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.

Novel single-entry point injection technique for masseter hypertrophy treatment using botulinum neurotoxin based on patient-reported comfort.

INTRODUCTION: Botulinum neurotoxin (BoNT) injections are widely used for the treatment of masseter muscle hypertrophy in Southeast Asia. However, there remains a lack of consensus regarding the optimal injection technique. This study aimed to compare the efficacy and patient discomfort associated with single-entry point injections versus multiple three-point injections for masseter muscle hypertrophy treatment with BoNT. MATERIALS AND METHODS: Sixteen participants, comprising both male and female Korean adults aged 22-63, were enrolled in the study. On the left side of the face, single-entry point injections were administered, followed by multidirectional injections, while on the right side, three-point injections were given. Pain intensity during the procedure was assessed using visual analogue scale scores. RESULT: Our results revealed that participants experienced lower levels of pain with single-entry point injections compared to three-point injections (average visual analogue scores of 3.31 and 5.19, respectively). CONCLUSION: These findings highlight the potential benefits of single-entry point injections in reducing patient discomfort during masseter muscle hypertrophy treatment with BoNT. We advocate for further research to validate these findings and encourage practitioners to consider single-entry point injections as a viable option for enhancing treatment outcomes in their clinical practice.

Safe Zones for Facial Fillers: Anatomical Study of SubSMAS Spaces in Asians.

The study "Spaces of the Face for Filler Procedures: Identification of subSMAS Spaces Based on Anatomical Study" explores the anatomy of facial spaces crucial for safe and effective filler injections. By delineating the subSMAS (sub-superficial musculoaponeurotic system) spaces, this research highlights how these virtual compartments, bordered by fat, muscles, fascia, and ligaments, facilitate independent muscle movement and reduce the risk of damaging critical structures. The thicker and more robust skin of East Asians necessitates deeper filler injections, emphasizing the significance of accurately identifying these spaces. A cadaver study with dyed gelatin validated the existence and characteristics of these subSMAS spaces, confirming their safety for filler procedures. Key spaces, such as the subgalea-frontalis, interfascial and temporalis, and prezygomatic spaces, were examined, illustrating safe zones for injections. The findings underscore the importance of anatomical knowledge for enhancing facial aesthetics while minimizing complications. This study serves as a guide for clinicians to perform precise and safe filler injections, providing a foundation for further research on the dynamic interactions of these spaces and long-term outcomes.

A Gaze into the Eyebrow Standards of Asian Versus Caucasian Women.

BACKGROUND: Eyebrow position affects perceived facial expression and youthfulness, and its modification is a key component of facial rejuvenation. OBJECTIVE: This investigation aimed to assess the preferred vertical eyebrow position, apex location, and eyebrow shape in Caucasian and Asian individuals and to analyze gaze patterns during aesthetic judgment using eye-tracking technology. MATERIALS AND METHODS: The study included 76 Asian and Caucasian volunteers with no medical background. Eye movements were captured with a Tobii Pro Nano eye-tracker. Participants viewed AI-generated images of Caucasian and Asian females with varied eyebrow positions (ratios 1:1.3 to 1:2.5), shapes (angles 8° to 20°), and apex positions. Aesthetic preferences were rated on a 5-point Likert scale. Eye-tracking metrics and aesthetic ratings were statistically analyzed using ANOVA and bivariate correlations. RESULTS: Both genders across ethnicities preferred a moderate eyebrow position ratio of 1:1.6. For eyebrow shapes, a 12° angle received the highest ratings, while extremes were less favored, indicating a preference for moderately curved eyebrows. The most appealing apex position was above the lateral canthus for Asians, and halfway between the lateral limbus and lateral canthus for Caucasians. Eye-tracking revealed longer fixations on unattractive features, suggesting more complex cognitive processing, while attractive features were processed more efficiently. CONCLUSION: The study revealed that aesthetic preferences for eyebrow features are influenced by both ethnic background and gender, with a general preference toward moderately curved eyebrows and subtle variations in preferred positions. These findings suggest a need for culturally sensitive approaches in facial aesthetic procedures and highlight the potential of eye-tracking technology to enhance surgical planning. Surgeons are advised to adopt a conservative, patient-centered approach when modifying eyebrow features, considering individual and cultural aesthetics to maximize patient satisfaction. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Volumizing Threads (Jamber) in the Midface and Managing Side Effects: Clinical Cases.

