Evaluation of Physicochemical Properties Following Syringe-to-Syringe Mixing of Hyaluronic Acid Dermal Fillers.

BACKGROUND: Historically, soft-tissue hyaluronic acid (HA) fillers have been mixed with agents to reduce pain or alter physicochemical properties. OBJECTIVE: Evaluate the impact of dilution and mixing on HA filler physicochemical properties. MATERIALS AND METHODS: Crosslinked HA filler (VYC-20L, 20 mg/mL) was diluted to 15 mg/mL using saline through 5 or 10 passes between 2 syringes connected using a luer connector. Extrusion force, rheological properties, and microscopic appearance were assessed. Undiluted VYC-15L (15 mg/mL) served as the control. RESULTS: Average extrusion force was higher for diluted VYC-20L versus the control, with an increase in slope for gel diluted using 5 passes (0.65) and 10 passes (0.52) versus the control (<0.1). For diluted samples mixed with 5 or 10 passes, the rheological profile was different between the 2 halves of the syringe, with the second half more elastic than the first half, compared with the consistent profile of undiluted samples. Microscopically, diluted VYC-20L samples seemed more liquid near the luer and more particulate near the piston compared with the control, which was smooth throughout. CONCLUSION: In addition to potentially introducing contamination, diluting or mixing soft-tissue HA fillers yields a heterogeneous product with physicochemical characteristics that vary substantially throughout the syringe.

Advanced quantitative proteomics to evaluate molecular effects of low-molecular-weight hyaluronic acid in human dermal fibroblasts.

Hyaluronic acid (HA) is physiologically synthesized by several human cells types but it is also a widespread ingredient of commercial products, from pharmaceuticals to cosmetics. Despite its extended use, the precise intra- and extra-cellular effects of HA at low-molecular-weight (LWM-HA) are currently unclear. At this regard, the aim of this study is to in-depth identify and quantify proteome's changes in normal human dermal fibroblasts after 24 h treatment with 0.125, 0.25 and 0.50 % LMW-HA (20-50 kDa) respectively, vs controls. To do this, a label-free quantitative proteomic approach based on high-resolution mass spectrometry was used. Overall, 2328 proteins were identified of which 39 significantly altered by 0.125 %, 149 by 0.25 % and 496 by 0.50 % LMW-HA. Protein networking studies indicated that the biological effects involve the enhancement of intracellular activity at all concentrations, as well as the extracellular matrix reorganization, proteoglycans and collagen biosynthesis. Moreover, the cell's wellness was confirmed, although mild inflammatory and immune responses were induced at the highest concentration. The more complete comprehension of intra- and extra-cellular effects of LMW-HA here provided by an advanced analytical approach and protein networking will be useful to further exploit its features and improve current formulations.

Providing Optimal Rejuvenation to the Periocular Area Using Botulinum Toxin A Neuromodulators and Hyaluronic Acid Dermal Fillers.

The periorbital area is the first area of the face to show signs of aging. To provide safe and natural looking rejuvenation of the delicate eyelids, and supporting structures, an advanced understanding of anatomy, ideal facial proportions, and the most effective methods for rejuvenation is discussed. Periocular rejuvenation is particularly challenging due to the intricate and delicate anatomy of the periocular area. To ensure safe and successful outcomes, it is crucial that injectors use a global approach when providing treatments and that they consider soft tissue, vasculature, and bone structure of the periocular region before administering treatments for aesthetic rejuvenation. Neuromodulators, specifically botulinum toxin A (BoNT-A), and hyaluronic acid (HA) dermal fillers are 2 nonsurgical treatments frequently used to address signs of aging in the periocular area. The objective of this article is to review different BoNT-A and HA filler treatments and discuss how these treatments can be used for optimal rejuvenation of the periocular area.

Enhanced liver fibrosis (ELF) score: Reference ranges, biological variation in healthy subjects, and analytical considerations.

