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“Facial fillers? Yes. For my most beautiful self.”

JUVÉDERM^® DISCOVER FILLER PRODUCTS.

The JUVÉDERM^® range of injectable hyaluronic fillers is designed to treat different areas of the face. Specially designed products are available for many treatment needs. Juvéderm^® Volbella^® with Lidocaine to refine facial features and reduce fine lines. Juvéderm^® Volift^® with Lidocaine fills wrinkles and sculpts facial features. Juvéderm^® Voluma^® with Lidocaine corrects volume in the mid-face area. Previous Next

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HYALURONIC ACID IN FACIAL FILLERS

What exactly is hyaluronic acid? It is increasingly mentioned in connection with anti-aging procedures such as injectable facial fillers. As a polysaccharide and part of human body tissue, hyaluronic acid can bind 1000 times its weight in moisture – making it perfect for serving the body as a moisture retainer and volumizing filler. Especially in the skin. This is because the hyaluronic acid content of the skin decreases significantly with age. A process that begins around the age of 25: by the age of 50, the hyaluronic acid content of the tissue has already been reduced by half. This is where the cosmetic and aesthetic use of hyaluronic acid comes into play. Unlike in the past, the hyaluronic acid used in facial fillers is now produced biotechnologically. Because it resembles the hyaluronic acid that occurs naturally in the body, the likelihood of side effects or allergies as a defensive reaction to the active ingredient is low. It is injected into and under the skin to (re)build volume in certain areas of the body or to reduce fine lines and wrinkles. Hyaluronic acid is broken down naturally. To slow down this process and thus prolong the effectiveness of the hyaluronic acid fillers administered, it is used in a slightly modified form.

FIND PLASTIC & AESTHETIC PRACTICE

Get more information about the possibilities of JUVÉDERM^® Fillers at a practice near you. Together with your doctor(s), you will create a treatment plan based on your personal goals. Please note that with fillers from JUVÉDERM^® side effects may occur immediately after treatment or after a certain period of time – and please consult your attending physician(s).

“MY MOST BEAUTIFUL ME IS MY STRONGEST ME.”

