Abdelmoez Hyaluronic Acid Dermal Filler Scoring System

Introduction: Dermal fillers industry is ever-expanding. Tens, if not hun-dreds, of brands are available to purchase legally or illegally. I have attempted in this paper to develop a scoring system for Hyaluronic acid dermal fillers that makes an injector’s verdict objective, fair and unbiased, and injection experience safer. Theoretically speaking, the worst filler will have, at least, −12 score and the best will have a score of 34 points. Some scoring points do not exist in any filler, suggesting hints to improve all brands. Objectives: To build a Hyaluronic acid dermal filler scoring system that deals with what the injector can easily read, see or experience on their own without using sophisticated technologies or the need to understand or estimate the physics or the chemistry behind the filler. Using a scoring system that depends more on objective than subjective findings will be easy and unbiased to apply, more practical. The scoring system structure should be holistic rather than being only results centered and more focused on safety.


Introduction
Speaking only about the major dermal filler manufacturers, the global dermal fillers market size was valued at USD 3.47 Billion in 2018 and is projected to reach USD 6.3 Billion by 2026. Hyaluronic acid takes the biggest share of the dermal filler market that is estimated by (77.2%) [1].
There are tens, maybe hundreds, of other less known Hyaluronic acid dermal filler brands worldwide produced by national, local or wholesale manufacturers, and sold through distributors, third parties or online to find their way sometimes to customers in countries even with strict pharmaceutical regulations.
When injectors are offered Hyaluronic acid dermal filler brands that they have never heard of to try, here comes the need for a scoring system. United States of America Food & Drug Administration (FDA) approval and major manufacturers' reputation definitely matter. However, Hyaluronic acid dermal fillers are injected all over the world in other countries that have their own regulating authorities. FDA is an American federal agency that is responsible for protecting and promoting public health [2]. However, as any other authority, FDA still faces criticism [3]- [8]. Growing manufacturers may be unfairly judged despite having a considerably good Hyaluronic acid filler [6].

Methods
While designing a Hyaluronic acid dermal filler scoring system (see Table 1), I considered the following points: 1) The scoring system deals with what the injector can easily read, see or experience on their own without using sophisticated technologies e.g. 3D cameras and without the need to understand or estimate the physics or the chemistry behind the Hyaluronic acid dermal filler e.g. innovations in crosslinking or superiority in physical properties. Approvals by official bodies and scientific literature can fill the gap and are considered as scoring points.
2) The scoring system depends more on objective than subjective findings, meaning that several aspects can be accurately judged by absolute findings, unlike other scoring scales that depend mainly on subjective criteria ( Table 2) by assessing the wrinkles severity or variation of injected area volume over time and sometimes demand sophisticated technologies, injection associated pain and discomfort scoring or patient satisfaction scoring. The thing that makes my scoring system more practical, easier to be applied, more focused on safety, holistic rather than being only results centered and accordingly unique in literature.
3) The scoring system does not only depend on judging the filler substance, but also comprises other components of the package e.g. the syringe, the needle, the manufacturer, the evidence, etc.
4) The scoring system does not consider individual variations regarding skills, techniques or personal injector preferences.
5) The scoring system has minus grades for mentioned, or even unmentioned, absolutely contraindicated findings that may threaten the patient safety if they were just reported even by another injector or in a literature source at least once.
Other unfavorable, yet not dangerous, findings should be personally experienced more than twice to be considered in the grading process.
6) The scoring system gives zero grade to positive yet basic characteristics of the product. Such characteristics are critical for patient safety.

7)
Official prices were not considered as a factor in the scoring process. 8) Theoretically speaking, the worst filler will have, at least, −12 score and the best will have a score of 34 points.   Table 2. Examples of popular subjective scoring systems that assess the wrinkles severity or variation of injected area volume over time.
10) Some scoring points do not exist in any filler, suggesting hints to improve all products. J. Cosmetics, Dermatological Sciences and Applications

11)
The importance of such a score is more prominent in countries with permissive regulations regarding filler brands allowed to use.

Discussion
My scoring system essentially depends on my experience. Feedback is required from readers side to check how practical the scoring system is and if it significantly relates to the procedure results and customer satisfaction. Next target is other dermal fillers and neuromodulators.

Conclusion
In the era of countless dermal filler brands and ever-growing market, a practical and unbiased scoring system is needed to emphasize product quality and patient safety.

Conflicts of Interest
The author declares no conflicts of interest regarding the publication of this paper.