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Background: Calcium hydroxyapatite (CaHA)-carboxymethylcellulose (CMC)+ has unique properties that make it optimal for lifting, contouring, and defining the jawline. This long-term follow-up of a randomized, multicenter, rater-blinded trial reports efficacy and safety of CaHA-CMC(+) through 48 and up to 60 weeks post-treatment., Methods: Eligible patients were randomized (2:1) to the treatment or the control/delayed treatment group to receive CaHA-CMC(+) injections in both jawlines. While touch-ups were permitted 4 weeks post-treatment for both groups, only the treatment group was eligible for optional retreatment after 48 weeks. The primary outcome was ≥1-point improvement on both jawlines on the Merz Jawline Assessment Scale (MJAS); secondary endpoints included the Subject Global Aesthetic Improvement Scale (SGAIS) among others. Post hoc analysis included pooling up to 48-week data from the combined treatment and control/delayed groups and 60-week data for the treatment group., Results: Overall, 175 received treatment. MJAS responder rates were 77.9%, 78.7%, and 62.9% at 12, 24, and 48 weeks post-treatment, respectively. Responder rate on the MJAS at 60 weeks was 74.6% for those who received retreatment and 43.5% for those patients who received only the initial and touchup treatments. SGAIS scores demonstrated 93.4%, 85.6%, and 68.5% of patients rated themselves very much improved after 12, 24, and 48 weeks, respectively. Adverse events consisted of procedure or CaHA-CMC(+)-related events that were mostly resolved and overwhelmingly mild., Conclusions: CaHA-CMC(+) produced clinically meaningful and long-lasting improvements in jawline contour and was well tolerated in patients through 60 weeks., Trial Registration: ClinicalTrials.gov Identifier: NCT03583359., (© 2024 The Author(s). Journal of Cosmetic Dermatology published by Wiley Periodicals LLC.)

Background: Vascular adverse events (VAEs) occurring during injections of soft-tissue fillers are still considered a challenging issue for both patients and practitioners. Hyaluronidase can dissolve hyaluronic acid (HA)-based soft-tissue fillers during a VAE. For VAEs induced by non-HA fillers, the absence of an "antidote" is regarded as exceptionally challenging., Methods: This multicenter study describes a case series of three VAEs induced by non-HA fillers, for which ultrasound-guided hyaluronidase injections were incorporated into the treatment approach., Results: Two cases of calcium hydroxylapatite and one case of poly-L-lactic acid-induced VAEs are described, all of which were resolved without necrosis or scarring using a treatment approach with ultrasound-guided hyaluronidase injections., Conclusions: Unlike the mechanical hypothesis, which assumes filler particles travel antegrade to block arterioles in a large skin area, we hypothesize vasoconstriction as the pivot in VAEs. Filler injection-induced spasms could lead to long-lasting vasoconstriction of the perforator arteries stemming from the central facial arteries. Our results underscore that perforasome vasoconstriction might be the leading cause of the ischemia and subsequent necrosis in VAEs and that relaxation of these perforasomes, rather than dissolving the filler material, resolves the clinical symptoms associated with VAEs., (© 2024 the International Society of Dermatology.)

Filler-induced alopecia is a transient alopecia characterized by localized hair loss and often attributed to vascular compromise following dermal filler injections in facial regions. Although an uncommon phenomenon, the rising incidence of filler-induced alopecia underscores the importance of understanding and managing this condition. We performed an extensive PubMed review of articles reporting filler-induced alopecia and summarizing the implicated filler types, injection areas, hair loss patterns, symptom onset, course progression, treatments, and prognosis. Hyaluronic acid injections were the most implicated in filler-induced alopecia cases, with calcium hydroxylapatite and autologous fat less frequently associated. No cases involved other dermal filler types. Although recovery times varied depending on the treatment, hyaluronidase (HAase) injections rapidly restored near-normal hair density within 3-4 months. Minoxidil and platelet-rich plasma play a more minor role in restoring hair growth but may be used as adjuncts with HAase to facilitate hair growth. Finally, alternative interventions like intralesional triamcinolone, warm compresses, and nitroglycerin warrant exploration, given limited robust clinical data. Our study promotes awareness of filler-induced alopecia's rising incidence and offers practical insights and evidence-based recommendations for effective management. By equipping dermatologists with this knowledge, our aim is to improve patient outcomes and reduce adverse events in filler-based procedures., (© 2024 the International Society of Dermatology.)

Background: Complications of temporary and permanent fillers have been extensively studied. However, there is a lack of comparative data regarding poly-L-lactic acid (PLLA), calcium hydroxyapatite (CaHA), and polycaprolactone (PCL) known as collagen biostimulators., Aims: This study addressed the complications of collagen biostimulators concerning their diagnosis, type of product, treatment, and monitoring., Patients/methods: An electronic questionnaire was sent to Brazilian dermatologic ultrasound experts to identify complications related to biostimulators. The type of biostimulator, location of application, number of vials injected, application plan, time between injection treatment and complication, injector profile, treatment, and prognosis were assessed., Results: Fifty-five cases were identified, of which 49.1% were caused by PLLA-Elleva®, 23.6% by CaHA (alone or combined with hyaluronic acid), 20.0% by PLLA-Sculptra®, and 7.3% by PCL. The most affected area was the face (72.7%), with nodules being the most common clinical form (89.1%), generally occurring late (60.0%) (>1 month). Only one case was injected at an incorrect depth (musculoaponeurotic system-SMAS). Despite several treatments, including saline (45.5%), hyaluronidase (25.5%), diluted corticosteroids (23.6%), and energy-based devices (10.9%), only five cases showed complete resolution. Hyaluronidase was beneficial in complications related to fillers when there was an association of calcium hydroxyapatite with hyaluronic acid (p < 0.01)., Conclusions: Complications from collagen biostimulators were more common on the face, typically manifesting about 1 month after treatment. These issues seemed to be related more to the properties of the products rather than inadequate technique. Furthermore, hyaluronidase demonstrated efficacy only in cases where there was an association with HA., (© 2024 The Authors. Journal of Cosmetic Dermatology published by Wiley Periodicals LLC.)

Background: Dermal fillers are widely used for facial rejuvenation and esthetic enhancement, offering temporary solutions for aging and volume loss. Despite their general safety, a rare but severe complication associated with these fillers is visual impairment, including blindness. This underscores the need for a thorough understanding of risks associated with various filler materials. Historical cases of blindness following filler injections date back to 1963, with increasing reports linked to the expansion of the cosmetic filler industry. While hyaluronic acid (HA) and autologous fat have been extensively studied, other fillers such as calcium hydroxylapatite and poly-l-lactic acid (PLLA) are less understood., Objective: This systematic review aims to address gaps in the literature by providing a comprehensive overview of visual impairment caused by fillers other than HA and autologous fat. We systematically examine the prevalence, causes, clinical features, and treatment outcomes associated with these less common fillers., Materials and Methods: A comprehensive literature search was conducted across databases including PubMed, Scopus, and Google Scholar using terms related to visual impairment and dermal fillers. Studies published between 2014 and 2021, including observational studies and case reports, were included. Studies were selected based on predefined inclusion and exclusion criteria, and a PRISMA flow diagram was used to illustrate the study selection process., Results: The review identifies and summarizes cases of visual impairment associated with calcium hydroxylapatite, poly-d,l-lactic acid (PDLLA), and PLLA fillers. Key findings reveal that visual impairment following these fillers is rare but can occur suddenly or within a few days of the procedure. Cases of delayed onset up to two weeks are also noted, emphasizing the need for extended post-procedure monitoring., Discussion: The review highlights unique insights into the risks associated with non-HA fillers, such as the heightened risk in the periorbital region and other facial areas. It explores mechanisms of complications, including retrograde flow of emboli leading to retinal ischemia. The discussion also covers emergency protocols and preventative measures, providing valuable guidance for managing and mitigating risks., Conclusions: Visual impairment caused by fillers other than HA and autologous fat, while rare, represents a serious complication that requires careful attention. This review contributes new perspectives on the differential risks of various fillers, symptom onset variability, and anatomical risk factors. Emphasizing the importance of proper patient selection, technique, and monitoring, it calls for further research to better understand and prevent these complications, ultimately aiming for safer and more effective use of soft-tissue fillers.

