Evaluation of facial pleasantness in patients with complete and unilateral cleft lip and palate rehabilitated and submitted to orofacial harmonization

ABSTRACT Objective: The objective of the present prospective case control study was to evaluate the facial pleasantness of patients with complete and unilateral cleft lip and palate at the end of interdisciplinary rehabilitation, submitted to facial fillers based on hyaluronic acid. Methods: The study group consisted of 18 individuals with complete unilateral cleft lip and palate, aged between 18 and 40 years (mean age 29 years) of both sexes. The patients presented a concave profile with mild to moderate maxillary deficiency, with completed orthodontic treatment and conducted by means of dentoalveolar compensations without orthognathic surgery. Participants underwent facial filling procedures with hyaluronic acid (HA) in the midface, inserted by a single operator. Standard photographs in frontal norm at rest, right profile at rest, and left profile at rest were obtained from each patient at the following operative times: (T1) pre-filler and (T2) and one-month post-filler. The photographs in T1 and T2 were randomly placed on a page of a virtual album. A 5-point Likert scale was used to assess facial pleasantness. The photographs were evaluated by two groups of evaluators consisting of 18 individuals with cleft lip and palate (CLPG=18) and 18 orthodontists with experience in the treatment of clefts (OG=18). For comparison between phases T1 and T2, and between evaluators with orofacial clefts and orthodontists, the Wilcoxon test was used (p<0,05). Results: People with cleft lip and palate rated their face as more pleasant after the midface filling procedure. In the perception of the orthodontists, on the other hand, the facial pleasantness remained similar after the facial filling procedure. Conclusions: The filling of the middle third of the face in patients with cleft lip and palate treated without orthognathic surgery increased the pleasantness of the face in the opinion of laypeople with cleft lip and palate.

RESUMO Objetivo: O objetivo do presente estudo caso-controle prospectivo foi avaliar a agradabilidade facial de pacientes com fissura labiopalatina completa e unilateral ao final da reabilitação interdisciplinar, submetidos a preenchimentos faciais à base de ácido hialurônico. Métodos: O grupo de estudo foi composto por 18 indivíduos com fissura labiopalatina unilateral completa, com idade entre 18 e 40 anos (média de 29 anos), de ambos os sexos. Os pacientes apresentavam perfil côncavo com deficiência maxilar leve a moderada, com tratamento ortodôntico concluído e realizado por meio de compensações dentoalveolares sem cirurgia ortognática. Os participantes foram submetidos a procedimentos de preenchimento facial com ácido hialurônico (AH) no terço médio da face, implantado por um único operador. Fotografias padrão em norma frontal em repouso, perfil direito em repouso e perfil esquerdo em repouso foram obtidas de cada paciente nos seguintes tempos operatórios: (T1) pré-preenchimento e (T2) um mês pós-preenchimento. As fotografias em T1 e T2 foram inseridas aleatoriamente em uma página de um álbum virtual. Uma escala Likert de 5 pontos foi utilizada para avaliar a agradabilidade facial. As fotografias foram avaliadas por dois grupos de avaliadores formados por 18 indivíduos com fissura labiopalatina (GFLP=18) e 18 ortodontistas com experiência no tratamento de fissuras (GO=18). Para comparação entre as fases T1 e T2, e entre avaliadores com fissura labiopalatina e ortodontistas, foi utilizado o teste de Wilcoxon (p<0,05). Resultados: As pessoas com fissura labiopalatina avaliaram seu rosto como mais agradável após o preenchimento do terço médio da face. Já na percepção do ortodontista, a agradabilidade facial permaneceu semelhante após o procedimento de preenchimento facial. Conclusões: O preenchimento do terço médio da face em pacientes com fissura labiopalatina tratados sem cirurgia ortognática aumentou a agradabilidade da face na opinião dos leigos com fissura labiopalatina.

