Cosmetic Medicine

Aesthetic Surgery Journal

2021, Vol 41(5) NP226–NP236
Intraarterial Degradation of Calcium © 2021 The Aesthetic Society.
Reprints and permission:
Hydroxylapatite Using Sodium journals.permissions@oup.com
DOI: 10.1093/asj/sjaa350
Thiosulfate–An In Vitro and Cadaveric Study www.aestheticsurgeryjournal.com

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Mariya Yankova, MD; Tatjana Pavicic, MD; Konstantin Frank, MD ;
Thilo L. Schenck, MD, PhD; Kate Beleznay, MD; Diana L. Gavril, MD;
Jeremy B. Green, MD; Daria Voropai, MD; Deanne Mraz Robinson, MD;
and Sebastian Cotofana, MD, PhD

Abstract
Background:  The most severe complications following soft tissue filler injections result from the intraarterial administra-
tion of the filler product. Although hyaluronic acid–based filler can be trans-arterially dissolved with hyaluronidase, no
information is available on calcium hydroxylapatite (CaHA)-based fillers.
Objective:  The authors sought to test whether CaHA-based fillers can be trans-arterially dissolved by sodium thiosulfate
(STS) when evaluated in cadaveric and in vitro models.
Methods:  Human cadaveric facial arterial segments were each filled with 0.2 cc of commercially available CaHA product
and submerged for 24 hours in 4 different STS-containing solutions: 10 cc STS (300 mg/cc) (pure, 1:1 dilution, 1:2 dilution),
0.9% saline and 10 cc STS (300 mg/cc), and 300 IU (bovine) hyaluronidase in a 1:1 ratio.
Results:  Intraarterial CaHA was detected in human facial artery segments after 24 hours independent of the STS concen-
tration employed. Submerging the arterial segments in STS (300 mg/cc) and 300 IU (bovine) hyaluronidase (1:1 ratio) also
did not dissolve the intraarterial CaHA product. Gray scale analyses did show, however, that increasing concentrations of
STS resulted in increased disintegration of CaHA in an in vitro experimental setting.
Conclusions:  The results of this study indicate that STS is limited in its potential to dissolve intraarterial CaHA of cadav-
eric human facial arteries, despite the fact that it appears effective when in direct contact with the CaHA. Adverse events
caused by intraarterial administration of CaHA-based fillers still lack a suitable antidote.

Editorial Decision date: August 14, 2020; online publish-ahead-of-print February 5, 2021.

