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was found to have a significantly lower WSRS rating than Autologous fat
Hylaform Plus®. [29] For more than a century, autologous fat transfer has been
utilized for soft tissue secondary to its advantages including
A randomized, split-face study was conducted for 12 months the absence of immune reaction and the feasibility in using
to assess the efficacy and safety of three HA formulations: large volumes. However, it suffers from various drawbacks
HA-1 (Belotero Basic/Balance), HA-2 (Restylane), and HA-3 including prior fat extraction from another source, and the
(Juvéderm Ultra 3/Juvéderm Ultra Plus XC) in the treatment inconsistent quality of fat due to the extraction technique.
of nasolabial folds. Participants were randomly assigned
[30]
[33]
to one of two study groups, each with twenty participants. A retrospective clinical study conducted by Kanchwala et al.
Each participant in group 1 received HA-1 on one side examined facial volume augmentation and wrinkle reduction
and HA-2 on the other, whereas participants in group 2 in 976 patients who received autologous fat, Restylane®,
received HA-1 on one side and HA-3 on the other. Fillers Hylaform® or Radiesse®. Patients were followed at least 1
were administered at the baseline visit, which took place year from the time of injection for an assessment of infection
during the initial phase, with follow-up injections at months rate, revision rate, and overall longevity. In this study, 378
1, 6, 9, and 12. All three of the HA formulations showed patients had theirnasolabial folds treated with autologous
minimal adverse reactions, the most common of which was fat. Self-limited bruising and swelling were observed 2-3 days
erythema. The mean pre-treatment and post-treatment after fat injection. Ten percent of patients required a second
nasolabial fold severity ratings did not show statistically treatment 6-12 months following the first treatment, and the
significant differences between the groups. overall longevity was shown to be greater than 12 months.
[30]
Forty-one and twenty-six patients received treatment of
HA is the most widely used filler yet has a relatively short their nasolabial folds with Restylane® and Hylaform®,
duration of action, resulting in the need for constant respectively. Although only minimal complications were
maintenance with frequent injections for optimal observed, they lasted for, on average, 4.5 and 3 months
[31]
treatment. Recently, HA has been combined with for Restylane® and Hylaform®, respectively. One hundred
radiofrequency (RF) devices to prolong the duration of action and two patients were treated with Radiesse® for their
of HA, reducing the need for maintenance injections. [31,32] RF nasolabial folds, and mild-to-moderate swelling was found
treatment has been found to play a crucial role in collagen at the injection sites for 24 h maximum. Twenty percent of
remodeling, skin tightening, and collagen deposition, but patients required a second treatment at the same injection
has a limited capacity to restore lost volume. Combination site less than 3 months following the first injection, and
[32]
therapy in which RF is used immediately prior to treatment longevity was 11 months on average. Significant swelling
with a HA can compensate for both products’ limitations and bruising that lasted for 1-2 weeks were noted in 87
patients who received autologous fat for lip augmentation,
while providing better treatment. Combination therapy was with nearly 30% of them requiring a second injection within
evaluated in both animal and human clinical studies where 6 months secondary to variable resorption. Overall longevity
RF was delivered through an intradermal needle to creat was greater than 12 months. Twenty-four patients received
tunnel-like setting inside the dermis and hypodermis. This Restylane® for lip augmentation with effects lasting for
theoretically acts as a barrier to external oxygen radicals and 4.5 months, while 17 patients received Hylaform® with
[31]
contains the HA filler, restricting its spread. The results of 3-month longevity and slightly more swelling for 1-3 days.
the animal study showed that RF treatment could increase Twenty percent of patients required a second injection 3
procollagen production with time. The total volume was months following the first injection. [33]
substantially increased with the RF treatment as compared
to HA filler injections alone [Figure 2]. Specifically, in the Biodegradable and non-permanent fillers last only for a few
areas injected, small filler particles were observed in the months, which is suboptimal in cases where maintenance
dermis. At sites injected with fillers following RF treatment, and cost are issues. This problem gave rise to the advent of
linear continuous filler distribution was observed in the semi-permanent fillers as discussed in the next section.
mid-dermis, and in the lower dermis of sites treated with
the tunneling method [Figure 2B]. The ECM components and Semi-permanent fillers
dermis were stained with Masson's trichrome and Verhoeff- Polymethyl methacrylate microspheres
Van Gieson, respectively. Enhancement of collagen bundle PMMA is a non-biodegradable, biocompatible, synthetic
deposition and fibroplasia was observed with Masson’s polymer used in various medical devices. Bovine collagen
trichrome while the formation of short elastin fibers was injections on the human face have been found to last only for
observed with Verhoeff-Van Gieson staining [Figure 2B]. 3 to 6 months, giving rise to the use of PMMA microspheres
It is thus believed that the combination therapy of HA as intradermal fillers. The main advantage of microspheres
[34]
filler injection with RF is a biocompatible and long-lasting is their size of 30-40 μm in diameter, which is small enough
improvement in skin rejuvenation. to pass through a needle but still large enough to avoid
phagocytosis. [35]
Although HA has shown excellent biocompatibility and
efficacy in facial volumization, it has side effects including Arteplast®, the first mixture which contained 20% PMMA and
erythema, bruising, induration and edema. More importantly, 80% bovine collagen, was noted to give rise to foreign body
they are all short-lived and therefore are of limited use in reactions due to the presence of a number of microspheres
[35]
patients looking for longer lasting solutions. less than 20 μm which made them prone to phagocytosis.
Plast Aesthet Res || Vol 3 || Mar 23, 2016 77