Hyaluronic Acid Dermal Fillers for Treatment of Congenital and Acquired Lip Asymmetries and Deformities

Hyaluronic acid (HA) dermal fillers are widely used in aesthetic treatments for facial and lip modeling. Despite HA fillers has largely known to be use in procedures for augmentation the lip volume, their application to management lip abnormalities is not widespread. This study reviewed the use of HA fillers for reconstruction of congenital and acquired li p asymmetries and deformities, searching to expand knowledge about this treatment modality. To undertake this narrative review, the Medline-Pubmed, Web of Science, Scopus, Embase, Google Schoolar e Lillacs databases were searched. Several studies have reported positive results in the use of HA fillers for the treatment of lip deformities caused by different factors such as: Insatisfactory dermal fillers, permanent lip implants, excision of lip carcinoma, post-operative scars and electrical burns. HA fillers are also an alternative for the management of lip asymmetries and residual surgical scars in patients with cleft lip. Moreover, injection of HA fillers in individuals with facial paralysis and facioscapulohumeral muscular dystrophy can also improve lip incompetence. Additionally, HA fillers can be used as a complementary treatment in cases of severe malocclusion associated with skeletal changes, helping to maintain the seal and refine the lip appearance. Therefore, HA fillers can be used as alternative treatment for several types of congenital and acquired lip deformities and asymmetries. However, it is necessary to carry out randomized clinical trials with a greater number of patients and follow-up time, in order to investigate the benefits of the HA fillers for carriers patients of lip abnormalities.

Los rellenos dérmicos de ácido hialurónico (AH) son muy utilizados en tratamientos estéticos para el modelado facial y de labios. A pesar de que se sabe en gran medida que los rellenos de HA se utilizan en procedimientos para aumentar el volumen de los labios, su aplicación para el tratamiento de anomalías labiales no está muy extendida. Este estudio revisó el uso de rellenos de HA para la reconstrucción de asimetrías y deformidades labiales congénitas y adquiridas, buscando ampliar el conocimiento sobre esta modalidad de tratamiento. Para realizar esta revisión narrativa, se realizaron búsquedas en las bases de datos Medline-Pubmed, Web of Science, Scopus, Embase, Google Schoolar y Lillacs. Varios estudios han reportado resultados positivos en el uso de rellenos de HA para el tratamiento de deformidades labiales causadas por diferentes factores tales como: rellenos dérmicos insatisfactorios, implantes labiales permanentes, escisión de carcinoma labial, cicatrices postoperatorias y quemaduras eléctricas. Los rellenos de HA también son una alternativa para el manejo de asimetrías labiales y cicatrices quirúrgicas residuales en pacientes con labio hendido. Además, la inyección de rellenos de HA en personas con parálisis facial y distrofia muscular facioescapulohumeral también puede mejorar la incompetencia de los labios. Además, los rellenos de HA se pueden usar como un tratamiento complementario en casos de maloclusión severa asociada con cambios esqueléticos, lo que ayuda a mantener el sellado y refinar la apariencia de los labios. Por lo tanto, los rellenos de HA se pueden utilizar como tratamiento alternativo para varios tipos de deformidades y asimetrías labiales congénitas y adquiridas. Sin embargo, es necesario realizar ensayos clínicos aleatorizados con mayor número de pacientes y tiempo de seguimiento, para investigar los beneficios de los rellenos HA para pacientes portadores de anomalías labiales.

Visual loss after aesthetic facial filler injection: a literature review on an ophthalmologic issue / Perda visual após preenchimento facial estético: uma revisão da literatura sobre complicações oftalmológicas

ABSTRACT Dermal filler injection is among facial rejuvenation treatments that have been increasingly used. Despite being a minimally invasive procedure, it can lead to severe complications such as blindness. A review of all cases of filler- -induced visual loss in the world literature was conducted to summarize the mechanisms, anatomical considerations, and clinical ophthalmologic course, current strategies of prevention and management, and trends over the years. We identified 233 cases of filler-induced visual loss, and 172 patients had a severe visual impairment in at least one eye. The typical patients are young women who received injections of hyaluronic acid or autologous fat in the glabella or nose, and the typical presentations were sudden ocular pain, ptosis, and ophthalmoplegia due to vascular occlusion. The findings of this study also suggest an increase in the number of unlicensed professionals performing the procedure. Even though the continued development of dermal fillers has improved the treatment options available, further studies and strategies are necessary to reduce the incidence and minimize the consequences of filler-induced visual loss.

