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Replacement fillers are always used in the lips. I also think a replacement filler, HA or collagen, would be the clear choice for a patient with an upcoming event who wants an immediate result. Although both HA and collagen can give immediate results, collagen is considered “camera ready” because it often results in less bruising and swelling than HAs.
In my experience, most novice filler patients have 2 main concerns “Am I going to look like a freak?” and “How much will it hurt?” Obviously, HA is a great choice for an extremely apprehensive patient new to fillers, because it is reversible with hyaluronidase. This also makes it a good choice for a physician just starting to use fillers.
A relatively young patient with a minimal amount of volume loss has a wide choice of agents. Replacement fillers are still a cost-effective choice in this age group despite their limited durability because not much product is needed for correction. I actually use a lot of PLLA in young patients with mild-to-moderate volume loss in my practice. I find they appreciate the fact that the changes are gradual and subtle; they respond well to very conservative amounts of product, and I like it because this agent allows me to use a little volume enhancement all over the face, resulting in a very natural correction. It’s easier to start early and replace a little volume at a time than it is to wait until substantial loss needs to be replaced. Of course, this age group often requests lip augmentation, and that is always done with replacement fillers.
As we age and lose more volume in the face, I think the stimulatory fillers offer a more cost-effective choice because they can replace more significant volume loss for a substantially longer duration. I like PLLA in this age group also, again because I can replace a little volume everywhere and in places of less obvious volume loss such as the temples, preauricular area, and earlobes. I think a replacement filler in this age group also offers distinct benefits, especially in lifting the oral commissures. I do think that when using these fillers on an older face it’s important to keep perspective in mind. For example, completely effacing nasolabial folds on an otherwise aged face may put it a bit out of perspective and contribute to a “done” look.
Some side effects, such as edema, bruising, and, very rarely, infection, are seen with all categories of injectable fillers. Other adverse events are more specific to the product used. The Tyndall effect, a visible bluish tint, is seen with superficial placement of HA products. Superficial placement of collagen may result in white/yellow bumps, while placement too deeply may sacrifice product longevity. With collagen stimulators, superficial placement will result in visible “lumps and bumps” in the skin. Very early “lumps and bumps” are likely accumulations of product, while later “lumps and bumps” are likely product plus host reaction. In addition, overstimulation from overcorrection can also lead to “lumps and bumps.” Too much product/surface area at 1 treatment session or inadequate time between treatment sessions are examples of overcorrection. In the case of PLLA, inadequate dilution or hydration time could also lead to inadvertent overcorrection. Additionally, use of these agents in areas of dynamic muscle movement, such as the lips or under the eyes, can lead to an accumulation of particles and a localized overcorrection. Frequent early reports of lip lumps led to recommendations against the use of CaHA or PLLA in the lips. We, of course, now recognize these events to be both predictable and preventable with proper technique, and we have seen a dramatic decrease in these types of side effects as our methodology with these agents has evolved over the past decade of use.
Granulomas, sometimes occurring months to years after administration, have been reported with all currently available products, including collagen, HA, PLLA, silicone, CaHA, polymethylmethacrylate, hydroxyethyl methacrylate, and polyacrylamide gel. The list seems to grow with every newly introduced product.
True inflammatory granulomas are rare and unpredictable, and the events leading to their appearance are not yet clearly understood. Fortunately, the rate of clinically detectable granuloma formation is very low, reported to vary between 0.01% and 0.1%, and most resolve with or without treatment.
Finally, we must also keep in mind the rare reports of vascular necrosis, which has been described with all bulking agents including replacement fillers, autologous fat, and CaHA. This may occur as a result of vascular occlusion from inadvertent intravascular injection, or from vascular compression secondary to edema. Although the use of hyaluronidase will remedy this problem if used early in the course with HA, there is no such antidote should this occur with fat, CaHA, PLLA, or collagens, sometimes leading to devastating consequences. Patient safety is a goal shared by everyone, and we must constantly adjust our techniques in alignment with currently established guidelines to reduce all these risks.
