At-home Cosmeceutical Application and Outpatient Treatments: A 3D Stepwise Facial Rejuvenation Approach

BACKGROUND: Aging affects the 3-dimensional structure of all the facial tissues: Bones, muscles, ligaments, adipose tissue, and skin. AIM: To customize minimally invasive treatments for facial rejuvenation, we present a standardized holistic approach characterized by at-home treatments in associations with outpatient procedures. METHODS: Forty-four patients underwent 3-dimensional stepwise facial rejuvenation and were evaluated prospectively. Each patient received a customized treatment plan based on a clinical examination and consultation. Treatment outcomes were evaluated from patient photographs with and skin analysis was performed with an A-One Smart automated skin analysis system. RESULTS: The mean age of the patients was 41.7 years and the approximate mean duration of treatment was 160 days. Patients applied cosmeceuticals such as retinoic acid. Outpatient procedures included the delivery of botulinum toxin or dermal fillers, thread lifting, chemical peels, etc. Upon treatment completion, significant improvements were noted in multiple domains: Skin elasticity and hydration increased, areas of hyper-pigmentation were less extensive, and there were fewer visible wrinkles and pores. CONCLUSION: Outcomes of the present article suggest how important is to customize facial anti-aging treatments. Nonsurgical treatments carried out progressively, involving the patient to perform at-home treatments in associations with outpatient procedures, let to achieve facial improvements in terms of increased skin elasticity and hydration, reduction of hyperpigmentation, wrinkles, and pores

Rheological Investigation as Tool to Assess Physicochemical Stability of a Hyaluronic Acid Dermal Filler Cross-Linked with Polyethylene Glycol Diglycidyl Ether and Containing Calcium Hydroxyapatite, Glycine and L-Proline

(1) Background: Dermal fillers are commonly used in aesthetic practice and their rheological characterization is of much interest today, as well as the stability study of the finished formula against external stimuli of a different nature (biological and physicochemical). Rheological tools have been exploited to characterize the physiochemical behaviour of a hyaluronic acid (HA) based dermal filler subjected to different thermal conditions over time. The collected results provide an index of its rheological stability. (2) Methods: After a preliminary Amplitude sweep test, the Frequency sweep test was performed in order to study the stability of a HA dermal filler cross-linked with Polyethylene Glycol Diglycidyl Ether (PEGDE) and containing Calcium Hydroxyapatite (CaHA), Glycine and L-Proline subjected to different conditions. Also, a shear rate ramp test was performed in order to investigate the filler's flow behavior. (3) Results and Conclusions: G' (elastic modulus), G'' (viscous modulus) and consequentially tan delta (tangent of the phase angle) show a similar trend at different thermal conditions, underlining that the product is not affected by the storage conditions. The viscosity of the dermal filler decreases with an increasing shear rate, so a non-Newtonian shear thinning pseudoplastic behavior was demonstrated in all tested conditions

An Italian Online Survey Regarding the Use of Hyaluronidase in Previously Hyaluronic Acid-Injected Noses Looking for Surgical Rhinoplasty

Background: Nonsurgical nasal reshaping (nSNR) with hyaluronic acid (HA) filler is a well-established procedure performed to ameliorate nasal appearance and is considered a valid alternative to surgical rhinoplasty in selected patients. Objectives: The aim of our study is to evaluate the decision-making process and management of patients undergoing rhinoplasty, with previous HA filler injection, and evaluate if consensus could be achieved to recommend guidelines. Methods: Between April and May 2021, an online survey was sent to 402 Italian surgeons of different specialties. The survey collected information regarding the types of treatment of patients who have previously undergone nSNR, who should undergo surgical rhinoplasty. For those surgeons using hyaluronidase, an additional information was collected. Results: In a range of time of 2 months (April and May 2021), a total of 72 surgeons replied and completed the survey: out of the 402 questionnaires sent, the response rate was approximately 18%. The majority of respondents (61.5%) replied to inject hyaluronidase (HYAL) in patients who had to undergo a rhinoplasty but reported previous nSNR. Of the surgeons who use HYAL, 70% performed rhinoplasty after a waiting time of 3 to 4 weeks. Conclusions: Either direct surgical approach or hyaluronidase injection first seems to be a viable options. The use of HYAL before surgery is the choice with the broadest consensus in our survey. However, a larger case-control study with long follow-ups is necessary to understand if in patient seeking surgical rhinoplasty who already received nSNR, the injection of hyaluronidase before surgery is mandatory, recommended, or not

Chemical Characterization of Hydrogels Crosslinked with Polyethylene Glycol for Soft Tissue Augmentation

