Nasal filling guided by high frequency ultrasound: Reducing risks.

BACKGROUND: Given the significant increase in the quantity of cosmetic procedures utilizing hyaluronic acid fillers, including in the nasal region, the initial evaluation of patients using high frequency ultrasound becomes a crucial instrument in evaluating and handling nonsurgical rhinoplasty. AIMS: The aim of this article is to introduce an assessment methodology for nasal filling guided by high frequency ultrasound. PATIENTS/METHODS: A prospective and single-center study was conducted with 12 Latin American patients. The patients underwent nasal filling with hyaluronic acid following high power ultrasound mapping. RESULTS AND CONCLUSIONS: In the evaluation of the GAIS scale, all patients reported improvement with the treatment. No infections, nodules, ischemia, or other relevant adverse effects were noted. Real-time ultrasound-guided filler techniques have been developed to reduce the risk of vascular compromise, confirming the distribution pattern of blood vessels. It's also crucial to visualize the cannula at the same moment as the vessels, even if the previous vascular mapping was performed. Therefore, the utilization of high frequency ultrasound can act as a pivotal tool in augmenting procedure safety.

Resolve and dissolve-An ultrasound-guided investigation on the effects of hyaluronidase on different soft tissue fillers.

BACKGROUND: Nonsurgical cosmetic procedures, particularly the use of hyaluronic acid (HA)-based soft tissue fillers, are becoming increasingly popular. This trend has catalyzed the development of a plethora of HA-based products differing in product characteristics, thereby catering to an ever-widening spectrum of aesthetic applications. However, complications rise concomitant with the increasing number of procedures. Among the strategies to manage such adverse events is the enzymatic breakdown with hyaluronidase. OBJECTIVE: To analyze the response of different HA-based soft tissue filler materials to hyaluronidase injections. METHODS: A total of 11 different HA-based soft tissue fillers were evaluated using noninvasive ultrasound imaging to assess their behavior in response to hyaluronidase injections. The HA-based soft tissue fillers were categorized according to their product characteristics into a structuring, volumizing, and lip volumizing group. Standardized injections of 0.2 cc were performed in chicken breast to simulate human tissue. Ultrasound measurements of width, height, and calculated volume were performed immediately after filler injection, 1 h and 24 h following hyaluronidase injection. RESULTS: Regardless of the soft tissue filler analyzed, the most significant volume reduction occurred within the first h after applying hyaluronidase, with a 64.1% decrease from the initial volume. After 24 h, the total volume reduction reached 81.7%. No statistically significant differences were found when comparing the three groups at each follow-up time period, except for the height measurement after 1 h. While width was statistically significant in all groups between the investigated follow-up groups, the volume reduction was only statistically significant in the groups with the highest and second highest G' values (i.e., Group 1-structuring, Group 2-volumizing). CONCLUSION: The effectiveness of hyaluronidase in dissolving HA-based fillers is initially independent of product characteristics of HA-based fillers such as G-prime, with increased efficacy in fillers with higher G-prime values, as evidenced by significant volume reductions in such groups.

Hyaluronic Acid-based Fillers for Facial Rehabilitation in Inherited Neuropath.

Charcot-Marie-Tooth (CMT) disease is the most prevalent inherited neuromuscular disorder. It commonly leads to various musculoskeletal deformities, profoundly impacting the quality of life. The present case report explores the often under-recognized body image dissatisfaction in CMT, highlighting the potential benefits of a multidisciplinary approach to enhance aesthetic satisfaction. We present a case of a 54-year-old woman with CMT, who experienced chronic facial asymmetry, significantly impairing her quality of life. Seeking cosmetic enhancement, she underwent two sessions of facial treatment using hyaluronic acid-based fillers. The first session focused on correcting right mandibular hypoplasia and other facial asymmetries, whereas the second session focused on enhancing perioral aesthetics. The treatment resulted in significant aesthetic improvements, as demonstrated by high ratings in both the Physician Global Aesthetic Improvement Scale and the Subject Global Aesthetic Improvement Scale. Besides, there was a marked reduction in lip corner asymmetry, the patient's primary concern. The role of hyaluronic acid fillers in facial aesthetic enhancement is well established, and their application in the context of CMT is a promising under-investigated field, to our knowledge. This case study highlights the importance of considering body image in CMT patients and suggests that minimally invasive aesthetic procedures can be a valuable addition to the multidisciplinary care of patients with inherited neurological disorders. Despite being a single-case study, the significant improvement in the patient's aesthetic satisfaction requires further research in this field.

