Injection Treatments for Vulvovaginal Atrophy of Menopause: A Systematic Review.

BACKGROUND: Injection treatments have been proposed as novel treatment options for Vulvovaginal Atrophy of Menopause (VVA) also known as Genitourinary Syndrome of Menopause (GSM). However, to date data about these treatments are poor. OBJECTIVE: To assess all available injection treatments for VVA. METHODS: A systematic review was performed by searching five electronic databases for peer-reviewed studies that assessed injection treatments for VVA. RESULTS: Eight studies (7 observational and 1 randomized) with 236 women were included. Assessed injection materials were: autologous platelet-rich plasma (PRP) + hyaluronic acid (HA), not cross-linked HA plus calcium hydroxyapatite (NCLHA + CaHA), micro-fragmented adipose tissue (MFAT), hyaluronan hybrid cooperative complexes (HCC), crosslinked HA, microfat and nanofat grafting + PRP, and PRP alone. Improvement in GSM symptoms after treatment was assessed through Visual Analogic Scale (VAS) for GSM symptoms or patient satisfaction, several validated questionnaires (FSFI, VHI, FSD, SF12, ICIQ UI SF, PGI-I, FSDS-R, VSQ), symptoms severity, changes in vaginal mucosa thickness, flora, pH, and expression on vaginal mucosal biopsies of Procollagen I and III and ki67 immunofluorescence or COL1A1 and COL3A1 mRNA. Injection treatments showing significant improvement in GSM-related symptoms were: (i) HCC in terms of VAS for GSM symptoms and FSFI score; (ii) Crosslinked HA in terms of VAS for GSM symptoms, FSFI and VHI score, COL1A1 and COL3A1 mRNA expression on vaginal mucosal biopsies; (iii) NCLHA + CaHA in terms of FSFI score; (iv) PRP + HA in terms of VHI, FSD and SF12 score; (v) microfat and nanofat grafting + PRP in terms of VHI score and FSDS-R score; (vi) PRP alone in terms of VHI and VSQ scores. CONCLUSIONS: All assessed injection treatments except for MFAT seem to lead to significant improvement in VVA symptoms on validated questionnaires. Further studies are necessary in the field. LEVEL OF EVIDENCE II: 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 .

Superficial versus deep injections of the upper midface-A prospective interventional split-face study.

BACKGROUND: Various injection algorithms have been proposed in the past which are in line with the three aesthetic principles: upper face first, lateral face first, and deep regions first. However, increasing evidence is provided that the upper midface can be targeted with superficial soft tissue filler injections alone too. OBJECTIVE: To investigate in a prospective split-face study design whether superficial or deep upper midfacial injections provide superior aesthetic outcomes. METHODS: A total of n = 20 study participants (100% females; age 43.95 (11.7) years; BMI 22.92 (2.6) kg/m2 ) were treated with superficial soft tissue filler injections on side of their face and deep injections on the contralateral side with a mean volume of 0.78 cc. Outcome was evaluated at 7 weeks follow-up for midfacial, and lower facial volume, for medial and lateral facial skin vector displacement, and for improvement of nasolabial, crow's feet, and upper cheek fullness severity scores. RESULTS: No adverse events related to safety or product tolerability were observed during the entire study period. All semiquantitative scores improved statistically significantly after the observational period (p < 0.001) but displayed no difference between the two applied injection techniques (p > 0.05). CONCLUSION: The results of this split-face study revealed that both the superficial and the deep cannula injection technique for midface volumization statistically significantly improve the midfacial volume, reduce nasolabial fold and crow's feet severity. No statistically significant difference was observed between the two injection techniques when compared via semiquantitative and objective outcome evaluation after 7 weeks follow-up.

Delayed hypersensitivity reaction to cosmetic filler following two COVID-19 vaccinations and infection.