A filler composed of calcium hydroxylapatite and carboxymethylcellulose gel (CaHA/CMC) has been shown to possess biostimulatory and skin-tightening properties that have been applied not just to the face but also to the body to boost rejuvenation. Recently, evidence and recommendations for CaHA/CMC treatment of the face have been provided, but they are still lacking in terms of body treatment. This article aims to perform a systematic review of the literature on CaHA/CMC applications on the body and provide evidence from the literature. Currently, the only FDA-approved indication on the body is treating the hands and a recent European Union Medical Device Regulation approval has been released for decolletage treatment. The application of hyperdilutions on the neck, feet, arms, thighs, abdomen, and other body parts has been proven to provide a skin-tightening effect. However, despite their wide use with a good safety profile in clinical practice, recent trends and guidelines of diluted and hyperdiluted CaHA/CMC have yet to be supported by randomized controlled trials., (© 2024 the International Society of Dermatology.)

Background: Calcium hydroxylapatite (CaHA) dermal filler is used for a variety of aesthetic treatments; however, the safety and effectiveness of diluted CaHA for the treatment of d&eacute;collet&eacute; wrinkles have not been established., Objective: To demonstrate the effectiveness and safety of diluted CaHA (Radiesse; 1:2 CaHA:saline) injection for the improvement of d&eacute;collet&eacute; wrinkles in females., Methods: Eligible females with moderate or severe ratings on the Merz Aesthetic Scale (MAS) Decollete Wrinkles - At Rest received up to 3 injection cycles of diluted CaHA either 8 weeks apart (3 injection cycles) or 16 weeks apart (2 injection cycles). Effectiveness was evaluated by improvement on the MAS. Adverse events were recorded over a 52 week period., Results: Sixteen weeks after the last treatment, the response rate (1-point improvement or greater) on the MAS Decollete Wrinkles - At Rest was 73.5% (P&lt;0.0001; pooled sample) for all patients. The use of diluted CaHA in the decollete also demonstrated a favorable safety profile., Conclusions: Diluted CaHA is a safe and effective treatment for the improvement of decollete wrinkles in females.J Drugs Dermatol. 2024;23(7):551-556.&nbsp; doi:10.36849/JDD.8261.

Radiesse ® is a filler composed of calcium hydroxylapatite microspheres suspended in a carboxymethylcellulose gel (CaHA/CMC). It has robust rheological properties that have been associated with its versatility. CaHA/CMC is employed for both on-label indications of filling wrinkles or lines, volumizing, and contouring of areas as well as off-label indications aiming at biostimulation and skin tightening. However, despite the expanding use of CaHA/CMC, overall evidence and recommendations for treatment are currently lacking. This paper aims to provide an up-to-date overview of CaHA/CMC clinical applications, together with a level of evidence of supporting literature, focusing on the face. Based on the data, CaHA/CMC may be considered a safe and effective treatment option for cheeks, jawline, HIV-related facial lipoatrophy, and nasolabial folds. Treatment of marionette lines, chin, pre-jowl, and corner of the mouth also tends to respond with a high degree of efficacy. Despite the recent trend, guidelines, and safety profile of diluted and hyperdiluted Radiesse ® , no randomized controlled trials have been published., (© 2023 the International Society of Dermatology.)

Purpose: Infection at the pin site remains the most common complication of external fixators (EFs). It is known that hydroxyapatite (HA)-coated pins increase bone adhesion and may lead to reduced rates of reported infections. The present study compares the rates of pin track infection associated with stainless steel and HA-coated pins., Methods: This is a prospective, multicenter, nonrandomized, comparative intervention study among patients undergoing surgical treatment with EFs of any type between April 2018 and October 2021. Patients were followed up until the removal of the EF, or the end of the study period (ranging from 1 to 27.6 months). The definition of pin track infection was based upon the Maz-Oxford-Nuffield (MON) pin infection grading system., Results: Overall, 132 patients undergoing external fixation surgery were included. Of these, 94 (71.2%) were male, with a mean age of 36.9 years (SD ± 18.9). Infection of any type (score > 1) was observed in 63 (47.7%) patients. Coated and uncoated-pin track-infection occurred in 45.7% and 48.5% of patients, respectively (P= 0.0887). The probability of developing infection (defined as a score ≥ 2) adjusted for comorbidities and follow-up time was not statistically higher among those who received uncoated pins compared to those who received pins coated with HA (odds ratio (OR) = 1.56, 95% confidence interval (95% CI): 0.67-3.67, p <0.05)., Conclusion: In the present study, the external fixator pin infection rates were similar when using HA coating and standard steel pins., (© 2023. The Author(s) under exclusive licence to SICOT aisbl.)

Introduction: Vocal fold injection augmentation is performed routinely for the treatment of glottic insufficiency especially due to unilateral vocal fold paralysis. There are numerous materials that are used for injection laryngoplasty, calcium hydroxylapatite being one of them., Case Report: We present an interesting case of a 64-year-old male patient with metastatic acinic cell carcinoma of the right parotid gland, who underwent right vocal cord injection laryngoplasty with calcium hydroxylapatite for right vocal cord paralysis with glottal insufficiency and developed a neck abscess., Discussion: This is the first report in the literature of neck abscess following vocal fold injection laryngoplasty using calcium hydroxylapatite. It seems that over injection of the vocal fold gave rise to extravasation of the injected material outside the laryngeal framework which later became a nidus for infection., Conclusions: We present the first case in the literature of neck abscess following vocal fold injection laryngoplasty using calcium hydroxylapatite. Clinicians should be aware of this rare but dangerous complication., (Copyright © 2020 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Purpose: This study aimed to evaluate the mid-term efficacy and safety of Escherichia coli-derived bone morphogenetic protein-2 (E.BMP-2)/hydroxyapatite (HA) in lumbar posterolateral fusion (PLF)., Methods: This multicenter, evaluator-blinded, observational study utilized prospectively collected clinical data. We enrolled 74 patients who underwent lumbar PLF and had previously participated in the BA06-CP01 clinical study, which compared the short-term outcomes of E.BMP-2 with an auto-iliac bone graft (AIBG). Radiographs and CT scans were analyzed to evaluate fusion grade at 12, 24, and 36 months. Visual analog scale (VAS), Oswestry disability index (ODI), and Short Form-36 (SF-36) scores were measured preoperatively and at 36 months after surgery. All adverse events in this study were assessed for its relationship with E.BMP-2., Results: The fusion grade of the E.BMP-2 group (4.91 ± 0.41) was superior to that of the AIBG group (4.25 ± 1.26) in CT scans at 36 months after surgery (p = 0.007). Non-union cases were 4.3% in the E.BMP-2 and 16.7% in the AIBG. Both groups showed improvement in pain VAS, ODI, and SF-36 scores when compared to the baseline values, and there were no statistically significant differences between the two groups. No treatment-related serious adverse reactions were observed in either group. No neoplasm-related adverse events occurred in the E.BMP-2 group., Conclusions: The fusion quality of E.BMP-2/HA was superior to that of AIBG. E.BMP-2/HA showed comparable mid-term outcomes to that of AIBG in terms of efficacy and safety in one-level lumbar PLF surgery., (© 2022. The Author(s).)