Sylvie Meis uses JUVÉDERM^® Face filler because she wants to feel 100% comfortable in her skin. She trusts the #1 premium brand*. *Based on market research conducted in 2021 among healthcare professionals with more than 1700 participants from the world’s 16 largest aesthetic markets. FOB Price: US $ 55-110 / box Minimum order quantity: 2 boxes/boxes. FOB Price: US $ 1.2-45.0 / piece Minimum order quantity: 1 piece/pieces FOB Price: US $ 16.0-120.0 / piece Minimum order quantity: 1 piece/piece FOB Price: EUR 135-145 / unit Minimum order quantity: 100 unit/units of measurement FOB Price: US $ 64.59-688.59 / piece Minimum order quantity: 5 pieces/piece FOB Price: US $ 100-110 / box Minimum order quantity: 2 boxes/boxes FOB Price: US $ 16.0-120.0 / piece Minimum order quantity: 1 piece/piece FOB Price: EUR 135-150 / unit Minimum order quantity: 100 unit/units of measure FOB Price: US $ 100-110 / box Minimum order quantity: 2 boxes/boxes FOB Price: US $ 100-110 / crate Minimum order quantity: 2 crates/crates FOB Price: US $ 100-110 / crate Minimum order quantity: 2 crates/crates FOB Price: US $ 100-110 / crate Minimum order quantity: 2 crates/crates FOB Price: US $ 100-110 / crate Minimum order quantity: 2 crates/crates FOB Price: US $ 100-110 / crate Minimum order quantity: 2 crates/crates FOB Price: US $ 50-110 / crate Minimum order quantity: 2 crates/crates FOB Price: US $ 100-110 / crate Minimum order quantity: 2 crates/crates FOB Price: US $ 70-110 / crate Minimum order quantity: 2 crates/crates FOB Price: US $ 100-110 / crate Minimum order quantity: 2 crates/crates FOB Price: US $ 100-110 / crate Minimum order quantity: 2 crates/crates FOB Price: US $ 100-110 / box Minimum order quantity: 2 boxes/boxes Postmarket Safety Surveillance of Delayed Complications for Recent FDA-Approved Hyaluronic Acid Dermal Fillers Joel L. Cohen, MD,*† Jessica Hicks, PhD,‡ Alessandra Nogueira, MD,‡ Vanessa Lane, PhD,§ and Bill Andriopoulos, PhDk DERMATOLOGIC SURGERY – February 2022 – Volume 48 – Number 2; 220-224 Data on adverse reactions to FDA-approved filler products are sparse. Side effects after treatments are divided into early onset <14 days and delayed onset >14 days side effects. Early onset side effects are considered technique associated and were not relevant to these studies. Late onset side effects include nodularity, hypersensitivity reactions, and granulomas. Between January 2016 and January 2021, postmarketing surveillance (PMS) data were collected for the following fillers in the Manufacturer and User Facility Device Experience (MAUDE) FDA Database: Juvederm Volbella (HAVOB; Allergan plc), Restylane Refyne (HAREF; Galderma SA), and Restylane Defyne (HADEF; Galderma SA), all approved in 2016; Juvederm Vollure (HAVLR; Allergan plc), Teosyal RHA2/3/4 (HARH2/3/4; Teoxane SA), and Revanesse Versa (HAVER; Prollenium Medical Tech- nologies), and Restylane Kysse (HA ). Revanesse Versa (HA ver) was not approved until 2017 and Restylane Kysse in 2020. RHa 2/3/4 were not available on the US market until mid-2020. The MAUDE database draws on company data as well as voluntary reports from physicians. The reports are not standardized. The authors considered entries that referred to hypersensitivity reactions, inflammatory and noninflammatory nodules, and granulomas. Among 585 reports, 195 (33.3%) were delayed onset adverse events: 71.8% were nodules (42.1% inflammatory and 29.7% noninflammatory), hypersensitivity reactions (21.5%), and granulomas (6.7%). The paper breaks down the adverse events by filler group. The relevance of this breakdown is questionable, as some of the preparations were not available on the US market at the time of the study. Inflammatory and non-inflammatory nodules represent the most common delayed onset side effect of filler treatments. The incidence of delayed onset nodules estimated in the literature ranges from 0.02 to 4%. According to data from the American Society of Plastic Surgery, 8 million dermal filler treatments were performed between 2016 and 2019. A higher number of filler side effects would thus be expected, in the MAUDE database. The authors assume that documentation of filler side effects is significantly underrepresented. Due to the paucity of data, no conclusions can be drawn regarding frequency and filler association.

Author

Dr. Daniela Greiner-Krüger Medicorium Center for Dermatology and Aesthetics Nassauer Str. 10 61440 Oberursel www.medicorium.de A systematic review and meta-analysis of treatment modalities for anterior accessory saphenous vein insufficiency Tamana Alozai, Eline Huizing, Michiel A. Schreve, Michael C. Mooij, Clarissa J. van Vlijmen, Willem Wisselink, Çağdaş Ünlü. A systematic review and meta-analysis of treatment modalities for anterior accessory saphenous vein insufficiency, Phlebology 2022 Apr;37(3):165-179. doi:10.1177/02683555211060998 The anterior saphenous vein (VSAA) is present in 41% of the population, runs superficial and lateral to the great saphenous vein (VSM) on the thigh, and opens into the saphenofemoral junction. Insufficiency of the VSAA is responsible for approximately 10% of all clinical pictures associated with varicosis and causes a severity score index similar to that of VSM insufficiency, as well as similar symptoms in affected patients. Furthermore, significantly more superficial leg vein thromboses are documented in isolated VSAA insufficiency compared with VSM insufficiency. Consequently, the treatment of insufficient VSAA is of great importance. The treatment of varicose veins has diversified and evolved in recent years, especially after the advent of minimally invasive endovenous procedures, although studies on the optimal treatment of VSAA insufficiency remain limited. This systematic literature review and meta-analysis addresses existing therapeutic options for the treatment of isolated VSAA insufficiency, including endovenous laser (EVLA) or radiofrequency ablation (RFA), cyanoacrylate glue, sclerotherapy, and surgical therapy. Literature searches were conducted in MEDLINE, Embase, and Cochrane Library. Studies were examined that presented outcomes of treatment for primary insufficiency of the VSAA, were written in English, and were available as full text. The primary end point was anatomic closure success, defined as successful occlusion of the vein without signs of flow. Secondary endpoints were pain during and after therapy, severity of disease as measured by the venous clinical severity score (VCSS), quality of life, patient satisfaction, aesthetic outcome, complications (deep and superficial leg vein thrombosis, burns, paresthesias, hyperpigmentation), and time to return to daily activities. The methodological quality of the studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) score. The literature search identified 861 studies, of which 81 appeared eligible for full-text review after initial screening. This systematic review then included 16 studies that met the inclusion criteria. Most studies were retrospective and of low to moderate quality as measured by the MINORS score. A total of 609 VSAAs were treated and documented. The anatomic success rate (first end point) was 91.8% after EVLA and RFA (11 studies), 93.6% after cyanoacrylate glue (3 studies), 79.8% after sclerotherapy (2 studies), 97.9% after phlebectomies, and 82% after CHIVA. Paresthesias were observed in 0.7% of patients after EVLA (6 studies). OVT occurred in 2.6% of patients after RFA (2 studies), in 27% after sclerotherapy (1 study), and in 12% of patients after phlebectomies. Deep vein thrombosis or skin burns were not documented. Isolated studies documented a high patient satisfaction rate of 84% after EVLA. In conclusion, treatment of isolated insufficiency of the VSAA is safe and effective. Treatment by phlebectomy provides very good success rates with intact saphenofemoral junction. Less successful results have been seen after CHIVA and sclerotherapy.

