Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61L—METHODS OR APPARATUS FOR STERILISING MATERIALS OR OBJECTS IN GENERAL; DISINFECTION, STERILISATION OR DEODORISATION OF AIR; CHEMICAL ASPECTS OF BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES; MATERIALS FOR BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES
  • A61L27/00—Materials for grafts or prostheses or for coating grafts or prostheses
  • A61L27/14—Macromolecular materials
  • A61L27/20—Polysaccharides
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
  • A61F2/00—Filters implantable into blood vessels; Prostheses, i.e. artificial substitutes or replacements for parts of the body; Appliances for connecting them with the body; Devices providing patency to, or preventing collapsing of, tubular structures of the body, e.g. stents
  • A61F2/0059—Cosmetic or alloplastic implants
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61L—METHODS OR APPARATUS FOR STERILISING MATERIALS OR OBJECTS IN GENERAL; DISINFECTION, STERILISATION OR DEODORISATION OF AIR; CHEMICAL ASPECTS OF BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES; MATERIALS FOR BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES
  • A61L27/00—Materials for grafts or prostheses or for coating grafts or prostheses
  • A61L27/02—Inorganic materials
  • A61L27/12—Phosphorus-containing materials, e.g. apatite
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61L—METHODS OR APPARATUS FOR STERILISING MATERIALS OR OBJECTS IN GENERAL; DISINFECTION, STERILISATION OR DEODORISATION OF AIR; CHEMICAL ASPECTS OF BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES; MATERIALS FOR BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES
  • A61L27/00—Materials for grafts or prostheses or for coating grafts or prostheses
  • A61L27/36—Materials for grafts or prostheses or for coating grafts or prostheses containing ingredients of undetermined constitution or reaction products thereof, e.g. transplant tissue, natural bone, extracellular matrix
  • A61L27/3683—Materials for grafts or prostheses or for coating grafts or prostheses containing ingredients of undetermined constitution or reaction products thereof, e.g. transplant tissue, natural bone, extracellular matrix subjected to a specific treatment prior to implantation, e.g. decellularising, demineralising, grinding, cellular disruption/non-collagenous protein removal, anti-calcification, crosslinking, supercritical fluid extraction, enzyme treatment
  • A61L27/3691—Materials for grafts or prostheses or for coating grafts or prostheses containing ingredients of undetermined constitution or reaction products thereof, e.g. transplant tissue, natural bone, extracellular matrix subjected to a specific treatment prior to implantation, e.g. decellularising, demineralising, grinding, cellular disruption/non-collagenous protein removal, anti-calcification, crosslinking, supercritical fluid extraction, enzyme treatment characterised by physical conditions of the treatment, e.g. applying a compressive force to the composition, pressure cycles, ultrasonic/sonication or microwave treatment, lyophilisation
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61L—METHODS OR APPARATUS FOR STERILISING MATERIALS OR OBJECTS IN GENERAL; DISINFECTION, STERILISATION OR DEODORISATION OF AIR; CHEMICAL ASPECTS OF BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES; MATERIALS FOR BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES
  • A61L27/00—Materials for grafts or prostheses or for coating grafts or prostheses
  • A61L27/50—Materials characterised by their function or physical properties, e.g. injectable or lubricating compositions, shape-memory materials, surface modified materials
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61L—METHODS OR APPARATUS FOR STERILISING MATERIALS OR OBJECTS IN GENERAL; DISINFECTION, STERILISATION OR DEODORISATION OF AIR; CHEMICAL ASPECTS OF BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES; MATERIALS FOR BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES
  • A61L27/00—Materials for grafts or prostheses or for coating grafts or prostheses
  • A61L27/50—Materials characterised by their function or physical properties, e.g. injectable or lubricating compositions, shape-memory materials, surface modified materials
  • A61L27/52—Hydrogels or hydrocolloids
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61L—METHODS OR APPARATUS FOR STERILISING MATERIALS OR OBJECTS IN GENERAL; DISINFECTION, STERILISATION OR DEODORISATION OF AIR; CHEMICAL ASPECTS OF BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES; MATERIALS FOR BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES
  • A61L27/00—Materials for grafts or prostheses or for coating grafts or prostheses
  • A61L27/50—Materials characterised by their function or physical properties, e.g. injectable or lubricating compositions, shape-memory materials, surface modified materials
  • A61L27/54—Biologically active materials, e.g. therapeutic substances
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61M—DEVICES FOR INTRODUCING MEDIA INTO, OR ONTO, THE BODY; DEVICES FOR TRANSDUCING BODY MEDIA OR FOR TAKING MEDIA FROM THE BODY; DEVICES FOR PRODUCING OR ENDING SLEEP OR STUPOR
  • A61M5/00—Devices for bringing media into the body in a subcutaneous, intra-vascular or intramuscular way; Accessories therefor, e.g. filling or cleaning devices, arm-rests
  • A61M5/178—Syringes
  • A61M5/31—Details
  • A61M5/32—Needles; Details of needles pertaining to their connection with syringe or hub; Accessories for bringing the needle into, or holding the needle on, the body; Devices for protection of needles
  • A61M5/329—Needles; Details of needles pertaining to their connection with syringe or hub; Accessories for bringing the needle into, or holding the needle on, the body; Devices for protection of needles characterised by features of the needle shaft
• • C—CHEMISTRY; METALLURGY
  • C08—ORGANIC MACROMOLECULAR COMPOUNDS; THEIR PREPARATION OR CHEMICAL WORKING-UP; COMPOSITIONS BASED THEREON
  • C08B—POLYSACCHARIDES; DERIVATIVES THEREOF
  • C08B37/00—Preparation of polysaccharides not provided for in groups C08B1/00 - C08B35/00; Derivatives thereof