Drs Yankova and Pavicic are physicians in private practice, Munich,
Germany. Drs Frank and Schenck are physicians, Department
for Hand, Plastic and Aesthetic Surgery, Ludwig—Maximilian
University Munich, Munich, Germany. Dr Beleznay is a physician,
Department of Dermatology and Skin Science, University of
British Columbia, Vancouver, British Columbia, Canada. Dr Gavril
is a physician in private practice, Cluj, Romania. Dr Green is a
physician in private practice, Coral Gables, FL, USA. Dr Voropai is
a physician, AEGIS Research Institute, London, United Kingdom.
Dr Robinson is a physician, Yale New Haven Hospital, New Haven,
CT, USA. Dr Cotofana is a physician and associate professor,
Department of Clinical Anatomy, Mayo Clinic College of Medicine
and Science, Rochester, MN, USA.
Corresponding Author:
Dr Sebastian Cotofana, Department of Clinical Anatomy, Mayo Clinic
College of Medicine and Science, Mayo Clinic, Stabile Building 9–38,
200 First Street, Rochester, MN, 55905, USA.
E-mail: cotofana.sebastian@mayo.edu;
Instagram: professorsebastiancotofana
Yankova et alNP227
Calcium hydroxylapatite (CaHA) has been globally accepted
as a well-studied and versatile medical implant material for uti-
lization in many different disciplines.1-4 However, over the last
2 decades it has achieved a prominent position in aesthetic
medicine as a biostimulatory semi-permanent dermal filler,
where it is indicated and US Food and Drug Administration
approved for the correction of moderate to severe facial
wrinkles, folds, HIV-related lipodystrophy, and the replace-
ment of volume loss in the dorsum of the hands.5-7 CaHA is
branded under the name of Radiesse (Merz, North-America,
Inc, Raleigh, NC) and consists of a combination of 70% of
sodium carboxymethyl cellulose gel carrier and 30% CaHA
microspheres. After injection of CaHA, the carboxymethyl
cellulose gel is broken down and the CaHA microspheres act
as a foundation for newly synthesized collagen. The CaHA
filler is slowly replaced by the newly formed collagen, hence
the biostimulatory categorization of this product.8
In its unadulterated form, CaHA has both volumizing and
biostimulating effects with a high satisfaction rate9 and low
risk of adverse events.2 These adverse reactions include
infection, inflammatory and non-inflammatory nodule for-
mation, tissue loss secondary to vascular compromise, and
injection-related visual compromise. A recent literature re-
view revealed that the rate of complications for treatments
with CaHA averages 3%, with nodule formation occurring
most commonly (96%), followed by persistent inflammation
(2%), persistent erythema (1%), and overcorrection (1%).2
These adverse events are no different compared with
the most commonly employed hyaluronic acid dermal
fillers. However, a major advantage of utilizing hyaluronic
acid–based fillers is that these can be dissolved with
hyaluronidase, an enzymatic degradation catalyzer ca-
pable of dissolving filler material both intralesionally10 and
intraarterially.11 Unfortunately, to date, there is no identi-
fied product that can dissolve CaHA, but a few promising
small studies have focused attention on sodium thiosulfate
(STS).12-14 A  previous study reported the degradation of
CaHA in porcine skin samples on intralesional injections
of STS and showed the potential reversibility of CaHA. The
proposed hypothesis is that STS acts as a chelating agent
primarily involving complexation with calcium ions or dis-
solution of calcium deposits. STS is also employed in non-
aesthetic medical domains to treat calciphylaxis-related
systemic complications and for intralesional injections to
treat cutaneous calcium lesions.12
However, because the most severe adverse events
that occur during soft tissue filler injections arise from
intraarterial product injection, it would be of great interest to
know whether STS can transmigrate human arterial vessel
walls and dissolve intraarterially located CaHA. Therefore,
the objective of this study was to investigate the effect of dif-
ferent STS concentrations on the intraarterial degradation
of CaHA-based soft tissue filler in both, an in vitro and
cadaveric model.
METHODS
Study Setup
The study was conducted in February 2019 and analyzed
in April 2020. Each body donor had given informed con-
sent while alive for the utilization of his or her body for
medical, scientific, and educational purposes. All aspects
of the study conform to the laws of the country where the
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study was conducted; all experiments were performed in
accordance with the Declaration of Helsinki principles.15
The facial artery was bilaterally dissected and ex-
planted. Small arterial branches were ligated, and the main
arterial trunk was flushed with water to detect and close
potential leakages using 6.0 mono filament sutures. The
artery was injected with 0.2 cc commercially available
CaHA (Radiesse) and ligated at 2-cm distances. This cre-
ated 2-cm-long facial arterial segments filled with 0.2 cc
CaHA (Figure 1).
Cadaveric Study Component
The 2-cm facial arterial segments were each filled with 0.2
cc CaHA and placed in tubes with the following solutions
(Figure 2):
Tube 1: 10 cc of STS (300 mg/cc) (NPC Escom, Stavropol,
Russia) (pure)
Tube 2: 10 cc of 5 cc of STS (300 mg/cc) and 5 cc saline
(1:1 dilution)
Tube 3: 10 cc of 3.3 cc of STS (300 mg/cc) and 6.6 cc
saline (1:2 dilution)
Tube 4: 10 cc of 5 cc of STS (300 mg/cc) and 5 cc of 300
IU (bovine) hyaluronidase (Hylase, Riemser Pharma GmbH,
Greifswald, Germany) in 1:1 ratio.
The arterial segments were submerged for 24 hours in
each of the tubes. After this period, the arterial segments
were dissected and visually inspected for the presence
as well as the consistency of the CaHA product (Figure 2).
In Vitro Study Component
In the in vitro study component, 0.5 cc CaHA was directly
injected into the solutions of the 4 tubes mentioned above
and additionally into a tube with 10 cc 0.9% saline (con-
trol) (Figure  2). The product was not manipulated during
the next 24 hours. After the 24-hour period, the tube was
gently vortexed for 1 minute, and a 0.05-cc droplet of the
obtained solution was placed on a glass surface for gray-
scale image analysis (Figure 3).
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Figure 1.  Facial arterial segments filled with calcium hydroxylapatite.