Author

Dr. med. Stefania Gerontopoulou Tabea Krankenhaus GmbH Zentrum für Venen- und Dermatochirurgie Kösterbergstraße 32 22587 Hamburg CEAP classification system and reporting standard, revision 2020 Fedor Lurie, Marc Passman, Mark Meisner, Michael Dalsing, Elna Masuda et al February 2020 Journal of Vascular Surgery Venous and Lymphatic Disorders 8(3) DOI:10.1016/j.jvsv.2019 .12.075 https://angiolife.com.ua/media/pages/files/CEAP%202020.pdf The CEAP classification is the definitive tool for grading chronic venous insufficiency and scientifically classifying the severity of a venous condition. It is recognized worldwide and associated with good reproducibility and that is why it is recommended and used in clinical trials and in everyday phlebological practice. The CEAP classification was introduced in 1994 by an international “Ad Hoc Committee of the American Venous Forum”. However, in clinical practice, the revised simple CEAP classification of 2004 is used, which summarizes the clinical (C), etiological (E), anatomical (A), and pathophysiological (P) aspects of venous disease: In May 2017, the American Venous Forum began a new revision, which proceeded in four phases and ended in 2020 with the above article. Important points were to maintain the good reproducibility and practical application of the CEAP classification, compatibility with the older version, and evidence-based outcome. What is the new CEAP classification now and what relevant changes do we expect? On the clinical aspects (C):

Recurrent varicosis is taken into account (C2r).
Corona phlebectatica paraplantaris will be integrated as a new subcategory (C4c)
Recurrence of a florid ulcer is given a new subcategory (C6r).

Regarding etiological aspects (E): There are two subcategories of secondary varicosis/CVI

Esi: for intravascular causes of a wall or valve defect, e.g., deep vein thrombosis, traumatic arteriovenous fistulas, intravenous sarcomas
Ese: extravascular causes, e.g., central venous hypertension due to obesity, venous compression due to tumors, motor dysfunction due to paraplegia, arthritis, or chronic immobilization

E class	Description
Ep	Primary
Esi	Secondary intravenous
Ese	Secondary extravenous
Ec	Congenital
En	No cause identified

Regarding anatomical aspects (A):

Numerical values that described a specific vessel have been replaced by anatomical abbreviations, e.g., “2nd” for insufficiency of the saphenous vein above the knee is now referred to as “GSVa.”

Regarding pathophysiological aspects (P):

The breakdown remains the same and includes pathologic findings that designate reflux (r), obstruction (o), both (r,o), or undetectable pathophysiology (n).
It is recommended to use the new abbreviations (A) additionally to describe the localization of the pathological findings.

In conclusion, the CEAP classification remains a very good tool for everyday phlebological practice as well as for clinical studies. It remains clinically very feasible and indisputably meaningful. The new revised items provide a more detailed statement of existing venous disease without affecting the practicality of the instrument.