BACKGROUND: With ongoing COVID-19 vaccination schedules and the popularity of cosmetic fillers, it is important to examine and record associated adverse reactions to a more general audience of health care professionals. Case reports exist in subspecialty journals outlining reactions after SARS-CoV-2 infection and vaccination. This is one of the first cases published in Canada, and it highlights priorities and challenges faced by physicians in assessing and managing patients presenting with adverse reactions post vaccination. CASE PRESENTATION: We present a case of a 43 -year-old women with delayed type 4 hypersensitivity reaction to hyaluronic acid cosmetic filler triggered by COVID-19 mRNA vaccination. We outline the clinical presentation, diagnosis, complications, and treatment of a late inflammatory reaction to hyaluronic acid filler and highlight the treatment priorities for clinicians faced with similar presentations. CONCLUSION: The differential diagnosis of delayed onset nodules formation post filler injection is broad and includes redistribution of fillers, inflammatory reaction to biofilm, and delayed hypersensitivity reaction. As result, in order to make the right diagnosis, administer the appropriate treatment and achieve great cosmetic results, we highly recommend seeking expert opinion from dermatologist, plastic surgeon and allergist immunologist in a timely manner.

[Neuromodulation therapies for premature ejaculation: Progress in studies].

Premature ejaculation is thought of as one of the most common male sexual dysfunctions, which is pathogenically very complex, involving the nervous, endocrine and muscular functions and psychology. With deeper insights into its pathophysiological mechanism, new therapies have been incessantly developed. At present, the first-line treatment of premature ejaculation is based on oral medication, but related drug resistance and adverse effects are evident. This review focuses on the neuromodulation therapies for premature ejaculation, including dorsal nerve block, local anesthetics, hyaluronic acid injections, and botulinum toxin, aiming to provide some reference for the treatment of different cases of premature ejaculation.

Traditional Korean Medicine as Collaborating Treatments with Conventional Treatments for Knee Osteoarthritis: A Protocol for a Systematic Review and Meta-Analysis.

BACKGROUND: Knee osteoarthritis (OA) is a degenerative disease of the joint cartilage with no definite treatment in the early stage. Several previous review studies have shown that alternative medical treatments, including acupuncture, moxibustion, and herbal medicines, are effective in improving the symptoms of the disease and the patient's quality of life. However, no systematic review study has shown the effectiveness of the combination of conventional and alternative therapies. Therefore, the aim of our study is to determine the most effective combination therapies and to provide evidence for the effectiveness and safety of integrated therapies. This article describes the protocol for the methods that will be applied in our systematic review. METHODS: We will conduct an electronic search of nine databases: PubMed, Embase, Cochrane, Google Scholar (first 100 articles), four Korean databases (KoreaMed, Korean Studies Information Service System, Research Information Service System, and Oriental Medicine Advanced Searching Integrated System), and one Chinese database (China National Knowledge Infrastructure). Only randomized controlled studies that reported on both conventional treatment (drugs and hyaluronic acid) and traditional Korean medicine (acupuncture, moxibustion, and herbal medicines) will be selected. The primary outcomes will be pain and function of the joint. The secondary outcomes will include pain relief duration, total effective rate, incidence of adverse events, and quality of life. We will assess the methodological quality of the included studies using the Cochrane risk of bias tool. For the meta-analysis, standardized mean differences and risk ratios with 95% confidence intervals will be applied for continuous and dichotomous data, respectively. RESULTS: This review will evaluate the effectiveness and safety of several Korean medicine treatments combined with conventional treatments for knee OA. CONCLUSION: Our review will provide a good foundation for the integrative treatment of knee OA.

Evaluation of Lidocaine and Metabolite Pharmacokinetics in Hyaluronic Acid Injection.

Lidocaine-incorporated hyaluronic acid injection (LHA) is considered a promising way to increase patient compliance. Various reviews and analyses have been conducted to verify that the addition of lidocaine had no effect on the product quality of hyaluronic acid injections. However, possible pharmacokinetic (PK) alterations of lidocaine and its active metabolites, monoethylglycylxylidide (MEGX) and glycylxylidide (GX), in hyaluronic acid injection have not been studied so far. Thus, the objective of this study was to evaluate lidocaine and its metabolite PK after 0.3% lidocaine solution or LHA injection and to investigate any changes in PK profiles of lidocaine and its active metabolites. To do this, a novel bio-analytical method for simultaneous determination of lidocaine, MEGX, and GX in rat plasma was developed and validated. Then, plasma concentrations of lidocaine and its active metabolites MEGX and GX following subcutaneous (SC) injection of 0.3% lidocaine solution or LHA with 0.3-1% lidocaine in male Sprague-Dawley rats were successfully determined. The obtained data were used to develop a parent-metabolite pharmacokinetic (PK) model for LHA injection. The half-life, dose-normalized Cmax, and AUCinf of lidocaine after SC injection of lidocaine solution and LHA did not show statistically significant difference. The PK characteristics of lidocaine after LHA administration were best captured using a two-compartment model with combined first-order and transit absorption and its clearance described with Michaelis-Menten and first-order elimination kinetics. Two one-compartment models were consecutively added to the parent model for the metabolites. In conclusion, the incorporation of lidocaine in hyaluronic acid filler injection did not alter the chemical's pharmacokinetic characteristics.