Background: Although much has been published on the use of poly-L-lactic acid (PLLA) and calcium hydroxyapatite (CaHA) for off-face indications, questions remain regarding their exact mechanisms of action in subcutaneous tissue and their comparative efficacy., Objective: To present the clinical and histological results of the PLLA and CaHA injections into the opposing arms of the same patients., Methods: Five women received superficial subcutaneous injections of PLLA into the left arm and CaHA into the right arm. After three sessions, the clinical and histological outcomes were analyzed., Results: After the first session, three patients showed improvement in the right arm (CaHA), but at the end of study, two patients showed better results in the left arm (PLLA). Histologically, moderate to intense lymphocytic and giant cell infiltrate, as well as collagen and elastic fiber neoformation, were observed equally near the particles of both products. Dermis had no inflammatory or fiber alterations., Conclusion: In this study, there were no clinical differences between these two fillers. Despite current thinking and previous histological studies, we found both products produced moderate to intense inflammatory reaction, as well as collagenic/elastogenic fiber neoformation, only in the subcutaneous tissue of the immediate vicinity and surrounding the individual filler particles., (© 2022 Wiley Periodicals LLC.)

This case study presents an abnormal complication after routine injection augmentation using calcium hydroxylapatite (CaHA) vocal fold filler in-office on a 73-year-old female. The patient presented initially with severe dysphonia, hypophonia, and a past surgical history of total thyroidectomy, bilateral neck dissection, and a right lateral neck dissection for history of metastatic papillary thyroid carcinoma. She also had a past medical history of hypothyroidism. Post-injection of CaHA, the patient developed severe laryngeal edema, limited vocal cord mobility, obliteration of the pyriform, and a significantly reduced airway aperture requiring intensive care monitoring. Although uncommon, injectable fillers can result in complications which can be severe. Careful technique, the volume of injectate, and hypersensitivity should be considered in reducing complications following injection augmentation. There are multiple injection techniques to consider. The most direct approach is with direct laryngoscopy to allow for visualization of glottic incompetence. A smaller slotted laryngoscope can be considered for vocal fold injection as an alternative and without endotracheal intubation. Although these techniques allow for injection, real-time assessment of vocal fold closure is done in an awake patient. Therefore, laryngeal injection can be considered via percutaneous, per-oral, and trans-nasal approaches.

Objective: Synthetic hydroxyapatite (HA) and its related materials have made great progress in basic research and clinical application in spinal repair and reconstruction. However, the effect of HA and its composites used in spinal fusion still remained controversial. This meta-analysis aimed at evaluating the efficacy and safety of HA compared with autologous bone., Materials and Methods: A systematic search in PubMed, MEDLINE, China National Knowledge Internet, EMBASE, and the Cochrane Library was conducted for relevant studies from inception until May 2021. Studies investigating the application of HA and its related composites in spinal fusion were selected for analysis., Results: The operation time of patients treated with artificial bone containing HA was less than that of patients with autologous bone (p = 0.02). The amount of operative blood loss in patients in the HA group was less than that in the autograft group (p = 0.007). Patients treated with autologous bone got a more significant advantage in fusion rate at 6 months (p = 0.009). Nevertheless, there was no significant difference in the fusion rate between patients in the two groups at 12 months or no less than 24 months postoperatively (p = 0.24; p = 0.87). Compared to the autograft group, the HA group significantly decreased postoperative adverse events (p = 0.03). Furthermore, there was no significant difference in the Oswestry Disability Index (p = 1.00) nor the Visual Analogue Scale score (p = 0.94) between the two groups., Conclusions: This meta-analysis suggests that the clinical application of HA and its related composite materials in spinal reconstruction is comparable to that of autologous bone, with satisfactory efficacy and safety.

Tear trough deformity is a popular target for the treatment with filler injections. The side effects are generally mild and transient. However, delayed complications may occur. We aim to perform a thorough systematic review of the published literature related to delayed complications after tear trough filler injections. A search of published literature was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in June 2021 and included PubMed, ScienceDirect, and Embase databases. The Medical Subject Headings (MeSH) terms used included the following terms: delayed complications, nodules, granulomas, swelling, discoloration, dermal filler, hyaluronic acid (HA), polyacrylamide, calcium hydroxyapatite (CaHA), poly-L-lactic acid (PLLA), eyelid, periorbital, periocular, and tear trough. Twenty-eight articles consisting of 52 individual cases were included in the final analysis. 98% (51/52) of patients were female and had an average age of 48.3 years. HA was the most reported product (71.2%, 37/52), followed by PLLA (4/52, 7.7%), and CaHA (4/52, 7.7%). The most common delayed complication with any dermal filler was swelling (42.3%, 22/52) followed by lumps or nodules (25.0%, 13/52). Xanthelasma-like reaction (17.3%, 9/52), migration (7.7%, 4/52), discoloration (3%, 3/52) also occurred. The average time of onset of any complication was 16.8 months with xanthelasma-like reaction appearing soonest (mean: 10 months) and discoloration appearing latest (mean: 52 months). Most swelling cases were caused by HA. Semi-permanent fillers such as PMMA and synthetic fillers such as PLLA were more likely to be associated with lumps and nodules than other complications. It is important that clinicians who perform tear trough augmentation with dermal fillers have a thorough understanding of the risks of the procedure to diagnose and manage them promptly as well as provide patients with accurate information regarding the potential adverse effects., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: In total, 2.7 million injectable filler treatments were performed in 2019 in the United States. Although generally considered to be a safe treatment modality, adverse events may occur in rare situations., Objective: Analyze serious adverse events from injectable filler treatments, including infections, cutaneous necrosis, blindness, or delayed-onset nodule formation, spanning 11 years for 3 board-certified dermatologists and review their incidence, management, and outcomes., Materials and Methods: A retrospective analysis was performed of injectable filler treatments spanning 11 years at a multipractitioner outpatient clinic. Serious adverse events were identified, and treatment measures were documented. A literature search was performed to determine recent trends and outcomes for comparison., Results: Between January 2009 and August 2020, 18,013 mL of injectable filler was administered to 7,659 patients. Of the 18,013 mL administered, 74.1% comprised hyaluronic acid derivatives, 19.19% poly-l-lactic acid, and 6.71% calcium hydroxylapatite. Four serious adverse events were identified. Three events were delayed-onset skin nodule formation. One adverse event was related to vascular compromise and subsequent cutaneous necrosis. After appropriate treatment, all adverse events resolved without significant long-term sequelae., Conclusion: Serious adverse events associated with injectable fillers, when performed by board-certified dermatologists, are extremely rare and can be successfully managed with appropriate treatment., (Copyright © 2022 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Soft tissue augmentation with calcium hydroxylapatite (CaHA) is a versatile technique for line filling, skin tightening, lifting, contouring, and volumizing. The present study was designed to confirm safety and effectiveness of the product with lidocaine (CaHA (+)) in a holistic treatment of nasolabial folds (NLFs), marionette lines, and/or cheeks., Methods: A total of 207 subjects with moderate to severe facial volume deficit were treated with CaHA(+) in this open-label study. Effectiveness assessments included Merz Aesthetics Scales&reg; (MAS), investigator- and subject-assessed Global Aesthetic Improvement Scales (iGAIS/sGAIS), and FACE-QTM questionnaires. Responder rates were defined as at least one-point improvement on MAS according to blinded rating. Safety was assessed through adverse event reporting., Results: Primary endpoint was evaluated 12 weeks after last injection. Responder rates were 93.6%, 88.7%, and 81.9% in the NLFs, marionette lines, and cheeks, respectively, and were statistically significant above the pre-defined 60% threshold (P&lt; 0.0001). Investigator- and subject-assessed GAIS were consistent and showed high rates of improvement throughout the study, with peak values of 98.0% at week 4 on iGAIS and 93.5% at 12 weeks after last injection on sGAIS. After 18 months, the majority of subjects (52.5%) still perceived improvement via sGAIS. Moreover, total FACE-Q scores demonstrated high subject satisfaction with treatment. All related treatment emergent adverse events were transient and expected injection-site reactions mostly of mild to moderate intensity., Conclusion: CaHA (+) has demonstrated safety and effectiveness in the treatment of NLFs, marionette lines, and cheek volume loss in real-life conditions up to 18 months. J Drugs Dermatol. 2022;21(5):481-487. doi:10.36849/JDD.6737.

