Complications of injectable fillers, part I

Recommendations for volume augmentation and rejuvenation of the face and hands with the new generation polycaprolactone-based collagen stimulator (Ellansé®)

Background

The range of fillers currently available for soft-tissue augmentation is constantly expanding. The latest advances in filler technology include collagen biostimulators that exert their esthetic effect by promoting neocollagenesis. One such product is the next-generation collagen biostimulator (Ellansé^®) that demonstrates properties as yet unseen in soft-tissue fillers. It is composed of polycaprolactone (PCL) microspheres in an aqueous carboxymethylcellulose gel carrier. Given its specific characteristics and the number of areas that can be treated with this innovative product, experts’ recommendations were deemed necessary and are therefore presented in this paper with a specific focus on the indications, treatment areas and procedures as well as injection techniques.

Methods

A multinational, multidisciplinary group of plastic surgeons and dermatologists convened to develop recommendations with a worldwide perspective. This publication provides information on the specific characteristics of the product and focuses on the recommendations on the injection techniques.

Results

Recommendations on injection techniques are provided for the upper face, mid-face and lower face and zone by zone for each of these areas, as well as hands. Based on the particular anatomy of each area, the focus is on the techniques and devices of injection and the volume and depth of injection. The information is tabulated, and photos are presented for illustration.

Conclusion

These recommendations provide a guideline for physicians who wish to perform safe and efficacious treatment with the PCL collagen stimulator for face and rejuvenation with volume augmentation.

Nonsurgical Facial Rejuvenation: Outcomes and Safety of Neuromodulator and Soft-Tissue Filler Procedures Performed in a Resident Cosmetic Clinic

BACKGROUND

The ability to perform nonsurgical facial rejuvenation procedures is a core competency requirement for plastic surgery residents. However, limited data exist on training models to achieve competency in nonsurgical facial rejuvenation and on outcomes of these procedures performed by residents. The purpose here is to evaluate patient-reported outcomes and safety of nonsurgical facial rejuvenation procedures performed by plastic surgery residents.

METHODS

We prospectively enrolled 50 patients undergoing neuromodulator and/or soft-tissue filler injections in a resident cosmetic clinic between April and August 2016. Patients completed FACE-Q modules pre-procedure, and at 1 week and 1 month post-procedure. Paired t-tests were used to calculate statistical significance of changes between pre- and post-procedure scores. Effect sizes were calculated to assess clinical improvement from pre- to post-procedure. The magnitude of change was interpreted using Cohen's arbitrary criteria (small 0.20, moderate 0.50, large 0.80).

RESULTS

Forty-five patients completed the study. Patients experienced significant improvements (p < 0.001) in all FACE-Q domains, including aging appearance appraisal (improved from 49.7 ± 29.4 to 70.1 ± 21.6, effect size 0.79), psychological well-being (44.0 ± 14.6-78.6 ± 20.7, effect size 1.93), social functioning (48.6 ± 16.6-75.5 ± 21.7, effect size 1.20), and satisfaction with facial appearance (50.1 ± 13.7-66.2 ± 19.7, effect size 0.95). At 1 month, overall satisfaction with outcome and decision were 75.8 ± 20.7 and 81.1 ± 20.4, respectively. No patients experienced complications.

CONCLUSIONS

Nonsurgical facial rejuvenation procedures performed by residents can improve patients' quality of life and provide high satisfaction without compromising safety.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Exploring the Possibility of a Retrograde Embolism Pathway from the Facial Artery to the Ophthalmic Artery System In Vivo

BACKGROUND

Blindness caused by soft tissue fillers is an extremely low-probability event, but it results in great concern because of its devastating consequences. Currently, the mechanism of an embolism is usually considered to be an accidental injection of fillers into the blood vessels of the face, such as a facial artery, and then retrograding into the ophthalmic artery system, which causes retinal ischemic necrosis. In addition, previous studies have shown that there are anastomoses between facial arteries and branches of the ophthalmic artery in cadavers. An in vivo study, however, has not yet been reported.