Complications and management of penile augmentation with hyaluronic acid injection.

Hyaluronic acid injection is becoming a popular way for penile augmentation. However, only few studies and follow-ups have investigated the various complications of hyaluronic acid injection and their corresponding management. In this study, a total of 230 patients who had penile augmentation with hyaluronic acid injection from January 2018 to December 2019 were examined on follow-up for penile girth, complications, and their corresponding management. At 1-month, 3-month, and 6-month postoperative follow-ups, the penile circumference had increased by 2.66 ± 1.24 cm, 2.28 ± 1.02 cm, and 1.80 ± 0.83 cm, respectively. During the entire 6-month follow-up, 4.3% had complications such as subcutaneous bleeding, subcutaneous nodules, and infection. There were no systemic or local allergic reactions among all the patients. All complications were treated accordingly, and no further deterioration or severe sequelae were observed. Although complications of hyaluronic acid injections are mild and rare, these may affect the patient's satisfaction postoperatively. Preoperative redundant prepuce may increase the incidence of penile edema or postoperative gel migration. Standardization of the surgery protocol and elucidation of the effects of other injection parameters are still lacking. Nevertheless, it still highlights the importance of preoperative preparation and surgical technique.

Use of hyaluronic acid injection after arthroscopic release in lateral patellar compression syndrome with degenerative cartilage changes: randomized control trial.

BACKGROUND: Degenerative cartilage changes can be seen, in cases of lateral patellar compression syndrome, involving the patellofemoral joint. Hyaluronic acid is a natural component of the synovial fluid and responsible for its elastic features and function of articular surfaces. The aim of this study is to show the effect of intra-articular injection of Hyaluronic acid, after arthroscopic lateral release in lateral patellar compression syndrome, on the functional outcome and knee pain in those patients with degenerative cartilage changes. METHOD: Ninety patients age (30-50) years with lateral patellar compression syndrome and degenerative cartilage changes were divided randomly into 2 groups. Group A was treated by arthroscopic lateral release and received intraarticular injection of Hyaluronic acid 2 weeks after surgery. Group B was treated by arthroscopic lateral release only. Both groups were assessed by Kujala score and visual analogue scale for knee pain preoperatively and re-assessed postoperatively at 3 months, 6 months, 12 months and 24 months. RESULTS: There was significant improvement in Kujala score and Visual analogue scale post-operatively in both groups (P-value< 0.001) with better improvement in Kujala score in group A after intra-articular injection of Hyaluronic acid up to 2 year of follow up (P-value = 0.006) as well as better improvement in visual analogue score at 6 months post-operatively (P-value = 0.035). CONCLUSION: Intra-articular injection of Hyaluronic acid after arthroscopic release, in patients with lateral patellar compression syndrome and degenerative cartilage changes, can result in better improvement of knee pain and functional outcome up to 2 years of follow up. TRIAL REGISTRATION: NCT, NCT04134611 . Registered 18 October 2019 -Retrospectively registered.

Complications and management of penile augmentation with hyaluronic acid injection / 亚洲男科学杂志(英文版)

Hyaluronic acid injection is becoming a popular way for penile augmentation. However, only few studies and follow-ups have investigated the various complications of hyaluronic acid injection and their corresponding management. In this study, a total of 230 patients who had penile augmentation with hyaluronic acid injection from January 2018 to December 2019 were examined on follow-up for penile girth, complications, and their corresponding management. At 1-month, 3-month, and 6-month postoperative follow-ups, the penile circumference had increased by 2.66 ± 1.24 cm, 2.28 ± 1.02 cm, and 1.80 ± 0.83 cm, respectively. During the entire 6-month follow-up, 4.3% had complications such as subcutaneous bleeding, subcutaneous nodules, and infection. There were no systemic or local allergic reactions among all the patients. All complications were treated accordingly, and no further deterioration or severe sequelae were observed. Although complications of hyaluronic acid injections are mild and rare, these may affect the patient's satisfaction postoperatively. Preoperative redundant prepuce may increase the incidence of penile edema or postoperative gel migration. Standardization of the surgery protocol and elucidation of the effects of other injection parameters are still lacking. Nevertheless, it still highlights the importance of preoperative preparation and surgical technique.