Background: Limited data are available describing effectiveness of combining the use of calcium hydroxylapatite (CaHA) and hyaluronic acid (HA)., Methods: The authors performed a retrospective chart review of patients injected with a premixed combination of CaHA and a cohesive polydensified matrix (CPM ® ) HA (CaHA:CPM-HA ) in the authors' aesthetic practices. The midface and lower face were injected. Patients' records were evaluated, and treatment results were scored using the Merz Aesthetics Scale for the jawline ® (clinician rated, CR-MASJ). Adverse events were recorded., Results: A total of 41 patients were included, all females with a mean age of 47.5 years (range 21-63 years). The mean CR-MASJ score improved from 2.12 at baseline to 0.68 at t = 3 months (SD = 0.69, 95% CI 1.28-1.60) and 1.27 at t = 12 months (SD = 0.74, 95% CI 0.43-0.74). 100% of the subjects had experienced a ≥1-point improvement in CR-MASJ score at t = 3 months, versus 85% at t = 12 months. No adverse events were reported., Conclusion: The results of this study support the volumizing and lifting potential of the hybrid mix CaHA:CPM-HA for treatment of cheeks and jawline., Level of Evidence Iv: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 ., (© 2021. The Author(s).)

Introduction: Jawline augmentation with calcium hydroxylapatite has not yet been evaluated in a prospective study with a split-face design. This study aims to perform the first randomized controlled, split-face study on the efficacy and safety of calcium hydroxylapatite for jawline augmentation using the needle and cannula technique., Objective: To perform the first randomized controlled, split-face study on the efficacy and safety of calcium hydroxylapatite for jawline augmentation using the needle and cannula technique., Materials and Methods: This is a single-site, randomized, evaluator-blind trial enrolling a total of 10 healthy subjects with at least Grade 1 (mild) on a 4-point Jawline Scale. One side of the face was randomized to receive 1 to 2 syringes of calcium hydroxylapatite with lidocaine (total of 3 mL) for correction of wrinkles and folds along the jawline using both the cannula and needle method, and a balancing treatment will be performed 1 month later. Blinded investigator and subject evaluations will be performed immediately after treatment and at the 30-, 60-, and 90-day visits., Results: Ten subjects were enrolled and completed the trial. There was a improvement in the degree of wrinkling and skin sagging in the 4-point Jawline Scale, with an average of a 1.3-point improvement in the scale on the day of treatment and at the Day 30 visit, which remained improved greater than baseline after 3 months as graded by blinded investigators. The Clinician Global Aesthetic Improvement Score for the treated side versus control, as assessed by blinded investigators, demonstrated a improvement with a 2.3-point improvement on the 5-point scale, and by the final visit on Day 90, most patients had a much improved appearance from baseline., Conclusion: This study demonstrates that calcium hydroxylapatite is effective and safe for restoration and augmentation of the jawline using the unique needle and cannula technique., (Copyright © 2020 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Injection laryngoplasty (IL) is considered safe in both the operating room and clinical setting. However, safety data is limited to single-institution studies with reduced sample sizes. The objective of this study is to examine a national database for adverse events related to IL in an effort to further confirm the safety of this procedure and better characterize potential complications., Materials and Methods: Retrospective analysis of the Manufacturer and User Facility Device Experience (MAUDE) database for reported adverse events of IL procedures utilizing calcium hydroxyapatite (CAHA), hyaluronic acid (HA) and carboxymethylcellulose (CMC) implants from 2009 to 2020., Results and Analysis: We identified 47 reported adverse events. The average patient age was 54 years old. 59.3% of patients were female. Adverse events more frequently involved the use of CAHA compared to HA or CMC (n = 27, 57.4%, n = 13, 27.7% and n = 7, 14.9%, respectively). The most common adverse events were laryngeal edema (n = 18, 39.1%), improper placement of injected material (n = 12, 26.1%), persistent dysphonia (n = 13, 28.3%), and post-injection dysphagia or odynophagia (n = 11, 23.9%). Major events, defined as requiring emergency room treatment, hospitalization, or surgical intervention accounted for 29 (60.4%) of cases. Four cases of edema required intubation, and one patient necessitated a surgical airway., Conclusion: Complications arising from IL range from minor events to airway obstruction and may happen with a variety of injectable materials including CAHA, HA and CMC. Few cases of airway obstruction requiring immediate intervention were identified, confirming the safety of IL in both the operative and office setting., (Copyright © 2021. Published by Elsevier Inc.)

Introduction: Prosthetic dentistry has shifted toward prevention of caries occurrence surrounding restorative margin through the anti-demineralization process. This study examines the ability of nanohydroxyapatite (NHA) gel and Clinpro (CP) on enhancing resistance to demineralization of enamel and cementum at margin of restoration., Materials and Methods: Thirty extracted mandibular third molars were segregated at 1 mm above and below cementoenamel junction (CEJ) to separate CEJ portions and substituted with zirconia disks by bonding to crown and root portions with resin adhesive. The enamel and cementum area of 4 × 4 mm 2 neighboring zirconia was applied with either NHA or CP, while one group was left no treatment (NT) before demineralized with carbopal. Vickers hardness (VHN) of enamel and cementum was evaluated before material application ( B M ), after material application ( A M ), and after demineralization ( A D ). Analysis of variance (ANOVA) and post hoc multiple comparisons were used to justify for the significant difference ( α  = 0.05). Scanning electron microscopy (SEM) and X-ray diffraction (XRD) were determined for surface evaluations., Results: The mean ± SD of VHN for B M , A M , and A D for enamel and cementum was 393.24 ± 26.27, 392.89 ± 17.22, 155.00 ± 5.68 and 69.89 ± 4.59, 66.28 ± 3.61, 18.13 ± 0.54 for NT groups, respectively, 390.10 ± 17.69, 406.77 ± 12.86, 181.55 ± 7.99 and 56.01 ± 9.26, 62.71 ± 6.15, 19.09 ± 1.16 for NHA groups, respectively, and 387.90 ± 18.07, 405.91 ± 9.83, 188.95 ± 7.43 and 54.68 ± 7.30, 61.81 ± 4.30, 19.22 ± 1.25 for CP groups, respectively. ANOVA indicated a significant increase in anti-demineralization of enamel and cementum upon application of NHA or CP ( p < 0.05). Multiple comparisons indicated the capability in inducing surface strengthening to resist demineralization for enamel and cementum of NHA which was comparable to CP ( p > 0.05) as evidenced by SEM and XRD data indicating NHA and CP deposition and crystallinity accumulation., Conclusion: NHA and CP were capable of enhancing anti-demineralization for enamel and cementum. The capability in resisting the demineralization process of NHA was comparable with CP. NHA was highly recommended for anti-demineralization for enamel and cementum surrounding restorative margin., Competing Interests: The authors declare that there are no conflicts of interest regarding the publication of this paper., (Copyright © 2021 Niwut Juntavee et al.)