BACKGROUND: Hyaluronic acid (HA) based hydrogels for esthetic applications found widespread use. HA should be crosslinked for this application to achieve the correct viscoelastic properties and avoid fast degradation by the hyaluronidase enzyme naturally present in the skin: these properties are controlled by the amount of crosslinker and the fraction that is effectively crosslinked (i.e. that binds two HA chains). AIM: Crosslinking by polyethylene glycol diglycidyl ether (PEGDE) has been more recently introduced and showed attractive features in terms of viscoelastic properties and reduced biodegradation. Aim of this paper is to define a method for the determination of the crosslinking properties of these recently introduced fillers, method that is lacking at the moment. MATERIAL AND METHOD: The percentage of crosslinker and the fraction that is effectively crosslinked were determined by proton Nuclear Magnetic Resonance (1H NMR) and by 13C NMR, respectively. The filler were preliminarily washed with acetonitrile to remove residual PEG and then digested by hyaluronidase to obtain a sample that can be analysed by NMR. RESULTS: The crosslinking parameters were determined in four samples of NEAUVIA PEG-crosslinked dermal fillers (produced by MatexLab S.p.A., Italy). The percentage of crosslinker was between 2.8% and 6.2% of HA, whereas the effective crosslinker ratios were between 0.07 and 0.16 (ratio between the moles of effectively crosslinked PEG and total moles of PEG). Moreover, a digestion procedure alternative to enzymatic digestion, based on acidic hydrolysis, was successfully tested for the determination of crosslinker percentage. CONCLUSIONS: The proposed method successfully determined the two crosslinking parameters in PEG-crosslinked dermal fillers. The estimated percentage of crosslinker is similar to previously reported data for other crosslinkers, whereas the effective crosslinker ratio is lower for PEG crosslinked hydrogels

HA PEGylated Filler in Association with an Infrared Energy Device for the Treatment of Facial Skin Aging: 150 Day Follow-Up Data Report

Background: The face is the area most exposed to the normal course of skin aging, both intrinsically and extrinsically. The aim of the study was to evaluate the cellular and clinical response of a therapeutic protocol aimed at countering facial skin aging. Materials and methods: Twenty female patients with facial skin laxity and photodamage underwent combined therapy including mesotherapy using non-cross-linked hyaluronic acid with calcium hydroxyapatite and an infrared energy-based device treatment with subsequent implementation of PEG-cross-linked hyaluronic acid soft tissue fillers. To evaluate the benefits, patients underwent histological, immunological, and biomechanical evaluations before the treatment and at 21 and 150 days after the treatment. Results: The histological results at 21 days and 150 days after the procedure showed an increase in the number of fibroblasts and angiogenesis. As for the immunological aspect, it was shown that the treatment has an immunomodulating action, avoiding the activation of CD4 and CD8 cells. Biomechanical data showed that, at 150 days after treatment, the average changes in skin elasticity increased by 72% and the skin hydration increased by 49%. Conclusions: A combination of an infrared energy-based device treatment with both non-cross-linked hyaluronic acid and novel PEG-cross-linked hyaluronic acid leads to numerous positive cutaneous changes after histological, immunological, and biomechanical evaluations

5-year study of a polyacrylamide hydrogel-based filler for rehabilitation of HIV-related facial lipoatrophy

Background: Lipoatrophy of the face negatively impacts the quality of life and body image of individuals on antiretroviral therapy. Facial fillers can minimize the stigma associated with the human immonodeficiency virus (HIV). Objectives: In this 5-year follow-up study, the author assessed the safety and efficacy of a permanent, non-biodegradable, polyacrylamide hydrogel for facial volume restoration, and compared the results with those of a previous 18-month follow-up study. Methods: Thirty-one HIV-positive individuals, initially enrolled in the study between January 2008 and January 2009, received treatment of facial wasting by injection of the polyacrylamide gel until complete volume restoration was achieved. Asepsis rules were strictly observed before and during each injection session. Patients evaluated their aesthetic outcomes on a visual analog scale. Results: Patient satisfaction was high. There was no occurrence of local infection, foreign-body reaction, or product during the 5 years of follow-up. Small, palpable, nonvisible nodules were recorded in nine cases. It appears that these same nodules were present in the 18-month study. It is believed that the nodules were caused by overfilling in the same site. Conclusions: As supported by the initial 18-month study, polyacrylamide hydrogel filler appears safe and effective for the treatment of HIV-related lipoatrophy. With strict observation of asepsis rules and patient adherence to posttreatment instructions, this filler can be ideal for treating facial wasting in patients with HIV

5-Year Study of a Polyacrylamide Hydrogel-Based Filler for Rehabilitation of HIV-Related Facial Lipoatrophy

Background: Lipoatrophy of the face negatively impacts the quality of life and body image of individuals on antiretroviral therapy. Facial fillers can minimize the stigma associated with the human immonodeficiency virus (HIV). Objectives: In this 5-year follow-up study, the author assessed the safety and efficacy of a permanent, non-biodegradable, polyacrylamide hydrogel for facial volume restoration, and compared the results with those of a previous 18-month follow-up study. Methods: Thirty-one HIV-positive individuals, initially enrolled in the study between January 2008 and January 2009, received treatment of facial wasting by injection of the polyacrylamide gel until complete volume restoration was achieved. Asepsis rules were strictly observed before and during each injection session. Patients evaluated their aesthetic outcomes on a visual analog scale. Results: Patient satisfaction was high. There was no occurrence of local infection, foreign-body reaction, or product during the 5 years of follow-up. Small, palpable, nonvisible nodules were recorded in nine cases. It appears that these same nodules were present in the 18-month study. It is believed that the nodules were caused by overfilling in the same site. Conclusions: As supported by the initial 18-month study, polyacrylamide hydrogel filler appears safe and effective for the treatment of HIV-related lipoatrophy. With strict observation of asepsis rules and patient adherence to posttreatment instructions, this filler can be ideal for treating facial wasting in patients with HIV