Author

Dr. med. Stefania Gerontopoulou Tabea Krankenhaus GmbH Centre for Vein and Dermatosurgery Kösterbergstraße 32 22587 Hamburg Prognostic Impact of Perineural Invasion in Cutaneous Squamous Cell Carcinoma: Results of a Prospective Study of 1,399 Tumors Konrad Haug 1, Helmut Breuninger 1, Gisela Metzler 2, Thomas Eigentler 1, Martin Eichner 3, Hans-Martin Häfner 1, Saskia M Schnabl 4 1 Department of Dermatology, University of Tübingen, Tübingen, Germany. 2 Centre for Dermatohistopathology and Oral and Maxillofacial Pathology Tübingen-Wuerzburg and Department of Dermatology, University of Tübingen, Tübingen, Germany. 3 Department of Clinical Epidemiology and Applied Biometry, University of Tübingen, Tübingen, Germany. 4 Department of Dermatology, University of Tübingen, Tübingen, Germany. Electronic address: [email protected]. J Invest Dermatol 2020 Oct;140(10):1968-1975. doi: 10.1016/j.jid.2020.01.035. Epub 2020 Mar 10. Approximately 95% of cutaneous squamous cell carcinomas can be treated with primary curative dermatosurgery. Local recurrence or locoregional and possibly distant metastasis occurs in only about 5%. Risk factors for this tumor progression are discussed again and again in the different guideline committees worldwide and are partly evaluated differently. Difficulties are caused by the often poorly powered studies due to the small number of patients and often very differently composed patient collectives with consequently differently presented local recurrence and metastasis risk. The S3 guideline “Actinic keratosis and squamous cell carcinoma of the skin” (version March 2020) summarizes the following risk factors for an increased risk of recurrence and/or metastasis: vertical tumor thickness > 6 mm, horizontal tumor diameter > 20 mm, desmoplastic growth, perineural infiltration, immunosuppression, localization ear/lip, dedifferentiation (G3,G4). According to a review of current international publications, vertical tumor thickness > 6 mm and desmoplasia have been considered the most important prognostic factors so far. The authors of the Tübingen Department of Dermatology led by Mr. Konrad Haug investigated in a prospective monocentric study 1399 patients who died of cutaneous squamous cell carcinoma (SCC) between 2005 – 2015, SCC) were treated. If a patient suffered from multiple SCC simultaneously, the tumor with the highest risk profile was included. SCC with a tumor thickness ≥ 6 mm and SCC with desmoplastic growth (dSCC) with a tumor thickness of 2.1 – 5.9 mm were also evaluated for perineural invasion (PNI) was investigated. The median follow-up was 36.5 months. 67% of patients were male, and the median age of onset was 78 years (30.0 – 96.8). A total of 145 tumors showed desmoplastic growth; 21 of these tumors also developed PNI. Tumors with development of PNI without desmoplasia and thinner SCC < 2 mm with PNI were thus not examined separately in this study. There were predominantly well-differentiated tumors with grading 1-3 in all subgroups studied (non dSCC, dSCC, dSCC with PNI). The subgroups differed significantly in the proportion of immunosuppressed patients: in the non dSCC group, 10% of patients were immunosuppressed, in the dSCC 26.9%, and in the dSCC with PNI 33.3%. In addition, it is notable that the mean tumor diameter was significantly larger in both the dSCC group (30.7 mm, p<0.0001) and the dSCC with PNI (40.7 mm, p<0.0001) compared to the nondSCC (21.7 mm). These statistically significant differences were also seen in mean tumor thickness: nondSCC averaged 4.31 mm thick, dSCC 6.7 mm (p<0.0001), and dSCC with PNI 8.8 mm (p< 0.0001). These differences were also reflected in tumor progression defined as local recurrence or occurrence of metastases, patient outcome, and tumor-specific death of the respective patient groups: both overall tumor progression (nondSCC 7.2 %; dSCC 35.2 %, p <0.0001; dSCC with PNI 71. 4 %, p < 0.0001) showed significantly higher values of dSCC and dSCC with PNI compared to non-desmoplastic SCC as well as all subtypes of progression individually (in transit/satellite metastases, local recurrence, lymph node metastasis, distant metastasis, tumor-specific death). Accordingly, progression-free survival at 5 years was also worse: if it was 89% in nondSCC, progression-free survival was only 50% in dSCC and only 17% in dSCC with PNI. In summary, this well-powered study shows a nice overview of the impact of risk factors on local recurrence and metastasis risk in SCC. It confirms all risk factors already presented in the S3 guideline, but in a slightly different weighting: in a multivariate analysis of risk factors, desmoplasia was the most severe risk factor with a hazard ratio of 3.32 followed by perineural infiltration (HR 2.48) and vertical tumor thickness ≥ 6 mm (HR 2.03). In particular, the combination of several risk factors, represented by the higher percentage of patients with immunosuppression, on average increased horizontal tumor diameter and on average increased vertical tumor thickness in the subgroup of desmoplasia and the subgroup of desmoplasia with perineural growth by the colleagues, impressively shows the significantly worse outcome, especially when several risk factors occur simultaneously. Especially in such high-risk tumors, an adjuvant procedure should be discussed in my opinion due to the significantly increased risk of local recurrence and metastasis even if R0 resection has been achieved surgically. However, adjuvant therapy concepts for SCC are currently limited: according to the current S3 guidelines, adjuvant radiotherapy should only be performed if the resection margin is narrow (< 2 mm without the possibility of resection), if there is extensive perineural sheath infiltration, and after resection of lymph node metastases. Other of the above risk factors have not been considered for initiation of adjuvant therapy to date. In view of the available study data, I believe that in individual cases, especially when several high-risk factors are combined, interdisciplinary tumor conferences should determine which adjuvant therapy concepts (radiotherapy) can be offered to the respective patient. It remains to be seen what role the only anti-PD1 cemiplimab approved to date for inoperable non-irradiable SCC may play in the adjuvant role. Currently, two phase II trials are evaluating the adjuvant use of cemiplimab in this regard.