RESUMO O uso de preenchedores dérmicos é uma prática bem estabelecida de rejuvenescimento facial. Embora seja um procedimento minimamente invasivo, pode levar a complicações graves como cegueira. Uma revisão de casos de perda visual pós preenchimento facial estético foi conduzida para descrever os mecanismos, considerações anatômicas, quadro oftalmológico, atuais estratégias de prevenção e manejo, e tendências ao longo dos anos. Foram identificados 233 casos, e 172 pacientes tiveram ao menos um olho com baixa visão ao final do seguimento. O paciente típico é uma mulher jovem submetida a preenchimento de ácido hialurônico na glabela ou nariz, apresentando dor ocular súbita, ptose e oftalmoplegia devido à oclusão vascular. Este estudo também destaca um possível aumento de profissionais não habilitados realizando este procedimento. Apesar do contínuo desenvolvimento dos preenchedores dérmicos e aprimoramento das opções de tratamento disponíveis, mais estudos e estratégias são necessários para reduzir a incidência de complicações e minimizar suas consequências.

Effects of injectable compound solution of hyaluronic acid combined with botulinum toxin on perioral wrinkles / 中华医学美学美容杂志

Objective:To evaluate the efficacy and safety of injectable compound solution of hyaluronic acid combined with botulinum toxin in the treatment of perioral wrinkles.Methods:A total of 60 female patients, aged 45-60 (53±5) years, with perioral wrinkles treated by the above mentioned method in Plastic Surgery Hospital, CAMS, PUMC from January 2018 to December 2020 were reviewed. Injectable compound solution of hyaluronic acid (2.5 ml) and botulinum toxin were injected intradermally into the upper and lower lips. Injectable compound solutions of hyaluronic acid (1.5 ml and Hearty Xiongmaozhen) were injected intradermally in the perioral static wrinkles and the lip border, respectively, as needed. The patients were followed up for 3 to 6 months after treatment. Photographs were taken before the treatment and during the follow-up visits. The pre- and post-treatment severity of perioral wrinkles were evaluated by two independent surgeons. Patients′satisfaction was evaluated.Results:All the 60 patients were included. The severity of perioral wrinkles was significantly reduced after the treatments. All the patients were satisfied with the results. Among them, 45 patients (75%) were very satisfied and 15 patients (25%) were satisfied with the results. Mild swelling occurred in all patients and was relieved in 1-5 days. Mild bruising was observed in 9 patients (15%) and was relieved in 7-10 days. No other complications were documented.Conclusions:Injectable compound solution of hyaluronic acid combined with botulinum toxin is a safe and effective method in the treatment of perioral wrinkles.

Complex Regional Pain Syndrome of the Upper Limbs Caused by Facial Pain / 계명의대학술지

Polyacrylamide hydrogel is a widely used filler material in cosmetic procedures performed on the face and breasts. Recently, however, complications including inflammation, deformity, and pain have been reported. The present article addresses unregulated materials/products injected as dermal fillers. The authors report a case involving a 29-year-old woman who developed severe facial pain after undergoing a cosmetic procedure with injectable triamcinolone and hyaluronidase. Two months later, the pain spread to her upper and lower limbs, and abdomen, which eventually led to the the development and diagnosis of complex regional pain syndrome (CRPS) in the upper limbs. The authors hypothesize that CRPS in the upper limbs was responsible for the facial pain through sensitization of third-order neurons and the trigeminal nucleus caudalis extending to the upper cervical segments.

Forehead reconstruction using modified double-opposing rotation-advancement flaps for severe skin necrosis after filler injection

Varying degrees of complications can occur after hyaluronic acid filler injections. Tissue necrosis due to interruption of the vascular supply is an early complication that can be severe. If the site of tissue necrosis due to the filler injection is the forehead, successfully reconstructing the region without distorting the key landmarks is challenging. We describe the case of a 50-year-old man who experienced widespread forehead skin necrosis after hyaluronic acid filler injection in the glabellar area. We successfully covered the forehead area with a 3×4-cm² midline necrotic tissue using the modified double-opposing rotation-advancement flap method. Although modified double-opposing rotation-advancement flap closure has the disadvantage of leaving a longer scar compared to conventional double-opposing rotation-advancement flap closure, the additional incision line made along the superior border of the eyebrow aids in camouflaging the scar and decreases eyebrow distortion. Therefore, it is believed that the modified double-opposing rotation-advancement flap technique is an excellent tool for providing adequate soft tissue coverage and minimal free margin distortion when reconstructing widespread skin necrosis in the central mid-lower forehead that can occur after filler injection in the glabellar area.