  • C08B37/006—Heteroglycans, i.e. polysaccharides having more than one sugar residue in the main chain in either alternating or less regular sequence; Gellans; Succinoglycans; Arabinogalactans; Tragacanth or gum tragacanth or traganth from Astragalus; Gum Karaya from Sterculia urens; Gum Ghatti from Anogeissus latifolia; Derivatives thereof
  • C08B37/0063—Glycosaminoglycans or mucopolysaccharides, e.g. keratan sulfate; Derivatives thereof, e.g. fucoidan
  • C08B37/0072—Hyaluronic acid, i.e. HA or hyaluronan; Derivatives thereof, e.g. crosslinked hyaluronic acid (hylan) or hyaluronates
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61L—METHODS OR APPARATUS FOR STERILISING MATERIALS OR OBJECTS IN GENERAL; DISINFECTION, STERILISATION OR DEODORISATION OF AIR; CHEMICAL ASPECTS OF BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES; MATERIALS FOR BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES
  • A61L2300/00—Biologically active materials used in bandages, wound dressings, absorbent pads or medical devices
  • A61L2300/20—Biologically active materials used in bandages, wound dressings, absorbent pads or medical devices containing or releasing organic materials
  • A61L2300/216—Biologically active materials used in bandages, wound dressings, absorbent pads or medical devices containing or releasing organic materials with other specific functional groups, e.g. aldehydes, ketones, phenols, quaternary phosphonium groups
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61L—METHODS OR APPARATUS FOR STERILISING MATERIALS OR OBJECTS IN GENERAL; DISINFECTION, STERILISATION OR DEODORISATION OF AIR; CHEMICAL ASPECTS OF BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES; MATERIALS FOR BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES
  • A61L2300/00—Biologically active materials used in bandages, wound dressings, absorbent pads or medical devices
  • A61L2300/40—Biologically active materials used in bandages, wound dressings, absorbent pads or medical devices characterised by a specific therapeutic activity or mode of action
  • A61L2300/402—Anaestetics, analgesics, e.g. lidocaine
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61L—METHODS OR APPARATUS FOR STERILISING MATERIALS OR OBJECTS IN GENERAL; DISINFECTION, STERILISATION OR DEODORISATION OF AIR; CHEMICAL ASPECTS OF BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES; MATERIALS FOR BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES
  • A61L2400/00—Materials characterised by their function or physical properties
  • A61L2400/06—Flowable or injectable implant compositions
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61L—METHODS OR APPARATUS FOR STERILISING MATERIALS OR OBJECTS IN GENERAL; DISINFECTION, STERILISATION OR DEODORISATION OF AIR; CHEMICAL ASPECTS OF BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES; MATERIALS FOR BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES
  • A61L2430/00—Materials or treatment for tissue regeneration
  • A61L2430/02—Materials or treatment for tissue regeneration for reconstruction of bones; weight-bearing implants

Definitions

• the present invention generally relates to injectable compositions and more specifically relates to injectable implants for adding structure and contour to the lower face.
• Dermal fillers are injectable, biocompatible compositions which are well known to correct wrinkles and folds and add volume to the face.
• Hyaluronic acid (HA) is still considered by many to be one of the most desirable dermal fillers in that it does not pose the risk of an allergic reaction and it is temporary and reversible.
• the great majority of hyaluronic acid -based dermal fillers have been specifically developed for treating wrinkles and folds in skin.
• To be useful for facial contouring or substantial volumizing it would be advantageous to increase the bulking effect of the compositions, also referred to as "lift”. It would also be advantageous to maximize resistances of the compositions to shear and normal deformation happening in the soft tissues of the face.
• One of the drawbacks of maximizing these resistances for example, elasticity and cohesivity, is that it is expected that in doing so, the viscosity of the compositions will increase to the point that they become difficult to inject with a thin needle.
• an injectable HA based implant that is specifically designed to be effective in adding substantial volume to the face, for example, for contouring the lower face, for example, for augmenting or correcting the chin, for example, for correction of chin retrusion, or for example, for augmenting or correcting the nose. It would be highly advantageous if such an implant, despite, its high viscosity, would remain easy to inject with a thin needle.
• the shape of the chin has long been recognized as an important feature of the face that elicits a strong aesthetic perception that tends to be associated with personality traits of an individual.
• a deficient chin that lacks projection is commonly labeled a "weak chin” while prominent chins are labeled "strong chins", both implying strength of personality.
• faces with average proportions are viewed as the most attractive and that small features including a small chin are interpreted as attractive in females while the expanded chin and jaw, as a result of maturation, are interpreted as attractive in males.
• the appearance of the chin is a determinant of perceived attractiveness and can even influence an individual's psychosocial well-being.
• Chin augmentation is conventionally performed by surgically placing a permanent implant above the jaw.
• the procedure is currently among the top aesthetic surgical procedures performed, based on the American Society for Aesthetic Plastic Surgery (ASAPS), and has increased 71 % since 2010.
• ASAPS American Society for Aesthetic Plastic Surgery
• a retrusive chin can be the result of changes in growth of the lower third of the face during maturation, trauma, or facial aging, the latter of which may exacerbate the deformities or asymmetries caused by the former two.
• the shape of the mandible affects the mouth, chin, and neck.
• Chin deformities are among the most common bony abnormalities of the face, the most common of which is horizontal microgenia characterized by the presence of normal vertical height with a retruded bony chin.
