in vivo 23: 479-486 (2009)
`
`Assessment of a New Hyaluronic Acid Filler. Double-blind,
`Randomized, Comparative Study between Puragen and
`Captique in the Treatment of Nasolabial Folds
`
`MARIAGIUSEPPINA ONESTI, MARCO TOSCANI, GIUSEPPE CURINGA,
`STEFANO CHIUMMARIELLO and NICOLÒ SCUDERI
`
`Department of Plastic and Reconstructive Surgery, University of Rome “La Sapienza”, Rome, Italy
`
`Abstract. Fillers represent a field of aesthetic medicine
`under remarkable expansion. Over the past few years, in the
`USA, there has been a huge increase in the use of fillers,
`especially for hyaluronic acid (400% in 2004). The causes
`of this increase have been the greater tolerability of this
`reabsorbable filler with respect to the others, and its
`prolonged efficacy in time due to chemical modifications of
`its molecular structure. In our study, we report the results of
`a double-blind comparative study between Puragen (latest-
`generation hyaluronic acid with double cross-linking) and
`Captique (second generation hyaluronic acid with single
`cross-linking), in the treatment of nasolabial folds. Each
`patient received Puragen in one nasolabial fold and Captique
`in the contralateral fold, at random. Clinical efficacy was
`assessed independently by the investigator and the patient 2,
`4 and 6 months after baseline or when the optimal cosmetic
`result was obtained. The tolerability assessment was made
`by the patient (using a daily diary to record any adverse
`events) for 2 weeks after each treatment, and by the operator
`2, 4, and 6 months after baseline. Sixty-eight patients
`completed follow up at 6 months. From the results obtained
`in this study, Puragen remained stably in the treated tissues
`even after 6 months while less satisfactory results were
`obtained with Captique.
`
`The term “filler”, in the field of plastic surgery and aesthetic
`medicine, refers to the vast and heterogeneous group of
`substances that can be applied by various injection
`techniques to fill wrinkles and skin sag for aesthetic and
`curative purposes. Over the past few years, there has been an
`unstoppable spread of these products in the field of plastic
`surgery, due to the ever-growing need for techniques that
`
`Correspondence to: Curinga Giuseppe, via Benedetta 24, 00153
`Rome, Italy. Tel: +39 3204748193, e-mail: giuseppecuringa@libero.it
`
`Key Words: Filler, hyaluronic acid, relaxation wrinkles, puragen,
`nasolabial folds.
`
`ensure high efficacy but minimum invasiveness. To eliminate
`blemishes caused by age, fillers currently represent a coded
`method. They are ever-increasingly refined and designed to
`meet the many needs in the field of plastic surgery, their use
`has increased by 25% over the past year and their growth
`since the year 2000 has been estimated at about 200% . The
`use of fillers is also indicated for a certain number of
`diseases in which they play a functional and curative, as well
`as an aesthetic role. In fact, they are used to correct inherited
`or traumatic defects of the soft tissues of the face, to cure
`patients suffering from scleroderma, progressive facial
`hemiatrophy, facial paralysis and finally, to treat patients
`suffering from lipodystrophy following treatment with
`antiretroviral drugs (1). Other indications for their use are
`represented by unilateral paralysis of the vocal cords,
`increase in size of the lips and soft palate in patients with
`labiopalatine cleft, anophthalmia and enophthalmos, and
`penis augmentation (2-4). The greatest demand for fillers,
`however, comes from patients with defects or disorders due
`to skin aging and/or photoaging (5). They are thus used to
`fill the lacrimal canaliculus/pit, remodel the shape and raise
`the tip of the nose, fill nasolabial folds and labial
`commissures, fill the cheeks and raise the zygomas, remodel
`the mandibular profile, rejuvenate the neck, increase and/or
`underline the profile and the labial contour. Numerous
`clinical results and studies conducted on animals have
`demonstrated a short and long-term efficacy according to the
`chemical structure and the surface characteristics of the
`microparticles making up the skin fillers. On the market
`there are various types of fillers that may be classified as
`reabsorbable (with temporary effect) and non-reabsorbable
`(with semi-permanent and permanent effect). Research is
`permanently oriented towards the discovery of new products
`that reach the “ideal filler” objective. Today, those that come
`the closest are those based on hyaluronic acid.
`Hyaluronic acid (HA) was isolated for the first time in
`1934 by Meyer and Palmer from the vitreous body of the eye
`of a cow (6). They found a substance containing two
`saccharidic fractions, one of which was HA.
`
`0258-851X/2009 $2.00+.40
`
`479
`
`ALL 2056
`PROLLENIUM V. ALLERGAN
`IPR2019-01505 et al.
`
`

