Current Practices in Hyaluronic Acid Dermal Filler Treatment in Asia Pacific and Practical Approaches to Achieving Safe and Natural-Looking Results.

Complications such as delayed inflammatory reactions (DIRs) and unnatural outcomes can sometimes arise from hyaluronic acid (HA) dermal filler treatments and can be challenging to address. Given the popularity of HA dermal fillers for aesthetic procedures, there is a need for preventive strategies to minimize these complications. Two hundred practitioners from 10 regions in Asia Pacific who administer HA fillers completed a survey on prevention of DIRs and unnatural outcomes. Thirteen global experts convened to evaluate the current practices and propose practical approaches for safe and appropriate use of HA dermal fillers. From the survey, the top three measures used to reduce the risk of DIRs included choosing an appropriate HA filler, aseptic technique, and patient selection. Key strategies employed to achieve natural-looking outcomes were treatment customization, understanding the rheological properties and behavior of different HA fillers, and being conservative in treatment approach. The panel developed a concise reference guide aimed at minimizing the risk of DIRs while achieving natural aesthetic outcomes. Five practical considerations were recommended: patient assessment and individualization of treatment plan, choice of an appropriate HA filler, adequate knowledge of facial anatomy, strict adherence to aseptic methods, and proper injection technique. The panel highlighted the need for education efforts to increase awareness of differential immunogenicity between HA fillers and to improve understanding on the importance of preserving aesthetic individuality for optimal results. These practical insights from the global experts support practitioners in optimizing safety and quality of aesthetic treatment with HA fillers.

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

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

Efficacy and safety of botulinum toxin injection in reducing deltoid muscle hypertrophy.

With the increasing demand for body contouring, botulinum toxin (BTX) injection is being widely used off-label for muscular hypertrophy. However, to the best of our knowledge, no study has investigated the clinical efficacy of BTX type A (BTX-A) in deltoid muscle hypertrophy. This study was conducted to evaluate the efficacy and safety of intramuscular injection of BTX in reducing deltoid muscle hypertrophy. Overall, 10 patients with bilateral deltoid muscle hypertrophy were treated with an intramuscular injection of prabotulinum toxin A, with a total of 50 units [U] administered per patient. As measured by ultrasonography, the thickness of the deltoid muscles was significantly decreased at weeks 2 and 12. In addition, the clinical assessment score by blinded investigators was improved after the treatment; however, patients' satisfaction scores were relatively low. No major complications were reported. Therefore, intramuscular injection of BTX-A seems to be a candidate for novel treatment option for deltoid muscle hypertrophy. Further larger clinical studies are warranted to confirm the efficacy of BTX-A.

A comparison of the safety, efficacy, and longevity of two different hyaluronic acid fillers in filler rhinoplasty: A multicenter study.

Filler rhinoplasty is a popular procedure in Asia, and it is of great importance to understand the clinical efficacy and durability of the different filler products that serve this purpose. Here, we aimed to evaluate and compare the safety, efficacy, and longevity of two different hyaluronic acid (HA) fillers in improving the nasal profile in Asians. A multicenter comparative trial was performed for 48 weeks after a single injection of a popular monophasic monodensified, and a newly developed biphasic HA filler. Assessments including patient satisfaction and three-dimensional (3D) imaging analysis were performed before, immediately after, 2 weeks, 12 weeks, 24 weeks, and 48 weeks after filler rhinoplasty. Twenty-eight Korean women underwent structured rhinoplasty were divided into monophasic monodensified (n = 14) and biphasic (n = 14) groups. There were significant changes in the facial profile following filler rhinoplasty throughout the study period. Overall, an increase of 1.75 mm in nose height, increase of 3.66° in the nasofrontal angle and 2.77° in the nasolabial angle, and radix elevation of 1.24 mm was noted at week 48 which was statistically different from the baseline values (P < .05). Between the different filler types, statistical difference was only noted in radix elevation (per milliliter of filler material) immediately after filler injection. No serious adverse event occurred during treatment or follow-up. Nonsurgical rhinoplasty with the specific HA filler products led to significant changes in the facial profile which persisted for 48 weeks. Overall, the clinical efficacy and safety were comparable between the two filler types except for radix elevation which was more prominent with C-C immediately after filler injection. J-V was superior to C-C in maintaining the radix elevation long term.

Intradermal Injection of Botulinum Toxin: A Safer Treatment Modality for Forehead Wrinkles.