International Consensus on Anti-Aging Dermocosmetics and Skin Care for Clinical Practice Using the RAND/UCLA Appropriateness Method.

BACKGROUND: The objective was to provide international recommendations on anti-aging dermocosmetics for clinical practice starting with essential ingredients for protection and repair before working up to advanced products for specific concerns.  Methods: Seven international experts reviewed 8 hypothetical case scenarios covering different ages, skin issues (eg, sensitivity, acne, melasma), and exposure to exposome factors for both sexes and all Fitzpatrick skin types (FST). The RAND/UCLA appropriateness method was used to obtain consensus. Seventeen key ingredients were rated on a scale from 1 (totally inappropriate) to 9 (totally appropriate). Statistical analysis, 2 meetings, and email discussions refined the recommendations. RESULTS: High-factor broad-spectrum sunscreen (ie, protects against ultraviolet [UV] A and B rays), niacinamide, and other topical antioxidants were recommended for all scenarios. Further discussions were required for other ingredients. Tinted sunscreen/iron oxide were recommended for all FST, although compliance may be sub-optimal for darker skin phototypes (IV-VI), if not cosmetically acceptable. Combining a facial foundation with broad-spectrum sunscreen was recommended for darker phototypes to obtain visible light protection closely matching diverse color tones. Retinols were not recommended as a first-line treatment for sensitive skin, especially FST V and VI, due to the risk of irritation. After ablative laser treatment, alpha hydroxy acids should be avoided or used with caution in FST IV to VI due to the risk of post-inflammatory hyperpigmentation. CONCLUSION: We describe a simple, practical tool for use in daily dermatology consultations for providing recommendations on anti-aging dermocosmetics to cover diverse and inclusive populations of patients, addressing all skin types and international needs.  J Drugs Dermatol. 2024;23(1):1337-1343.     doi:10.36849/JDD.7798.

Durability of the improvement of collagen I and collagen III with the use of oral isotretinoin in the treatment of photoaging.

BACKGROUND: Oral isotretinoin (ISO) is the drug of choice for the treatment of severe acne. For photoaging treatment, ISO has been proved to be effective in some controlled and noncontrolled trials and is an alternative to topical retinoic acid (RA) therapy, which causes an expected skin irritation. OBJECTIVE: To evaluate and compare the skin remodeling in patients taking ISO 20 mg 3 times a week for 12 weeks and 12 weeks after the end of the treatment to quantify collagen I and collagen III augmentation. MATERIAL AND METHODS: Immunohistochemical studies were performed to evaluate the expression of collagen I and collagen III, metalloproteinases (MMPs) -1, -3, -7, -9, -12, and the tissue inhibitor of MMP type-1 (TIMP-1) of the skin of 20 45 to 50-year-old women through morphometry in a semiquantitative method. The inclusion criteria were facial aging 2 and 3 of Glogau's classification, with phototypes between II and V who had not entered menopause. Biopsies of the skin of the left preauricular region were performed at three different times: pre-treatment (T0), end of 12-week treatment (T1), and 12 weeks posttreatment (T2). RESULTS: Collagen fibers I and III increased with statistical significance in T1 (50.7%; P = 0.012) but not in T2 (49.7%), which in turn was higher than in T0 (47.2%) for collagen I and T1 (33.3%; P = 0.002) but not in T2 (32.7%), and also was higher than T0 (32.0%) for collagen III. MMP-9 presented a decreased activity with statistical significance in T1 (P = 0.047) and T2 (P = 0.058). MMP-1 showed a reduction in T2 only (P = 0.015). MMPs -3, -7, -12, and TIMP-1 did not present significant modification in their expressions during or after the treatment. CONCLUSIONS: Low-dose ISO is effective in remodeling the extracellular matrix (ECM). This study found that the increase of collagen occurs through the augmentation of both collagen I and collagen III fibers. With originality, it was possible to verify the durability of these fibers for at least 12 weeks. This may be related to the decrease in MMP-9 expression verified at the end of the treatment and 12 weeks posttreatment.