`

`in vivo 23: 479-486 (2009)
`
`HA may be defined as a glycosaminoglycan with an
`unbranched polysaccharide chain produced by the aggregation
`of thousands of disaccharidic units made up in turn of
`glycuronic acid residues (a glucose derivative) and N-acetyl
`glucosamine. In vivo all carboxyl groups of glucoronic acid
`and N-acetyl-glucosamine are completely ionized giving the
`hyaluronic acid molecule high polarity and, consequently, high
`solubility in water. Due to this property, HA can form
`complexes with numerous molecules of water reaching a high
`degree of hydratation. In the amorphous matrix of a
`connective tissue, HA therefore maintains the degree of
`hydratation, turgidity, plasticity and viscosity. It can also act
`as a binding agent, an anti-shock molecule and an efficient
`lubricant, preventing the damage caused to tissue cells by
`physical stress. The extremely long structure of the molecule
`together with its high degree of hydratation enables several
`HA polymers to form a particular structure with the following
`two main functions: to create a molecular framework that
`maintains the form and tone of the tissue; and to function as a
`filter against the dispersion of particular substances, bacteria
`and infectants in the tissue. Only substances with a sufficiently
`low molecular weight to pass through the gaps in this mesh
`can spread freely in the tissue, all substances with a higher
`molecular weight such as bacteria or viruses will remain
`trapped in the mesh. It should be noted that many bacteria
`have hyaluronidase (an enzyme that breaks up HA) and can
`open a gap for themselves. In its natural form, HA is broken
`up and reabsorbed quickly due to the action of hyaluronidase
`and free radicals. In the past, this has considerably limited its
`use in all medical and specialist applications that require a
`more lasting effect such as the correction of dermal and
`subdermal tissue defects, such as wrinkles and scars, and to
`augment the soft tissues of the face.
`The aim of this study was to assess a new-generation HA
`(Puragen™), in comparison with an old-generation HA
`(Captique™). Puragen™ is a hydrogel of non-animal origin,
`with double cross linking. These ultrastructural characteristics
`increase the resistance of HA to breakdown by enzymes and
`free radicals (7). Captique™ is a HA of non-animal origin,
`with single cross-linking.
`
`History and evolution of the concept of filler. In the seventies,
`when aesthetic plastic surgery was only available to the elite
`or, in any case, represented a niche, fillers began to constitute
`an alternative to surgery or an integration of it and the
`leading pharmaceutical companies began to operate in this
`sector, which was destined to give huge profits, the current
`level of which could not even have been imagined. The
`collagen introduced in the mid seventies represented a
`turning point in this sector in that it put on the market a
`potentially safe product that could compete with the only
`true leader of fillers: silicone (8-10). At the time, this
`substance represented, for the doctors who used it, the only
`
`480
`
`product that could eliminate blemishes and achieve the
`desired augmentation in a short time and at limited
`management costs. The same applies for patients who saw
`their expectations fulfilled immediately and could be sure
`that they would obtain a long-lasting result.
`Passing through the success of silicone (which represented
`the only solution) and collagen, in time, we have witnessed
`the invention of an increasing number of fillers which, in one
`way or another, contributed to the growth of this market, as
`they were aimed at an increasingly broad public. In the 80-
`90s, the use of fillers spread at a breathtaking pace. The
`attempts to obtain a molecular compound capable of
`ensuring a long-lasting improvement stable in time led to the
`spread of fillers of a disputable nature and chemical
`composition with quite disastrous results. During the same
`period, silicone was taken off the market (not in all
`countries). Even today, however, silicone can still be
`purchased in some European countries.
`The attention from the media and doctors and scientists’
`awareness of the many cases of “malpractice” attributed to
`the inappropriate use of the numerous fillers available
`contributed to the elaboration of a new concept of fillers (10,
`11). From a long-lasting result stable in time at all costs, the
`objective has become a treatment that guarantees safety,
`efficacy and, where possible, a long-lasting effect (12).
`Reabsorbable fillers (mainly HA and collagen) have thus
`grown at a remarkably rapid rate on the international scene
`(13-16). Therapeutic procedures such as lipofilling may, in
`some cases, be likened to a genuine “autologous filler”, well
`tolerated by patients and giving unexpected aesthetic results
`when compared with traditional fillers (17-21).
`Biostimulation and skin revitalization are other concepts
`that have developed over the past few years, finding their
`rationale in the injection of substances that nourish and
`regenerate the layers of the skin (22, 23).
`The latest novelty in the vast field of fillers is the use of
`autologous fibroblasts for eliminating dermal defects (acne
`scars and wrinkles) (23).
`In countertendency, “silicone” returns with a vengeance in
`the science magazines. The authors sustain with numerous
`reasons that silicone’s “failure” as an “ideal filler” was due
`to methodological and production errors (failure to purify the
`particles). The “love-hate” relationship, as the authors
`sustain, could bring the historical product back onto the
`market as a long-lasting “ideal” filler (24-26). According to
`the experience gained over several decades at the Department
`of Reconstructive and Plastic Surgery, this hypothesis could
`take us back in time with very high risks for patients and
`operators (10).
`From the aforesaid considerations, it clearly emerges how
`the complex world of fillers is a topical subject of debate
`from many points of view and, above all, at an important
`crossroads of its growth.
`
`