BACKGROUND: The Enhanced Liver Fibrosis score has been recognized as a non-invasive test for liver fibrosis. However, reference intervals, biological variation and analytical performance have not been studied in detail so far. The aim was to acquire data that are essential for correct interpretation. METHODS: A total of 40 apparently healthy volunteers were evaluated for reference ranges of serum concentration of hyaluronic acid, aminoterminal propeptide of type III collagen, and tissue inhibitor of metalloproteases-1, and calculated ELF score. A subgroup of 20 subjects was evaluated repeatedly for 7 weeks. For all variables, reference intervals, within-subject and between-subject biological variations, reference change values, and the indexes of individuality were assessed. Analytical performance (intermediate precision) and interlaboratory comparison were also evaluated. RESULTS: The reference ranges were 5.1-62.7 µg/L for HA, 3.56-12.6 µg/L for PIIINP, 143.6-265.3 µg/L for TIMP-1, and 7.14-9.55 for the ELF score. The within-subject variations were 32.7, 10.6, 4.2, and 3.2% for HA, PIIINP, TIMP-1, and ELF score, respectively. Similarly, the between-subject variations were 59.0, 13.3, 12.8, and 5.2%. For the ELF score, RCV was 10.1% and II was 0.62. The intermediate precisions were <5%, <6%, and <10% for HA, PIIINP, and TIMP-1, respectively. CONCLUSION: The reference range of the ELF score overlap with the area defined as moderate fibrosis by the manufacturer. High biological variation of HA was diminished by the natural logarithm in the calculation of the ELF score. The use of the ELF score has suitable analytical and acceptable biological performance characteristics for clinical practice. However, the transfer of results evaluated in healthy persons to the populations with chronic liver diseases deserves caution.

Rheological and molecular weight comparisons of approved hyaluronic acid products - preliminary standards for establishing class III medical device equivalence.

Hyaluronic acid of various molecular weights has been in use for the treatment of osteoarthritis knee pain for decades. Worldwide, these products are regulated as either as drugs or devices and in some countries as both. In the US, this class of products is regulated as Class III medical devices, which places specific regulatory requirements on developers of these materials under a Pre-Market Approval process, typically requiring data from prospective randomized controlled clinical studies. In 1984 pharmaceutical manufacturers became able to file an Abbreviated New Drug Application for approval of a generic drug, thus establishing standards for demonstrating equivalence to an existing chemical entity. Recently, the first biosimilar, or 'generic biologic', was approved. Biosimilars are biological products that are approved by the FDA because they are 'highly similar' to a reference product, and have been shown to have no clinically meaningful differences from the reference product. For devices, Class II medical devices have a pathway for declaring equivalence to an existing product by filing a 510 k application for FDA clearance. However, until recently no equivalent regulatory pathway was available to Class III devices. In this paper, we consider the critical mechanical performance parameters for intra-articular hyaluronic products to demonstrate indistinguishable characteristics. Analogous to the aforementioned pathways that allow for a demonstration of equivalence, we examine these parameters for an existing, marketed device and compare molecular weight and rheological properties of multiple batches of a similar product. We propose that this establishes a scientific rationale for establishing Class III medical device equivalence.

[Injection treatment with hyaluronic acid]. / Injektionsbehandlung mit Hyaluronsäure.

This article presents the spectrum of indications for the use of hyaluronic acid (HA) based on the recommendations of the European League Against Rheumatism (EULAR), the American College of Rheumatology (ACR), the Osteoarthritis Research Society International (OARSI), the International Institute for Health and Clinical Excellence (NICE) and the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) taking the reality of patient care in Europe into account.

[Ideas about registration for sodium hyaluronate facial derma fillers].

OBJECTIVE: To review the registration and technical data for sodium hyaluronate facial derma fillers. METHODS: Recent literature concerning registration for sodium hyaluronate facial derma fillers was reviewed and analyzed. RESULTS: The aspects on registration for sodium hyaluronate facial derma fillers include nominating the product, dividing registration unit, filling in a registration application form, preparing the technical data, developing the standard, and developing a registration specification. CONCLUSION: The main difficulty in registration is how to prepare the research data of that product, so the manufacturers need to enhance their basic research ability and work out a scientific technique routing which could ensure the safety and effectiveness of the product, also help to set up the supportive documents to medical device registration.

[Biocompatibility analysis of hyaluronic acid sodium gels for medical application].

Hyaluronan acid sodium gels are used in ophthalmic surgery, orthopedic treatment and cosmetic surgery. In 2009,there were 12 domestic manufacturers in China producing 33 kinds of products. 23 kinds of imported products were allowed by SFDA to sale in the meantime. Since manufacturers use different production processes, product performances are quite different. According to the GB/T 16886. 1-2001, we designed a pilot program to evaluate the sodium hyaluronate gel products comprehensively in this paper. The results showed that, except chromosome aberration test of gel A and subchronic systemic toxicity of gel C appeared positive, the remaining samples of the test results were negative. This article provides a reference to write standard of cross-linked hyaluronic sodium gel and the revision of standard YY0308-2004.

Size determination of hyaluronan using a gas-phase electrophoretic mobility molecular analysis.