Background: Soft tissue filler injections are frequently performed with a relatively low number of severe adverse events reported. While venous complications have been described, the majority of adverse events are generally associated with the arterial vascular system. Intra-arterial product application can present with pain, skin discoloration, and potential tissue loss and/or injection related visual compromise., Aim: We present the clinical case and the consecutive symptomology of a 39-year-old woman injected with calcium hydroxylapatite at the zygomatic arch with five perpendicular needle (27G 12mm) supraperiosteal bolus injections of 0.2 cc per site., Methods: Immediately after the injections, weakness, nausea, vomiting, and loss of consciousness occurred. Additionally, left-sided loss of sensation of her face, scalp, oral, and nasal mucosa occurred, with absence of left corneal reflex and ipsi-lateral ear congestion. Subsequently, left-sided masseteric atrophy and dysphagia occurred., Results: One year after the injection procedure the sensory loss of her facial skin and scalp persisted, while the other symptoms improved. Medications involved in the symptomatic (not causal) partial recovery process were Dexamethasone, Vitamin B complex, Vinpocetine, Pentoxifyllin, and Thioctic acid., Conclusion: The symptoms presented and the time-related relationship to the injection procedure increases the likeliness of an association between the administration of the calcium hydroxylapatite product and a lesion of the trigeminal ganglion. The resulting symptoms can altogether be related to the functions of the ganglion. The connecting pathway between the injection site and the ganglion can be explained by the arterial vascular pathway., (© 2021 Wiley Periodicals LLC.)

Background: Calcium hydroxylapatite (CaHA) is indicated for correcting moderate-to-severe facial wrinkles and folds. Hyperdilute CaHA is increasingly being used for stimulating neocollagenesis to improve skin quality and firmness., Objective: This study assessed long-term effects of hyperdilute CaHA for improving chest wrinkle appearance., Methods and Materials: Adult female subjects (N=20) were treated with a 1:2 dilution of CaHA and evaluated at week 6, week 12, day 180, and day 360 using validated Merz D&eacute;colletage Scales. A Subject Satisfaction Questionnaire was used to assess overall satisfaction on a scale from 0 (Completely Dissatisfied) to 6 (Completely Satisfied)., Results: Subjects achieved significant improvements in baseline Merz D&eacute;colletage Scale&ndash;Dynamic scores at week 6, after a single treatment (P=0.02), at week 12 (two treatments) (P=0.01), day 180 (P=0.01), and day 360 (P&lt;0.01). Subjects also demonstrated significant improvement in baseline Merz D&eacute;colletage Scale&ndash;At Rest scores at week 6 (P&lt;0.01), remaining significant at week 12 (P&lt;0.01), day 180 (P&lt;0.01), and day 360 (P&lt;0.01). Subject Satisfaction scores increased from 3.25 at day 180 to 3.59 at day 360 using a 7-point scale., Conclusion: Hyperdilute CaHA significantly improves the dynamic and resting appearance of wrinkles of the d&eacute;collet&eacute;. These durable improvements persist for at least 1 year. J Drugs Dermatol. 20(5): doi:10.36849/JDD.5680.

Background: Dermal fillers such as hyaluronic acid, poly-l-lactic acid, and polymethyl-methacrylate are often used to treat cutaneous defects such as lipoatrophy. However, concern exists regarding their use in patients with a connective tissue disease (CTD) because of a theoretical risk of disease reactivation or exacerbation. Evidence regarding their use in patients with CTD also remains limited., Objective: This review intends to summarize and evaluate the available literature regarding the use of dermal fillers in patients with CTD., Materials and Methods: A literature search until May 2020 was conducted through PubMed, Ovid MEDLINE, and Ovid Embase to identify articles discussing the treatment of cutaneous defects secondary to CTD. Articles discussing the use of autologous fat transfer alone were excluded., Results: Twenty-three articles were reviewed. The amount of available evidence varies between the type of CTD and type of filler with morphea having the most published evidence out of the CTDs discussed and hyaluronic acid having the most published evidence out of the fillers discussed. Most studies demonstrated positive results with no report of disease reactivation or exacerbation., Conclusion: Despite limited available evidence, dermal fillers seem to be safe as an adjunctive treatment for cutaneous defects in patients with CTD., (Copyright © 2021 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Intra-arterial injection of fillers can lead to occlusion of the ophthalmic artery or its branches supplying the retina or the optic nerve. The mechanism through which this occurs is incompletely understood. We investigated the possibility of generating microparticles after injecting commercially available fillers into a flowing system in vitro., Methods: Three hyaluronic acid fillers and one calcium hydroxylapatite filler were injected into an artificial saline flow system mimicking arterial systolic blood pressure and corresponding to the diameter of the facial artery. All the saline at the end of the tube was collected, centrifuged, and inspected for filler particles., Results: After injection into the system, all fillers immediately disintegrated into small particles that were carried downstream with the flow of the saline. The saline at the end of the tube contained collections of filler., Conclusion: Hyaluronic acid and hydroxylapatite fillers break up into small particles immediately after injection into a flowing system, generating emboli rather than a column of filler. The results of this study lead us to hypothesize another potential mechanism leading to filler-related blindness., (Copyright © 2020 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Diluted/hyperdiluted calcium hydroxylapatite (CaHA) represents an emerging biostimulatory treatment. However, limited data concerning the effects of this agent on the face have been provided so far., Objective: To investigate the efficacy and safety of hyperdiluted CaHA 1:2 treatment for mid and lower face rejuvenation., Patients and Methods: A retrospective study of 40 patients seeking skin rejuvenation for mid and lower face, treated with hyperdiluted CaHA 1:2 technique at baseline (T0), was performed. Patients were classified according to validated scales of aging in the mid to lower face at T0 and efficacy was established with scales calculated again at 4-month post-treatment (T1). In addition, efficacy was assessed by blinded evaluation of T0/T1 clinical pictures, non-invasive skin imaging and patient satisfaction. Safety was assessed through pain scale and minor/major adverse events., Results: Hyperdiluted CaHA 1:2 successfully decreased aging severity scores of the mid and lower face. Variations of collagen morphology and increased vessel density at T1 were observed with noninvasive skin imaging. Most patients were very satisfied. Mean pain score was low and only minor adverse events were reported., Conclusion: Hyperdiluted CaHA 1:2 technique seems to be effective and safe for mid and lower face skin rejuvenation.