Replacement fillers are preformed bulking agents supplied in a syringe that can be injected virtually anywhere on the face, including lips, to instantly replace a fixed amount of volume. This category includes collagen and hyaluronic acid (HA) fillers. Newer formulations of these products with various pros and cons are now being introduced to the marketplace. These agents have the shortest learning curve, can be used in any quantity desired at a single session, and can deliver immediate results with a duration of 12-36 weeks — a cost-effective choice for mild volume replacement. In addition, commercially available preparations of hyaluronidase can be used to dissolve the HA should an undesirable result occur. Stimulatory fillers, which are also referred to as biostimulatory agents or collagen stimulators, stimulate the host’s collagen production, and this newly formed collagen supplies the replacement volume. This category includes poly-L-lactic acid (PLLA) and calcium hydroxylapatite (CaHA). CaHA is a collagen stimulator supplied in a “bulky” carrier delivering immediate results, as seen with a replacement filler, but with a bit longer duration of effect. PLLA is a very low viscosity agent that can be used to replace “a little volume everywhere.” The amount of stimulatory filler used at any 1 treatment session is determined by the surface area to be treated at that session, and the final volumetric correction is determined by the number of treatment sessions. A period of 4-6 weeks between treatments allows time for the new host collagen to develop in response to the agent. Stimulatory fillers should not be used in the lips or in areas of dynamic muscle movement, and the optimal results are a little more technique dependent. They can, however, replace significant amounts of volume, address facial shape, balance, and proportions, and, in the case of PLLA, offer the longest duration of effect — 24 months or longer.
There has been a significant paradigm shift in the way we look at aging over the past decade. It is now becoming widely accepted that volume changes contribute greatly to age-related facial reshaping. Gravity, once considered the major culprit in facial aging, is now recognized as an opportunistic bystander that determines the direction rather than the extent of falling tissue in the face. We now also recognize that the changes seen in an individual face can be as individualized as each face itself. That is, although the sequence of events observed in aging is somewhat predictable, its pace among individuals is variable and may be influenced by both intrinsic (eg, gender, genetics) and extrinsic (eg, photoaging, smoking, stress) factors. Changes in different tissue layers within a single individual do not occur independently but interdependently — changes in 1 tissue within an individual may influence subsequent changes in other tissues. In other words, although we sometimes focus on nasolabial folds, marionette lines, or jowls, for example, we’re now recognizing that these are manifestations of a more global process. This is easily conceptualized by thinking of a raisin and a grape, or a slowly deflating balloon — the individual lines and folds are all part of an overall process. Volume loss in 1 area may cause sagging or changes in a different area, and sometimes replacing the volume in 1 area subsequently improves a second area.
PURPOSE: To evaluate binocular visual acuity (VA), contrast sensitivity, and stereopsis in myopic patients after laser in situ keratomileusis (LASIK)-induced monovision. DESIGN: Prospective, observational study. METHODS: We performed a prospective study of 37 consecutive patients older than 45 years who underwent bilateral myopic LASIK with planned monovision. At the 6-month postoperative visit, we evaluated distance and near binocular visual acuity, contrast sensitivity, and stereopsis. Binocular tests were done without spectacles (in monovision condition) and compared with the results obtained by repeating the same binocular tests with the same patients (serving as a control group) after spectacle correction of the residual myopic defect in the nondominant eye for distance tests (reverting monovision) and after spectacle correction of the presbyopia bilaterally for near tests (near best spectacle-corrected VA). RESULTS: By inducing a mean residual spherical equivalent defect of -0.97 diopter in the nondominant eye, the patients achieved a mean near binocular uncorrected visual acuity (UCVA) of 0.74, a mean reading test binocular UCVA of 0.88 using an acceptable spontaneous reading distance (48 cm), and a mean distance binocular UCVA of 1.08. A slight decrease in contrast sensitivity and stereopsis was observed in monovision compared to full distance correction. CONCLUSIONS: Monovision is a valid option for myopic patients with presbyopia who are considering LASIK. Good distance and near UCVAs can be obtained with this procedure.
BACKGROUND: Consistent with the public health approach to prevention, surveillance analyses are needed to fully understand a health problem. U.S. military eye injury rates have not been fully described using medical surveillance data. METHODS: Medical visit data on active duty personnel, 1996-2005, and causes of eye injury hospitalizations (identified by Standard NATO Agreement injury cause codes) were obtained from the Defense Medical Surveillance System. Eye injury-related ICD-9-CM codes beyond the traditional 800-999 injury code set were included. Rates by age and gender are reported for 1996-2005, along with the frequency of causes of injury hospitalizations and leading eye injury diagnoses for 2005. RESULTS: Eye injury rates among active duty military personnel increased from 1996 to 2005 among both men and women (p<0.001), with the highest rates in 2004 (26/1000 person-years and 21/1000 person-years, women and men, respectively). Women consistently had 7%-21% higher rates than men (rate ratios=1.07; 95% CI=1.04, 1.11) to 1.21 (95% CI= 1.17, 1.25). From 1996-2005, eye injury rates increased among all age groups (p<0.001). From 2002-2005, rates were highest for those aged > or =40 years compared to those aged 17-19 years (rate ratios=1.17 [95% CI=1.11, 1.24] to 1.24 [95% CI=1.18, 1.31]). Leading causes of eye injury hospitalizations were ordnance handling (16.9%), enemy action (13.1%), and fighting (11.9%). CONCLUSIONS: Medical surveillance data enable the assessment and monitoring of overall active duty eye injury rates, trends, and causes. Outpatient data could be improved with the addition of cause of injury codes and eye protection use. Current data suggest that continued use of eye protection during ordnance handling, combat, motor vehicle use, and sports could help reduce eye injury rates.