Intramuscular injection of botulinum toxin A (BTXA) is commonly used for the treatment of forehead wrinkles. In practice, physicians often use an intradermal injection for this purpose, as they feel that there is a lower risk of adverse effects compared with intramuscular injection. However, there are no direct comparative studies between those two injection modalities. We conducted a 24-week long, double-blinded, split-face, pilot study of three participants to compare the efficacy and safety of intradermal or intramuscular injection of BTXA for the treatment of forehead wrinkles. Maximum improvement of wrinkles and the time to achieve maximum effect were similar for both methods. The brow level was lower on the intramuscular injection side throughout the follow-up period for all participants. Subjective satisfaction with wrinkles was similar on both sides, but patients felt more heaviness of the eyebrow on the intramuscular side. No serious side effects were noted. In conclusion, the anti-wrinkle effect of BTXA was not significantly different between intramuscular and intradermal injections. However, side effects such as eyebrow ptosis, and heaviness were more prominent after intramuscular injection.

A review of hydrolifting: A new modality for skin rejuvenation.

BACKGROUND: Hydrolifting is a newly developed modality of skin rejuvenation, which enhances overall facial volume augmentation and recovers skin thickness through multi-pass HA injection. Although it is commonly performed, only a few articles have reported on the rejuvenating effects of hydrolifting. Moreover, clear protocols and possible mechanisms of the procedure have not been elucidated. OBJECTIVE: To define a novel technique for injecting HA and to clarify how to choose an appropriate HA filler based on the procedural purpose. METHODS: This article is based on a review of the medical literature and the authors' clinical experience in investigating and treating skin wrinkles with the hydrolifting method. RESULTS: In hydrolifting, HA filler serves as a hydration source, dermal volumizer, and stimulator of dermal collagen and antioxidants. Hydrolifting is frequently indicated in minor wrinkles, minor volume depletion and rough skin texture. CONCLUSION: The hydrolifting method is a newly introduced antiaging treatment modality. It effectively covers the blind spots of conventional HA injection, such as infraorbital, perioral and hand dorsal wrinkles. However, further investigations are needed to reach a consensus on the basic concepts of treatment, choice of appropriate fillers and optimal technique in hydrolifting.

Treatments of Infra-Orbital Dark Circles by Various Etiologies.

Dark circles refer to visible darkness of the infra-orbital areas. Dark circles are a cosmetic concern for many individuals, although not a medical concern. Moreover, clear definitions and possible causes of dark circles have not been elucidated. This study reviews the possible causes and treatment options for dark circles based on a review of the medical literature and the authors' clinical experience. Potential factors that contribute to dark circles include excessive pigmentation, shadowing due to tear troughs and infra-orbital fat herniation, shadowing due to infraorbital laxity and wrinkles, and thin, translucent skin overlying the orbicularis oculi muscle. Given the different possible causes for dark circles, therapeutic modalities must be individualized for each patient. Because various factors cause dark circles, it is useful to identify the underlying causes in order to select the appropriate treatment.

Early Changes in Facial Profile Following Structured Filler Rhinoplasty: An Anthropometric Analysis Using a 3-Dimensional Imaging System.

BACKGROUND: Quantitative measurements are important for objective evaluation of postprocedural outcomes. Three-dimensional (3D) imaging is known as an objective, accurate, and reliable system for quantifying the soft tissue dimensions of the face. OBJECTIVE: To compare the preprocedural and acute postprocedural nasofrontal, nasofacial, nasolabial, and nasomental angles, early changes in the height and length of the nose, and nasal volume using a 3D surface imaging with a light-emitting diode. METHODS: The 3D imaging analysis of 40 Korean women who underwent structured nonsurgical rhinoplasty was conducted. The 3D assessment was performed before, immediately after, 1 day, and 2 weeks after filler rhinoplasty with a Morpheus 3D scanner (Morpheus Co., Seoul, Korea). RESULTS: There were significant early changes in facial profile following nonsurgical rhinoplasty with a hyaluronic acid filler. An average increase of 6.03° in the nasofrontal angle, an increase of 3.79° in the nasolabial angle, increase of 0.88° in the nasomental angle, and a reduction of 0.83° in the nasofacial angle was observed at 2 weeks of follow-up. Increment in nasal volume and nose height was also found after 2 weeks. Side effects, such as hematoma, nodules, and skin necrosis, were not observed. CONCLUSION: The 3D surface imaging quantitatively demonstrated the early changes in facial profile after structured filler rhinoplasty. The study results describe significant acute spatial changes in nose shape following treatment.