Figure 2.  Dissected facial arterial segments, exposing the visible calcium hydroxylapatite independent of the concentration
employed. Concentrations are shown on the labels of the tubes (from left to right): Tube 1: 10 cc sodium thiosulfate (300 mg/cc)
in a 1:1 ratio with 300 IU (bovine) hylase; Tube 2: 10 cc of 6.6 cc saline and 3.3 cc sodium thiosulfate (300 mg/cc) (1:2 dilution);
Tube 3: 10 cc of 5 cc saline and 5 cc sodium thiosulfate (300 mg/cc) (1:1 dilution); Tube 4: 10 cc sodium thiosulfate (300 mg/cc)
(pure).
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Figure 3.  Overview of the droplets containing calcium hydroxylapatite taken from each of the tubes in the background.
From left to right: Tube 1: 10 cc sodium thiosulfate (300 mg/cc) (pure); Tube 2: 10 cc of 5 cc saline and 5 cc sodium thiosulfate
(300 mg/cc) (1:1 dilution); Tube 3: 10 cc of 6.6 cc saline and 3.3 cc sodium thiosulfate (300 mg/cc) (1:2 dilution); Tube 4: 10 cc of
0.9% saline; Tube 5: 10 cc sodium thiosulfate (300 mg/cc) in 1:1 ratio with 300 IU (bovine) hylase.

Statistical Analysis dissection in all of the analyzed arterial segments. On

The presence and the consistency of CaHA within each of the
arterial segments were estimated based on visual inspection
and palpation. The CaHA within each of the droplets (0.05 cc)
from the in vitro study was objectively analyzed employing
the gray-scale-analysis function of the picture analysis pro-
gram ImageJ (National Institutes of Health, Bethesda, MD).
In detail, the droplet was captured and the density of gray-
scales was analyzed, with higher values representing less
transparent components of the droplet; this was interpreted
as more CaHA being present in the droplet (Figures 4-8).
RESULTS
Cadaveric Study Component
The study employed unembalmed, previously frozen (and
thawed for the purposes of the study) facial arterial seg-
ments of 7 Caucasian body donors (4 males, 3 females)
with a mean age of 75.29 ± 4.95 years (range, 70-87) and
a mean body mass index of 23.53 ± 3.96  kg/m2 (range,
16.46-32.23). The arterial segments filled with 0.2 cc CaHA
were dissected after they were submerged 24 hours in
tubes 1 through 4, respectively. Product was identified on
closer inspection, the consistency was unaltered com-
pared with the original product. No additional quantita-
tive or semi-quantitative investigations were conducted
(Figure 2).
In Vitro Study Component
Gray-scale analysis revealed that the investigated droplet
containing pure STS had a mean gray value of 101 ± 9.1
(range, 72-132) (Figure  4), whereas the 1:1 solution had a
mean gray value of 112 ± 18.5 (range, 62-161) (Figure  5),
the 1:2 solution had mean gray value of 115 ± 29.4 (range,
43-198) (Figure 6), the solution with STS and hyaluronidase
had a mean gray value of 126 ± 36.3 (range, 84-239)
(Figure  7), and the saline-only solution had a mean gray
value of 140 ± 44.6 (range: 51-224) (Figure  8). Results are
shown in Figure 9.
DISCUSSION
The results of the study reveal that intraarterial CaHA was
detected in human facial artery segments after 24 hours
independent of the STS concentration in which they were
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Figure 4.  Analysis of the droplet from the solution containing 0.5 cc calcium hydroxylapatite product and 10 cc sodium
thiosulfate (300 mg/cc) (pure) (A). (B) 3-Dimensional representation of the gray-scale analysis, which is also shown in C as a
histogram for a better understanding of the range of the gray scales.

submerged (pure, 1:1 and 1:2 dilution of 300  mg/cc STS).
Submerging the arterial segments in STS (300 mg/cc) to-
gether with 300 IU (bovine) hyaluronidase in a 1:1 ratio
likewise did not dissolve the intraarterial CaHA product.
Gray-scale analyses did show, however, that increasing
concentrations of STS resulted in increased disintegration
of CaHA in an in vitro experimental setting (Figure 6).
A strength of the study is the experimental setting
utilizing human facial arterial segments filled with CaHA
to investigate the ability of STS to penetrate human ar-
terial walls. The postintervention dissection exposed the
intraarterial material for verification. This unique and es-
tablished study setup11 allows researchers to control the
arterial wall transmigration. Another strength of the study
is that the solution employed to submerge the arterial seg-
ments was additionally tested in direct contact with the
CaHA. This allows to draw comparative conclusions about
the intra- and extraarterial potential of STS to dissolve
CaHA. In this study setup, it was shown that increasing
concentrations of STS in vitro decrease the concentration
of CaHA; this was objectively measured by utilizing gray-
scale analyses.
Limitations of the study are the small sample investi-
gated and the cadaveric and in vitro study design, which
might not reflect accurately an in vivo setting. The small
sample size is due to the limited availability of facial arte-
rial segments. Not every facial artery could be harvested
because arteries with too many branches per 2-cm
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Figure 5.  Analysis of the droplet from the solution containing 0.5 cc calcium hydroxylapatite product and 10 cc of 5 cc saline
and 5 cc sodium thiosulfate (300 mg/cc) (1:1 dilution) (A). (B) 3-Dimensional representation of the gray-scale analysis, which is
also shown in C as a histogram for a better understanding of the range of the gray scales.