Upper Eyelid Pseudocyst Related to Forehead Filler Migration: A Rare Complication of an Illegal Filler Injection

We report a very rare case of unilateral blepharoptosis and swelling as an unusual complication of a filler injection. The patient received a filler injection into the forehead 4 years previously by an unlicensed practitioner. In the operation, an encapsulated yellowish cyst with inflammation was found to be adhered to the orbital septum and was excised. To prevent additional inferior migration of the remaining foreign body in the forehead, the retro-orbicularis fascia and preaponeurotic fat pad area were sutured, with the exception of the levator aponeurosis. This cyst-like mass was histopathologically proven to be a multiple pseudocyst. After excision, the swelling disappeared and the ptotic eyelid also improved. The galea is connected with the posterior orbicularis fascia. The galea and posterior orbicularis fascia layer can function as a pathway through which the injected material can migrate from the forehead to the upper eyelid. Weakening of the orbicularis retaining ligament and leakage of the foreign body through the supraorbital foramen may also cause filler migration. This case underscores the need for clinicians to be aware of the potential migration of filler even many years after an injection. We advise that filler injections should be performed by trained physicians and that it should be made known that migration is possible.

Upper Eyelid Pseudocyst Related to Forehead Filler Migration: A Rare Complication of an Illegal Filler Injection

We report a very rare case of unilateral blepharoptosis and swelling as an unusual complication of a filler injection. The patient received a filler injection into the forehead 4 years previously by an unlicensed practitioner. In the operation, an encapsulated yellowish cyst with inflammation was found to be adhered to the orbital septum and was excised. To prevent additional inferior migration of the remaining foreign body in the forehead, the retro-orbicularis fascia and preaponeurotic fat pad area were sutured, with the exception of the levator aponeurosis. This cyst-like mass was histopathologically proven to be a multiple pseudocyst. After excision, the swelling disappeared and the ptotic eyelid also improved. The galea is connected with the posterior orbicularis fascia. The galea and posterior orbicularis fascia layer can function as a pathway through which the injected material can migrate from the forehead to the upper eyelid. Weakening of the orbicularis retaining ligament and leakage of the foreign body through the supraorbital foramen may also cause filler migration. This case underscores the need for clinicians to be aware of the potential migration of filler even many years after an injection. We advise that filler injections should be performed by trained physicians and that it should be made known that migration is possible.

A Randomized, Evaluator-Blinded, Split-Face Comparison Study of the Efficacy and Safety of a Novel Mannitol Containing Monophasic Hyaluronic Acid Dermal Filler for the Treatment of Moderate to Severe Nasolabial Folds

BACKGROUND: Mannitol containing monophasic filler with higher crosslinking has not been well studied for moderate and severe nasolabial fold (NLF) correction. OBJECTIVE: To compare the efficacy and safety of a novel mannitol containing hyaluronic acid (HA) filler (HA-G) with biphasic HA filler (HA-P) for moderate and severe NLF correction. METHODS: Thirteen subjects with symmetric moderate to severe NLF received HA-G (in one NLF) and HA-P (in other NLF) and were evaluated for 24 weeks. RESULTS: At both 12 and 24 weeks, the mean improvement in Genzyme 6-point grading scale from baseline was significantly greater in the side of face that was treated with HA-G than HA-P (1.96±0.91 vs. 1.54±0.73 at week 12; p=0.044, 1.88±0.78 vs. 1.3±0.79 at week 24; p=0.027, respectively). At 12 weeks, the mean Global Aesthetic Improvement Scale score was 2.92±0.93 for HA-G and 2.31±0.95 for HA-P (p=0.008). Both fillers were well tolerated. CONCLUSION: The HA filler HA-G provides better efficacy and similar local tolerability compared with HA-P in 6 months following treatment for moderate and severe NLF.