Novel Anti-Melanogenesis Properties of Polydeoxyribonucleotide, a Popular Wound Healing Booster.

Polydeoxyribonucleotide (PDRN), a deoxyribonucleotide polymer, is popularly used for faster healing of cutaneous wounds and boosting of neocollagenesis of photoaged skin among current dermatologic practitioners. Some patients receiving PDRN injection treatment also reported improvement of photoaging-associated mottled pigmentation (PMP). To investigate the effect of PDRN on cutaneous melanogenesis, we examined the effect of PDRN and an available product (Placentex(®)) containing PDRN on melanogenesis using human melanocytes-keratinocytes cocultures and mouse melanocytes. Melanin content, tyrosinase activity, and levels of microphthalmia-associated transcription factor (MITF), tyrosinase, and tyrosinase-related protein (TRP-1) were determined. Intracellular signaling pathways were assessed by Western blotting. PDRN and Placentex(®) led to decreases in melanin content, tyrosinase activity, and MITF and TRP-1 expression with concomitant increases in phosphorylated forms of extracellular signal-regulated protein kinase (ERK) and AKT in mouse melanocytes. More importantly, both PDRN and Placentex(®) significantly suppressed the melanin content in human melanocyte-keratinocyte cocultures. Clinical evaluation of six female patients with facial hyperpigmentation after three sessions of intradermal PDRN injections using a 5-point scale revealed that PDRN led to more than noticeable improvements in hyperpigmented lesions. This is the first study to demonstrate that PDRN, which is known for its wound-healing properties, may have novel anti-melanogenesis and potential skin whitening properties.

RimabotulinumtoxinB versus OnabotulinumtoxinA in the treatment of masseter hypertrophy: a 24-week double-blind randomized split-face study.

BACKGROUND: Masseter hypertrophy can be ameliorated by botulinum toxin. OBJECTIVE: To compare the efficacy and safety of RimabotulinumtoxinB (BTX-B) and OnabotulinumtoxinA (BTX-A) in the treatment of masseter hypertrophy. METHODS: Sixteen women with bilateral masseter hypertrophy received single injections of BTX-A or BTX-B at a dose ratio of 1:50 or 1:70 in a 24-week double-blind randomized split-face study. RESULTS: Both BTX-A and BTX-B produced significant improvements in masseter hypertrophy. The maximum volume reduction, as determined by computed tomography scanning, at week 12 was comparable between BTX-A and BTX-B at a dose ratio of 1:70 (15.6 and 14.2%, respectively). At week 24, only masseters treated with BTX-A maintained a significant volume reduction. Investigator ratings and patient satisfaction scores paralleled objective computed tomography measurements. CONCLUSION: Both BTX-A and BTX-B are effective in the treatment of masseter hypertrophy. BTX-B, at a dose ratio of 1:70, has a comparable efficacy but a shorter duration of action than BTX-A.

Combined use of botulinum toxin type A and B for forehead rhytides: a randomized, double-blind, split-face study.

BACKGROUND: This is the first well-controlled study of the combined use of botulinum toxin type A (BoNT-A) and botulinum toxin type B (BoNT-B) for hyperkinetic lines in forehead. OBJECTIVE: To evaluate the effectiveness and safety of a mixture of BoNT-A and BoNT-B with that of equipotent BoNT-A alone for treating patients with forehead rhytides. MATERIALS AND METHODS: Fourteen patients with forehead wrinkles completed this clinical study. On day 0, patients received a mixture of BoNT-A (5 U) and B (500 U) on one side of the forehead and BoNT-A (10 U) symmetrically on the other side. Clinical evaluation was made at the beginning and at weeks 1, 2, 4, 8, 12, and 16. Therapeutic efficacy was evaluated using clinical improvement scale by investigators and the subjective wrinkle assessment by patients. RESULTS: According to investigator assessment, the differences between the average improvement scores of the two differently treated sides were not statistically significant at all follow-up visits. Moreover, the plateau of the clinical benefit was achieved at week 4. CONCLUSION: We observed the equivalent efficacy in the mixture of both toxins and BoNT-A alone.

Exaggeration of wrinkles after botulinum toxin injection for forehead horizontal lines.