The clinical application of polydioxanone (PDO) threads, traditionally utilized for tissue lifting, is now being explored for its volumizing effects in midface rejuvenation. The novel approach involves employing PDO volumizing threads to achieve physical augmentation akin to a "solid filler." The study introduces a more convenient insertion method for these threads, prioritizing ease and efficacy. Clinical cases demonstrate the efficacy of volumizing threads in addressing midface concerns, such as nasolabial folds and midcheek grooves. Additionally, the integration of volumizing threads to provide support in sagging areas is examined for achieving natural-looking enhancements. While highlighting positive outcomes, potential side effects like thread protrusion are addressed, along with strategies for their mitigation. Volumizing threads are presented as a suitable procedure for patients wary of traditional fillers or seeking subtle enhancements, with the recommendation of combining them with cog threads for those desiring more pronounced changes in facial contour. In summary, volumizing thread offers a minimally invasive alternative with fewer side effects for midface rejuvenation.

Energy-based devices and hyaluronic acid filler, polymer filler, and threads: Cadaveric study.

INTRODUCTION: The objective of this experiment was to investigate the thermal effects on hyaluronic acid fillers, PCL fillers, and PDO threads when exposed to controlled heat. This study aims to provide insights into how these materials respond to thermal energy, which is crucial for safe and effective cosmetic procedures involving combined modalities. MATERIALS AND METHODS: Cadaveric tissue was utilized to simulate clinical conditions. Hyaluronic acid fillers were injected at approximately 1 mm and 5 mm thicknesses, with variations in G' value (high and low). PCL fillers were similarly injected in 1 mm and 5 mm thicknesses. PDO threads were also inserted. All materials were injected at a depth of 2 cm. A thermometer was used to measure heat penetration, and a multi-wavelength laser was applied to the tissue. The temperature was maintained at 60°C for 5 min to assess whether heat penetrated more than 3 cm in thickness. Observations were made regarding the heat distribution and any physical changes in the fillers and threads. RESULTS: In thick layers, heat accumulated above the PCL filler without penetrating deeper layers. In thin layers, heat penetration was observed. For the HA fillers, heat energy was not blocked, regardless of the G' value or thickness. For the threads, no significant heat blockage effect was observed. For all materials, no visual changes were detected in any of the materials due to temperature exposure. DISCUSSION: The findings suggest that the thickness and composition of fillers significantly influence heat penetration. Thick PCL fillers act as a thermal barrier, whereas thin PCL fillers allow deeper heat penetration. Hyaluronic acid fillers do not impede heat transfer, regardless of their physical properties. PDO threads do not exhibit any notable thermal resistance. These insights are essential for optimizing the safety and efficacy of combined filler and energy-based device treatments in esthetic medicine.

Anatomical considerations of medial eye wrinkles: Guidelines for botulinum neurotoxin injections.

Crow's feet lines in the lateral canthal region are a common concern among aging patients, initially appearing as dynamic wrinkles during facial expressions and becoming more pronounced with age. Botulinum neurotoxin temporarily paralyzes muscles by inhibiting acetylcholine release, smoothing wrinkles and enhancing skin's youthful appearance. Effective treatment requires tailored approaches considering individual anatomy and muscle activity. Recent cadaveric studies identified the tear trough muscle, emphasizing its role in infraorbital support and aging. Clinically, patients often present medial eye wrinkles after BoNT treatment for crow's feet, prompting exploration of underlying mechanisms and management strategies. Three cases demonstrated that medial BoNT injections in the orbicularis oculi muscle significantly improve medial eye wrinkles and tear trough appearance. The study underscores the importance of understanding muscle hyperactivity and anatomical variations for precise treatment. Enhanced injection techniques targeting specific areas can achieve better outcomes and minimize complications, particularly in culturally sensitive regions where facial expressions are valued. This research highlights the necessity for comprehensive anatomical knowledge and patient-specific treatment strategies to address medial eye wrinkles effectively.

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.

Clinical Applications of Exosomes: A Critical Review.

Exosomes, small membrane-bound vesicles secreted by cells, have gained significant attention for their therapeutic potential. Measuring 30-100 nm in diameter and derived from various cell types, exosomes play a crucial role in intercellular communication by transferring proteins, lipids, and RNA between cells. This review analyzes existing literature on the clinical applications of exosomes. We conducted a comprehensive search of peer-reviewed articles and clinical trial data to evaluate the benefits, limitations, and challenges of exosome-based therapies. Key areas of focus included regenerative medicine, cancer therapy, gene therapy, and diagnostic biomarkers. This review highlights the vast clinical applications of exosomes. In regenerative medicine, exosomes facilitate tissue repair and regeneration. In cancer therapy, exosomes can deliver therapeutic agents directly to tumor cells. In gene therapy, exosomes serve as vectors for gene delivery. As diagnostic biomarkers, they are useful in diagnosing various diseases. Challenges such as the isolation, purification, and characterization of exosomes were identified. Current clinical trials demonstrate the potential of exosome-based therapies, though they also reveal significant hurdles. Regulatory issues, including the need for standardization and validation of exosome products, are critical for advancing these therapies. While significant progress has been made in understanding exosome biology, further research is essential to fully unlock their clinical potential. Addressing challenges in isolation, purification, and regulatory standardization is crucial for their successful application in clinical practice. This review provides a concise overview of the clinical applications of exosomes, emphasizing both their therapeutic promise and the obstacles that need to be overcome.

