Objectives: This work aim to present some vascular complications that are typical or atypical (using cannula) which aesthetic practitioner may encounter in everyday work with nonsurgical nose jab and lip augmentation. Different protocol for complication management may result in different outcome. Aim is to show that early recognition and prompt reaction to vascular lesions are the key figure in providing the best outcome of the procedure.

Introduction: There has been an increased global demand for dermal filler injections in recent years. Although hyaluronic acid-based dermal fillers generally have a good safety profile, serious vascular complications have been reported.

Materials / method: Here we present 10 typical and atypical cases of skin ischemia and necrosis following a nonsurgical rhinoplasty and lip augmentation using hyaluronic acid filler. We provided day by day photos of our patients with vascular complications. Different protocol with hyaluronidase and rescuing management have been used. Some of the patient received hyaluronidase injections in the first 4h following th evascular impairment, whilst others received it after 24h.

Results: In 7 cases we manage to treat the complication with no scaring, but despite various rescuing managements, unsightly superficial scars were left at 3 patient. The hyaluronidase-treated aereas in the 4-h intervention group had significantly smaller necrotic areas (p<0.05), while the 24-h intervention group had no differences in the area of necrosis. Hyaluronidase reduced the vascular complications of HA fillers when used early, but there was no benefit to hyaluronidase injection after 24 h.

Conclusion: It is critical for plastic surgeons and dermatologists to be familiar with the vascular anatomy and the staging of vascular complications. Any patients suspected to experience a vascular complication should receive early management under close monitoring. Meanwhile, the potentially devastating outcome caused by illegal practice calls for stricter regulations and law enforcement.

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Objectives: To correct/ improve the tear trough deformity or palpebromalar groove deformity by double layer technique using low G prime fillers

Introduction: Eyes are important part of face.Tear trough and palpebromalar groove gives tired look to face and contribute to sadness and under eye darkness. Sometime under eye darkness is solely because of treat trough groove. These deformities formed due to interplay of loose orbicularis retaining ligament, atrophy +/_ descent of medial SOOF, deep medial cheek fat pad and protrusion of retro-bulbar fat. Correction of these deformities improve these emotional attributes of face.

Materials / method: supporting loose orbicularis retaining ligament and replacing fat pads is key in correcting tear trough deformity or palpebromalar groove deformity. Injecting low g prime Hyaluronic acid filler under orbicularis oculi muscle in groove by cannula in medial part and by needle in lateral part supports loose retaining ligament and spreading small amount of same filler by cannula above muscle in tear trough area corrects fine irregularity not corrected by deep injection.This not only improves tear trough but also correct mild to moderate eye bags.

Results: showing 6 cases of tear trough correction with good improvement with technique described above

Conclusion: Double layer technique is effective and safe technique to effectively correct tear trough and palpebromalar deformity.

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Objectives: How to recognize and treat the peri-orbital over-correction and/or fillers complications

Introduction: Hyaluronic Acid (HA) has been used in the periorbital area for over 20 years. Appropriate selection and placement of products helps avoid complications. However, apparent incorrect or excessive placement of product may not always appear so initially and may present as a complication when patients request further repeat or top-up treatments some time later.

Materials / method: We present 25 female patients with HA complications related to incorrect or excessive placement in the periorbital area. All patients presented requesting improvement of contour irregularities with a translucid mass under the skin. Ecography showed foreign material in all cases. Due to the accumulation without signs of inflammation and/or infection. All patients received Hyaluronidase injection. Pictures were taken and ecography post injection was repeated.

Results: All patients had good results that were well seen on the pictures and were documented by ecography. All were very satisfied. One patient had changes in skin quality with a depression requiring filler injection to achieve a final good result.

Conclusion: Periorbital HA related over-fill, or prominence can appear late as irregularities or greyish discolouration. It is important to consider and be familliar with the use of hyaluronidase for such cases.

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Objectives: The author presents a detailed technique of infraorbital area treatment with agarose gel filler. The technique is based on personal experience and analysis of published data. The proposal of the treatment is not only good aesthetic outcome, but also the attempt to avoid numerous manipulations of the area and consequently less side effects.

Introduction: Infraorbital area represents one of the most important units of facial anatomy in terms of requests of correction. Not only age-related signs, but also genetically determined hollowing are disturbing for the patients. The atrophy of infraorbital area can involve tear trough, palpebro-malar groove and anteromedial cheek area. It’s important to make a correct pre-treatment evaluation and consequent specific treatment for each area.

Materials / method: 10 patients (2 M, 8 F) were selected for the treatment of tear trough, palpebro-malar groove, anteromedial cheek after pre-treatment evaluation. Agarose gel filler was injected through 25 or 22 G cannula. The injection volume was adapted to the atrophy grade.
Follow up at 1 and 3 months.