Knee Osteoarthritis Treatment Costs in the Medicare Patient Population.

BACKGROUND: Several nonoperative options have been recommended for the treatment of knee osteoarthritis (OA), with varying degrees of evidence. Adhering to the American Academy of Orthopaedic Surgeons clinical practice guidelines has been suggested to decrease direct treatment costs by 45% in the year before knee arthroplasty, but this does not consider the cost of the entire episode of care, including the cost of surgery and postsurgery care. OBJECTIVES: To analyze the total treatment costs after a diagnosis of knee OA, as well as the proportion of arthroplasty interventions as part of the total knee OA-related costs, and whether the total costs differed for patients who received intra-articular hyaluronic acid and/or had knee arthroplasty. METHODS: We identified patients newly diagnosed with knee OA using the 5% Medicare data sample from January 2010 to December 2015. Patients were excluded if they were aged <65 years, had incomplete claim history, did not reside in any of the 50 states, had claim history <12 months before knee OA diagnosis, or did not enroll in Medicare Part A and Part B. The study analyzed knee OA-related costs from a payer perspective in terms of reimbursements provided by Medicare, as well as the time from the diagnosis of knee OA to knee arthroplasty for patients who had knee arthroplasty, and the time from the first hyaluronic acid injection to knee arthroplasty for those who received the injection. We compared patients who received hyaluronic acid and those who did not receive hyaluronic acid injections. Patients who received hyaluronic acid injection who subsequently had knee arthroplasty were also compared with those who did not have subsequent knee arthroplasty. RESULTS: Of the 275,256 patients with knee OA, 45,801 (16.6%) received a hyaluronic acid injection and 35,465 (12.9%) had knee arthroplasty during the study period. The median time to knee arthroplasty was 16.4 months for patients who received hyaluronic acid versus 5.7 months for those who did not receive hyaluronic acid. Non-arthroplasty-related therapies and knee arthroplasty accounted for similar proportions of knee OA-related costs, with hyaluronic acid injection comprising 5.6% of the total knee OA-related costs. For patients who received hyaluronic acid injections and subsequently had knee arthroplasty, hyaluronic acid injection contributed 1.8% of the knee OA-related costs versus 76.6% of the cost from knee arthroplasty. Patients who received hyaluronic acid injections and did not have knee arthroplasty incurred less than 10% of the knee OA-related costs that patients who had surgery incurred. CONCLUSION: Although limiting hyaluronic acid use may reduce the knee OA-related costs, in this study hyaluronic acid injection only comprised a small fraction of the overall costs related to knee OA. Among patients who had knee arthroplasty, those who received treatment with hyaluronic acid had surgery delayed by a median of 10.7 months and associated costs for a significant period. The ability to delay or avoid knee arthroplasty altogether can have a substantial impact on healthcare costs.

Case Report: The role of intradermal micro-droplet hyaluronic acid injection in the correction of filler nodules complication.

Filler injection has been widely used as a non-surgical intervention for skin rejuvenation and augmentation for the past decade. Hyaluronic acid (HA) is considered the most common treated material with high safety profile. Various mechanisms, including promoting collagen synthesis are postulated the efficacy of this powerful skin rejuvenation. The greater number of its used, the more complications were seen. Among the non-vascular complications from filler injection, the most frequent one is nodule formation. It could occur as early or late onset even with HA injection. One of the causes of these nodule formation is from poor injection technique leading to visible skin beads and lumps. The current treatments of these filler side effects mainly aim to remove or reduce excessive or displaced filler product. To the best of our knowledge, there has been no report of using the intradermal injection of the micro-droplet HA to correct filler nodule and simultaneously revitalize the skin quality. This novel treatment technique could be a safe alternative for nodule formation correction.

A pilot study on the use of a non-crosslinked hyaluronic acid with associated anti-oxidant ingredients to improve the effectiveness of Nd:YAG laser toning in the treatment of melasma in six patients.