`

`Onesti et al: Comparative Study between Two Hyaluronic Acid Fillers
`
`Materials and Methods
`
`Table I. Wrinkle severity rating scale (WSRS).
`
`Materials. Puragen (Mentor Corporation), is a transparent gel of
`non-animal origin, based on hyaluronic acid with double cross-
`linking, made up of particles having a diameter of 240 μm. Captique
`(Inamed) is a stabilized and cross-linked hyaluronic acid gel (5.5
`mg/mL), with particles having a diameter of 500 μm. Both
`biomaterials are contained in a 1.0 mL syringe with a 30-gauge
`needle in sterile form.
`
`Patient selection and clinical study. This double-blind patient-
`investigator randomized study was conducted at the Department
`of Dermatology and Plastic Surgery of the “La Sapienza”
`University of Rome. The criteria for inclusion in the study were
`men and women aged between 25 and 80 years with marked
`nasolabial folds. All patients recruited on the study were duly
`informed by the operator, who had them sign the specific
`informed consent form. The study did not include patients who
`needed repair of the soft tissues following traumas, facial
`asymmetries, patients with dermatological problems, systemic
`diseases (diabetes mellitus, coagulation disorders, connective
`tissue diseases), patients under immunosuppressive treatment,
`with reported sensitivity to HA, alcoholics, drug addicts or
`pregnant women. Patients subjected previously to treatment with
`fillers were also excluded.
`The study was conducted in accordance with the principles of
`the Helsinki Declaration, and the ICH (International Conference
`of Harmonization) and GCP
`(Good Clinical Practice)
`international guidelines. Each patient received Puragen in one
`nasolabial fold and Captique in the contralateral fold, in a totally
`random fashion. To assess clinical efficacy, an investigator
`worked alongside the operator performing the injections, who did
`not know the name of the product injected. The treatment was
`performed with the patient keeping his eyes closed, so that he
`could not recognize the product.
`The patients were assessed 2 weeks after the initial injection
`implant of Puragen and Captique. If the correction was
`suboptimal, treatment was repeated with the same product used
`previously and the patient was reassessed after another 2 weeks,
`until the “optimal cosmetic result” was obtained; in this way, a
`baseline of the study was established, following the patients over
`a period of 6 months.
`
`Injection technique. Use was made of local analgesics (ice, topical
`anaesthetics for local injection, and/or with 1% lidocaine block)
`chosen by the operator according to the patients to be treated. The
`injection implant method used by the operator was linear, serial or
`in combination. The depth of injection and the volume to be injected
`were at the operator’s discretion. The skin defects to be treated were
`filled but not overcorrected. Having completed treatment, a hand
`massage was performed at the injection site to aid the distribution of
`the material injected in the adjacent tissues.
`
`4
`
`3
`
`Description of scores
`5
`Extreme: Long, deep folds, detrimental to facial appearance; 2-
`4 mm V-shaped folds when stretched, unlikely to be corrected
`by injectable implant alone
`Severe: Very long and deep folds; prominent facial features; 2
`mm folds when stretched; significant improvement expected
`from injectable implant
`Moderate: Moderately deep folds; normal appearance of folds
`when not stretched; excellent improvement expected from
`injectable implant
`Mild: shallow but visible folds
`Absent: no visible fold
`
`2
`1
`
`Table II. GAIS (Global Aesthetic Improvement Scale) Scale.
`
`Result
`
`Description
`
`Very much improved
`Much improved
`
`Improved
`
`No change
`Worse
`
`Excellent cosmetic result
`Improvement from original condition but not
`excellent. Touch-up required for excellent
`result
`Marked improvement in appearance with
`respect to original condition. A touch-up or
`retreatment is indicated
`No change obtained by injection implant
`Worse than original condition
`
`Improvement Scale (GAIS). The WSRS is a scale used to quantify
`the results obtained in treating nasolabial folds, on the basis of
`photographic images. The scores for evaluating the nasolabial folds
`were given according to the length and depth of the folds without
`reference to pretreatment pictures or baseline (Table I). The GAIS
`scale assesses the improvement obtained (Global Aesthetic
`Improvement Scale: Worse, No change, Improved, Much improved
`and Very much improved) in each fold at baseline and during the
`follow-up, comparing the results with the pretreatment photographs
`(Table II).
`The main assessment was made by the investigator using the
`WSRS 6 months after baseline; secondary assessments were made
`by the investigator and the patient 2 and 4 months later with the
`WSRS, and 2, 4 and 6 months after baseline the assessment was
`completed with the GAIS scale.
`
`Assessment. Clinical efficacy was assessed independently by the
`investigator and the patient 2, 4 and 6 months after baseline. The
`tolerability assessment was made by the patient (using a daily diary
`to record any adverse events) 2 weeks after each treatment, and by
`the operator 2, 4 and 6 months after baseline.
`The efficacy of the treatments was assessed using the Wrinkle
`Severity Rating Scale (WSRS) and
`the Global Aesthetic
`
`Statistical analysis. The WSRS (pretreatment) ratings obtained with
`Puragen and Captique were compared using Mc Nemar’s test. The
`variable categories (“Puragen is superior to Captique”, “Puragen is
`equivalent to Captique”, “Captique is superior to Puragen”) were
`based on the WSRS and GAIS ratings and were expressed as a
`frequency. A probability of less than 5% was considered statistically
`significant.
`
`481
`
`