Results: Subjective evaluation by patients reveals very good aesthetic outcome. There were few side effects in terms of moderate swelling (2 persons). No bruises or other side effects drawn attention.

Conclusion: Agarose gel filler represents a good alternative to commonly used fillers for the correction of infraorbital area: totally natural product without hydrophilic effect, low migration rate, good tolerability. The described cannula technique seems to guarantee less trauma and less side effect.

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Objectives: The aim of this work was to demonstrate that CaHa can be used in difficult areas such as cheeks, neck, and décolleté with significant results without losing the elastic capacities of relaxation and neocollagenogenesis. Difficult body areas such as the inside of the arms and knees were also treated.

Introduction: Calcium hydroxylapatite is also used in the treatment of skin aging, thanks to its biostimulant properties.
Using the product with greater dilutions than its use as volumizing, it is possible to obtain a wide superficial diffusion of the material in the treated area, thus determining its distension and improving the skin texture. Recent work has shown that the rheological properties of hyperdilution material do not change.
Significant results have been obtained thanks to the effect on the stimulation of new collagen fibers, a greater effect of relaxation of superficial wrinkles due to the reac

Materials / method: 1.5 ml of Ca hydroxylapatite in 116 patients, The amount of material injected was in almost all cases 1.5 ml, in 3 cases 0.8 ml.
The dilution varied according to the areas to be treated: for the cheeks and neck 1.5 ml Caha + 4.0 ml physiological and 0.5 ml lidocaine for the décolleté 1.5 ml + 5.5 ml physiological + 0.5 ml lidocaine. Microcannules of 25 and 27 G
With 0.8 ml dilution with 3 physiological ml and 0.5 ml lidocaine. A cross-linked or cross-fan
Inclusion criteria: age between 35 and 72 years.
Clinical check and confirmation: immediate, 1 month, 6 months.

Results: The results were positive in almost all the cases treated, with an improvement in the texture already at a distance of one month and an evident immediate cutaneous cut.
In about 30% of cases, a touch-up was carried out after three months.

Conclusion: The treatment with this "off label" dilution did not alter the elasticity and regenerative potential of this filler which determines a different cutaneous effect compared to a hyaluronic acid, favoring the distension with respect to the volumization.

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Objectives: Objective of treatment is don't just volumize but individualize faces. Tailoring your procedures by detailed history, accessing, planning, choice of products, choice of technique and injecting, tailoring the face according to age, whether it falls in enhancement category [20 plus], restoring category [30 plus], rejuvenating category[40 plus],tailoring with respect of structural and morphological component of face, tailoring according to their ethnic and cultural backgrounds with harmony n proportion, by joining the puzzles of deep structure building to skin rejuvenation and creating natural fa

Introduction: In reality harmonious facial aesthetics can only be achieved through a comprehensive assessment & total facial approach that can only be reached by COMBINING THE TREATMENTS from contouring with hyaluronic acid, rejuvenating with calcium hydroxyapetite relaxing the muscles with botulinum toxin and lifting with sustainable threads, which means all products have different indication and combining them give aesthetically pleasing results

Materials / method: Picture of patients will be shared on whom different products are used to create 6/10 faces into 9/10, in this presentation we will discuss about 3D evaluation of faces & planning their treatment corresponding to budget as it is still a challenge for us and patients, listening carefully and engaging actively will earn the long term loyalty of patient, it is important for the medical aesthetic community to bring up the awareness of overfilled syndromes and prevent this happening

Results: Incorrectly placed products, poor selection of products, overzealous attempts by injectors, and overly enthusiastic clients who chase the lines are result of disasters in practices loss their topography and lose their identity & they keep on chasing for better results change doctors & get overfilled. No single manoeuvre can address the multitude of changes that occur with facial ageing, customised, individually adapted treatment with the toxins n advanced dermal fillers injection techniques with biodegradable dermal filler materials helps deliver subtle results in aesthetically appealing way.

Conclusion: Nonsurgical face lifts & contours are one of the leading treatments done in our practices and what we are mostly taught in conferences but, "WHY FILLERS AND BOTOX ARE EASY TO LEARN STILL DIFFICULT TO MASTER" the integrated approach with neurotoxins along with HA complementing the gender n age of patients, patient’s assessment, well formulated treatment plan, knowledge of anatomy, technique, with access to superficial to deep rhytides & volume restoration can maximize patients satisfaction and lead to successful outcome while minimizing complications

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Objectives: This lecture is going to introduce the comprehensive strategy of injection and threads lifting in upper, middle and lower facial rejuvenation in Asian patients. This strategy provides the evaluation of the Asian facial aging status and can make the doctor to provide the comprehensive treatment plan for improving facial rejuvenation.

