Hyaluronic Acid Gel Injection for the Treatment of Tear Trough Deformity: A Multicenter, Observational, Single-Blind Study.

BACKGROUND: Hyaluronic acid (HA) gel injections were first used to treat the tear trough in 2005 and since then it has been a mainstay of the approach to lower eyelid deformities. OBJECTIVE: The authors present this retrospective multicentric observational study based on single-blind objective and subjective evaluation and patient satisfaction in relation to the aesthetic improvement of a large group of patients treated. METHODS AND MATERIALS: Between January 2016 and December 2019, 600 patients (468 women and 132 men), were enrolled in this study, and 1200 tear trough deformities were treated with both needle and cannula techniques. RESULTS: Average follow-up time was 12 ± 1 months, and the outcomes were assessed both objectively and subjectively with respect to Hirmand's classification. Statistical analysis shows an inverse correlation between age and class amelioration. CONCLUSION: HA injection of the tear trough is most effective in patients between 30 and 40 years of age, while its benefits extend to up to 50 years old; afterward, it should no longer be the treatment of choice. This confirms that correction of tear trough with hyaluronic acid injections may provide an option to achieve immediate and durable results for up to one year after the injection. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Efficacy and Safety of 3 New Resilient Hyaluronic Acid Fillers, Crosslinked With Decreased BDDE, for the Treatment of Dynamic Wrinkles: Results of an 18-Month, Randomized Controlled Trial Versus Already Available Comparators.

BACKGROUND: Three new hyaluronic acid (HA)-based fillers made of long chains crosslinked with reduced amounts of 1,4-butanediol diglycidyl ether (BDDE) were developed for the treatment of dynamic facial areas. Their resilience and increased stretching ability were optimized to ease injectors' practice and provide patients with most natural aesthetic results. OBJECTIVE: This study aimed at evaluating the efficacy, durability, and safety of these resilient HA fillers versus commercially available comparator gels. METHODS: A prospective, monocentric, split-face, double-blinded, randomized, controlled trial was performed on 90 subjects presenting moderate to severe bilateral nasolabial folds (NLFs). Efficacy parameters were assessed over 18 months, including improvement on the Wrinkle Severity Rating Scale and Global Aesthetic Improvement Scale, as well as quantitative imaging and analysis of NLF correction. Physicians' and subjects' satisfaction, together with safety, were assessed throughout the study. RESULTS: The new HA fillers offered efficacy and safety profiles at least equivalent to comparators. These dynamic facial fillers elicited higher satisfaction immediately after injection but also on the long run, according to both investigators and subjects. CONCLUSION: This pilot trial demonstrated the numerous benefits of 3 new resilient HA fillers with decreased BDDE crosslinking in the treatment of dynamic wrinkles.

Proposed Guide to Lip Treatment in Caucasian Women Using Objective and Measurable Parameters.

BACKGROUND: The lips are a focal point of the face; however, their aesthetic proportions and effect on perceived facial beauty remain poorly defined. Perioral aging is highly individual, with several distinct and often simultaneous processes contributing to changes in lip contour and surface. These processes can affect lip volume and length, shape, and the degree of vermilion inversion. OBJECTIVES: We aimed to develop a treatment guide for Caucasian women that combined a complete analysis of the lips (including the effects of aging) with consideration of the rheological characteristics of the products used to assist practitioners in tailoring rejuvenation treatment to individual patients. METHODS: We reviewed existing literature to analyze the parameters that make the lips of Caucasian women "attractive" and investigated the rheological characteristics of different hyaluronic fillers to provide guidance on the optimal treatment for each woman. RESULTS: Our numerical definition of the lips is based on 4 specific parameters: philtrum height, upper vermillion height, ratio between philtrum and upper vermillion height, and golden ratio between upper and lower vermillion height. In our opinion, conserving the length of hyaluronic acid chains results in dynamic fillers that may provide better results with lower risk of asymmetry compared with conventional products. CONCLUSIONS: This new classification and associated treatment guideline aims to allow accurate assessment and enable practitioners to customize treatment for individual patients.

Gummy Smile Treatment: Proposal for a Novel Corrective Technique and a Review of the Literature.