METHODS

This study was approved by the institutional review board of Xijing Hospital, Fourth Military Medical University. Under general anesthesia, we dissected the same side of the face and eyeball in rabbits to manifest the facial artery and retina separately. Later, a needle (27 g) connected to a syringe (10 ml) full of methylene blue was inserted into a rabbit facial artery. Then, after poking a tiny hole in the central retinal artery, methylene blue was injected into the facial artery as quickly as possible (0.5 ml per second). At the same time, we carefully observed whether the central retinal artery had dye spillover or staining in the sclera. If blue dye was observed in the eye ground and/or the sclera, then it was thought to have entered the ophthalmic artery system (a positive result). In contrast, if none of the blue dye was observed, it was considered a negative result. A Chi-square (χ ²) test with a fourfold table was used to compare the differences in the frequencies of blue dye observed between living and dead rabbits. A value of p < 0.05 was considered significant.

RESULTS

One of the 20 rabbits showed the appearance of blue dye in the ophthalmic artery system in vivo, and the remaining 19 living rabbits had negative results. All 20 of the dead rabbits showed dye appearance in the eye ground. A statistically significant difference existed between the living and dead rabbits (p < 0.05).

CONCLUSION

In vivo, fillers can retrogradely enter the ophthalmic artery if the fillers entered the facial artery. Although the possibility is much lower in vivo than it is in corpses, adequate attention should be paid because of the catastrophic complications.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Immunological reaction after facial hyaluronic acid injection

We report two rare cases of inflammatory reactions with multiple subcutaneous facial painful collections after Hyaluronic acid injections, expose their management and discuss aetiologic hypothesis. Due to unfavourable evolution despite antibiotic treatment, surgical drainage was performed. Immune-mediated delayed hypersensitivity reactions were the most probable cause.

Hand rejuvenation with fat grafting: A 12-year single-surgeon experience

Background

Fat grafting has been successfully used for reconstructive and esthetic surgery of the breast, face, and other body parts. In this article, we present our protocol for hand fat grafting and over a decade of clinical experience.

Methods

Fat tissue is obtained from the flanks, peri-umbilical region, or internal side of the thigh or knee. No centrifuge machine is used to prevent fat damage. After decantation, fat is injected into the dorsum of the hand using a cannula from the wrist and not from the fingers. Fat is distributed gently above the dorsal deep fascia to avoid perforation of the vessels.

Results

The proposed technique was applied to 65 patients. The amount of fat injected ranged from 10 to 30 cm³. No allergic reactions were noticed. Each patient’s progress was followed-up for a minimum of 12 months. Over this period, contour changes and the effects of the procedure(s) on the skin were analyzed. Fifty-six patients (84%) were satisfied with the results during the observation period, 7 patients (12%) were somewhat satisfied and needed one more fat grafting procedure to achieve complete satisfaction, and 2 patients (4%) were dissatisfied with the results. Three cases of temporary swelling of the hands resolved naturally. No long-term complications were seen.

Conclusions

This study covers over a decade of practical experience in applying fat grafts to hands. The procedure is effective in reshaping and rejuvenating the hand as it shows long-lasting results after 1-year follow-up.

Consensus statement on prevention and management of adverse effects following rejuvenation procedures with hyaluronic acid-based fillers

Facial fillers play an important role in the correction of facial changes associated with ageing. They offer quick treatments in the outpatient setting with minimal subsequent downtime that provide predictable, natural-looking, long-lasting results. Adverse reactions after hyaluronic acid injections tend to be mild or moderate and rather temporary. However, as with all injected or implanted biomaterials, severe adverse events can occur and patients must be fully informed of potential risks prior to undergoing treatment. A panel of experts from Germany (D), Austria (A) and Switzerland (CH) developed recommendations, and this study provides the 'DACH Consensus Recommendations' from this group specifically on the use of hyaluronic acid fillers. The aim is to help clinicians recognize potential risks and to provide guidance on how best to treat adverse events if they arise. Contraindications to hyaluronic acid fillers are also detailed, and ways to prevent adverse events occurring are discussed. Hyaluronic acid-based products are claimed to be very close to an ideal tissue augmentation agent; nevertheless, profound medical, anatomical and product knowledge are of paramount importance to minimize the occurrence of adverse reactions.

Preventing the Complications Associated with the Use of Dermal Fillers in Facial Aesthetic Procedures: An Expert Group Consensus Report

Background

The use of dermal fillers in minimally invasive facial aesthetic procedures has become increasingly popular of late, yet as the indications and the number of procedures performed increase, the number of complications is also likely to increase. Paying special attention to specific patient characteristics and to the technique used can do much to avoid these complications. Indeed, a well-trained physician can also minimize the impact of such problems when they do occur.