There have been no long-term complications or life-threatening adverse effects related to botulinum toxin treatment for any cosmetic indications. Nevertheless, there are well-known, mild side effects of botulinum toxin treatment on the upper face, though most of them are self limited with time. However, excluding brow ptosis, reports about site specific side effects are few and anecdotal. We experienced cases of exaggeration of wrinkles after botulinum toxin injection for forehead horizontal lines, and report them here. In our cases, new appearance of a noticeable glabellar protrusion following botulinum toxin injection on the forehead was observed in 2 patients. Also, a new deep wrinkle on one side of the forehead just above the eyebrow appeared in another 2 patients. The exaggerated wrinkles nearly disappeared without treatment by week 4 in all subjects. These exaggerations of wrinkles may be caused by hyperactivity and overcompensation of untreated muscles. With the increasing availability of diverse botulinum toxin for cosmetic purposes, physicians and patients should be aware of this temporary change after therapeutic injections. We recommend explaining this possible effect prior to injection, for better understanding of treatment for cosmetic indications.

The effects of heating and cooling on ultraviolet radiation-induced erythema and pigmentation in human skin.

BACKGROUND/PURPOSE: As most biochemical systems are affected by temperature, thermal changes before or after ultraviolet (UV) irradiation could influence skin vascular blood flow changes and inflammatory responses. In this study, our aim was to investigate the influence of thermal changes on UV-induced acute skin reactions, namely, erythema and pigmentation. METHODS: Our volunteers consisted of 10 males, with ages ranging from 22 to 24 years and with Fitzpatrick's skin type III or IV. Skin temperatures were changed with a 45 degrees C heating pad or by ice pack application before or after UV irradiation (control, 1 minimal erythema dose (MED), 2 MED) and then changes in erythema and pigmentation were measured by a Minolta Spectrophotometer CM-2002. RESULTS: The present study demonstrates that both heating and cooling increase skin erythema and reduce pigmentation, and that the timing of heating and cooling influences the UV-induced skin reaction. Pre-heating and post-cooling groups showed more UV-induced erythema than the post-heating and pre-cooling groups, respectively. CONCLUSION: Our results indicate that alteration of skin surface temperature could modulate UV-induced erythema and pigmentation responses.

Effect of pregnancy and menopause on facial wrinkling in women.

Women appear to be at greater risk of developing wrinkles with age than men. To evaluate the effect of pregnancy and menopause on facial wrinkling, a total of 186 Korean women volunteers aged between 20 and 89 years were interviewed for information on menstrual and reproductive factors. An 8-point photographic scale developed for assessing the severity of wrinkles in Asian skin was used. Cumulative sun exposure, both occupational and recreational, was estimated. In Korean women, the risk of facial wrinkling increases significantly with increasing number of full-term pregnancies (OR = 1.835, 95% confidence interval (CI) 1.017-3.314) and menopausal age (number of years since menopause) (OR = 3.909, 95% CI 1.071-14.275), while hormone replacement therapy is associated with a significantly lower risk for the development of facial wrinkling in postmenopausal women (OR = 0.221, 95% CI 0.047-0.949). Hypo-oestrogenism may play a part in the decrease of skin collagen leading to skin wrinkling in postmenopausal women.

Differential effects of photoaging vs intrinsic aging on the vascularization of human skin.

OBJECTIVE: To quantify the distinct effects of photoaging vs intrinsic aging of human skin on cutaneous vascularization in the Korean population. DESIGN: Case series. SETTING: University hospital. PARTICIPANTS: A total of 21 healthy Korean volunteers from the third to the ninth decades of life. INTERVENTION: Skin biopsy specimens were obtained from chronically sun-exposed and sun-protected skin of each participant. MAIN OUTCOME MEASURES: Frozen sections were stained for the platelet endothelial cell adhesion molecule CD31 (PECAM-1), and computer-assisted quantitative image analysis was performed to quantify cutaneous vascular density and vessel size. RESULTS: Intrinsically aged and photoaged skin showed an age-dependent reduction of cutaneous vessel size. However, only photoaged skin exhibited significantly reduced numbers of dermal vessels, in particular in the subepidermal areas that displayed extensive matrix damage. Linear regression analysis revealed an inverse relation of vessel numbers and age in sun-damaged, but not in sun-protected, skin. CONCLUSIONS: In Korean skin, chronic photodamage results in a gradual decrease in the number and size of dermal vessels over several decades of sun exposure, most likely due to degenerative changes of the dermal extracellular matrix. Because the present investigation was restricted to ethnic Korean volunteers, future studies are needed to evaluate whether similar changes can be observed in whites.