Abordagens antigas e atuais: sulco nasolabial, linhas de marionete e rugas periorais / Old and new approaches: nasolabial fold, marionette lines and lip lines

O envelhecimento facial é consequência de múltiplos fatores intrínsecos e extrínsecos que interagem entre si e que contribuem de forma importante para as alterações na pele associadas ao envelhecimento. A perda de volume que resulta da perda e do reposicionamento da gordura facial, assim como o remodelamento ósseo, agora é considerada componente fundamental no envelhecimento facial. Com essas alterações, as convexidades típicas de uma aparência jovem, tendem a se tornarem achatadas e côncavas. O rejuvenescimento facial mudou do simples apagamento de rugas e estiramento cirúrgico para um enfoque no qual se faz o relaxamento muscular e volumerização com restauração do contorno facial. Este artigo descreve técnicas consagradas e novas para o tratamento do sulco nasolabial, das linhas de marionete e das rugas periorais.

Inflammatory granuloma caused by injectable soft tissue filler (Artecoll)

Artecoll (Artes Medical Inc., San Diego, CA, USA) has recently been developed as a permanent synthetic cosmetic filler. We experienced an inflammatory granuloma resulting from a previous injection of Artecoll at the upper lip, which was regarded as a rare side effect of this filler. A 50-year-old female patient complained of swelling, dull pain, and heat in the right upper nasolabial fold area, which had started one week before her visit to Kyungpook National University Hospital. The patient received topical steroid therapy at a local clinic, which was not effective. At the injection site, a hard nodule was palpated and erythema was observed with mild tenderness. Antibiotic treatment and subsequent incision and drainage did not result in complete cure of the facial swelling, and the facial swelling and pain persisted. Computed tomography showed a lesion approximately 1-cm in size without clear boundaries and relatively increased nodular thickening. Finally, a subdermal lesion was removed via an intraoral vestibular approach. The lesion was diagnosed as inflammatory granuloma by a permanent biopsy. The patient had healed at two months after the filler injection. Although the soft tissue filler is widely used for cosmetic purposes, there is potential for complication, such as the inflammatory granuloma should be considered before treatment.

Effects of laser, radiofrequency and intensive pulse light on injectable polymethylmethacrylate ( Artecoll) / 中华医学美学美容杂志

Objective To evaluate the safety and efficacy of polymethylmethacrylate/PMMA (Artecoll) as an injectable dermal filler after using laser, radiofrequency and intensive pulse light. Methods In vitro, factional photothermolysis (Affirm) was directly used on the PMMA to see if there was any change in the structure or surface smoothness. In vivo, pig and guinea pig were used as the short-term and long-term models, respectively, for Artecoll. The dermal filler was first injected and then laser treatments conducted.The skin sample was observed through light microscope, scanning electronic microscope and transmission electronic microscope to see whether there were any structural changes, infiltration of inflammatory cells and the regeneration of collagen. Results Through the microscopic observation of in vitro experiment and the animal models, no distortion or rupture of the microsphere were found after the laser treatment. No uneven surface was found in the PMMA microsphere either. The microshpere was surrounded by the inflammatory cells. The infiltration was mild to intermediate with few foreign body giant cells even after several treatments of laser. There was no macrophage seen. But the collagen regeneration was distinguishable after the laser treatment. No obvious structural change was found eventually. Conclusion Artecoll is a safe and effective permanent injectable dermal filler for wrinkle reduction and contour refining.

Envelhecimento facial: perda de volume e reposição com ácido hialurônico / Facial aging: volume loss and hialuronic acid ment

O envelhecimento facial é consequência de múltiplos fatores intrínsecos e extrínsecos que interagem entre si e que contribuem de forma importante para as alterações na pele associadas ao envelhecimento, como as rugas, as manchas castanhas, a perda de elasticidade, dentre outras. A perda de volume que resulta da perda e do reposicionamento da gordura facial, assim como o remodelamento ósseo, agora é considerada componente fundamental no envelhecimento facial. Com essas alterações, as convexidades típicas de uma aparência jovem, tendem a se tornarem achatadas e côncavas.O rejuvenescimento facial mudou do simples apagamento de rugas e estiramento cirúrgico para um enfoque no qual se faz o relaxamento muscular e volumerização com restauração do contorno facial.Os preenchedores subdérmicos são uma ferramenta fundamental para a abordagem do rejuvenescimento facial atual.Este artigo descreve técnicas adaptadas para uso dos géis de ácido hialurônico de alta viscosidade no espaço subdérmico para obtenção de melhor rejuvenescimento facial.