• chin implants As the mandible and chin make up the framework of the lower face, augmentation methods to treat age-related chin retrusion and contour changes of the chin area or to treat microgenia have been explored for decades. Where the approach in correcting chin retrusion is to add volume, treatment methods have included chin implants, genioplasty, and injection of silicone and semi-permanent fillers, such as polymethylmethacrylate microspheres, and calcium hydroxyapatite. However, all of these treatment methods have drawbacks. For example, chin implants and genioplasty involve painful surgery that may not result in correction of chin retrusion and aesthetic blending of the area. This approach may exacerbate bone resorption and infection, resulting in the need for implant removal. Injection of semi-permanent fillers have trade-offs between volumizing capacity and adverse events associated with semi-permanent fillers. SUMMARY OF THE INVENTION
• an injectable implant for facial sculpturing, for example, for augmenting, correcting, restoring or creating volume in the chin and other facial features in a human being.
• the present invention provides temporary, reversible, HA-based structural gels manufactured specifically to provide a safe, minimally invasive method to create facial volume or facial contours.
• the present implants provide improved volumizing and lift properties relative to other HA-based injectables, due to a combination of mechanical properties including high elasticity and high cohesivity, while still being easily injectable with a thin needle.
• the present implants may be used for injection into the subcutaneous and/or supraperiosteal space.
• the implants are moldable after injection, and therefore permit sculpting, contouring, and shaping across the injected areas, for example, the chin and jaw area.
• the implants generally comprise a composition comprising a hyaluronic acid (HA) crosslinked with a crosslinking agent selected from the group consisting of 1 ,4-butanediol diglycidyl ether (BDDE), 1 ,4-bis(2,3-epoxypropoxy)butane, 1 ,4- bisglycidyloxybutane, 1 ,2-bis(2,3-epoxypropoxy)ethylene and 1 -(2,3-epoxypropyl)- 2,3-epoxycyclohexanethe.
• the implants generally comprise a composition comprising a hyaluronic acid (HA) crosslinked with BDDE.
• compositions are suitable for injection, for example, through a fine gauge needle, and are capable of augmenting, correcting, or creating volume or lift in the face, for example, the lower face, for example, the chin or jaw, or for the midface, for example, the nose.
• the HA concentration is greater than 20 mg/g. In some embodiments, the HA concentration is about 21 mg/g, or about 22 mg/g, or about 23 mg/g, or about 24 mg/g, or about 25 mg/g, or about 26 mg/g, or about 27 mg/g, or about 28 mg/g, or about 29 mg/g, or about 30 mg/g or greater. In other embodiments, the composition has an HA concentration of between 22.5 mg/g to 27.5 mg/g, for example, 25.0 mg/g.
• the method adds volume and lift to the chin or jawline or nose of the patient for a period of time in the range of about 9 months to about 24 months after the administration or injection into the chin or jawline of the patient.
• the composition may be moldable, for example, by physical manipulation of the tissue near the implant for a period of time after injection.
• the compositions may have a setting time, when the composition is no longer moldable and substantially retains its shape for the duration of the implant, within about 24 to about 48 hours after being implanted or injected.
• compositions further include an anesthetic agent, for example, lidocaine HCI.
• an anesthetic agent for example, lidocaine HCI.
• the compositions may include about 0.3% w/w lidocaine HCI.
• compositions comprise a hyaluronic acid gel, preferably in an amount of about 25 mg; and lidocaine hydrochloride, preferably in an amount of about 3 mg, in a phosphate buffer (pH 7.2), preferably in a volume q.s. 1 ml_.
• compositions are made with a mixture of low molecular weight hyaluronic acid and high molecular weight hyaluronic acid.
• the crosslinked hyaluronic acid may be made from about 50% and about 100% of a low molecular weight hyaluronic acid prior to being crosslinked with the crosslinking agent.
• the crosslinked hyaluronic acid is made from about 70% to about 90% of a low molecular weight hyaluronic acid prior to being crosslinked with the crosslinking agent.
• the crosslinked hyaluronic acid is made from about 90% of a low molecular weight hyaluronic acid prior to being crosslinked with the crosslinking agent.
• the HA has a degree of crosslinking of between about 4% and about 12%.
• the HA has a degree of crosslinking of about 4%, or about 6%, or about 8%, or about 10%.
• the HA has a degree of crosslinking of about 6.5%.
• the HA has a degree of crosslinking of about 7.5%, or about 8.5%, or about 9.5%, or about 10.5%.
• methods for correcting chin retrusion in a patient generally comprise supraperiostally administering in the chin of the patient, an effective amount of a composition comprising BDDE-crosslinked hyaluronic acid (HA), the HA having a degree of crosslinking of about 10%, and having a HA concentration of greater than 20 mg/g.
• HA concentration is about 25 mg/g.
• the compositions comprises low molecular weight hyaluronic acid (NaHA) crosslinked with about 10% BDDE (w/w), and formulated to a concentration of about 25 mg/g with 0.3% lidocaine hydrochloride (w/w) in a phosphate buffer, pH 7.2, and supplied in a 1 mL COC (cyclic olefin copolymer) syringe.
• NaHA low molecular weight hyaluronic acid
• BDDE w/w
• lidocaine hydrochloride w/w
• compositions are extrudable through a fine gauge needle, for example, a needle having a gauge of 25G, 26G, 27G, 28G, 29G or 30G.
• the needle is a needle of 27 gauge X 13 mm / 27 G1 /2 X 26mm.
• An extrusion force is the force (in Newtons N) needed to extrude the composition from its syringe at a certain rate.
• the extrusion force of some of the compositions of this invention can be between about 4N and about 15N at 13 mm/min, which is considered as very low.
• the extrusion force can be between about 7N and about 12N, and preferably between about 8N and about 10 N.
• methods are provide for contouring or correcting a facial feature, for example, a retruded chin, of an individual.
• the methods comprise, for example, the step of subdermally administering into a treatment area of the patient, an effective amount, for example, about 1 .0 ml, or more, for example, about 2.0 ml or more, for example, about 3.0 ml or more, for example, 4.0 mL, of a composition of the invention.
• the facial feature to be improved or contoured may be a chin, for example, a retruded chin of a patient.