Dermal Thickness Increase and Aesthetic Improvement with Hybrid Product Combining Hyaluronic Acid and Calcium Hydroxyapatite: A Clinical and Sonographic Analysis.

Hyaluronic acid filler injections are regarded as the gold standard procedure for facial rejuvenation. Standing as the second most injected cosmetic filler, calcium hydroxyapatite-based fillers are also widely used worldwide. However, to our knowledge, prospective studies assessing patient satisfaction and sonographic changes in dermal thickness after a single session of a hybrid filler combining hyaluronic acid and calcium hydroxyapatite have not been previously published. Methods: This was a single-center, prospective, quasi-experimental study comprising 15 participants between 32 and 63 years of age. Each participant received a single-session treatment based on facial subcutaneous injections of HArmonyCa, a hybrid combination filler comprising hyaluronic acid and calcium hydroxyapatite. This study involved an intrapatient control design and a 120-day follow-up with clinical and sonographic assessment. For this purpose, standardized photographic images, high-frequency ultrasound evaluations, and physician- and patient-oriented overall aesthetic improvement scores were recorded at 0, 30, 90, and 120 following the procedure. Results: According to our findings, 20% of the subjects had an exceptional improvement; 20%, "very improved"; and 60%, "improved." Intrapatient sonographic comparison showed a significant increase in dermal thickness, at 90 and 120 days, only on the side treated (P < 0.001). Conclusion: In our clinical study, a single-session treatment with a hybrid product combining hyaluronic acid and calcium hydroxyapatite resulted in positive cosmetic satisfaction and increased dermal thickness.

Precision of Soft-Tissue Filler Injections: An Ultrasound-Based Verification Study.

BACKGROUND: Uncontrolled product spread is an important issue to consider in facial filler injections. Lack of precision can result in reduced effectiveness and surface projection, as well as irregularities and product visibility. OBJECTIVES: The authors sought to assess the precision of soft-tissue filler injections in the face by employing a cannula. METHODS: This single-center observational study investigated soft-tissue filler distribution utilizing real-time non-invasive ultrasound imaging. Outcome parameters included (1) the tissue plane of product distribution, (2) the extent of horizontal as well as vertical product spread at the injection site, and (3) the product surface area taking into account the multifactorial influence of several independent variables. Participants were followed up to 30 days post-injection. RESULTS: A total 100 facial injections were performed in 8 patients (2 males, 6 females) with a mean age of 37.20 (±6.34) years and a mean BMI of 22.21 (±1.39) kg/m.2. The plane of product distribution remained constant in approximately 90% of cases at day 0 (d0), d14, and d30. Mean horizontal product spread was higher compared with vertical spread, and both significantly decreased over all time points (P < .001). Mean product surface area was 22.51 ± 16.34 mm2 at d0, 15.97 ± 11.28 mm2 at d14, and 12.9 ± 9.15 mm2 at d30. Analysis employing generalized linear models revealed that injection volume and injection depth significantly influenced product surface area. CONCLUSIONS: Injection of soft-tissue filler employing a cannula allows precise application of the product within the intended tissue plane. Precision can be improved by injecting less product into deeper tissue layers.

Benefits of topical hyaluronic acid for skin quality and signs of skin aging: From literature review to clinical evidence.

Skin aging goes beyond a chronological process and also results from extrinsic factors referred to as the exposome. Hyaluronic acid (HA) is an important component of the extracellular matrix, with loss starting at 25 years old. While many studies of HA concern topical use, few literature reviews only address the use of topical HA in dermatology. This review describes the different characteristics of HA-containing cosmeceuticals, with a focus on skin aging and the impact of exposome factors on HA synthesis and degradation. A review was performed using the terms HA, hyaluronan, topical, dermatology, cosmetic, aging treatment, exposome, and cosmeceuticals. Results are also presented from a recent randomized controlled trial (RCT), which investigated the additional benefit of using a HA epidermic filler (HA-filler serum) combined with Botulinum toxin type A (BoNTA) to treat signs of skin aging. Subjects were randomized to two groups: HA-filler serum starting 24 h after the BoNTA injection then twice daily for 24 weeks, or the control group, which received BoNTA. HA is a key ingredient used in cosmeceuticals for its hydration/antiaging properties (hygroscopic, rheological, and viscoelastic). Several clinical studies indicate that HA is both well tolerated and effective, adjuvant to both post-surgical and facial rejuvenation procedures. In the RCT, one of few studies to combine BoNTA and HA with a 6-month follow-up, the HA-filler serum lengthened the duration of BoNTA's effect in reducing wrinkles. Numerous studies support HA-based cosmeceuticals as a noninvasive, effective solution for improving skin hydration and rejuvenation.