segment were excluded. It could be argued that utilizing
cadaveric tissue might not reflect in vivo conditions best.
However, it can be assumed that arteries of living individ-
uals have a reduced permeability due to the living nature
of the tissue. This would imply that the potential of STS to
penetrate extra- to intraarterially is actually less in vivo.
The results of our analyses revealed that the intraarterial
product was mostly unaltered, which would be even
less altered in vivo according to the above assumption.
Another limitation of the study is that there was no objec-
tive quantification of the intraarterial product’s interaction
with the STS solutions. The assessment was conducted
by visual inspection and by palpation of the consistency
of the product. A more precise approach would have been
to investigate the CaHA particle size or the osmolality per
concentration investigated before and after the 24-hour
observational period. However, to account for this limita-
tion, the in vitro study was performed. Here, the product
was submerged in direct contact for 24 hours in 10 cc of
the varying solutions utilized. This study component re-
vealed that CaHA could not be dissolved completely even
if in direct contact with the agent at different concentra-
tions for 24 hours. These results support each other and
show the inability of STS to completely dissolve CaHA
in the conducted experimental setting. Lastly, it is postu-
lated that although STS did not exhibit a degradational
effect on CaHA, it may nonetheless be capable of diluting
the material.
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Figure 6.  Analysis of the droplet from the solution containing 0.5 cc calcium hydroxylapatite product and 10 cc of 6.6 cc saline
and 3.3 cc sodium thiosulfate (300 mg/cc) (1:2 dilution) (A). (B) 3-Dimensional representation of the gray-scale analysis, which is
also shown in C as a histogram for a better understanding of the range of the gray scales.

STS has been shown to be successful in lowering the in-
cidence of cisplatin-induced hearing loss among children
with standard-risk hepatoblastoma when administered
intravenously16 and when treating cyanide poisoning de-
spite that reliable evidence for the latter indication remains
elusive.17,18 STS has also been shown to reduce the forma-
tion of calcium kidney stones when taken orally in patients
with recurrent calcium urolithiasis,19 and intralesional
STS injections have proved effective at resolving the
deep cutaneous lesions of uremic calcifying arteriopathy
(calciphylaxis) in patients with chronic kidney disease.20 In
2 case studies, intralesional STS and topical sodium meta-
bisulfite have proved effective at reducing lesions associ-
ated with calcinosis cutis nodules.13,14 The most commonly
reported side effects of STS are hypotension (infusion rate
dependent), nausea/vomiting, disorientation, headache,
prolonged bleeding therapy, hypersensitivity reactions,
contact dermatitis, warmth, local irritations, and potential
tissue necrosis.
A previous study provided support that 0.2 cc STS
(concentration 12.5 g/50 cc) has the potential to dissolve
CaHA in porcine skin after a period of 24 hours when
analyzed histologically.12 This study provided for the first
time, to our knowledge, evidence that adverse events fol-
lowing aesthetic treatments with CaHA could be resolved
by the intralesional injection of STS, perhaps serving as
an antidote analogous to hyaluronidase for hyaluronic
acid–based fillers. This study additionally mentioned that
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Figure 7.  Analysis of the droplet from the solution containing 0.5 cc calcium hydroxylapatite product and 10 cc 0.9% saline (A).
(B) 3-Dimensional representation of the gray-scale analysis, which is also shown in C as a histogram for a better understanding
of the range of the gray scales.

