' records showed the procedure was painless. CONCLUSION: The hyalurostructure technique reduces the number of punctures compared to that of the conventional method. The microcannula's blunt tip reduces the risks of intravascular injection of the substance and of reach and disruption of the key structures like vessels and nerves. Results revealed that the hyalurostructure used for lips rejuvenation and helps to maintain a natural effect and avoids pain.

Oculofacial contour asymmetries: Management of combined treatment with hyalurostructure and botulinum toxin injections.

PURPOSE: To assess the long-term results of the treatment of oculofacial asymmetries using a combined injection schedule for injections of hyaluronic acid, with a specific micro cannula and botulinum toxin. METHOD: A retrospective study was conducted from January 2009 to January 2010. Patients were treated in the Alcazar Eye Clinic and Oculoplastic Department in Princess Grace Hospital, Monaco. We selected patients complaining of asymmetrical periorbital features who received treatment with hyalurostructure and botulinum toxin injection in one or more sessions. Nine patients were selected and presented with the following symptoms: asymmetry of eyebrow position (2 patients), superior orbital hollow (2 patients), tear trough (2 patients) and orbital volume (ocular prosthesis) (3 patients). The objective was to evaluate the efficiency of combined treatment in one or more sessions on these oculofacial asymmetries. Hyaluronic acid injections were done using hyalurostructure. Hyaluronic acid gel (Restylane Lidocaine) was used with a 25 gauge reinforced micro-cannula (pix'l +, Thiebaud). This was combined with injections of botulinum toxin (azzalure*) to areas of muscular hyperaction. Follow-up was done at 1 year by clinical examination, photography and patient satisfaction. Complications of this combined treatment have been identified. RESULTS: At 1-year follow-up, 88% of patients were satisfied or very satisfied with their results. There were no more complications secondary to both treatments in the same session. It was not noticed more hematomas and bruises than in classical injection method. The action of toxin is constant over time despite the association of hyaluronic acid injections. CONCLUSION: Combined treatments with toxin and hyaluronic acid in oculofacial asymmetries are efficient and can be proposed in the same session. These treatments must be repeated to maintain and optimize muscle contraction and volume loss. Use of hyalurostructure and botulinum toxin treatment in the same session is effective and safe.

How to achieve synergy between volume replacement and filling products for global facial rejuvenation.

The objective of this paper is to provide an expert consensus regarding facial rejuvenation using a combination of volume replacement (Juvéderm(®) VOLUMA(®)), filling products (Juvéderm(®) Ultra product line) and botulinum toxin. The Juvéderm product line exploits innovative 3-D technology, producing a range of cohesive, homogenous gels that produce predictable, long-lasting and natural results. The products are easy to use by practitioners and are well-tolerated by patients, and used in combination can provide additional benefits not achieved with one product alone. An assessment of facial anatomy and consideration of the aging process, as well as available treatment options, are also addressed in determining the best combination of products to use. Outcomes from a questionnaire and workshop sessions focusing on specific aspects of use of the Juvéderm product line and botulinum toxin in daily clinical practice are discussed, and recommendations for product use following debate amongst the experts are provided.

Periorbital contour abnormalities: hollow eye ring management with hyalurostructure.

PURPOSE: A new technique for treating "periorbital hollowing" with hyaluronic gel filling using a unique cannula designed specifically for periorbital use. METHOD: The study was conducted from December 2008 to July 2009. All the patients presenting to the Alcazar aesthetic and Orbital clinic for periorbital contour abnormality complains where included. A total of 26 patients (52 injections) in both functional and aesthetic categories were identified. The inclusion criteria where contour abnormalities in the periorbital area. These included contour abnormalities of the periorbital and brow region that presented clinically as: "hollow eye ring" and "hollow cavities" and "deflated eyebrow". The aim was to evaluate a new technique with a cannula specific for periorbital injections. This was designed in consultation with the author and was manufactured by the Thiebaud Company. Treatments where performed using local anaesthesia (emla 5% and an injection of 1% Xylocaïne adrenalised to 32-gauge needle) using the same protocol as Coleman lipostructure but using hyaluronic acid gel. The hyaluronic acid gel used in each case was Restylane (Q-Med-Sweden). Follow-up was over 6 months and performed photographically and with a patient self-evaluation questionnaire. The clinical postoperative assessment examined for bruising or swelling postinjection. The rates of complication were compared to published results and the authors own series before switching to the new cannula. RESULTS: After analysis of the patient responses 24 patients (92%) with a 6 months' follow-up were satisfied or very satisfied of aesthetic result after hyalurostructure of periorbital region. The use of the specially designed cannula led to less complication. There were 3 cases of bruising (3/52) and 4 cases of lymphatic stasis (4/52). We also noted fewer surface irregularities and a better distribution of the product as the injection was a retro orbicular pre periosteal plane). CONCLUSION: Treatment of the periorbital region and tear trough by hyaluronic acid injection has been described previously. But often the risks of this delicate anatomic region and bruises caused by needles followed by the appearance of hollow eye ring due to deposition of haemosiderin have limited the development of this technique. We propose a new treatment for hollow eye rings and for peri orbital region adapted from Lipostructure but with hyaluronic acid and facilitating treatment protocol of that region with improved aesthetic results: hyalurostructure.

[Botulinum toxin, description and clinical applications in the treatment of the face wrinkles]. / La toxine botulique description et applications cliniques dans le traitement des rides du visage.

UNLABELLED: The botulinum toxin is used more and more in the treatment of the wrinkles of the face and mainly in its 1/3 superior part. OBJECTIVES: To describe the technique of injection and to establish a treatment program based on the anatomical data. MATERIALS AND METHODS: The description of the muscles and the elements constituting the face makes it possible to specify the play of the muscular balances of the face. RESULTS: The technique of injection needs certain requirements: It must be of small quantity and not diffuse. The treatment program must be integrated in a unit based on the study of each muscular group of the face and the opposite skin to release a reasonable attitude in the handling in safety of this toxin. CONCLUSION: The technique is sure and effective by respecting the indications and the conditions of use.