• the treatment area may include an area selected from the group consisting of the pogonion, the mentum, the left pre-jowl sulcus, the right pre-jowl sulcus, and the sublabial crease.
• the treatment may comprise administering the composition into two or more of the treatment areas.
• Figure 1 shows a facial profile and landmarks for calculating G-Sn-Pog angle of a patient.
• Figure 2 shows the Burstone Angle of an average chin.
• the intrinsic viscosity is measured according to the procedure defined European Pharmacopoeia (HA monograph N°1472, 01 /2009).
• the molecular weight refers to the weight average molecular weight (Mw).
• the HA used to make the present compositions may comprise a mixture of high molecular weight HA, low molecular weight HA, and/or medium molecular weight HA, wherein the high molecular weight HA has a molecular weight greater than about 2,000,000 Da (or an intrinsic viscosity greater than 2.2 L/g) and wherein the low molecular weight HA has a molecular weight of less than about 1 ,000,000 Da (or an intrinsic viscosity lower than 1 .4 L/g).
• the high molecular weight HA in the present compositions may have an average molecular weight in the range about 2 MDa to about 4.0 MDa, for example, about 3.0 MDa (2.9 L/g).
• the high molecular weight HA may have an average molecular weight of between about 2.4 MDa to about 3.6 MDa, for example, about 3.0 MDa.
• the high molecular weight HA may have an intrinsic viscosity greater than about 2.2 L/g, for example, between about 2.5 L/g to about 3.3 L/g.
• Low molecular weight HA can have a molecular weight of between about 200,000 Da (0.2 MDa) to less than 1 .0 MDa, for example, between about 300,000 Da (0.3 MDa) to about 750,000 Da (1 .1 L/g), up to but not exceeding 0.99 MDa (1 .4 L/g).
• the low molecular weight HA may have an intrinsic viscosity of less than about 1 .40 L/g, for example, between about 0.6 L/g and about 1 .2 L/g.
• the mixture of the low molecular weight HA and high molecular weight HA has a bimodal molecular weight distribution.
• the mixture may also have a multi-modal distribution.
• compositions comprise HA having a high molecular weight component and a low molecular weight component, and the high molecular weight component has a weight average molecular weight at least twice the weight average molecular weight of the low molecular weight component.
• Degree of crosslinking refers to the intermolecular junctions joining the individual HA polymer molecules, or monomer chains, into a permanent structure, or as disclosed herein the soft tissue filler composition.
• degree of crosslinking for purposes of the present disclosure is further defined as the percent weight ratio of the crosslinking agent to HA-monomeric units within the crosslinked portion of the HA based composition. It is measured by the weight ratio of crosslinker to HA monomers.
• Uncrosslinked HA refers to individual HA polymer molecules that are not crosslinked. Uncrosslinked HA generally remains water soluble. An uncrosslinked HA fraction may optionally also be included in the compositions, for example, to act as a lubricant and facilitate injection into the facial tissues. Such a composition may comprise an uncrosslinked HA fraction where the added uncrosslinked HA is present at a concentration between about 0.1 mg/g and about 3 mg/g. Preferably, the uncrosslinked HA may be present at a concentration between about 0.2 mg/g and about 1 .5 mg/g.
• no uncrosslinked HA is present in the gels, or at least no uncrosslinked HA is added to the gels to act as a lubricant.
• compositions described herein display a high level of elasticity, expressed as a value of elastic modulus (G') measured by oscillation rheology with a strain of 0.8%, using a cone-plate system and measured over a range of frequencies.
• G' elastic modulus
• the elastic modulus of the compositions measured at 5Hz frequency are from about 500 Pa to about 900 Pa. This is considered as high elasticity in the context of HA-based dermal fillers and contributes to the lifting effect by making the implant more resistant to shear deformation.
• Cohesivity refers to the capacity of the gel to stay attached to itself, for example, meaning the resistance to cutting and the ability to elongate or compress the gel without it separating into pieces.
• the cohesivity of the gels according to the present invention can be quantified as follows (cf. Arthur Jones “Injectable Filers: Principles and Practice", Wiley, 201 1 , Chapter 3).
• a small sample of the gel e.g. 1 ml_
• the sample is placed such that it forms a little heap.
• a moveable upper plate is placed onto the sample so that the sample is fully covered, e.g.
• the sample when looking at the plate in a direction perpendicular to the surface of the rheometer, the sample cannot be seen. In order to ensure this, one must chose a plate size that is larger than the sample size. Ideally, the center of the plate is placed over the sample. Typically, for 1 ml_ of gel material, a 25mm diameter upper plate is used.
• a force of 20 gmf (0.1962 N) or more indicates a cohesive material in the sense of the present invention.
• Gels with lower compression force values are generally not considered cohesive in the context of the present invention.
• the accuracy of this measurement is in the order of ⁇ 5 gmf.
• the injectable formulation has a high cohesivity of at least about 60 gmf, for example about 60 to about 200 gmf.
• cohesivity is between about 60 and about 100 gmf, which will give to the implant a high resistance to pressure and normal forces in the soft tissues of the face.
• the cohesivity as defined above will contribute to the lift capacity (clinically called the volumizing / bulking effect) provided by the gel clinically, along with its elastic modulus G'. While cohesive gels can show a good volumizing effect, non-cohesive or weakly cohesive materials with a similar elastic modulus exhibits lower lift capacity due to the non-cohesive gel material spreading more than a more cohesive material when submitted to vertical compression. In the context of this invention, the compositions exhibit both high levels of elastic modulus and high levels of cohesivity, to maximize the lifting effect upon implantation.
• the present implants or fillers generally comprise a cohesive, sterile composition which is implantable subdermally or supraperiostially into the chin area, nose or jawline of the patient in need thereof, for example a patient desiring an improved facial profile or stronger chin.