Dermoscopic classification of melasma: Concordance study and correlation with the melanophages count.

BACKGROUND: Melasma is a common hypermelanosis characterized by symmetrical brownish macules, especially on the face. Histologic analysis demonstrates increased epidermal and dermal melanin. Dermoscopy is useful to estimate the depth of the melanin and may help in the diagnosis and classification of melasma, with therapeutic importance. OBJECTIVES: To evaluate the diagnostic concordance of dermoscopic classification of epidermal or mixed subtypes of melasma and the correlation between dermoscopic and histopathological findings. METHODS: Twenty-eight women with facial melasma, phototypes III to V, ages between 30 and 61 years were selected. Based on the evaluation of clinical and dermoscopic images, two independent observers classified melasma into epidermal or mixed subtypes. The intra and interobserver concordances were calculated. Histopathological analysis of epidermal melanin extension and maximum number of melanophages per high-power field (400×; HPF) have been assessed. Association between the melanophages count and the dermoscopic classification was evaluated. RESULTS: Intraobserver agreement was 82.1%, and between observers, from 78.6% to 89.3%, according to the Kappa index. Histopathology revealed increased intraepidermal melanin and the presence of dermal melanophages in all the samples. Ten or more melanophages/HPF was significantly associated with mixed melasma. CONCLUSIONS: Moderate to substantial concordance in the dermoscopic classification of melasma was found, and the correlation between this classification and the dermal melanophages count have been suggested. Intradermal component of every case of melasma should be considered for therapeutic and prognostic purposes.

Applied anatomy of the layers and soft tissues of the forehead during minimally-invasive aesthetic procedures.

BACKGROUND: An increasing demand of minimally-invasive aesthetic procedures of the forehead concomitantly leads to higher numbers of adverse events. Adequate application of anatomical knowledge is required to increase safety and efficacy of different minimally-invasive aesthetic procedures in this anatomical region. OBJECTIVE: To describe the layered anatomy of the forehead soft tissues with respect to their thicknesses and how they relate to different minimally-invasive aesthetic treatments. METHODS: A total of n = 85 healthy study participants (69 females and 16 males) with a mean age of 40.84 ± 10.9 years and a mean body mass index of 22.65 ± 2.6 kg/m2 were investigated with ultrasound-based imaging to measure the thickness of different forehead soft tissues. RESULTS: The mean overall soft tissue thickness of the forehead was measured to be 4.18 ± 0.7 mm for the entire study population. Increasing BMI values correlated statistically significantly with increasing thickness of all measured forehead soft tissues with exception of the frontalis muscle. On a statistically significant level, males showed thicker forehead soft tissues than females, with exception of the retrofrontalis fat and the frontalis muscle. CONCLUSION: On basis of the findings obtained in this study, basic treatment principles can be derived and improved for the injection of neuromodulators, hyaluronic acid as well as the application of polydiaxonane (PDO) threads and micro-focused ultrasound. Precise knowledge and thorough understanding of the layers and soft tissues of the forehead is required to guarantee safe and effective procedures in this aesthetically important facial region.

Improvement of Facial Skin Laxity by a Combined Technique With Hyaluronic Acid and Calcium Hydroxylapatite Fillers: A Clinical and Ultrasonography Analysis.