Background: A perfect smile is dictated by the balance among 3 parameters: the white (teeth), the pink (gum), and the lips: excessive gingival display while smiling has been a cause of esthetic embarrassment for many patients, thus affecting their psychosocial behavior. With respect to different etiologies, treatment of gummy smile must be properly planned: treatment options include facial surgery, oral surgery, or laser. Objectives: Given the growing demand for less invasive techniques and observed complications secondary to botulinum toxin injection, we present a novel treatment option aimed at correcting gummy smile using hyaluronic acid injection and review the published techniques and the anatomy of the involved facial muscles. Methods: The treatment was performed by infiltration in the paranasal area, in the location of the most cranial portion of the nasojugal fold, about 3 mm lateral to the alar cartilage wing, according to a vector perpendicular to the cutaneous plane, to gently compress the lateral fibers of the levator labii superioris alaeque nasi without invading it. A Vycross® technology filler was used for all the treatments. Results: All patients had an immediate improvement, with a maximum duration ranging from 186 to 240 days (mean, 213 days), according to parameters of the Global Aesthetic Improvement Scale (GAIS 4.06). Conclusions: This new, less invasive and safer technique to correct dynamic excessive gingival display was shown to be feasible and safe with a long-lasting result. This treatment could be a novel effective option for experienced injectors to treat aesthetic facial flaws.

Safety of botulinum toxin A in aesthetic treatments: a systematic review of clinical studies.

BACKGROUND: The use of botulinum toxin A (BoNT-A) for aesthetic treatments is growing steadily, and new safety data have been reported in recently published studies. OBJECTIVE: To investigate the safety data on the use of the three BoNT-A formulations approved for facial aesthetics from recent studies and to confirm their safety profiles. METHODS: The literature search was conducted using three online databases restricted to the timeframe from January 2000 to June 2012. Only clinical trials, randomized or open label, with safety as the primary or secondary endpoint, were included. RESULTS: Thirty-five papers were selected, with a total of subjects 8,787 studied. OnabotulinumtoxinA was used in 60.0% of the studies, abobotulinumtoxinA in 37.1%, and incobotulinumtoxinA in 2.8%. The glabella was the most investigated area (51.4%), followed by the upper face (25.7%), crow's feet (11.4%), and lower face (11.4%). Treatment-related adverse events were blepharoptosis (2.5%), brow ptosis (3.1%), and eye sensory disorders (3%) in the upper face and lip asymmetries and imbalances in the lower face (6.9%). All of these events resolved spontaneously. CONCLUSION: The short-term safety profile of BoNT-A in cosmetic nonsurgical procedures was confirmed for all the three commercial formulations.

Use of Macrolane VRF 30 in emicircumferential penis enlargement.

BACKGROUND: Penis enlargement is increasingly in demand. Methods for penis enlargement can be classified into surgical, nonsurgical (filling), and mechanical. Each method has shown only relatively successful results. A new formulation of injectable, stabilized, hyaluronic acid (HA)-based, nonanimal gel is available that may have applications for this use. OBJECTIVES: The authors propose a new technique for emicircumferential-injection filling of the penis and assess the safety and efficacy of this procedure compared with lipofilling. METHODS: The authors retrospectively reviewed the charts of 83 patients who underwent penis enlargement with either their HA-injection technique or lipofilling between December 2007 and July 2011. Safety, efficacy, and patient satisfaction were assessed. RESULTS: The circumferential enlargement obtained from both techniques ranged from 3.2 to 4.5 cm, with a decrement during erection. In all patients, the increase in penis length ranged from 1.8 to 3.6 cm. No complications were seen in patients treated with HA, whereas 8 patients treated with lipofilling developed granuloma, and another experienced fat necrosis. The vast majority (n = 72) of patients reported being "very satisfied" with the results. CONCLUSIONS: The ideal technique for penis enlargement should be nonsurgical, with a satisfactory and predictable result, a low rate of complications, and long-term stability. Emicircumferential enlargement with HA filler meets these requirements. However, results have been durable but not definitive, and repeated treatment (with associated costs) is necessary.

Microbotox: A prospective evaluation of dermatological improvement in patients with mild-to-moderate acne and erythematotelangiectatic rosacea.

BACKGROUND: Botulin toxin (BTX) is a potent neurotoxin produced by the bacterium Clostridium botulinum, since its approval by FDA in 2002 for cosmetic purpose has been widely used. Recent studies indicate that it exerts its activity on various type of skin cells and can be used in some dermatological disease. OBJECTIVE: The aim of the study was to demonstrate how to use a peculiar dilution of botulinum toxin type A in the treatment of some dermatological disease like mild-to-moderate acne vulgaris and erythematotelangiectatic rosacea. MATERIAL AND METHODS: 50 patients were enrolled, 35 with mild-to-moderate acne and 15 with erythematotelangiectatic rosacea. Both group of patients were treated with a specific dilution of Onabotulinum toxin A called Microbotox. Patient images were taken before and 4 weeks after the treatment. RESULTS: The authors and patients were extremely satisfied with their treatments. There were no immediate or delayed complication in none of both group of patients. CONCLUSION: Botulinum toxin shows a great promise either in dermatological disease like mild-to-moderate acne vulgaris and erythematotelangiectatic rosacea. Microbotox appears to be a valid, long-lasting, and a standardized approach to treat these kind of two disease.