• the composition generally comprises a crosslinked hyaluronic acid (HA) crosslinked with 1 ,4-butanediol diglycidyl ether (BDDE); and the HA concentration of the composition is greater than 20 mg/g.
• the HA concentration is about 22.5 mg/g, or about 25 mg/g, or about 27.5 mg/g.
• the HA used for crosslinking may be made with a mixture of low molecular weight hyaluronic acid and high molecular weight hyaluronic acid.
• the compositions have an elastic modulus between about 500 Pa and about 900 Pa at 5Hz, and a cohesivity above about 60 gmf.
• the compositions exhibit an extrusion force between about 4N and about 15N, for example, between about 8N and about 10 N, at 13 mm/min using a 1 ml_ COC syringe and a 27G x 13mm needle.
• injectable HA-based implants having an improved lift capacity, relative to commercial HA-based dermal fillers.
• the present implants are, in some instances in the present disclosure, referred alternatively as dermal fillers and subdermal fillers.
• the implants and fillers of the present invention are based on hyaluronic acids (HA) and pharmaceutically acceptable salts of HA, for example, sodium hyaluronate (NaHA). Methods of making these compositions, and methods of use of these compositions, are also provided.
• HA hyaluronic acids
• NaHA sodium hyaluronate
• hyaluronic acid can refer to any of its hyaluronate salts, and includes, but is not limited to, sodium hyaluronate (NaHA), potassium hyaluronate, magnesium hyaluronate, calcium hyaluronate, and combinations thereof. Both HA and pharmaceutically acceptable salts thereof can be used in this invention.
• the concentration of one or more anesthetics is in an amount effective to mitigate pain experienced upon injection of the composition.
• the at least one local anesthetic can be selected from the group of ambucaine, amolanone, amylocaine, benoxinate, benzocaine, betoxycaine, biphenamine, bupivacaine, butacaine, butamben, butanilicaine, butethamine, butoxycaine, carticaine, chloroprocaine, cocaethylene, cocaine, cyclomethycaine, dibucaine, dimethisoquin, dimethocaine, diperodon, dicyclomine, ecgonidine, ecgonine, ethyl chloride, etidocaine, beta-eucaine, euprocin, fenalcomine, formocaine, hexylcaine, hydroxytetracaine, isobutyl p-aminobenzo
• the at least one anesthetic agent is lidocaine, such as in the form of lidocaine HCI.
• the compositions described herein may have a lidocaine concentration of between about 0.1 % and about 5% by weight of the composition, for example, about 0.2% to about 1 .0% by weight of the composition. In one embodiment, the composition has a lidocaine concentration of about 0.3% by weight (w/w %) of the composition.
• the concentration of lidocaine in the compositions described herein can be therapeutically effective meaning the concentration is adequate to provide a therapeutic benefit without inflicting harm to the patient.
• the present compositions may be manufactured by the steps of providing purified HA material for example, in the form of NaHA fibers; the HA material having a desired molecular weight, for example, a mixture of low molecular weight and high molecular weight HA at a desired ratio, hydrating the HA material; and crosslinking the hydrated HA material with a suitable crosslinking agent at the desired ratio to form a crosslinked HA-based gel.
• the gel may then be neutralized and swollen.
• a solution containing lidocaine preferably an acidic salt of lidocaine chlorohydrate, may be added to form a HA/lidocaine gel.
• the gel may be homogenized, for example, by beating or mixing with a shear force.
• the homogenized composition may then be packaged in syringes.
• the syringes are then sterilized by autoclaving at an effective temperature and pressure.
• the compositions are sterilized by autoclaving, for example, being exposed to temperatures of at least about 120°C to about 130°C and/or pressures of at least about 12 pounds per square inch (PSI) to about 20 PSI for a period of at least about 1 minute to about 15 minutes.
• PSI pounds per square inch
• the sterilized syringes are packaged along with a fine gauge needle for use by a physician.
• the initial raw HA material may comprise fibers or powder of NaHA, for example, bacterial-sourced NaHA fibers.
• the HA material may be animal derived, for example, from rooster combs. It is contemplated that the HA material may be a combination of raw materials including HA and at least one other polysaccharide, for example, another glycosaminoglycan (GAG).
• GAG glycosaminoglycan
• pure, dry NaHA fibers are hydrated in an alkaline solution to produce an uncrosslinked NaHA gel.
• Any suitable alkaline solution may be used to hydrate the NaHA in this step, for example, but not limited to aqueous solutions containing sodium hydroxide (NaOH), potassium hydroxide (KOH), sodium bicarbonate (NaHC03), lithium hydroxide (LiOH), and the like.
• the resulting alkaline gel will have a pH above 7.5.
• the pH of the resulting alkaline gel can have a pH greater than 9, or a pH greater than 10, or a pH greater than 12, or a pH greater than 13.
• the next step in the manufacturing process may include the step of crosslinking the hydrated, alkaline NaHA gel with a suitable crosslinking agent.
• the crosslinking agent may be any agent known to be suitable for crosslinking polysaccharides and their derivatives via their hydroxyl groups.
• One particular suitable crosslinking agent is 1 ,4-butanediol diglycidyl ether (BDDE).
• the crosslinking of the HA is accomplished during hydration of the HA fibers, by hydrating the combined high and low molecular weight fibers in an alkaline solution containing a crosslinking agent, for example, BDDE.
• a crosslinking agent for example, BDDE.
• the degree of crosslinking in the HA component of the present compositions is at least about 4% and is up to about 12% BDDE/HA, w/w, for example, about 10%, for example, about 8%, for example, about 6%, for example, about 4%.
• the degree of crosslinking is about 6.5%.
• the HA has a degree of crosslinking of about 6.5%.
• the HA has a degree of crosslinking of about 7.5%, or about 8.5%, or about 9.5%, or about 10.5%.