Author

Dr. med. Sonja Dengler Senior Physician Dermatological Clinic Dortmund gGmbH Beurhausstraße 40 44137 Dortmund Incidence and risk factors of blood splatter in dermatological surgery: how protective are full facial masks? Like many a spectacle-wearing surgeon, I am well acquainted with the condition of sometimes minute drops of blood on the glasses. So far, I have not had any major concerns about the risk of blood splashes. In searching for a particular dermatosurgical publication from last year for this newsletter, a study in the BJD “splashed” me in a way: Aguilar-Duran S, Panthagani A, Naysmith L, Holme SA British Journal of Dermatology (2017) 176, pp270-280 In the context of dermatosurgical procedures, contamination of the surgeon and OR assistant by blood splatter was estimated at 33 and 15%, respectively. Surgical mouthguards with visors were therefore more commonly used to protect operating room personnel from mucocutaneous viral transmission. The authors report in a letter about a study on the protective effect of visor mouthguards: In a total of 345 dermatosurgical procedures in a period of three weeks 410x mouthguards with visor (355x operator, 57x assistant) were checked. Using a very sensitive test, hemoglobin was detected on the mouthguard in 62 cases (15.1%) (surgeon 14.4%, assistant 19%), with blood detected only on the outside of the visor in 84%. On average, 7.6 drops of blood (1-30) were counted on the outside of the visor. In 5%, blood was only detectable microscopically on the outside of the visor, but blood spatter or hemoglobin was found on the inside of the visor in 4 cases (6%). In univariate analysis, duration of surgery and use of bipolar forceps were significant risk factors for blood spatter on the mouthguard, whereas patient anticoagulation was not. In multivariate analysis, the use of bipolar electrocoagulation was the most significant risk factor for blood spatter (odds ratio 12.52; 95% CI 3.87-40.43; p<0.001). The unique feature of this study is that even low-level contamination was detected with a sensitive hemoglobin test and that arguably aerosol-related blood contamination could even be detected on the inside of the visor. The authors therefore called for the mouthguard to be changed as a matter of principle after every procedure, even in the absence of visible blood splatter. The admittedly low risk after mucocutaneous blood exposure should not be ignored. Because only the detection of hemoglobin was used as an indication of contamination and not exposure to other body fluids containing virus, an additional risk may not have been considered. The results of the study appear very plausible. The most important message of the work is to wear a mouthguard with a visor especially when using bipolar electrocoagulation.