Microbotulinum: A Quantitative Evaluation of Aesthetic Skin Improvement in 62 Patients.

BACKGROUND: Microbotulinum refers to the systematic injection of tiny blebs of diluted botulinum toxin at repeated intervals into the skin. This targets the superficial fibers of the facial muscles, and weakens their insertion into the undersurface of the skin, which is responsible for the fine lines and wrinkles on the face. The authors present a pilot study based on quantitative evaluation, by means of a skin-scanning technology, of the aesthetic improvement of skin texture, microroughness, and enlarged pore size in a patient group treated with microbotulinum injections for cosmetic purposes. METHODS: The treatment was performed using a 32-gauge needle to deliver injections on a regular 1-cm grid from the forehead to the cheek and down to the jawline. RESULTS: Sixty of the 62 patients completed the study. All analyzed parameters improved significantly (p < 0.0001) at 90 days with respect to the pretreatment time point (skin texture, -1.93 ± 0.51; microroughness, -2.48 ± 0.79; and pore diameter, 2.1 ± 0.43). Best results have been obtained in patients aged between 42.7 and 46.8 years, and standard deviation calculation allows us to recommend it in patients aged between 36.5 and 53 years. CONCLUSIONS: The results of this pilot study suggest that intradermal botulinum toxin injection, or so-called microbotulinum, is a safe and effective method to treat skin flaws. Because of the high satisfaction rate among both physicians and patients, further studies are indeed mandatory to determine the optimal number of units needed for a longer and lasting effect with this particular novel dilution. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Vascular Complications after Facial Filler Injection: A Literature Review and Meta-analysis.

Background: Vascular occlusion during the injection of facial fillers is uncommon, but can result in serious adverse events, including necrosis, blindness, and stroke. Objectives: We explored factors that influence the frequency and severity of vascular complications during filler injections. Methods: This was a meta-analysis that included case reports and case series published during the years 2004 to 2016 describing patients who experienced any type of vascular complication after an aesthetic procedure. In addition to the descriptive analysis of the variables retrieved, a logistic regression for predicting the outcome of the vascular event was performed. Results: The analysis included 93 cases described in 30 articles. Blindness was the main consequence of the vascular complications (n=57; 61%). The reported outcome was partial or total recovery in 24 cases (28%) and no improvement in 61 cases (72%). Hyaluronic acid (HA) and autologous fat were the two fillers most frequently involved in vascular occlusions, with autologous fat showing a stronger trend toward no improvement than HA. Involvement of the ophthalmic and retinal arteries was most frequently associated with no improvement. Conclusion: Injury to ophthalmic and retinal arteries during the injection of facial fillers can result in irreversible serious adverse events. Physicians performing facial filler injections should have a proficient knowledge of anatomy.

Transoral injection of Restylane SubQ for aesthetic contouring of the cheeks.

For malar augmentation procedures with Restylane SubQ, the transoral route of injection offers some advantages over the transdermal route. It allows ready access to the zygomatic periosteum, avoids the need for identification of soft tissue fascia planes and detachment of muscle, and reduces the risk of damage to important nerves and blood vessels and resulting hematoma. By using the transoral technique, the possibility of visible local complications (edema and ecchymosis) can be reduced. Use of this injection route does not appear to increase the risk of introducing infection into the soft tissues, and prophylactic antibiotic use is considered unnecessary, although good oral hygiene is important and mouth washing should be encouraged. In summary, the transoral method of Restylane SubQ injection is as reliable as the transdermal route, and this approach is likely to appeal to patients because of its lower risk of inflammatory reactions following treatment.

Bio-Alcamid in drug-induced lipodystrophy.

The development of new drugs to counter human immunodeficiency virus (HIV) infection has led to an increase in lipodystrophic syndrome among HIV-infected individuals receiving combination therapy. Bio-Alcamid(TM) is a recently developed polymeric substance that can be implanted to compensate for adipose effects. We have implanted this substance in 73 patients with up to three years' follow-up. The aesthetic results were deemed excellent by both physicians and patients. No implant dislocation, implant migration, granuloma, allergic reaction or intolerance were recorded.