Singular entry point technique for forehead and temple filler augmentation: Anatomical and clinical perspectives.

BACKGROUND: The depressed volume of the forehead and temple is resolved by filler injection. However, the current method has the potential to cause pain and side effects in patients, depending on the skill of the clinician. Therefore, this study proposes a new method for safer and simpler injection using only one injection entry point. METHODS: Using the novel injection method, the filler was injected into the forehead and temple regions in three unembalmed cadavers and two healthy Korean volunteers. The cannula and filler locations were identified using dissection, ultrasonography, and three-dimensional (3D) scanning. RESULTS: Ultrasonographic images and dissection results showed that the filler injected into the cadavers was in the target layer. The cannula and filler were located on the layer as the supraperiosteal layer on the forehead and the supra deep temporal fascia layer in the temple. Finally, 3D scanning images showed that the filler was injected precisely and effectively into the forehead and temples of the volunteer who underwent the procedure. CONCLUSIONS: This method can reduce pain and minimize externally visible wounds caused by injections. The injected filler was naturally connected from the forehead to the temple and maintained for around 3 months. Additionally, it is possible to inject fillers into the forehead and temple at a constant and safe depth without requiring specific skills. It is expected that this method will become a universal method because it minimizes the burden on both patients and clinicians.

Poly­d,l­lactic acid­enhanced atrophic scar treatment via transdermal microjet drug delivery in Asians.

BACKGROUND: Acne vulgaris often results in permanent scars, with atrophic scars being the most common type and posing a significant therapeutic challenge due to their prevalence and impact on patients' quality of life. Various treatment options exist, including the use of poly-d,l-lactic acid delivered via different methods. OBJECTIVE: This study aimed to assess the efficacy and safety of poly-d,l-lactic acid delivered via laser-assisted needle-free microjet injection for treating atrophic scars. METHODS: Five Korean participants with atrophic facial scars were recruited. Poly-d,l-lactic acid solution was administered via the Mirajet system in five sessions, with clinical assessments conducted at baseline, before each session, and at 12-week and 22-week follow-ups. Outcome measures included the Global Aesthetic Improvement Scale and patient satisfaction scores. RESULTS: Positive results were observed at the 12-week and 22-week follow-ups, with high patient satisfaction and improvements in atrophic scars and skin texture. Mild discomfort and transient side effects were reported, with no adverse events observed during the follow-up period. CONCLUSION: Poly-d,l-lactic acid delivered by a laser-assisted needle-free microjet injector was judged to be effective for improving atrophic the facial area. Further research, particularly through randomized controlled trials, is needed to validate these findings and assess the longer-term safety and sustainability of outcomes.

Sonoanatomy of injecting botulinum neurotoxin into the facial muscles.

INTRODUCTION: Ultrasonography (US) has become an essential tool for guiding botulinum neurotoxin (BoNT) injections in facial muscles, enhancing precision and safety. This narrative review explores the role of US in BoNT administration, particularly in complex anatomical regions, highlighting its impact on treatment customization, real-time visualization, and complication reduction. MATERIALS AND METHODS: A comprehensive literature search was conducted using PubMed, MEDLINE, Embase, and Cochrane Library for articles published from January 2018 to December 2023. Search terms included "Botulinum neurotoxin," "facial anatomy," "ultrasonography guided injection," and "facial muscle sonoanatomy." Studies focusing on US-guided BoNT injections in facial muscles were included. Data extraction and synthesis were performed independently by two reviewers, focusing on study design, ultrasonography techniques, outcomes, and conclusions. RESULTS: The review found that US guidance significantly enhances the precision of BoNT injections by providing real-time visualization of facial muscles and blood vessels, thereby reducing the risk of adverse events. US enables tailored injection strategies, ensuring symmetrical facial expressions and minimizing over-treatment. The technique also offers immediate feedback, allowing for on-the-spot adjustments to improve treatment efficacy and safety. However, the review identified limitations, including potential selection bias and variability in US techniques across different studies. CONCLUSION: US guidance for BoNT injections into facial muscles offers substantial benefits in terms of precision, safety, and treatment customization. Despite the identified limitations, the integration of US into clinical practice is poised to enhance patient outcomes in aesthetic and therapeutic procedures. Further research is needed to standardize US techniques and broaden the inclusivity of studies to validate these findings comprehensively.