BACKGROUND: Facial aging involves skeletal changes, loss of volume in the fat compartment, and skin component changes. The current objective of cosmetic facial filling is to reestablish the overall aspect that was lost during the aging process. Hyaluronic acid (HA) and calcium hydroxyapatite (CaHA) fillers are indicated for facial rejuvenation, and these agents promote dissimilar effects regarding volume restoration and dermal biostimulation. OBJECTIVE: This study aimed to assess clinical and ultrasonographic improvements in facial skin laxity using a technique that combines the injection of HA and CaHA. METHODS: A 120-day follow-up, quasi-experimental study was conducted based on the enrollment of fifteen women (36–47 years old) with mild face flaccidity scores who underwent subcutaneous injection of up to 3 mL of HA (zygomatic-malar region, pyriform aperture, temporal region, and jaw) followed by 3 mL of 1:1 diluted CaHA using a fan technique (temporal, zygomatic-malar, and jaw regions). OBJECTIVE: Adverse effects were registered, and the monthly assessed outcomes included clinical improvement, satisfaction, and high-frequency ultrasonography (dermal thickness) parameters. RESULTS: At 120 days of follow-up, clinical assessment by blinded physicians yielded six (40%) very improved patients and nine (60%) exceptionally improved patients. All the participants were highly satisfied with the results and reported exceptional improvement. Dermal thickness increased 11.1% (8.8–13.4%), and augmented dermal homogeneity was evidenced by ultrasonography. Local adverse effects were mild and transient. CONCLUSION: In conclusion, the combined technique with HA and CaHA fillers was well-tolerated and yielded high satisfaction and safe improve in facial skin laxity and dermal thickness in women with mild midface aging. J Drugs Dermatol. 2022;21(1): 102-106. doi:10.36849/JDD.633.

A vacinação contra SARS-CoV-2 afeta o efeito imediato da toxina botulínica? Primeiras impressões / Does SARS-CoV-2 vaccination affect the immediate effect of botulinum toxin? First impressions

Introdução: A infecção por SARS-CoV-2 se espalhou rapidamente pelo mundo desde sua identificação no final de 2019. Globalmente, até abril de 2021, houve mais de 150 milhões de casos confirmados de Covid-19, incluindo mais de 3 milhões de mortes. Portanto, uma corrida foi prontamente iniciada para produzir uma vacina eficaz contra o novo vírus. A injeção de toxina botulínica continua sendo o principal procedimento cosmético não cirúrgico em todo o mundo, com alto índice de eficácia e satisfação do paciente. Objetivos: Este estudo tem como objetivo analisar a associação entre a vacina SARS-CoV-2 e a resposta imediata à toxina botulínica. Materiais e Métodos: Estudo observacional, retrospectivo e multicêntrico. Os dados foram coletados entre abril e junho de 2021, e revisão de prontuários de 71 pacientes de 27 a 76 anos que foram tratados com injeção de toxina botulínica. Resultados e Conclusão: Não houve mudanças significativas no desfecho imediato dos pacientes vacinados para Covid-19 e toxina botulínica, mas é de suma importância ressaltar que são necessários acompanhamento e mais estudos para definir se a vacina Covid-19 é capaz de alterar a duração do efeito e a eficiência da toxina botulínica.

Background: The SARS-CoV-2 infection has spread worldwide rapidly since its identification at the end of 2019. Globally, until April 2021, there have been more than 150 million confirmed cases of Covid-19, including over 3 million deaths. Therefore, a race was promptly started to produce an effective vaccine against the new virus. Botulinum toxin injection remains the leading non-surgical cosmetic procedure worldwide, with a high rate of efficacy and patient satisfaction. Aims: This study aims to analyze the association between the SARS-CoV-2 vaccine and the immediate botulinum toxin response. Materials and Methods: This was an observational, retrospective, and multicenter study. Data were collected between April and June 2021, and a medical record review of 71 patients from 27 to 76 years old treated with botulinum toxin injection. Results and Conclusion: There were no meaningful changes in the immediate outcome of patients vaccinated for Covid-19 and botulinum toxin. However, it is vital to underline that follow-up and further studies are needed to define whether the Covid-19 vaccine can alter the duration of effect and efficiency of the botulinum toxin.

Real-Time Ultrasound Imaging of the Tear Trough: Lessons Learned From Functional Anatomy.