Author

Prof. Dr. Matthias Möhrle Praxisklink Tübingen – Haut und Venen Lehrpraxis der Universität Tübingen für das Fachgebiet Dermatologie Europaplatz 2 D-72072 Tübingen The sterility of partially used hyaluronic acid fillers after long storage. Al-Haddab M1, Abduljabbar A1, Al-Somaily A. † 1Departments of Dermatology, and †Microbiology, King Saud University, Riyadh, Saudi Arabia.

Abstract

Background: Hyaluronic acid (HS) gel fillers currently represent the majority of soft tissue augmentation procedures because they have lower rates of complications compared with other materials. Many patients do not consume an entire syringe of filler, but may require a touch-up (retouch) or intermittent treatments after some time. The remaining material is stored for follow-up use on the same patient. Objective: There are insufficient recommendations in the literature regarding the safety of dermal filler storage and post-treatment use due to a lack of studies. The aim of this study is to investigate possible infectious contamination associated with storage of HS fillers after patient treatment. Methods: Hyaluronic acids from previously used syringes were stored at room temperature under sterile conditions for varying periods of time from 2009. Later, the materials were subjected to cultural studies, including gram-positive and gram-negative bacteria, mycobacteria, and fungi. Results: Fungi or mycobacteria were not cultured from any sample. Some positive bacterial cultures were seen, but these were predominantly contaminated with normal skin surface flora. Conclusion: Although generally practiced, storage of HS fillers after initial patient injection carries a real but small risk of contamination. Dermatol Surg 2017;0:1-4- DOI: 10.1097/DSS.00000000001091

Comment

The authors investigated the potential risk of contamination of hyaluronic acid fillers after they had already been opened and partially injected on the patient. They labeled 36 used syringes (Juvéderm® Ultra and Restylane®), replaced the original caps, and stored them in their original packaging at room temperature in a cabinet for an average of 57.8 months (32.87-71.57 months). Subsequently, the authors performed several in vitro studies to exclude any contamination with anaerobic and aerobic bacteria, mycobacteria, and fungi. The contents of 5 of the 36 syringes were contaminated with Staphylococcus epidermidis, Corynebacterium species, and Bacillus species. The authors point out that the risk of contamination in the opened syringe is small but real, without inferring any resulting infections in the tissues. The storage of opened hyaluronic acid syringes for re-injection on the same patient is an increasing habit of many physicians, not least for commercial reasons. Since there are only few and incomplete data in the literature on the subject of storage after opening an HS filler and a possible associated contamination1-4 , the current work contributes to obtaining scientific data on the safety of storage. A positive aspect is the very long follow-up period beyond the expiry date of the respective HS syringes investigated. However, taking into account the fact that most reinjections with hyaluronic acid are performed within a few weeks as part of a touch-up, the publication unfortunately does not provide any data in this regard. It would have been desirable to integrate corresponding cultural examinations already after 2 weeks and, for example, after 16 weeks to obtain additional information on the temporal onset of a possible contamination. This statement would certainly have had a meaningful clinical relevance. In conclusion, based on the studies of Al-Haddab et al. it can be stated that caution should be exercised when storing opened HS fillers, as sterility after opening cannot be guaranteed. In each treatment session, the material should be used up or the remaining amount discarded regardless of any commercial interests.

Literature

Bellew SG, Carroll KC, Weiss MA, Weiss RA. Sterility of stored nonanimal, stabilized hyaluronic acid gel syringes after patient injection. J Am Acad Dermatol 2005;52:988-90.
Goulart JM. Groysman T. LaBombardi V. Comite S, et al. Sterility of injectable fillers containing nonanimal stabilized hyaluronic acid, hyaluronic acid, or calcium hydroxylapatite after long-term storage. Cosmet Dermatol 2010;23:400-2.
Bhatia AC, Arndt KA, Dover JS, Kaminer M, et al. Bacterial sterility of stored nonanimal stabilized hyaluronic acid-based cutaneous filler. Arch Dermatol 2005;141:1317-8.
Safo PK, Wahlgren C, Obagi S. Safety of storing and reusing hyaluronic acid fillers: a retrospective chart review. Cosmet Dermatol 2011;24:22-6.

Author

Dr. med. Matthias Imhof Hautmedizin Bad Soden Ästhetische Dermatologie im Medico Palais Parkstrasse 6 65812 Bad Soden www.hautmedizin-badsoden.de H97 Panasonic Microwave.

Anna Hein

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