Application of Hard Tissue Filler for Chin Contouring

With hightened interest in bone contouring surgeries, newer and lesser invasive treatment modalities for bone augmentation surgeries are being introduced. Bone augmentation effects with long lasting injectable tissue fillers were studied. Between June, 2006 and November, 2008, 33 cases of small chin patients underwent chin augmentation via Royamid(R) and Radiesse(R) injections, 9 and 24 cases respectively. No complications were observed through the follow up period. Twenty six patients showed satisfaction with aesthetic results at 6 months follow up. In 7 cases, temporary swelling and erythema were observed. The augmentation effect lasted more than 6 momths in both Royamid(R) hard and Radiesse(R) groups. In 7 cases of Royamid(R) hard group, the aesthetic effects lasted more than one year. Long lasting tissue filler seems to be a good alternative treatment modality for bone augmentation surgery if approached with strict protocol indications and careful patient selection.

A Trial of Radiesse(R) for Facial Soft Tissue Augmentation

Ideal charateristics of soft tissue fillers include longevity, biocompatibility, low adverse event profile and a reasonable cost. Radiesse(R) have many advantage as the desirable properties of facial filler. Authors introduce Radiesse(R) was recently introduced as a facial filler agent. Radiesse(R) was injected to 81 male and female patients in the study, using 27G fine needle. The age range of the patients was 22 to 48 years. The injected areas were nasal root, tip, nasolabial folds and jaw. We measured patient satisfaction scale during the period of follow up 2 to 6 months. The scale of satisfaction was good to excellent in 69 cases of 81 cases and fair in 9 cases of 81 cases. Patients satisfaction was poor in only 3 cases. Patients were observed no systemic effects but minimal adverse events which are leakage, nodule and subclinical inflammation. Radiesse(R) was highly effective, long lasting material for facial soft tissue augmentation. If a precise injection technique were applied, Radiesse(R) can be a very good option for real volumetric facial soft tissue augmentation.

Choice of Filler and Suitable Procedure for Augmentation Rhinoplasty

Because of its simplicity, augmentation rhinoplasty with filler material has been used as alternative choice of the operative augmentation rhinoplasty. With development of various filler materials the duration of which is long, the augmentation rhinoplasty using filler material has wide usage. This article describes the choice of filler suitable for augmentation rhinoplasty. As skin and soft tissue are abundant at the nasal tip and root, they are easily elevated when filler material is injected. However, in case of nasal dorsum, especially supratip depression, there is a lack of skin and soft tissue, therefore, the filler material injected is redistributed into the nasal tip and dorsum. Ideal filler material for augmentation rhinoplasty should be located at the injection site without quantitative change. Fortunately, 3.3% PAAG(polyacrylamide gel) has hard consistency, but no component change, and has long duration. Therefore, it seems to be an ideal filler material among numerous filler materials currently sold.

A Case of Sudden Unilateral Visual Loss Following Injection of Filler into the Glabella / 대한피부과학회지

Dermal fillers have been used with increasing frequency over the past three decades in the management of facial lines and atrophic scars and in the correction of facial contours. Injectable soft tissue fillers are ideal for office procedures because of their associated ease, cost, and minimal discomfort. Although complications are rare, they can occur with any dermal filler. However, although most complications are mild and transient, severe, persistent, or recurrent adverse effects can occur. Serious complications include complete or partial visual loss caused by occlusion of a retinal artery. We report a case of a 65-year-old female who experienced sudden visual loss and local necrosis of the glabellar area, secondary to retinal branch artery occlusion, following injection of a filler. Prompt consultation with an ophthalmologist is recommended when there is evidence of visual problem arising after facial injection with dermal fillers.