Hyaluronan (HA) is a linear non-sulfated polysaccharide mainly found in the extracellular matrix. The size of HA can vary from a few disaccharides up to at least 25,000 units, reaching molecular weights of 10 10(3) kDa. HA has many biological functions, and both its size and tissue concentration play an important role in many physiological and pathological processes. It is relatively easy to determine the HA concentration using enzyme-linked binding protein assays, but the molecular weight of HA has so far been shown to be a more challenging task to measure. Here, we present a method for size determination of HA using gas-phase electrophoretic mobility molecular analysis (GEMMA), which utilizes the electrophoretic mobility of molecules in air to estimate the molecular weight of the analyte. We show that this method gives reliable molecular weight estimations of HA in the range of 30-2400 kDa, which covers almost its whole biological range. The average measuring time for one GEMMA spectrum is between 5 and 10 min using only 6 pg of HA. In addition, the peak area in a GEMMA spectrum can be used to estimate the HA concentration in the sample. The high sensitivity and small sample volumes make GEMMA an excellent tool for both size determinations and estimation of concentration of samples with low HA concentration, as is the case for HA extracted from small tissue samples.

[Product standard and quality control of sodium hyaluronate].

OBJECTIVE: To analyze and compare the domestic quality standard and foreign quality standard of sodium hyaluronate (HA), and to expatiate on the critical process monitoring parameters. METHODS: Different quality standards of HA were compared by translating and sorting, and some experimental data were analyzed as well as the manufacturing practice was elaborated. RESULTS: Differences exist in raw materials standard or specifications of products between domestic and foreign, but the basic control points are concordant. CONCLUSION: The company should set up reasonable and controllable quality standard based on quality requirements and related process characteristics so as to assure the safety and effectiveness of the clinical application.

Safety and effectiveness of hyaluronic acid fillers in skin of color.

OBJECTIVES: To assess the safety and effectiveness of hyaluronic acid (HA) fillers in skin of color. METHODS: Two prospective studies followed up subjects with Fitzpatrick skin phototypes of IV, V, or VI for 24 weeks after dermal filler injections. In a double-blind, randomized study, subjects were injected with one of three high concentration (24 mg/mL) HA fillers (Juvéderm Ultra, Ultra Plus, and 30) in one nasolabial fold and Zyplast collagen in the other. In an open-label, randomized study, subjects received one of three low concentration (5.5 mg/mL) HA fillers (Hylaform, Hylaform Plus, and Captique) in both nasolabial folds. RESULTS: A total of 160 subjects (a subset of 439 study subjects) were randomized and treated with one of the three high concentration fillers, and 119 subjects were randomized and treated with one of the three low concentration fillers. For subjects treated with the high concentration fillers there were no occurrences of hypersensitivity or hypertrophic scarring, and no increased incidence of hyperpigmentation or hypopigmentation in non-Caucasian vs. Caucasian subjects. For subjects treated with the low concentration fillers there were no occurrences of keloid formation, hypertrophic scarring, hypopigmentation, hypersensitivity, and three instances of mild hyperpigmentation. For all of the fillers the majority of subjects maintained >/=1 point improvement in nasolabial fold severity scores through 24 weeks. CONCLUSIONS: All of the HA fillers were well tolerated in individuals with skin of color and demonstrated effectiveness throughout the 24 week period. Furthermore, the fillers provided smooth, natural-looking wrinkle correction in darker skin types.

Standard guidelines for the use of dermal fillers.

UNLABELLED: Currently used fillers vary greatly in their sources, efficacy duration and site of deposition; detailed knowledge of these properties is essential for administering them. Indications for fillers include facial lines (wrinkles, folds), lip enhancement, facial deformities, depressed scars, periocular melanoses, sunken eyes, dermatological diseases-angular cheilitis, scleroderma, AIDS lipoatrophy, earlobe plumping, earring ptosis, hand, neck, décolleté rejuvenation. PHYSICIANS' QUALIFICATIONS: Any qualified dermatologist may use fillers after receiving adequate training in the field. This may be obtained either during postgraduation or at any workshop dedicated to the subject of fillers. The physicians should have a thorough knowledge of the anatomy of the area designated to receive an injection of fillers and the aesthetic principles involved. They should also have a thorough knowledge of the chemical nature of the material of the filler, its longevity, injection techniques, and any possible side effects. FACILITY: Fillers can be administered in the dermatologist's minor procedure room. PREOPERATIVE COUNSELING AND INFORMED CONSENT: Detailed counseling with respect to the treatment, desired effects, and longevity of the filler should be discussed with the patient. Patients should be given brochures to study and adequate opportunity to seek information. Detailed consent forms need to be completed by the patients. A consent form should include the type of filler, longevity expected and possible postoperative complications. Preoperative photography should be carried out. Choice of the filler depends on the site, type of defect, results needed, and the physician's experience. Injection technique and volume depend on the filler and the physician's preference, as outlined in these guidelines.