• the hydrated crosslinked, HA gels may be swollen to obtain the desired HA concentration. This step can be accomplished by neutralizing the crosslinked, hydrated HA gel, for example by adding an aqueous solution containing of an acid, such as HCI. The gels are then swelled in a phosphate buffered saline (PBS) solution for a sufficient time and at a low temperature.
• PBS phosphate buffered saline
• the gels may now be purified by conventional means such as, dialysis against a phosphate buffer, or alcohol precipitation, to recover the crosslinked material, to stabilize the pH of the material and to remove any un-reacted crosslinking agent. Additional water or a slightly alkaline aqueous solution can be added to bring the concentration of the HA in the composition to a desired concentration. In some embodiments, the HA concentration of the compositions is adjusted to above 20 mg/g, for example, to about 25 mg/g.
• the HA concentration is adjusted to yield an HA concentration of about 21 mg/g, about 22 mg/g, about 23 mg/g, about 24 mg/g, about 26 mg/g, about 27 mg/g, about 28 mg/g, about 29 mg/g, or about 30 mg/g.
• the pH of the purified crosslinked HA gels may be adjusted to cause the gel to become slightly alkaline such that the gels have a pH of greater than about 7.2, for example, about 7.5 to about 8.0.
• This step may be accomplished by any suitable means, for example, by adding a suitable amount of dilute NaOH, KOH, NaHC03 or LiOH, to the gels or any other alkaline molecule, solution and/or buffering composition.
• lidocaine such as lidocaine HCI
• an effective amount of the anesthetic is then added to the purified crosslinked NaHA gels.
• the lidocaine HCI is provided in a powder form which is solubilized using water for injection (WFI).
• WFI water for injection
• the gels are kept neutral with a buffer or by adjustment with diluted NaOH in order that the final HA/lidocaine composition will have a desired, substantially neutral pH.
• the final compositions including lidocaine may have a lidocaine concentration of between at least about 0.1 % and about 5%, for example, about 2% by weight of the composition, or in another example about 0.3%.
• the HA/lidocaine gels, or compositions are homogenized to create highly homogenous HA/lidocaine gels having a desired consistency and stability.
• the homogenization step comprises mixing, stirring, or beating the gels with a controlled shearing force obtaining substantially homogenous mixtures.
• an amount of uncrosslinked HA solution or gel may be added to the composition to increase lubricity.
• no solution of uncrosslinked HA is added to the composition after homogenization.
• compositions may then be introduced into syringes and sterilized.
• Syringes useful according to the present description include any syringe known in the art capable of delivering viscous dermal filler compositions.
• the syringes generally have an internal volume of about 0.4 ml_ to about 3 ml_, more preferably between about 0.5 ml_ and about 1 .5 ml_ or between about 0.8 ml_ and about 2.5 ml_. This internal volume is associated with an internal diameter of the syringe which plays a key role in the extrusion force needed to inject high viscosity dermal filler compositions.
• the internal diameters are generally about 4 mm to about 9 mm, more preferably from about 4.5 mm to about 6.5 mm or from about 4.5 mm to about 8.8 mm.
• the extrusion force needed to deliver the HA compositions from the syringe is dependent on the needle gauge.
• the gauges of needles used generally include gauges between about 18G and about 40G, more preferably about 25G to about 33G, or from about 25G to about 30G.
• the compositions are packaged in a 1 ml_ syringe and injected using a 27 G needle.
• One preferable method of sterilization of the filled syringes is by autoclave.
• Autoclaving can be accomplished by applying a mixture of heat, pressure and moisture to a sample in need of sterilization.
• Many different sterilization temperatures, pressures and cycle times can be used for this step.
• the filled syringes may be sterilized at a temperature of at least about 120°C to about 130°C or greater. Moisture may or may not be utilized.
• the pressure applied is in some embodiments depending on the temperature used in the sterilization process.
• the sterilization cycle may be at least about 1 minute to about 20 minutes or more.
• Another method of sterilization incorporates the use of a gaseous species which is known to kill or eliminate transmissible agents.
• ethylene oxide is used as the sterilization gas and is known in the art to be useful in sterilizing medical devices and products.
• a further method of sterilization incorporates the use of an irradiation source which is known in the art to kill or eliminate transmissible agents.
• a beam of irradiation is targeted at the syringe containing the HA composition, and the wavelength of energy kills or eliminates the unwanted transmissible agents.
• Preferable energy useful include, but is not limited to ultraviolet (UV) light, gamma irradiation, visible light, microwaves, or any other wavelength or band of wavelengths which kills or eliminates the unwanted transmissible agents, preferably without substantially altering of degrading the HA composition.
• the present compositions also remain stable when stored for long periods of time.
• many of the present compositions have a shelf life of about 6 months, about 12 months, about 18 months, or about 24 months or greater, when stored at a temperature between about 2 to 25 degrees C.
• the compositions are stable at a temperature of between 2 to 25 degrees C for a period of at least 18 months.
• the compositions are stable at a temperature or between 2 to 25 degrees C for a period of at least 24 months.
• the technique for injection of the present compositions may vary with regard to the angle and orientation of the bevel, and the quantity administered.
• the present compositions are injected subcutaneously and/or supraperiosteally to increase chin projection, limiting treatment to the pogonion, the mentum (inferior aspect of the chin), pre-jowl sulci (left and right), and sublabial (mental) crease to achieve optimal correction and aesthetic chin contour.
• the appropriate injection volume will be determined by the investigator but is generally not to exceed a maximum total volume of about 4.0 ml_ for initial and top-up treatments combined. Up to about 4.0 ml_ total is allowed for repeat treatment.
• No more than about 2.0 ml_ is permitted to be injected into a single treatment area at any treatment session, where treatment areas are defined as the pogonion, the mentum, the pre-jowl sulci (left and right), and the sublabial (mental) crease.