BACKGROUND: Melasma is a common skin disorder. Nd:YAG laser toning is a popular treatment for melanin clearance. Treatment efficacy is limited by factors such as presence of reactive oxygen species, DNA damage, TEWL, and skin barrier disruption. AIMS: The purpose of this pilot study is to explore the efficacy of a non-crosslinked hyaluronic acid with anti-oxidant ingredients in mitigating the above-stated factors in the treatment of melasma using Nd:YAG laser toning. METHOD: In this pilot retrospective study of six cases with melasma, Nd:YAG laser toning was performed for each case until improvement of melasma has plateaued (after 4-6 sessions) and at which point treatment was paused. After injecting non-crosslinked hyaluronic acid (9-12 mL) with anti-oxidant ingredients into the face with focus on the lesional skin, further sessions (4-6) of Nd:YAG laser toning was resumed. Before, interim (improvement has plateaued), and after (on completion of the remaining sessions of laser toning after hyaluronic acid injection) photos of the six cases were scored using modified MASI. ANOVA analysis was applied to the scores. RESULTS: All six melasma cases had further improvement in melasma clearance after hyaluronic acid injection beyond the point when improvement has plateaued. ANOVA analysis of before, interim, and after scores showed statistical significance in difference between the three groups. CONCLUSION: This pilot study of six cases suggests that the use of a non-crosslinked hyaluronic acid with anti-oxidants may improve the efficacy of Nd:YAG laser toning in the treatment of melasma.

Efficacy Comparison of Hyaluronic Acid and Corticosteroid Injection in Treatment of Trigger Digits: A Randomized Controlled Trial.

Background: Although the current nonsurgical treatment for trigger digits is corticosteroid (CS) injection, it often comes with adverse effects that may cause some limitations. Currently, Hyaluronic acid (HA) has been successfully used in tendinopathy and may be used in stenosing tenosynovitis. The aim of this study is to compare the efficacy of ultrasound-guided injection between the HA and CS in trigger digits treatment. Methods: Double-blind randomized controlled trial was conducted. Fifty patients with 66 trigger digits were randomly assigned into an intervention group (1 ml of low-molecular weight HA) and a control group (1 ml of 10mg/ml triamcinolone acetate). The ultrasound-guided injection and local anesthesia (0.5 ml of 1% lidocaine without adrenaline) were used. The Quinnell grading, Visual Analog Scale (VAS) score of pain, Disabilities of the Arm, Shoulder and Hand (DASH) score and complications were collected at 1-, 3-and 6-month follow-up. Results: The mean age of HA group (33 digits) and CS group (33 digits) were 58.3 years and 54.7 years respectively. Nine patients were loss of follow-up (7 in HA group and 2 in CS group). The Quinnell grades have shown an improvement in both group. The CS group had a significant better improvement at 1-month (p-value < 0.001) and there was no significant difference at 3-and 6-month follow-up between the two groups. The median of VAS and DASH score were significantly improved by time in both groups (p-value < 0.01). The CS group showed a better significant improvement in early period of follow-up (p-value < 0.05). However, there was no significant difference between the two groups in the last follow-up. Conclusions: HA and CS injection has a comparable therapeutic effect in treatment of trigger digits. However, CS injection has higher efficacy of pain and inflammation reduction in the early phase of the disease.

Complete recovery of filler-induced visual loss following subcutaneous hyaluronidase injection.

The rise in popularity of hyaluronic acid (HA) dermal filler injection has caused an exceptional increase in the number of cases of reported irreversible blindness. Here, we reported a case of ischemic optic neuropathy and ophthalmoplegia following subcutaneous HA filler injection with complete visual recovery. A 31-year-old Chinese woman presented with sudden onset of right monocular visual impairment associated with diplopia. Patient had received a hyaluronic acid-containing filler injection for nasal dorsum augmentation twelve hours prior to presentation. Visual acuity of the right eye was counting finger. A right relative afferent pupillary defect was demonstrated with ophthalmoplegia. Humphrey visual field test disclosed a right inferior altitudinal field defect with impairment of colour vision. Computed tomography of the orbit revealed mild enlargement of the right medial and inferior recti muscles. Our patient showed a tremendous improvement of vision after a subcutaneous hyaluronidase injection with complete visual recovery within 2 weeks.

Prevention of post-traumatic osteoarthritis after intra-articular knee fractures using hyaluronic acid: a randomized prospective pilot study.