Background: Inadvertent intra-arterial injection of dermal fillers including calcium hydroxylapatite (CaHA) can result in serious adverse events including soft tissue necrosis, permanent scarring, visual impairment, and blindness. When intra-arterial injection occurs, immediate action is required for optimal outcomes, but the infrequency of this event means that many physicians may never have experienced this scenario. The aim of this document is to provide evidence-based and expert opinion recommendations for the recognition and management of vascular compromise following inadvertent injection of CaHA., Methods: An international group of experts with experience in injection of CaHA and management of vascular complications was convened to develop a consensus on the optimal management of vascular compromise following intra-arterial CaHA injection. The consensus members were asked to provide preventative advice for the avoidance of intravascular injection and to produce a treatment protocol for acute and delayed presentation. To ensure all relevant treatment options were included, the recommendations were supplemented with a PubMed search of the literature., Results: For prevention of intra-arterial CaHA injection, consensus members outlined the importance of a thorough knowledge of facial vascular anatomy and patient history, as well as highlighting potential risk zones and optimal injection techniques. Individual sections document how to recognize the symptoms of vascular occlusion leading to vision loss and tissue necrosis as well as detailed treatment protocols for the management of these events. For impending tissue necrosis, recommendations are provided for early and delayed presentations with treatment protocols for acute and follow-up treatment. A separate section details the treatment options for open and closed wounds., Conclusions: All physicians should be prepared for the eventuality of intra-arterial injection of a dermal filler, despite its rarity. These consensus recommendations combine advice from aesthetic experts with the latest reports from the published literature to provide an up-to-date office-based protocol for the prevention and treatment of complications arising from intra-arterial CaHA injection., (© 2020 The Authors. Journal of Cosmetic Dermatology published by Wiley Periodicals, Inc.)

Background: Calcium hydroxylapatite (CaHA) is effective for dorsal hand rejuvenation. Higher dilutions are used for biostimulation with fewer side effects., Objective: To evaluate the efficacy and safety of 2 techniques of diluted CaHA injection for dorsal hand treatment., Methods: A prospective, evaluator-blinded study was performed to compare (side-to-side) techniques for treating the dorsum of the hands with diluted CaHA: deep fat lamina or subdermal injection. Fifteen women with aging grades between 1 and 3 on the MHGS (Merz hand grading scale) were enrolled and followed up for 24 weeks. The outcomes were a histological analysis of collagen, skin viscoelasticity, high-frequency ultrasound parameters, MHGS score, and the global aesthetic improvement scale (GAIS) score., Results: Improvement in the MHGS and GAIS scores (p < .01) was observed, with no difference between techniques (p > .05). Skin viscoelasticity measures and ultrasonography for dermal parameters improved for both treatments (p < .01). The mean total collagen density increased from the baseline for both techniques (p < .01). Pain during the procedure as well as adverse effects within the follow-up did not differ between treatments (p > .4). The overall satisfaction was 12% greater for the subdermal technique (p < .05)., Conclusion: Diluted CaHA improves the skin quality of aging hands with a safe profile, without substantial differences between the techniques.

Introduction: Dentin hypersensitivity is a painful clinical condition. The frequency of its occurrence varies from 8 to 57%, depending on tested group and different methods of investigations. Recommended desensitizing agents have different mechanism of action and effectiveness. We are still looking for solutions that will improve their effectiveness and simultaneously allow for wider use of e.g. as a base material, counteracting postoperative hypersensitivity, reducing marginal microleakage. The aim of the study was to assess the effect of a selected desensitizing agent occluding dentin tubules with calcium hydroxyapatite on marginal microleakage formation of a class V composite restorations subjected to thermocycles., Materials and Methods: In study it was used 40 molars and premolars, which were alternately assigned into two groups. In both groups standardized cavities were prepared. In the study group (study group - SG) before application of bonding agent Teethmate Desensitizer (f. Kuraray, Noritake Dental Inc., Okayama, Japan) was used. In the control group (control group - CG) OptiBond All-in-one (f. Kerr, Bioggio, Switzerland) bonding agent was used and cavities were filled using composite material Gradia Direct (f. GC Europe N.V., Leuven, Belgium). After storage in saline, teeth were subjected to 600 thermocycles, passive dye penetration test was done, teeth were cut in the area of filling, according to its long axis. Under light microscope magnification value of microleakage was measured and marginal microleakage rate (M) was counted. The results of the tests were statistically analyzed using the package STATISTICA 12.0 (StatSoft, USA)., Results: The average value of M for the SG group was 0.46 (min 0.05, max 0.76, SD 0.226) and for CG was 0.22 (min 0, max 0.74, SD 0.235). The differences between M values were statistically significant (p = 0.0094)., Conclusion: A reduction in the number of retention sites for the bonding system, facilitates the formation of microleakage in the experimental conditions and reduces the degree of adhesion of the composite material to the hard tissues of the tooth.

Background: Soft-tissue filler administration is an increasingly popular minimally invasive cosmetic procedure. Simultaneously, there have been a greater number of adverse events reported, including the devastating complication of blindness., Objective: To report cases of filler-related blindness published since 2015., Materials and Methods: The Ovid MEDLINE database was searched from January 1, 2015, to August 1, 2018, using a previously described Boolean string., Results: Sixty new cases of filler blindness were identified. The most common type of filler reported was hyaluronic acid (HA) (N = 42, 70.0%), followed by autologous fat (N = 7, 11.7%), and calcium hydroxyapatite (CaHA) (N = 7, 11.7%). The most common injection locations were the nose (N = 33, 55.0%), glabella (N = 21, 35.0%), and forehead (N = 11, 18.3%). Ten cases reported vision restoration (16.7%). Four of the successful cases involved hyaluronidase administration, including 1 retrobulbar hyaluronidase injection., Conclusion: Since 2015, there have been 60 newly reported cases of soft-tissue filler blindness. Most recent cases have occurred with HA, which is a shift from previous reports. In HA cases, hyaluronidase injection may be successful in restoring vision if administered promptly. It is imperative for providers to be familiar with strategies for managing soft-tissue filler blindness.

Beta-type Ti-based alloys are promising new materials for bone implants owing to their excellent mechanical biofunctionality and biocompatibility. For treatment of fractures in case of systemic diseases like osteoporosis the generation of implant surfaces which actively support the problematic bone healing is a most important aspect. This work aimed at developing suitable approaches for electrodeposition of Sr-substituted hydroxyapatite (Srx-HAp) coatings onto Ti-45Nb. Potentiodynamic polarization measurements in electrolytes with 1.67 mmol/L Ca(NO 3 ) 2 , which was substituted by 0, 10, 50 and 100% Sr(NO 3 ) 2 , and 1 mmol/L NH 4 H 2 PO 4 at 333 K revealed the basic reaction steps for OH - and PO 4 3- formation needed for the chemical precipitation of Srx-HAp. Studies under potentiostatic control confirmed that partial or complete substitution of Ca 2+ - by Sr 2+ -ions in solution has a significant effect on the complex reaction process. High Sr 2+ -ion contents yield intermediate phases and a subsequent growth of more refined Srx-HAp coatings. Upon galvanostatic pulse-deposition higher reaction rates are controlled and in all electrolytes very fine needle-like crystalline coatings are obtained. With XRD the incorporation of Sr-species in the hexagonal HAp lattice is evidenced. Coatings formed in electrolytes with 10 and 50% Sr-nitrate were chemically analyzed with EDX mapping and GD-OES depth profiling. Only a fraction of the Sr-ions in solution is incorporated into the Srx-HAp coatings. Therein, the Sr-distribution is laterally homogeneous but non-homogeneous along the cross-section. Increasing Sr-content retards the coating thickness growth. Most promising coatings formed in the electrolyte with 10% Sr-nitrate were employed for Ca, P and Sr release analysis in Tris-Buffered Saline (150 mM NaCl, pH 7.6) at 310 K. At a sample surface: solution volume ratio of 1:200, after 24 h the amount of released Sr-ions was about 30-35% of that determined in the deposited Srx-HAp coating. In vitro studies with human bone marrow stromal cells (hBMSC) revealed that the released Sr-ions led to a significantly enhanced cell proliferation and osteogenic differentiation and that the Sr-HAp surface supported cell adhesion indicating its excellent cytocompatibility., (Copyright © 2019 The Authors. Published by Elsevier B.V. All rights reserved.)