• the treatment area Prior to injection of the present compositions, the treatment area has to be thoroughly disinfected to ensure that there is no contamination of the injectable filler with bacteria or a foreign body (e.g., make-up, talc from gloves).
• a foreign body e.g., make-up, talc from gloves.
• the 27G 1/2727 G x 13 mm needle supplied should be attached to the syringe (according to Directions for Use).
• the plunger rod Prior to injecting the present compositions, the plunger rod has to be depressed until the product visibly flows out of the needle and wipe any excess on sterile gauze.
• the present compositions are injected as follows: Inject the present compositions slowly, and observe the skin for signs of colour change or discolouration. Observe the subject for pain or discomfort. Inject the present compositions in a smooth and measured manner. Insert the needle being mindful of the local vascular anatomy at the injection site. Aspirate to ensure there is no blood backflow to suggest an intravascular location of the tip of the needle.
• Pogonion may be injected supraperiosteally using multiple small boluses. Mentum may be injected supraperiosteally using multiple small boluses. Pre-jowl sulci (left and right) may be injected using a deep subcutaneous fanning technique. Sublabial (mental) crease may be injected using linear, retrograde or anterograde superficial subcutaneous threading.
• the treated site may be gently massaged to assure that the product is evenly distributed and conforms to the contour of the surrounding tissues. If overcorrection occurs, gently massage the area between your fingers or against an underlying bone to obtain optimal results.
• compositions are not to be injected into the blood vessels (intravascular).
• Introduction of hyaluronic acid into the vasculature may occlude the vessels and could cause infarction or embolization.
• Symptoms of vascular occlusions and embolization include pain that is disproportionate to the procedure or remote to the injection site, immediate blanching that extends beyond the injected area and that may represent vascular tributary distribution, and colour changes that reflect ischemic tissue such as a dusky or reticular appearance.
• an ice pack may be applied to the site for a short period. If subjects report inflammatory reactions which persist for more than 1 week, or any other side effect which develops, the medical practitioner should use an appropriate treatment.
• the present compositions comprise a hyaluronic acid gel, preferably in an amount of about 25 mg; and lidocaine hydrochloride, preferably in an amount of about 3 mg, in a phosphate buffer (pH 7.2), preferably in a volume q.s. 1 mL, prefilled in e.g. a 1 mL single-use syringe, wherein the hyaluronic acid gel is crosslinked with BDDE.
• This prefilled e.g. 1 mL single-use syringe may be contained in a kit (blister pack) along with two single use needles (e.g. 27G 1 /2727 G x 13 mm needles) .
• the content of the syringe may be sterilised by moist heat.
• the single-use needles may be sterilised by radiation.
• compositions are injectable implants intended for restoration and creation of facial volume, e.g. in the chin and jaw area.
• the presence of lidocaine is meant to reduce the subject's pain during treatment.
• Predried fibers of sodium hyaluronate (NaHA) (0.9 g) having a molecular weight of about 0.9 MDa is weighed out into a first receptacle.
• Predried fibers of NaHA (0.1 g) having a molecular weight of about 3.0 MDa is weighed out into a second receptacle.
• the two different grades of NaHA are combined and diluted into a 1 % sodium hydroxide solution and mixed for one to two hours at between 20 Q C and 50°C to obtain a substantially homogenous, alkaline HA gel.
• the chosen crosslinking agent 1 ,4-butanediol diglycidyl ether (BDDE)
• BDDE 1 ,4-butanediol diglycidyl ether
• PB phosphate buffer
• crosslinked HA polymer so obtained is then immersed in baths of phosphate buffer to remove unreacted crosslinking agent and HA, providing the purified hydrogel, wherein the degree of crosslinking is about 6.5%.
• dry HA material having a high molecular weight is hydrated in 1 liter of phosphate buffer to obtain an uncrosslinked HA gel.
• This uncrosslinked HA gel can be added to the crosslinked HA composition to represent up to 5% (w/w) of the total HA concentration.
• the hydrogel obtained is then homogenized mechanically to ensure the final homogeneity, and packed into syringes which are sterilized in an autoclave.
• the gel obtained is an injectable composition that can be administered subdermally or supraperiostally through a fine gauge needle (e.g. 27 Gauge).
• the composition is useful for restoring, contouring, or creating facial volume, for example, in the chin, jaw area, or nose of a person, as described elsewhere herein.
• methods are provided for improving a patient's facial profile. For example, in some embodiments, methods are provided for changing a person's G-Sn-Pog facial angle, for example, for increasing a person's G-Sn-Pog facial angle. For example, in some embodiments, methods of treatment are provided for correcting chin retrusion in a patient.
• the patient treated an initial pre-treatment G-Sn-Pog facial angle of less than about 1 65°.
• the patient has an increased G-Sn-Pog facial angle, that is, a facial angle greater than the initial pre-treatment facial angle.
• the patient has a G-Sn-Pog angle of about 1 69° or greater after the step of administering.
• the G-Sn-Pog angle may be measured using conventional equipment and calculations, for example, may be based on calculations of facial angle derived from digital images of the patient, for example, using Canfield scientific facial imaging equipment.
• Figure 1 shows facial profile and landmarks for calculating G-Sn-Pog angle of a patient, which can be used to diagnose or determine the presence and/or degree of chin retrusion, using know methods.
• the methods generally comprise administering into at least one treatment area of the face of the patient, an effective amount of a composition comprising BDDE-crosslinked hyaluronic acid (HA), the HA having a degree of crosslinking of about 6.5%, or about10%, and having a HA concentration of greater than 20 mg/g.
• a composition comprising BDDE-crosslinked hyaluronic acid (HA), the HA having a degree of crosslinking of about 6.5%, or about10%, and having a HA concentration of greater than 20 mg/g.