PURPOSE: Based on the irreversible destruction of hyaline cartilage, post-traumatic osteoarthritis (PTOA) is a notorious sequelae after intra-articular knee fractures. This study evaluates the clinical efficacy and applicability of immediate post-operative intra-articular injection of hyaluronic acid (IA HA) into the knee joint with an intra-articular fracture. METHODS: Prospective randomized case-control study involving 40 patients (20 in each group) with intra-articular knee fracture with an average follow-up of 23 months (range 18-24 months). Twenty patients with intra-articular distal femoral or intra-articular proximal tibial fractures who met our inclusion criteria received three intra-articular hyaluronic acid injections weekly starting immediately after ORIF. Another 20 patients serving as a control group received no injection after ORIF. Patients were assessed functionally with Knee injury and Osteoarthritis Outcome Score (KOOS) and International Knee Documentation Committee (IKDC) score. Plain X-rays and when indicated CT scans were used to assess radiological union. RESULTS: The results showed patients treated with intra-articular hyaluronic acid injection after fixation had significantly less pain (KOOS) (p = 0.01). No significant difference was found between both groups in other KOOS-related outcome measures, complications, functional outcome, or quality of life. CONCLUSIONS: These preliminary results support a direct role for hyaluronic acid in the acute phase of the inflammatory process that follows articular injury and provides initial evidence for the efficacy of IA HA.

The synovial fluid neuropeptide PACAP may act as a protective factor during disease progression of primary knee osteoarthritis and is increased following hyaluronic acid injection.

The correlation of serum and synovial fluid (SF) pituitary adenylate cyclase-activating polypeptide (PACAP) levels with disease progression of primary knee osteoarthritis (OA) was explored. Radiographic severity of OA was determined by Kellgren-Lawrence (K-L) grades. PACAP levels were measured by ELISA before treatment, and 4 and 8 wk following hyaluronic acid (HA) injection. Levels of IL-1ß and MMP-3 were also detected. The numeric pain scale (NPS), revised Oxford Knee Score (OKS), and American Knee Society Score (AKSS) were employed to evaluate to symptomatic severity. Receiver-operating-characteristic (ROC) curve analysis was carried out to compare the diagnostic value of PACAP, IL-1ß, and MMP-3 for the K-L grade. PACAP concentrations in SF but not serum were significantly lower in OA patients compared with controls. SF PACAP levels were negatively associated with K-L grades and higher NPS as well as worse AKSS and OKS. Further analysis demonstrated that PACAP concentration in SF was negatively correlated with expressions of IL-1ß as well as MMP-3 and may act as a marker for radiographic progression along with MMP-3. Last, we found SF PACAP levels exhibited an incremental trend after HA injection. These findings confirmed the crucial role of PACAP deficiency in the development of primary knee OA.

Investigation of the presence and variation of the ascending mental artery: Conventional dissections and ultrasonographic study.

BACKGROUND: Tongue and mouth floor infarction following filler injections for chin augmentation is a rare complication that has the increase in incidence been reported. OBJECTIVE: This study investigated the arterial anastomosis between the submental and sublingual arteries that can lead to the emboli and subsequent tongue infarction during chin augmentation. METHODS: Forty-two formaldehyde-embalmed cadavers and four soft-embalmed cadavers were dissected to verify the incidence and source of the ascending mental artery. Ultrasonographic study of the artery was performed in 10 healthy volunteers. Attention was paid to discriminate whether the ascending mental artery arose from the submental artery or the sublingual artery using the arch of the mylohyoid muscle as the discriminating landmark. RESULTS: Incidence of ascending mental artery from the sublingual artery was 7.1% in the studied population. All ascending mental arteries were 0.7 ± 0.2 mm in diameter at the mental protuberance and were branches of the submental artery that arose from the facial artery, except for two arteries that arose from the sublingual artery. Ultrasonographic study revealed that one left and one right sublingual artery from the lingual arteries penetrated the mylohyoid muscle near the midline to become the ascending mental artery in two volunteers. The ascending mental artery from the other side continued from the submental artery. CONCLUSION: Findings from the cadaveric dissections and ultrasonographic study revealed that the ascending mental artery may be a branch that continues from the lingual artery, or communicates with the sublingual artery through the mouth floor.

Severe vision loss caused by cosmetic filler augmentation: Case series with review of cause and therapy.