`

`in vivo 23: 479-486 (2009)
`
`Results
`
`Of the 84 patients initially selected for the study, 74 (70
`women and 4 men) continued the comparative study. The
`average age was 50.2 years. Of this population 68 patients
`completed 6 months of follow up; 6 patients withdrew
`prematurely from the study, 3 because of protocol violation
`and 3 because of loss to follow-up.
`
`Efficacy. Prior to treatment, the nasolabial folds were
`assessed (Wrinkle Severity Rating Scale) by the investigator
`as mild (5% ), moderate (50% ), severe (35% ) or extreme
`(15% ). On achievement of the “optimal cosmetic result”
`(baseline), no differences were noted between the sides
`treated with Puragen and those treated with Captique, and
`most patients improved their result on the WSRS scale by
`one or two grades, with a larger percentage of patients
`without folds or with “mild” folds (Figure 1).
`Puragen proved significantly superior to Captique in the
`WSRS rating at all post-baseline check-ups (p<0.05). At six
`months post-baseline, Puragen was superior to Captique in
`60.4% of cases, and Captique proved superior to Puragen in
`5.8% of cases (p<0.05) (Table III). According to the GAIS
`scale ratings, Puragen obtained significantly higher ratings
`than Captique after baseline (p<0.05). At six months post-
`baseline Puragen was superior to Captique in 75% of
`patients, and Captique superior to Puragen in 5.8% (Table
`IV). The efficacy assessment of the treatments undergone by
`patients gave equivalent results to those obtained by the
`investigator (Table V and Table VI).
`The number of sessions required to obtain the optimal
`cosmetic result ranged from 1 to 3 treatments (for an average
`of 1.5 for both products) and did not reveal any significant
`differences between the two products.
`Pre- and post-treatment photographs with Captique and
`Puragen are represented in Figures 2 and 3.
`
`Tolerability. After the initial treatment, the adverse reactions
`at the injection point (recorded by the patients in a diary)
`were 92% and 90.3% for Puragen and Captique,
`respectively, mainly of a mild to moderate intensity and
`short-lived (less than 5 days). The most frequent symptoms
`for both products were swelling, redness, itching, pain and
`hardening. The incidence of adverse reactions was less in
`subsequent sessions (touch-up) with respect to the initial
`injection implants. During the 6-month follow-up, adverse
`reactions were observed exclusively at the injection site in
`14.7% with Puragen and 11.8% with Captique, in most
`cases represented by swelling and redness (reactions of mild
`to moderate intensity).
`Complications arising 14 days after the last treatment had
`a similar incidence between the two products (Puragen 3
`cases, Captique 2 cases) (Figure 4); none of these reactions
`
`482
`
`Figure 1. Mean variation of WSRS ratings after 6 months.
`
`were considered by the investigator as a hypersensitivty
`response
`to
`the
`implant. All
`these delayed-onset
`complications subsided spontaneously within a period of 2
`months of treatment.
`
`Discussion
`
`The results of this double-blind, randomized, comparative
`study have established that both products used, Puragen and
`Captique are equally effective and safe in eliminating
`nasolabial folds. The difference between the two products
`was observed in time, in that the biochemical and structural
`characteristics of Puragen enabled more long-lasting and
`stable results to be obtained.
`Differences in the behaviour of HAs having different
`structures have been demonstrated, in vitro, by several
`authors (7, 27).
`The first HA based fillers created with a filling function,
`known as “first generation” fillers, are obtained from two
`main sources: bacterial fermentation – some species of
`streptococcus produce HA or extraction from animal tissues,
`cockerel crests and other animal sources used previously
`Manna et al. (27) conducted a comparative study on two
`HAs of different origin, demonstrating the rheological
`differences between a HA of animal origin and a HA of
`bacterial origin.
`The long-lasting effect of the HA depends on 3 factors:
`Concentration: the higher the concentration of the HA in the
`filler, the longer-lasting its effect is. Size: the larger the
`particles of HA, the longer-lasting its effect is. Cross-linking:
`the greater the cross linking between the HA molecules, the
`longer-lasting its effect is. The first two factors could also be
`varied in 2nd generation fillers. The novelty introduced by
`2nd generation fillers concerns cross-linking. The functional
`groups for cross-linking in these fillers are the hydroxyl
`
`