BACKGROUND: The tear trough is one of the most challenging facial regions for soft-tissue filler injections. A thorough understanding of the underlying facial, muscular, and vascular anatomy is crucial to perform safe and effective tear trough injectable treatments. OBJECTIVES: The authors sought to evaluate the location and function of the angular vein in the tear trough in 3 different facial expressions: repose, smiling, and max. orbicularis oculi contraction. METHODS: Twenty study participants with a mean age of 48.3 years and mean BMI of 24.5 kg/m2 were investigated via functional ultrasound imaging. The diameter of the angular vein and the velocity and direction of venous blood flow were analyzed in repose, smiling, and during max. orbicularis oculi contraction. RESULTS: The angular vein was identified in 100% of the cases to travel inside the orbicularis oculi muscle (intra-muscular course) within the tear trough, whereas the angular artery was not identified in this location. The distance between the angular vein and the inferior orbital rim was (lateral to medial): 4.6 mm, 4.5 mm, 3.9 mm, and 3.8 mm. The caudally directed blood flow was in repose 10.2 cm/s and was 7.3 cm/s at max. orbicularis oculi muscle contraction; however, no blood flow was detectable during smiling. CONCLUSIONS: The diameter and the venous blood flow of the angular vein varied between the 3 tested facial expressions. Based on these anatomical findings, the deep injection approach to the tear trough is recommended due to the intramuscular course of the angular vein.

Hyaluronidase: What is your fear?

BACKGROUND: The aesthetic treatment based on fillers with hyaluronic acid presents an increasing demand in the present day because it is considered a safe and minimally invasive procedure. In the management of adverse effects or more severe complications of hyaluronic acid-based fillers, hyaluronidase is the treatment of choice. AIMS: To demonstrate efficacy in reversibility and safety in the treatment of HA complications. PATIENTS/METHODS: It is a retrospective study article that reports the use of hyaluronidase in the main undesirable effects of fillers in 114 patients in a private dermatological clinic from 2015 to 2018. RESULTS: The target of the application was 51 cases of overcorrection (45%), 50 cases of Tyndall effect (44%), and 13 late nodules (11%). When we evaluated the areas where HYAL was injected, we found that the area with the most indication of the application of the product was the eyelid region (58 injections). CONCLUSION: This study concluded that HYAL is a safe and effective drug in the management of mild adverse events of HA applications with no severe side effects in our protocol of use.

A Retrospective Study Supporting the Importance of Individualizing the Dose of Botulinum Toxin According to the Age.

BACKGROUND: Botulinum toxin type A injection remains the leading nonsurgical cosmetic procedure worldwide with a high rate of efficacy and patient satisfaction. OBJECTIVE: This study aims to demonstrate the importance of individualization of botulinum toxin doses to treat the upper face according to the age of the patients, considering the muscles particularities and the specificities of each face area. MATERIALS AND METHODS: A retrospective study with 389 female patients treated with botulinum toxin type A in the upper third of the face (forehead, glabellar, and periorbital lines). Statistical analysis of the data was performed. RESULTS: The mean age was 47.49 years old and the median total dose of botulinum toxin type A was 53.76 units, whereas the median dose in the glabella was 26.28 U, the mean forehead dose was 12.23 U, and in the periorbital area was 14.79 U, adding both sides. It is possible to observe that the doses are negatively correlated with age, except in the periorbital area, where an increase in the dose was observed. CONCLUSION: It is important to highlight that although there is consensus on pre-established dose suggestions, the treatment should be individualized, respecting the individual characteristics of each patient.

Supraperiosteal application of hyaluronic acid with cannula: Is it possible?

INTRODUCTION: The aging process occurs in all anatomical layers of the face; therefore, rejuvenation should not be limited to the dermic signs of aging (Aesthet Surg J. 2018;38:73) The treatment with fillers in strategic points can reconstruct young anatomy, providing natural results (Aesthet Surg J. 2018;38:73). There are two instruments used for facial application of hyaluronic acid: cannula and needle. Both of them have advantages and disadvantages. OBJECTIVE: In this study, we aim to compare the limitations of application with cannula by cutaneous ultrasound when compared to the needle by ultrasound, since some injectors suggest that one of the disadvantages would be the inability to reach certain application plans (periosteum). MATERIALS AND METHODS: A 52-year-old female patient was treated with 22 mg/ml hyaluronic acid (Juvéderm® Voluma), guided by high-frequency ultrasound (LogicE device, Logic brand (GE Healthcare), with high-frequency linear probe (L8-L18i-RS). The left hemiface was treated with a 27G needle and the right hemiface with a 5 cm 22G cannula (SoftFil®). CONCLUSION: This study proved that, in the malar/zygomatic and the chin region, it is possible the cannula and needle reached the supraperiosteal region. In the temporal region, the cannula did not reach the supraperiosteal plane.

Septal Ulcer After Nasal Filling with Hyaluronic Acid.