Injection of fillers has gained popularity over the past decades in aesthetic treatments. Calcium hydroxylapatite (CaHA; Radiesse) was introduced in the year 2003 and received approval from the Food and Drug Administration in 2006 for the treatment of moderate-to-severe wrinkles. The properties of CaHA include biostimulation, neocollagenesis, and stability over a long period. However, similar to other fillers, CaHA is associated with the risk of complications such as ecchymosis, inflammation, local infection, skin necrosis, and vascular occlusion. Iatrogenic vision loss remains the most devastating complication related to vascular occlusion. Development of vision impairment is associated with a relatively high risk of permanent damage to vision acuity and poor prognosis. The current report presents a case of a patient who suffered from skin necrosis, vision impairment, and ophthalmoplegia after the injection of CaHA into the nasal dorsum. Significant improvement in visual acuity was observed during hospitalization after the treatment. The patient recovered to near-normal visual acuity and completely recovered from ophthalmoplegia. We aimed to discuss the current treatment employed and review the literature on CaHA-related vision loss.

Objective: To assess long-term results and present experience with a high-porosity hydroxyapatite ceramic for obliterating large open mastoid cavities., Study-Design: Cross-sectional cohort study., Setting: Tertiary academic referral center., Patients: All patients who underwent tympanomastoid surgery for chronic middle ear disease or revision surgery with reduction of an open mastoid cavity using a highly porous hydroxyapatite matrix material (HMM) between May 2005 and June 2013 were assessed for eligibility. Twenty three patients (56.9 ± 18.3 yr) were included., Intervention: Primary middle ear surgery or revision surgery using a HMM., Main Outcome Measures: Pure-tone average, computed tomography (CT), and magnetic resonance imaging (MRI) to investigate osseoinduction, osseointegration and presence of cholesteatoma, current quality of life assessed by Zurich Chronic Middle Ear Inventory and change in quality of life post-intervention assessed by the Glasgow Benefit Inventory., Results: Patients were reexamined after a mean follow-up period of 88.3 months (SD 21.4 mo) after obliteration of the open mastoid cavity with HMM. Compared with visit 1, patients showed a significantly reduced ABG at visit 2 (29.22 dB ± 2.71 dB versus 12.77 dB ± 3.46 dB).CT scan was carried out in 21 patients (91%) patients and 17 patients (74%) underwent MRI.Revision surgery was required in a total of 17 cases (74%). In four patients recurrent cholesteatoma was found at follow up., Conclusions: Poor cavity obliteration, a high rate of revision surgery and difficult differentiation between recurrent cholesteatoma and granulation tissue in CT scan was observed.

Calcific tendinitis is a well-documented and extensively studied disease in the literature. Intramuscular and intraosseous migration are rare complications, which may present diagnostic challenges. This pictorial essay illustrates the imaging findings of these complications. Considering that neoplastic processes and infectious diseases are included in the differential diagnosis, recognizing the imaging findings of these complications is of critical importance.

Hydroxyapatite powder was mixed into photosensitive resin to form complex shape scaffold using SLA-3D printing technology, and then the final entity was obtained successively by debinding and sintering. It is crucial to confirm whether the prepared hydroxyapatite scaffold have the toxic effects after our designed printing, debinding, and sintering processes because the photosensitive resin in the starting printing paste is poisonous to cells. To investigate these issues in details, thermogravimetric analysis (TG), differential scanning calorimetry (DSC), in vitro cytotoxicity test, and implantation pre-experiment in the rabbit parietal were performed, aiming to develop the SLA-3D prepared hydroxyapatite scaffold. Through thermal analysis, it was proved that photosensitive resin would be completely pyrolyzed at temperature ranging from 350 °C to 580 °C, corresponding to a secondary chemical reaction mechanism. Combined with cytotoxicity test results, it is unquestionable that the toxic substances would be totally decomposed after debinding process and a good biocompatible HAP samples could be obtained. The finally prepared HAP samples with micro-holes showed good biosafety in pre-experiment of the rabbit parietal implantation., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Volume restoration using filler in the dorsum of the hand is a simple and effective procedure to improve wrinkles and hide veins and tendons. Currently, calcium-hydroxyapatite (CaHA) filler is the only FDA-accepted material to use in the hand dorsum. However, it is not easy to inject due to swelling and redness. In addition, hand anatomy through sonography is wrongly described in Plastic and Reconstructive Surgery® Journal. Through incorrect marking in sonographic hand anatomy, physicians will conduct erroneous procedures and surgeries., Objectives: CaHA filler and hyaluronic acid (HA) filler were both injected into the hand to compare intra-individually the effect of each filler. Through this study, the author introduced detailed and refined sonographic anatomy. Overall, the author identified the correct injection method and depth., Methods: In this prospective, intra-individual, comparative study, patients were injected 1 cc of CaHA filler to the left hand and 3 cc (36 mg) of microphasic hyaluronic acid to the right. Outcomes were assessed by Merz hand grading scale, skin bio-parameters, dermascopic finding, and Global Aesthetic Improvement Scale (GAIS) with follow-up at 3, 6, 9, and 12 months., Results: The average GAIS score improved in both hands and generally maintained over the course of the study. There was significantly more bruising and swelling in the CaHA-injected hands compared with the HA-injected hands. The skin roughness and appearance improved in both sets of hands on dermascope. The average Trans-Epidermal-Water-Loss decreased and the average Stratum Corneum Hydration increased in HA-injected hands. The biopsy study showed that the HA particles lasted for 9 months., Conclusions: The author reestablished sonographic anatomy. Veins and tendons became less apparent after injections., (© 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.)

Background: Several hydroxyapatite (HA)-coated femoral stems from a single manufacturer were identified to have aseptically loosened at mid-term follow-up despite prior radiographic appearance of osseointegration. Possible causes and associated risk factors for stem loosening were explored through radiographic review and implant retrieval analysis., Methods: Forty-six retrieved hip stems (Corail, DePuy-Synthes) were identified and grouped by bearing type: metal-on-metal (MoM), metal-on-polyethylene, and ceramic-on-ceramic. Stem lucency was graded on post-operative radiographs up to the time of revision. Stems were examined for stripping of the HA coating, taper corrosion, and bearing wear in metal-on-metal cases. Patient demographics, implant design features, and perioperative data were collected from electronic databases and patient charts., Results: Aseptic loosening occurred in 37% of cases examined. MoM bearings were associated with 7.25 times greater risk of loosening compared to other bearing types. Stem radiolucency was more prevalent for MoM cases and, although not statistically significant, demonstrated progressive lucency. Taper corrosion appeared more severe for MoM cases and correlated with proximal stem radiolucency. Removal of the HA coating from the stems was associated with both taper corrosion and MoM bearing wear. Length of implantation was a confounding factor for the MoM cases., Conclusion: This study has demonstrated a high risk of mid-term loosening of previously osseointegrated HA-coated femoral stems when paired with a MoM bearing. The mechanism of loosening appears progressive in nature and related to the MoM bearing, possibly interacting with the HA coating. If such loosening is recognized early, rapid revision may allow for retention of the femoral stem.