AIMS: We sought to examine whether waist-to-thigh ratio (WTR) performed better than waist-to-height ratio (WHtR), waist-to-hip ratio (WHpR), waist circumference (WC), or body mass index (BMI) in relation to diabetes among US adults. METHODS: Data of 6277 men and nonpregnant women 20 years or older from the Third National Health and Nutrition Examination Survey (1988-1994) were analyzed. RESULTS: In men, AUC of WTR (0.83) was larger than that of WHtR (0.78) (P=0.003), WHpR (0.79) (P<0.001), WC (0.76) (P<0.001), and BMI (0.72) (P<0.001) for diabetes. In women, the AUC of WTR (0.80) was similar to that of WHtR (0.80) (P=0.89), WHpR (0.79) (P=0.55), and WC (0.78) (P=0.36), but larger than that of BMI (0.73) (P=0.03) for diabetes. After adjustment for potential confounders, WTR had the strongest association with diabetes in men (OR, 2.13; 95% CI, 1.57-2.88; per 1 SD increment), whereas WHpR had the strongest association with diabetes in women (OR, 1.94; 95% CI, 1.60-2.35). CONCLUSIONS: WTR performed better than other four indices in men and WTR performed similarly to WHtR, WHpR, and waist circumference, but better than BMI in women for the association with diabetes.
OBJECTIVE: To determine whether bimatoprost (Lumigan, Allergan Inc., Irvine, CA) causes increased lash length when used in gel suspension applied to the base of the eyelashes. DESIGN: Randomized controlled trial. PARTICIPANTS: Nineteen subjects were enrolled. METHODS: Subjects recruited from the Bascom Palmer Eye Institute were screened, and those who met inclusion criteria were enrolled. Each participant received 2 vials of gel suspension, which contained bimatoprost and normal saline, respectively, each mixed 1:1 with Gonak gel (Akorn Inc., Lake Forest, IL) and labeled “right eye” and “left eye” according to randomization. The suspension was applied to the upper eyelid eyelashes every evening on the designated eye for 6 weeks. MAIN OUTCOME MEASURES: Lash length was measured with a caliper at enrollment, at weekly intervals during the application of the gel, and at 1 and 3 months after discontinuation of its use. Visual acuity, ocular symptoms, intraocular pressure, and photographs were documented at these same intervals. RESULTS: The mean eyelash growth from baseline in the bimatoprost group was 2.0 mm versus a mean of 1.1 mm in the placebo group, which was a statistically significant difference (P=0.009). The average intraocular pressure decreased equally in both groups (2 mmHg). No change in visual acuity or iris discoloration was noted in any of the subjects. CONCLUSIONS: Our data showed an increase in eyelash length with the use of bimatoprost in gel suspension, suggesting the product’s eyelash-lengthening properties.
Since 2001 the femtosecond laser has primarily been used in refractive surgery, e. g., for lasik, implantation of intracorneal ring segments or antiastigmatic corneal incisions. However, the femtosecond laser is more and more used for therapeutic reasons in corneal surgery. In this context it is used for profiled trephinations in penetrating keratoplasty where various profiles of the cutting edge can be designed (e. g., top-hat profile, mushroom profile, zig-zag profile). The potential advantages of these profiles include improved graft adaptation, better and more stable wound healing leading to earlier suture removal and eventually prolonged graft survival. However, none of these potential advantages has been demonstrated by reliable study results until now. First clinical experiences show that much earlier suture removal is possible without significant complications. However, with sutures in there seems to be no advantage of the femtosecond laser compared to mechanically guided trephination systems regarding visual acuity and postoperative astigmatism. Besides penetrating profiles, the femtosecond laser also allows for lamellar cuts. As deep anterior lamellar keratoplasty can only be supported by the femtosecond laser, it is mostly used for posterior lamellar grafts in this context. However, first clinical results using the femtosecondlaser for DSAEK (descemet stripping automated endothelial keratoplasty) are poorer than those using microkeratome-prepared lamellar grafts for DSAEK.