Introduction: During the recent years, minimally invasive facial rejuvenation treatments had been brought to attention because of various methods of injection and threat lifting. The singleness of previous facial rejuvenation therapy had limitations. Therefore, the indication of comprehensive strategy has become more significance in facial rejuvenation.

Materials / method: According to the author’s experiences in recent 2 years, we retrospectively reviewed all the patients who underwent facial rejuvenation procedures by using comprehensive evaluation methods with the suggestion of the comprehensive treatments. We separated the face into three compartments with upper, middle and lower compartments and by injection of Botulinum toxin, lipofilling , threat lifting and facial liposuction , the result of comprehensive treatments was effective with reduce down-time and stable results during follow up.

Results: All patients who underwent comprehensive procedures was satisfied with the results. For botulinum toxin injection the recovery period was 1-3 days with the effect started after one week. For hyaluronic acid filler injection with 2-5 days recovery time and persistence of effect for 6-12 months with or without retouch. For lipofilling , it has 4-7 days of downtime and retouched after one month post-op with the stable results after 2-4 times injections according to individuals. Lastly the downtime of thread-lifting was 3-7 days with the high satisfaction after one year follow up ( combination of

Conclusion: The combination of injections and threat-lifting treatments and the sequential treatment strategy can enhance the safety with high patient satisfaction and stable results in facial rejuvenation in Asian population.

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Objectives: This paper aims to improve the understanding of the dangers of periorbital and midface filler injection through the study of anatomy.

We present clinical cases of severe vascular and infective complications, and correlate clinical scenarios to radiological (MRI/MRA) studies, anatomical dissection of the lymphatic anatomy, and ICG studies.

Introduction: Lower eyelid and midface filler injections are among the most common non-surgical procedures performed for facial rejuvenation. Complications, although uncommon, can be devastating and include vascular compromise and infection leading to abscess formation.

Materials / method: Case discussions: we present cases of major intravascular injection and severe infection and abscess formation from peri-orbital injections.

Clinical cases are correlated with radiological studies (MRI and MRA), as well as anatomical dissection and ICG studies.

Results: Radiological studies: MRI and MRA studies are correlated with anatomical dissection to examine potential sites of intravascular injection.

Cadaveric Dissection and ICG Study: accompanying lymphatic studies establish lymphatic vessels lie both superficial and deep to SMAS. These provide a potential pathway for infection from either plane to track in either direction within the lymphatic system. ICG injections demonstrate clearly the occurrence of retrograde flow in the lymphatics making it possible for superficial infections to spread post-septally.

Conclusion: Although a fantastic tool in the armament of the aesthetic surgeon, injectable fillers have known severe complications including vascular compromise and severe infections. With increasing knowledge of the vascular and lymphatic anatomy, we are in a better position to understand and prevent complications. Nevertheless, care must be taken when conducting these procedures in order to avoid this serious complication.

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Objectives: The aim of the study was to assess the efficacy and persistence of eyebrows lifting after resilient HA filler injection.

Introduction: Ptosis of eyebrows is a sign of aging face and it is partially due to decrease of bone volume with age and partially to skin that tends to become uneven in color, roughened, lax and wrinkled. Today, a three-dimensional approach with injectable fillers prevails over previous techniques in which this materials were used in specific areas of the face: “lifting” effect in order to provide a “natural look”. Hyaluronic acid (HA) is the most common filler used to rejuvenate this area.

Materials / method: Patients with eyebrow’s ptosis were prospectively enrolled. Resilient HA filler (volume range 0.3-0.6 ml per side) was injected with a 30 Gauge needle on the periosteum in the lateral third of the eyebrow. Every patient was followed-up every 3 months with photographic evaluation, 3D-high-resolution camera with measurement of the distance between ocular lateral cantus and eyebrow tail (LCE) and GAIS until the disappearance of the correction of the ptosis which was defined as pre-treatment LCE.

Results: 20 female patients were enrolled, range of age 42-65 yrs old. Treatment resulted in a significant elongation of LCE compared to baseline: median +3,6 mm compared to baseline. GAIS revealed an overall improvement with a score >2 in 87% of patients. Percentage of patients who remained corrected after the treatment was 97%, 92%, 78%, 65% and 30% at 3, 6, 9, 12 and 15 months respectively. Lifting of eyebrows last at maximum 18 months in 4 patients (20%).

Conclusion: Eyebrows lifting performed with resilient HA filler offers a natural and prolonged result with a high degree of patients’ satisfaction.

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