Hyaluronic acid versus albumin in human embryo transfer medium.

We compared the implantation and pregnancy rate through in vitro fertilization (IVF) using hyaluronic acid and albumin as transfer medium in 60 women randomly allocated to 2 groups. In treatment group A (n = 30), embryos were transferred to medium supplemented with hyaluronic acid. In the control group B (n = 30), embryos were transferred to medium containing albumin. There were no significant differences between the groups in terms of mean age of the females, mean duration of infertility and mean number of embryos. The pregnancy rate in groups A and B were 81.8% and 71.4% respectively, a non-statistically significant difference. Hyaluronic acid can successfully replace albumin as transfer medium.

Cross-linked hydrogels for middle ear packing.

OBJECTIVE: To develop an ideal supportive packing material for ossiculoplasty, tympanoplasty, or other otologic procedures. MATERIALS AND METHODS: Several materials, namely, Carbylan-SX (P-C; Sentrx Surgical, Inc., Salt Lake City, UT), Gelfoam (P-GF; Pharmacia & Upjohn, Kalamazoo, MI), and Merogel (P-MG; Medtronics, Inc., Minneapolis, MN), were prepared and then placed into a Hartley guinea pig's (Elm Hill, Chelmsford, MA) middle ear cavities through a large myringotomy incision. The contralateral ear underwent a large myringotomy without packing material being placed. Preoperative and posteroperative auditory brainstem response studies were performed using Intelligent Hearing system software. The animals were examined weekly. Two weeks after packing placement, the animals were killed, and the temporal bones were harvested. Whole temporal bone sectioning was performed to analyze the presence of implant, surrounding inflammation, presence of osteoneogenesis and fibrosis, or adhesions. RESULTS: All the materials, except the P-MG, were easy to place into the middle ear cavity. The P-MG contains woven strands that are difficult to trim into the small sizes needed for placement. The P-MG group had a smaller average amount of implant present compared with the other groups at 2 weeks. The degree of osteoneogenesis was similar among the P-GF, P-C, and P-MG groups. The P-MG and P-C groups contained the lowest amount of fibrosis between the implant and surrounding middle ear structures. CONCLUSION: This study demonstrates promising results with P-C as a potential supportive packing material for otologic procedures. P-C compares favorably with P-MG and P-GF in a guinea pig model with respect to ease of placement and amount of fibrosis.

Intra-articular hyaluronic acid in the treatment of haemophilic arthropathy of the knee. Clinical, radiological and sonographical assessment.

Hyaluronic acid has been used successfully in the treatment of osteoarthritis since 1989. There is no experience in haemophiliacs in larger study groups. In a prospective study, 20 patients (21 knees) with haemophilic arthropathy of the knee received 20 mg hyaluronic acid by intra-articular injection for 5 consecutive weeks. Assessment included clinical scores, X-ray, magnetic resonance imaging (MRI) and biomechanical motion analysis before and 3 months after the first injection. The score of the WFH advisory committee and the Aichroth score for special evaluation of the knee were used. After an average period of 26 months, the World Federation of Hemophilia (WFH) score, the Aichroth score and the visual analogue scale were evaluated again. All patients had pain caused by their arthropathy, nine of them had positive antibodies to human immunodeficiency virus, and 15 had chronic hepatitis C. The mean WFH score was 8.1 points, the Petterson score was 7.3 points and the Aichroth score was 38 points (maximum 55 points). The WFH score decreased to 7.3 points, the Aichroth score improved to 40 points and the subjective assessment measured with a visual analogue scale improved from 5.3 to 3.7 points. No differences from MRI controls were detected. After 3 months, 14 of 20 patients improved subjectively, particularly in longer walking distance, stair-climbing or initial pain. These positive aspects were limited by arthropathy in adjacent joints. After 26 months 10 patients still are benefiting for up to 31 months follow-up. The average WFH score was 7.3 points, the Aichroth score 39 points, the visual analogue scale 4.0 points. We recommend hyaluronic acid for haemophilic arthropathy of the knee when regular conservative therapy has failed and operative treatment is not feasible.