`

`Onesti et al: Comparative Study between Two Hyaluronic Acid Fillers
`
`Table III. Investigator’s assessment on the WSRS scale during follow-up: results in three categories (number of patients and frequency).
`
`Puragen is superior to Captique
`
`Puragen is equivalent to Captique
`
`Captique is superior to Puragen
`
`P
`
`2 months
`4 months
`6 months
`
`23 (33.8)
`35 (51.4)
`41 (60.4)
`
`40 (58.8)
`18 (26.4)
`23 (33.8)
`
`5 (7.3)
`15 (22.1)
`4 (5.8)
`
`<0.05
`<0.05
`<0.05
`
`Table IV. Investigator’s assessment on the GAIS scale after baseline (optimal cosmetic result): results in three categories (number of patients and
`frequency).
`
`Puragen is superior to Captique
`
`Puragen is equivalent to Captique
`
`Captique is superior to Puragen
`
`P
`
`Baseline
`2 months
`4 months
`6 months
`
`4 (5.8)
`16 (23.5)
`45 (66.2)
`51 (75)
`
`58 (85.3)
`47 (69.1)
`18 (26.5)
`13 (19.2)
`
`6 (8.8)
`5 (7.3)
`5 (7.3)
`4 (5.8)
`
`<0.05
`<0.05
`<0.05
`<0.05
`
`Table V. Patient’s assessment on the WSRS scale during follow-up: results in three categories (number of patients and frequency).
`
`Puragen is superior to Captique
`
`Puragen is equivalent to Captique
`
`Captique is superior to Puragen
`
`P
`
`2 months
`4 months
`6 months
`
`6 (8.8)
`20 (29.4)
`43 (63.2)
`
`50 (73.5)
`40 (58.9)
`22 (32.3)
`
`10 (14.7)
`8 (11.7)
`3 (4.4)
`
`<0.05
`<0.05
`<0.05
`
`Table VI. Patient’s assessment on the GAIS scale after baseline (optimal cosmetic result): results in three categories (number of patients and
`frequency).
`
`Puragen is superior to Captique
`
`Puragen is equivalent to Captique
`
`Captique is superior to Puragen
`
`P
`
`Baseline
`2 months
`4 months
`6 months
`
`6 (8.8)
`29 (42.6)
`43 (63.2)
`45 (66.1)
`
`54 (79.4)
`33 (48.5)
`19 (28)
`19 (28)
`
`8 (11.8)
`6 (8.8)
`6 (8.8)
`4 (5.8)
`
`<0.05
`<0.05
`<0.05
`<0.05
`
`groups. In fact, all technologies of this generation of HA
`(Single-cross-linked) use cross-linked agents to obtain ether
`bonds (BDDE 1,4- butandiol diglycdyl ether) or ester bonds
`(DVS divinylsulphone). Breakdown by hyaluronidase is
`much slower than in 1st generation fillers: in fact, studies
`conducted on biodegradation times indicate a period ranging
`from a minimum of 15 to a maximum of 30 days. Viscosity
`is one of the least analysed rheological properties (7, 27).
`Studies show that a 2nd generation HA with a viscosity
`of 20% has the same hyaluronidase biodegradation time as
`a natural HA (7). This is very important because if the
`viscosity of the 2nd generation HA is raised to the level of
`
`the natural acid, the half-life obtained quadruples: in other
`words, if natural HA has a half-life of between 2 and 4
`days, this method lengthens the half-life of 2nd generation
`hyaluronic acid up to 16 days (7, 27). The 2nd generation
`HAs, defined precursors, have given rise to the 3rd
`generation HA, which introduces a major chemical and
`structural innovation represented by the presence of a new
`and unique feature: a second cross link, in which the
`particles form an insoluble network of hydrophilic polymers
`with two binding sites (DXL), one hydroxyl and one
`carboxyl, leading to the formation of two stable bridges, one
`ether and one ester. The introduction of the second cross
`
`483
`
`