there is a lack of knowledge regarding whether STS can
penetrate intact arterial walls and dissolve intraarterially in-
jected CaHA. With the results of the present study, we tried
to answer this question by submerging CaHA-filled facial
arterial segments into various concentrations of STS. It was
revealed that in the experimental cadaveric setting, the
product could not be dissolved, and CaHA was identified
within the arterial segments independent of the STS con-
centration in which the arterial segment was submerged.
When extending the study setup to an in vitro model, it was
observed that pure STS (300 mg/cc) in direct contact with
CaHA dissolved best. The other tested concentrations (1:1
and 1:2 dilutions) showed proportionally less effectiveness.
Interestingly, STS (300 mg/cc) in a 1:1 ratio with 300 IU (bo-
vine) hyaluronidase was even less effective (Figure 7).
Clinically, the results indicate that for aesthetic adverse
events like nodule formation or overcorrection, that is,
too much product injected, STS might be useful. Future
studies will need to repeat these tests presented herein
and previously12 in a clinical setting to verify its applica-
bility and safety profile. Multiple variables like dosage,
concentration, duration, and additional therapy will need
to be identified. For more severe adverse events like
tissue loss or injection-related visual compromise due
to an intraarterial product administration, the results of
this study do not provide evidence that a CaHA-based
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Figure 8.  Analysis of the droplet from the solution containing 0.5 cc calcium hydroxylapatite product and 10 cc sodium
thiosulfate (300 mg/cc) in a 1:1 ratio with 300 IU (bovine) hyaluronidase (A). (B) 3-Dimensional representation of the gray-scale
analysis, which is also shown in C as a histogram for a better understanding of the range of the gray scales.

product can be dissolved by STS. All dissected facial

Figure 9.  Bar graph showing the mean value of the gray-
scale analysis for each of the droplets shown in Figure 3.
STS, sodium thiosulfate.
arterial segments showed visible CaHA intraarterially
despite submergence for 24 hours. The lifespan of ret-
inal tissue on embolization is limited, and therefore any
remaining occluding material could significantly affect
structural integrity and thus retinal function.21-23 Further,
it is not known whether the intima damage causing a
local and/or disseminated coagulopathy by the injected
CaHA is worse or less compared with hyaluronic acid–
based fillers. A previous study has shown that the com-
bination of hyaluronidase and urokinase were effective
in restoring hyaluronic acid–based injection-related
visual compromise, indicating that the thrombogenic
component of a product-related embolus needs to be
incorporated in the treatment algorithm.24 However,
Yankova et alNP235
the thrombogenic component of intraarterial CaHA in-
jection still needs to be investigated. For the latter,
hyaluronidase has been shown to have an effect espe-
cially when combined with thrombolytic agents.24
To date, the risk profile for soft tissue fillers is low, but
when severe adverse events occur they are devastating.
When an injection-related visual compromise results from
hyaluronic acid–based soft-tissue fillers, hyaluronidase
is a potential treatment; however, the rate of success of
hyaluronidase alone or in combination with urokinase
was reported to be 42% when injected directly into the
internal carotid artery via catheterization.24 For CaHA-
based products, the risk profile must be assumed to be
higher because to date no agent is available to reverse
its embolizing effects. It is additionally not known whether
the consequences of an intraarterial application are solely
due to the embolus or additionally due to the intima
damage as observed in hyaluronic acid–based fillers.
Future studies will need to conduct more investigations
to evaluate further the utilization of STS to reverse CaHA,
which could increase safety for aesthetic patients.
CONCLUSIONS
The results of this study reveal that STS is limited in its
potential to dissolve intraarterial CaHA of cadaveric
human facial arteries. Even though the arterial segments
were submerged for 24 hours in various STS concentra-
tions (pure, 1:1, and 1:2), almost no visible change in the
amount of intraarterial product was observed. The in vitro
study component revealed, however, that STS has the cap-
ability to dissolve CaHA in the study setting utilized when
in direct contact with the product; this was dependent on
the concentration employed.
Disclosures
The authors declared no conflicts of interest with respect to
the research, authorship, and publication of this article.
Funding
The authors received no financial support for the research,
authorship, and publication of this article.
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The ASJ in-house team, editorial board, staff, and reviewers
are incredibly engaged and committed; they have successfully
combined the utmost in professionalism with friendliness to create a
close relationship with readers and authors. ASJ is so valuable because
of its excellent peer review process. The success of this comprehensive
quality control is evident in the rapidly increasing relevance of ASJ in the
aesthetic surgery community. Case in point: In 2011, the journal had an
Impact Factor of 1.469; increased to 3.480 in 2018. As one of the most
awarded journals for education, members of the Norwegian Society of
Aesthetic Plastic Surgery have been delighted by the introduction of ASJ
to our community, especially given our collaboration with the American
Society for Aesthetic Plastic Surgery. I am grateful to Dr. Foad Nahai for
bringing the journal to the world and for bringing the world to the journal.

Dr. Amin Kalaaji, MD. PhD, Specialist in Plastic Surgery, President, Norwegian Society of Aesthetic
Plastic Surgery, Oslo Plastic Surgery Clinic, Oslo, Norway

@ASJrnl Aesthetic Surgery Journal Aesthetic Surgery Journal aestheticsurgeryjournal_asj

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