Methods

A multidisciplinary group of experts in aesthetic treatments reviewed the main factors associated with the complications that arise when using dermal fillers. A search of English, French and Spanish language articles in PubMed was performed using the terms “complications” OR “soft filler complications” OR “injectable complications” AND “dermal fillers”. An initial document was drafted that reflected the complications identified and recommendations as to how they should be handled. This document was then reviewed and modified by the expert panel, until a final text was agreed upon and validated.

Results

The panel addressed consensus recommendations about the preparation, the procedure and the post-procedural care. The panel considered it crucial to obtain an accurate medical history to prevent potential complications. An additional clinical assessment, including standardized photography, is also crucial to evaluate the outcomes and prevent potential complications. Furthermore, the state of the operating theatre, the patient’s health status and the preparation of the skin are critical to prevent superficial soft tissue infections. Finally, selecting the appropriate technique, based on the physician’s experience, as well as the characteristics of the patient and filler, helps to ensure successful outcomes and limits the complications.

Conclusions

This consensus document provides key elements to help clinicians who are starting to use dermal fillers to employ standard procedures and to understand how best to prevent potential complications of the treatment.

Level of Evidence V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Intravenous Hyaluronidase with Urokinase as Treatment for Rabbit Retinal Artery Hyaluronic Acid Embolism

BACKGROUND

Although various salvage methods have been proposed to treat intraretinal artery hyaluronic acid embolism, their applications are still limited by various factors. The authors investigated the effectiveness of intravenous hyaluronidase with urokinase for resolving retinal artery hyaluronic acid embolism.

METHODS

The anatomy of rabbit ophthalmic and fundus arteries (retinal and choroid artery) was studied. Approximately 0.35 ml of hyaluronic acid was injected into the ophthalmic artery to create a retinal artery embolism model. The rabbits were grouped randomly (groups A, B, C, D, E, and F) and given hyaluronidase with urokinase intravenously at different postobstruction time points (10, 20, 30, 40, 50, and 60 minutes). Saline was given to the control group. Fundus vascular (retinal and choroid artery) reperfusion status and the effectiveness of the solution on the obstruction of each group were observed for 5 days.

RESULTS

The animal model closely imitated actual hyaluronic acid ophthalmic/retinal artery obstructions. Three vascular conditions were observed after hyaluronidase with urokinase injection: total, partial, and no reperfusion. Groups A, B, and C showed a significantly higher overall solution effectiveness rate (total/partial reperfusion) compared with the control group (p = 0.001, p = 0.001, and p = 0.005, respectively). Solution effectiveness in groups D, E, and F showed no difference compared with the control group (p = 0.628, p = 1.000, and p = 1.000, respectively). The effectiveness of the solution drops dramatically if given after 30 minutes of obstruction.

CONCLUSIONS

The authors' method can indeed help resolve retinal artery hyaluronic acid obstruction. Intravenous hyaluronidase with urokinase technique shows possible potential to become a standardized treatment protocol for intraretinal artery hyaluronic acid embolism with further clinical tests.

Safety and Effectiveness of Juvéderm Ultra Plus Injectable Gel in Correcting Severe Nasolabial Folds in Chinese Subjects

Background:

Hyaluronic acid dermal fillers are effective in correcting severe nasolabial folds (NLFs) in non-Asian populations. We assessed safety and effectiveness of Juvéderm Ultra Plus in a Chinese population.

Methods:

This double-blind study randomized Chinese subjects with severe NLFs to Juvéderm Ultra Plus (24 mg/mL) in 1 NLF and Restylane injectable gel (20 mg/mL) in the other NLF. NLFs were evaluated using the validated 5-point photonumeric Allergan NLF Severity Scale (0 is “no wrinkle” and 4 is “very deep wrinkle”). Investigator-assessed responder rates (primary outcome at 6 months), NLF mean improvements, and subject-assessed responder rates and preference were assessed.

Results:

Of 124 subjects randomized, 122 completed the 6-month visit. NLFs treated with Juvéderm Ultra Plus required less volume than those treated with Restylane (median [range]: 0.80 [0.3–2.0] vs 1.00 [0.3–1.9]; P<0.001). Investigator-assessed responder rates were 90.4% for Juvéderm Ultra Plus and 89.6% for Restylane, establishing noninferiority of Juvéderm Ultra Plus. Mean (SD) improvements in NLF Severity Scale scores from baseline at 6 months were 1.5 (0.75) for Juvéderm Ultra Plus and 1.6 (0.73) for Restylane. Subject-assessed responder rates were similar to investigator-assessed rates (87.3%, Juvéderm Ultra Plus; 83.9%, Restylane). Of subjects reporting a preference, 62.1% preferred Juvéderm Ultra Plus. The most common treatment site responses were swelling and tenderness; most were mild or moderate in severity and resolved without intervention. Juvéderm Ultra Plus had fewer severe treatment site responses than Restylane.