`

`in vivo 23: 479-486 (2009)
`
`Figure 2. Clinical case 6 months after treatment (treated with Captique).
`
`Figure 3. Clinical case 6 months after treatment (treated with Puragen).
`
`Figure 4. Complications 1 month after treatment (on left Puragen, on right Captique).
`
`484
`
`

`

`Onesti et al: Comparative Study between Two Hyaluronic Acid Fillers
`
`link has led to major differences between the 3rd generation
`HA (Puragen) and the previous ones. The substantial
`differences are to be found in the physicochemical
`properties, biodegradation and stability. The ultrastructural
`modifications obtained through the presence of an ether
`(hydroxyl) and ester (carboxyl) double cross link, in place
`of the single ether link (BDDE or DVS) between two
`hydroxyl groups present in the 2nd generation HAs, change
`the rheological properties of the compound. In addition to a
`higher resistance to biodegradation, this gives the molecule
`hydrophilic and hydrophobic capabilities very useful in its
`relations with
`the other substances present
`in
`the
`extracellular matrix.
`The first of the parameters that the operating doctor must
`take into consideration when choosing a filler is the safety
`of the product to be used. Reabsorbable fillers guarantee
`maximum safety. This experimental study is based on the use
`and composition of HA in various formulations for the
`aesthetic treatment of a large sample of patients. The
`differences between 2nd generation HA (Captique), and
`Puragen, whose particular structural feature is its double
`cross-linking making the molecule more stable and long-
`lasting, were assessed.
`The results obtained have enabled the establishment of the
`advantages that Puragen presents with respect to the HA
`based products used up to now.
`From the results obtained in this study, Puragen remained
`stably in the treated tissues even after 6 months while less
`satisfactory results were obtained with 2nd generation HA
`(Captique). The safety of the product is thus ascertained,
`taking the lack of significant side effects after 6 months into
`account.
`The search for the ideal filler is, in our opinion, at a
`turning point due to the positive and negative experiences
`gained over the past thirty years. Irrespective of the filler
`chosen, the approach to the patient who is to undergo
`treatment with a filler must be as scrupulous as with a
`surgical operation.
`Detailed and exhaustive information about the product, its
`limits and possible complications should therefore be given,
`complete informed consent should be obtained and, above
`all, it should be remembered that the use of these methods
`requires an adequate level of experience and specialist
`professional training.
`
`References
`
`1 Onesti MG, Renzi LF, Paoletti F and Scuderi N: Use of
`polylactic acid in face lipodystrophy in HIV positive patients
`undergoing treatment with antiretroviral drugs (HAART). Acta
`Chir Plast 46(1): 12-15, 2004.
`2 Kim JJ, Kwak TI, Jeon BG, Cheon J and Moon DG: Human
`glans penis augmentation using injectable hyaluronic acid gel.
`Int J Impot Res 15(6): 439-443, 2003.
`
`3 Duskova M and Kristen M: Augmentation by autologous adipose
`tissue in cleft lip and nose. Final aesthetic touches in clefts: part
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`Received November 17, 2008
`Revised January 15, 2009
`Accepted February 25, 2009
`
`486
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`