Nonsurgical rhinoplasty is a good treatment choice when surgery is not a viable option. However, serious complications, including blindness or cerebral ischemia, can occur given this area is one of external and internal carotid anastomosis. Here, we describe a case of a patient with a septum ulcer secondary to local ischemia postnasal fillling with hyaluronic acid without skin lesion. Due to the rarity of the condition, her diagnosis was made late, but she was treated with hyaluronidase and showed total resolution.

Analysis of the Columellar-Labial Angle in Perioral Aging.

BACKGROUND: The young face presents a convex and rounded aspect; with aging, this changes to a more concave and flattened aspect, with the angles of the face undergoing changes through soft tissue repositioning and bone remodeling. The columellar-labial angle is one of the features that change. OBJECTIVES: The objective of the present study was to analyze the columellar-labial angle at different stages of adult life and assess its contribution to facial changes during aging. METHODS: We analyzed a database (December 2017-March 2018) of 722 female patients, aged 21 to 88 years, and obtained anthropometric measurements of the columellar-labial angle with a Canfield Vectra 3D image analysis system. Our database originates from a private clinic where all patients were registered and photographed. RESULTS: Our analysis showed a decrease in the columellar-labial angle, mainly observed from patients aged 60 years and older. This decrease can be explained by the absorption of body structures that occurs during aging. CONCLUSIONS: The columellar-labial angle decreases with age, and this finding may provide a better understanding of the transformation that occurs with aging. Obtaining a clearer view of the changes that occur in the face will improve treatments for facial rejuvenation, either conservative or surgical, and provide a basis for future studies and knowledge expansion.

Safety in immediate reconstitution of poly-l-lactic acid for facial biostimulation treatment.

Poly-L-lactic acid is presented as freeze-dried preparation of 150 mg per vial and, according to consensus, the recommendation on your preparation is hydrate in sterile water for injection (SWFI) or bacteriostatic water at room temperature for ≥24 hours. (J Drugs Dermatol; 2014;13:s44) However, in these long periods of hydration, it is time-consuming and costly for the physicians. To demonstrate the safeness of immediate reconstitution of facial biostimulation treatment with PLLA. A clinical prospective study with 26 Latin American female patients, aged between 27 and 80 years, complaining of facial laxity of treated with immediate PLLA reconstitution. One PLLA vial was injected per session in 12 mL total dilution. All patients had their pictures taken before and after the treatment in Photo Analysis Program Vectra 3D (Canfield® ). A follow-up 90 days was performed. The total of 58 facial applications of PLLA was reported in female patients with a mean age 52.62 (±13.46) years. Pain was reported in 17 injections (29.31%) and ecchymosis in 6 (10.34%). Also, 2 patients (3.44%) developed a nodule. None of the patients presented significant bruising, edema, or papules formation. Despite the literature declare that a longer hydration times (up to 48 hours) have been shown to reduce the risk of nodule formation (Aesthet Surg J; 2011;31:95), our study demonstrated the safeness of injection with immediate reconstitution and a very low adverse events rate. Immediate PLLA reconstitution is a great asset for physicians, injections in account of being less laborious, less time-consuming, and reducing product loss for the injector.

Ultrasound-guided poly-l-lactic acid nodule excision: The importance of the injector ultrasonographic experience.

The possibilities for facial and body treatments are wide, but when it comes to treatment for the cervical region, the options are more restricted and among them, the use of poly-l-lactic acid (PLLA) stands out. PLLA is used for collagen biostimulation and improvement of skin turgor with good results; however this procedure is not free of complications, and for the treatment of these, a correct diagnosis is essential. As it is esthetic medicine, the guarantee of results requires that complications are not tolerated, and thus, any resource that enriches the diagnostic and therapeutic arsenal is of great value. The objective of this study is to report the diagnosis of a PLLA nodule with the help of high-frequency ultrasound, establishing a clinical, radiological, and histopathological correlation, in a patient submitted to PLLA injection for esthetic improvement of the cervical region. We present a case in a female patient presenting a nodule in the cervical region after the application of PLLA, where we performed the excision guided by high-frequency ultrasound. Mastering the diagnostic technique with high-frequency ultrasound can play a valuable role in indicating early surgical exeresis, also contributing to complete patient care. It allows the application of the product, monitoring, diagnosis of the complication, and treatment to be carried out dynamically and precisely by the injector.