• treatment methods comprising supraperiostally administering a composition, such as described herein, into at least one treatment area of the face of a patient, wherein the patient has a G- Sn-Pog facial angle of 145° to 1 65°.
• the facial angle value may be based on calculations of facial angle derived from digital images of the patient, or using other techniques.
• the step of administering results in the patient having an increased G-Sn-Pog angle relative to the patient's G- Sn-Pog facial angle prior to the treatment, for example, immediately prior to the administering step.
• the patient has an increased G-Sn-Pog angle for a period of time in the range of at least about 3 months, or more preferably, for at least about 6 months, for example, for about 9 months to about 24 months, after the step of administering.
• the patient has an increased G-Sn- Pog angle for at least about 6 months, or for at least about 9 months, or for at least about 12 months or for at least about 18 months or for at least about 24 months for after the step of administering.
• the treatment area is an area selected from the group consisting of the pogonion, the mentum, the left pre-jowl sulcus, the right pre- jowl sulcus, and the sublabial crease.
• the treatment may comprise administering the composition into two or more of the treatment areas.
• the administration comprises supraperiostally or subdermally injecting the compositions in an amount of between about 0.5 ml_ and about 3.0 ml_ per treatment area. In some embodiments, the amount injected into a given treatment area is no greater than 2.0 ml_.
• the total amount injected in a single treatment session, over all treatment areas is between 2.0 ml_ to about 6.0 ml_, for example, about 2.5 ml_, about 3.0 ml_, about 3.5 ml_. about 4.0 ml_, about 4.5 ml_, about 5.0 ml_, about 5.5 ml_, or about 6.0 ml_. In some embodiments, the amount administered into a single treatment session is about 4.0 ml_ or less.
• the present invention provides methods for restoring and creating volume in the chin and jaw, for example, in sculpting, shaping, and contouring across specific treatment areas of the face.
• the treatment areas may include one or more of the pogonion (the most projecting point on the anterior surface of the chin), mentum, (the lowest point on the chin), left and right pre-jowl sulci (left antigonion notch and right antigonion notch), and sublabial (mental) crease (the crease between the lower lip and the mentum).
• the shape and projection of the chin contribute to the proportional balance of the face that underlies attractiveness.
• a chin lacking projection is commonly labeled a "weak chin” whereas prominent chins are labeled “strong chins” and imply strength of personality.
• faces with average proportions are viewed as the most attractive and that juvenile features including a small chin are interpreted as attractive in females while a strong chin and jaw are interpreted as attractive in males.
• the appearance of the chin is a determinant of perceived attractiveness and can influence an individual's psychosocial well being [00096] Average proportions are dictated by analysis of a representation of facial profiles in a population and include the distances and angles between the nose, lip, and mentum.
• a composition of the invention is administered as an injectable implant, by subdermal or supraperiosteal injection in the chin and/or jaw area of a 32 year old male subject.
• the subject complains he has a "weak chin”.
• the doctor measures the subject's facial angle and determines that the a G-Sn-Pog angle of about 150°, which is substantially lower than the classic Burstone angle of the average chin (approximately 1 69°). The measurement is based on calculations of facial angle derived from digital images obtained using Canfield imaging equipment and software.
• the subject undergoes three treatment sessions, including initial treatment, top-up treatment, and repeat treatment, as described below.
• the treatment areas include at least one or more of the following treatment areas: the pogonion (the most projecting point on the anterior surface of the chin), the mentum (the lowest point on the chin), the left pre-jowl sulcus (left antigonion notch), the right pre-jowl sulcus (right antigonion notch), and/or the sublabial crease (the crease between the lower lip and the mentum).
• the pogonion the most projecting point on the anterior surface of the chin
• the mentum the lowest point on the chin
• the left pre-jowl sulcus left antigonion notch
• the right pre-jowl sulcus right antigonion notch
• sublabial crease the crease between the lower lip and the mentum
• the doctor implants no more than 2.0 mL into a single treatment area at any of the treatment sessions.
• the initial treatment is performed on the subject as follows.
• the doctor uses aseptic skin preparation and administers anesthesia following his standard practice.
• the application of ice and topical anesthesia may reduce injection discomfort.
• Injectable anesthesia is limited to the treatment areas only is and administered with certainty not to distort the planned treatment areas.
• the doctor injects the compositions described herein subcutaneously and/or supraperiosteally to increase chin projection (horizontally in the profile view), as well as to aesthetically sculpt, contour, and shape, limiting treatment to the pogonion, mentum, pre-jowl sulci, and sublabial (mental) crease. Suitable injection techniques have been described above.
• the treatment goal is to increase chin projection (horizontally in the profile view) and achieve aesthetic chin contour.
• the doctor determines the appropriate injection volume up to about 4.0 ml_ for initial and possible top-up treatments combined.
• the doctor gently molds the treated area using manual manipulation of the overlying tissue to achieve the desired facial contour.
• a top-up treatment occurs approximately 30 days after the initial treatment if desired by the subject, or if in the doctor's opinion, optimal (full) increase in chin projection and/or aesthetic contouring was not achieved by the initial treatment.
• the volume of the administered composition as a combined total (initial treatment and top-up treatment) is between about 2.0 ml_ to about 4.0 ml_. ).
• the doctor evaluates the treatment areas for any localized reaction and discusses any reported symptoms.
• 3D facial digital images frontal and profile images are captured for objective calculation of the angle of chin retrusion. If the doctor determines at top-up follow-up visit that optimal (full) increase in chin projection or aesthetic contouring was not achieved after the initial treatment, then subject is advised that he may receive a top-up treatment.
• a single repeat treatment is administered at a scheduled visit between months 18 and 24 if repeat treatment is warranted in the doctor's opinion and/or is desired by the subject.
• Injection volume for the chin does not exceed a total volume of 4.0 ml_ for the repeat treatment.

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