Purpose of Review: Endoscopic injection of bulking agents for the treatment of vesicoureteral reflux (VUR) has become a therapeutic alternative to antibiotic prophylaxis and ureteral reimplantation. Although considered as a safe and efficient procedure, several studies have reported cases of ureteral obstruction (UO) after endoscopic correction of VUR. This review article evaluates the present VUR literature to estimate the incidence of UO following endoscopic injection of different substances, while also discussing the impact of injection technique and implant volume., Recent Findings: Twenty-five publications were identified that provided detailed information on 64 females and 32 males (age range, 7 months-48 years) that developed UO after endoscopic treatment of VUR using dextranomer/hyaluronic acid (Dx/HA), polyacrylate polyalcohol (PP), polydimethylsiloxane (PDMS), calcium hydroxyapatite (CaHA), polytetrafluoroethylene (PTFE), or collagen. There was some variation in the reported incidence of UO among these materials: Dx/HA (0.5-6.1%), PP (1.1-1.6%), PDMS (2.5-10.0%), CaHA (1.0%), and PTFE (0.3%). Postoperative UO was described following subureteric transurethral injection (STING), intraureteric hydrodistension implantation technique (HIT), combined HIT/STING and double HIT. The injected volume ranged widely, also depending on the type of bulking agent: Dx/HA (0.3-3.0 mL), PP (0.3-1.2 mL), PDMS (1.0-2.2 mL), CaHA (0.4-0.6 mL), and PTFE (1.5-2.0 mL). The timing of UO varied from immediately after the procedure to 63 months. Over half of patients showed asymptomatic hydroureteronephrosis on follow-up imaging, whereas the remaining presented with symptoms of acute UO or fever. UO remains a rare complication after endoscopic correction of VUR, generally reported in less than 1% of treated cases, which appears to be independent of the injected substance, volume, and technique. However, long-term follow-up is recommended as asymptomatic or delayed UO can occur, potentially leading to deterioration of renal function.

Wear particle-induced bone resorption leads to prosthesis loosening, which is a major complication associated with total joint arthroplasty. Although the exact mechanism remains unclear, wear particle-induced extensive osteoclastogenesis plays a critical role in this process. Thus, a potential treatment of prosthetic loosening is focused on suppressing extensive osteoclast formation and bone resorption, which prevents wear particle-induced osteolysis. Arctigenin isolated from Arctium lappa has numerous beneficial pharmacologic effects, including anti-inflammatory, antiviral, and anticancer activities. Here, we explored the potential impact of arctigenin on titanium (Ti) particle-induced osteolysis in vivo. Our data showed that arctigenin significantly suppressed Ti particle-induced osteolysis and prevented bone destruction compared with Ti group. In addition, the number of osteoclasts reduced after treatment with arctigenin in vivo, indicating osteoclastogenesis might be inhibited by arctigenin. Next, bone marrow-derived macrophages were used to examine osteoclast differentiation, bone resorption, and activation of osteoclast-related signaling pathways. The results showed that arctigenin inhibited RANKL-induced osteoclastogenesis without any cytotoxicity and suppressed osteoclastic marker genes expression and hydroxyapatite resorption activity in a dose-dependent manner. Additionally, arctigenin suppressed receptor activator of nuclear factor κΒ (NF-κB) ligand-induced NF-κB activation, concomitant with retarded IκBɑ degradation and inhibition of p65 nuclear translocation, leading to impaired osteoclastogenesis. Collectively, our results suggest that arctigenin is a promising candidate for the treatment of osteoclast-related osteolytic diseases caused by excessive osteoclast formation., (© 2018 Wiley Periodicals, Inc.)

The biomaterials physicochemical characteristics influence their cellular reaction, degradation and regenerative capacities. Macrophages and multinucleated giant cells (MNGCs) are observed in the augmentation area of biomaterials. This study, for the first time, evaluated the polarization pattern of macrophages and MNGCs in response to two different bone substitute materials (synthetic bone substitute material [SBSM] = NanoBone vs. xenogeneic bone substitute material [XBSM] = Bio-Oss) in human bone biopsies compared to non-augmented bone (control). Histomorphometrical analysis of the polarization in proinflammatory (M1) and anti-inflammatory (M2) cells was performed using different immunohistochemical markers: CD-68 = macrophages; CCR-7 and Cox-2 (M1) and CD-206 and CD-163 (M2) and tartrate-resistant acid phosphatase (TRAP). The macrophage polarization pattern in SBSM showed a significantly higher number of M1 cells than did XBSM and non-augmented bone. XBSM induced a significantly higher number of CD-206-positive macrophages than SBSM did. No significant difference was found between XBSM and the non-augmented bone. MNGCs expressed CD-68 and TRAP. In both test-groups, MNGCs showed a high proinflammatory character (CCR-7 and Cox-2-positive) and their number in the SBSM group was significantly higher than that of XBSM. The tissue distribution showed a significantly low percentage of the remaining biomaterial in SBSM compared to XBSM. Within the limitations of this study, these findings show that MNGCs exhibit a rather proinflammatory character and lead to biomaterial degradation, once they are induced in a high number. The premature degradation of bone substitute materials is compensated with a high percentage of connective tissue and not new bone formation. © 2018 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 107A: 780-790, 2019., (© 2018 Wiley Periodicals, Inc.)

Background: Langerhans cell histiocytosis (LCH) is a rare dendritic histiocytic disorder that affects the bones, especially the skull. Langerhans cell histiocytosis (LCH) developing in a burr hole site for chronic subdural hematoma is extremely rare., Case Description: A 53-year-old man underwent a burr hole irrigation for chronic subdural hematoma, and the burr hole was covered with a burr hole button made of hydroxyapatite. Seven months after the first surgery, the connective tissue rapidly proliferated around the burr hole button, and the pathologic diagnosis was LCH. LCH recurred at 13 and 19 months after the first operation, with curettage performed each time. At 3 months after the final operation, no recurrence was identified on magnetic resonance imaging., Conclusions: If there is rapid proliferation of connective tissue at an operative site where artificial material has been used, LCH should be considered., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Calcium hydroxylapatite (CaHA, Radiesse®) with integral 0.3% lidocaine (CaHA(+)) has recently been approved for use in aesthetic medicine. This study assessed the performance of CaHA(+) in subjects undergoing treatment for facial volume loss and evaluated subject and physician satisfaction. Methods: In a prospective, open-label, post-marketing study, 25 women seeking treatment for age-related facial volume loss received CaHA(+) injections in 1–3 facial areas including the cheeks, marionette lines, prejowl sulcus, and jawline. Subjects returned for follow-up at 14 and 120 days, with the option of touch-up injections at day 14 if required to achieve optimal correction. Filler performance was assessed using the Merz Aesthetics Scales (MAS) and subject satisfaction using the Global Impression of Change Scale (GICS). Physician satisfaction was assessed in terms of CaHA(+)-related properties (eg, ease of injection, distribution, positioning) and aesthetic outcomes. Adverse events were recorded. Results: Mean MAS scores at baseline were ~2 corresponding to moderate facial volume loss/sagging in the treated area. At day 14, the mean score had improved to ≤1.4 for all treated areas, indicating mild volume loss. At day 120, mean scores had further improved to ≤1.1. At both follow-up visits, mean GICS scores were ≥2 indicating facial appearance was ‘much improved’ compared with baseline. All subjects reported willingness to repeat treatment and recommend it to family/friends. Physician ratings were high for ease of CaHA(+) injection, distribution, positioning, sculpturing outcome, and effect on skin tension. Compared to CaHA without lidocaine, the physician rated CaHA(+) as better or similar in performance. Adverse events were mostly mild and expected with CaHA and filler injections in general. Conclusion: The well-established efficacy and safety profile of CaHA appears unchanged by the addition of integral lidocaine. CaHA(+) was effective for volume enhancement in a number of facial areas and associated with high subject and physician satisfaction. J Drugs Dermatol. 2019;18(1):86-91.