Hyaluronic acid (HA) injection is a popular nonsurgical, facial rejuvenating procedure. Due to the rapidly expanding use of HA injections, significant potential complications have also increased in frequency. Among these complications, the rare but most devastating one is arterial occlusion, which can result in skin necrosis or blindness. To describe the mechanisms behind vision loss secondary to hyaluronic acid injection and the efficacy of treatments to restore vision and associated ocular functionality. We reviewed six cases of patients from October 2011 to December 2017 who experienced vision loss after receiving facial HA injections and the subsequent treatments undertaken to attempt to reverse the vision loss and additional eye complications. Of the six patients, four received nose, one received forehead, and another one received temple injections. All six patients developed vision loss secondary to hyaluronic acid embolization in retinal or ophthalmic arteries. Additional complications included severe periorbital pain, ptosis, impairment of extraocular muscle functionality. Recovery of vision was dependent on the type, frequency, and duration of subsequent treatment. Vision loss is a rare but catastrophic complication caused by hyaluronic injection that occurs secondary to hyaluronic acid embolization in retinal or ophthalmic arteries due to retrograde flow from facial vascular anastomoses. We suggest the early supratrochlear/supraorbital hyaluronidase injection, ocular massage, and re-breathing into a plastic bag as safe, uncomplicated and effective methods to restore the retinal circulation and reverse vision loss.

Exploring determinants predicting response to intra-articular hyaluronic acid treatment in symptomatic knee osteoarthritis: 9-year follow-up data from the Osteoarthritis Initiative.

BACKGROUND: The weight of recommendation for intra-articular therapies such as hyaluronic acid injections varies from one set of guidelines to another, and they have not yet reached unanimity with respect to the usefulness of intra-articular hyaluronic acid (IAHA) injections for the symptomatic treatment of knee osteoarthritis (OA). Among the reasons for the controversy is that the current literature provides inconsistent results and conclusions about such treatment. This study aimed at identifying determinants associated with a better response to IAHA treatment in knee OA. METHODS: Subjects were selected from the Osteoarthritis Initiative database. Participants were subjects who had radiographic OA, received one IAHA treatment, and had data on demographics and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores at visits before (T0) and after (T1; within 6 months) treatment. Pain was analyzed for demographic, clinical, and imaging characteristics at T0 and change over time (T0 to T1). Subjects with WOMAC pain > 0 at T0 were subdivided into Low, Moderate, and High pain groups based on tertile analysis. Further analyses were done with the High pain group (score ≥ 8), which was divided into responders (improvement in pain ≥ 20%) and nonresponders (unchanged or worsening of pain). RESULTS: Participants (n = 310) received a total of 404 treatments (one per knee). In the Low and Moderate pain groups vs the High pain group, participants had significantly lower score at T0 (p < 0.001), and the Low vs High pain group had significantly lower BMI (p = 0.002), greater joint space width (JSW) (p = 0.010) and knee cartilage volume (p ≤ 0.009), and smaller synovial effusion (p = 0.033). In the High pain group, responders vs nonresponders were usually younger (p = 0.014), with greater cartilage volume in the medial compartment (p = 0.046), a trend toward greater JSW, and a significant improvement in all WOMAC scores (p < 0.001), while nonresponders showed worsening of symptoms. CONCLUSIONS: This study identified reliable predictive determinants that can distinguish patients who could best benefit from IAHA treatment: high levels of knee pain, younger, and less severe structural damage. These could be implemented in clinical practice as a useful guide for physicians.

Treating the tear trough: A new classification system, a 6-step evaluation procedure, hyaluronic acid injection algorithm, and treatment sequences.

INTRODUCTION: The tear trough deformity is commonly requested for correction, most often by filler injections. However, the tear trough remains difficult to treat due to its complex anatomy, a variety of other concurrent deformities, and the high risk of complications. OBJECTIVES: To create a standardized categorization, evaluation, and treatment protocol for the management of tear troughs with fillers. METHODS: (1) Patient deformity profiles are determined using three categories of traits: A (Atrophy), B (Bulging), L (Laxity). (2) A 6-step evaluation process (Tilt, Snap, Smile, Squint, Pull, Push) aids in ABL determination. (3) Treatment is simplified into a comprehensive protocol for each category (with 6 major injection points and a variety of injection depths and volumes). RESULTS: The author has achieved satisfactory results using the presented protocols, with photographic examples. CONCLUSION: The author proposes a comprehensive categorization system that takes into account both the tear trough and other concurrent deformities. The author also presents 6 tests to aid in categorization, and simple protocols with injection sequences, amounts, and depth.