Conclusion:

In this study in Chinese subjects, Juvéderm Ultra Plus was safe and effective for correcting severe NLFs.

An Overview of Infections Associated With Soft Tissue Facial Fillers: Identification, Prevention, and Treatment

PURPOSE

The purpose of this study was to provide an overview of infections associated with facial soft tissue fillers.

MATERIALS AND METHODS

A literature review was performed which evaluated infections associated with facial soft tissue fillers.

RESULTS

Infection rates with soft tissue fillers are low and are estimated at 0.04 to 0.2%. Most of these infections arise when skin contaminants infiltrate the injection site at the time of injection. These infections can occur early, up to several days after treatment, or delayed, occurring weeks to years after treatment. Reactions vary based on the filler absorbability and duration. Early recognition and treatment are important factors in managing our cosmetic surgery patients.

CONCLUSION

Although facial fillers are safe and predictable, infections can still occur. Oral and maxillofacial surgeons need to be able to prevent, recognize, and properly manage infections related to these popular injections.

Experience and Management of Intravascular Injection with Facial Fillers: Results of a Multinational Survey of Experienced Injectors

BACKGROUND

Intravascular injection leading to skin necrosis or blindness is the most serious complication of facial injection with fillers. It may be underreported and the outcome of cases are unclear. Early recognitions of the symptoms and signs may facilitate prompt treatment if it does occur avoiding the potential sequelae of intravascular injection.

OBJECTIVES

To determine the frequency of intravascular injection among experienced injectors, the outcomes of these intravascular events, and the management strategies.

METHODS

An internet-based survey was sent to 127 injectors worldwide who act as trainers for dermal fillers globally.

RESULTS

Of the 52 respondents from 16 countries, 71 % had ≥11 years of injection experience, and 62 % reported one or more intravascular injections. The most frequent initial signs were minor livedo (63 % of cases), pallor (41 %), and symptoms of pain (37 %). Mildness/absence of pain was a feature of 47 % of events. Hyaluronidase (5 to >500 U) was used immediately on diagnosis to treat 86 % of cases. The most commonly affected areas were the nasolabial fold and nose (39 % each). Of all the cases, only 7 % suffered moderate scarring requiring surface treatments. Uneventful healing was the usual outcome, with 86 % being resolved within 14 days.

CONCLUSION

Intravascular injection with fillers can occur even at the hands of experienced injectors. It may not be always associated with immediate pain or other classical symptoms and signs. Prompt effective management leads to favorable outcomes, and will prevent catastrophic consequences such as skin necrosis. Intravascular injection leading to blindness may not be salvageable and needs further study.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Periorbital Injectables: Understanding and Avoiding Complications

Periorbital rejuvenation with neurotoxins and dermal fillers address several aging changes. Safe and effective results require a thorough understanding of periorbital anatomy, proper injection techniques, and complications of these products. Prompt recognition and treatment of complications can minimize their adverse impacts. Complications can be divided into ischaemic and non-ischaemic effects. Hylauronidase, an enzyme that degrades hyaluronic acid, may improve outcomes after intravascular hyaluronic acid fillers.

Global Aesthetics Consensus: Avoidance and Management of Complications from Hyaluronic Acid Fillers-Evidence- and Opinion-Based Review and Consensus Recommendations

BACKGROUND

Although the safety profile of hyaluronic acid fillers is favorable, adverse reactions can occur. Clinicians and patients can benefit from ongoing guidance on adverse reactions to hyaluronic acid fillers and their management.

METHODS

A multinational, multidisciplinary group of experts in cosmetic medicine convened the Global Aesthetics Consensus Group to review the properties and clinical uses of Hylacross and Vycross hyaluronic acid products and develop updated consensus recommendations for early and late complications associated with hyaluronic acid fillers.

RESULTS

The consensus panel provided specific recommendations focusing on early and late complications of hyaluronic acid fillers and their management. The impact of patient-, product-, and technique-related factors on such reactions was described. Most of these were noted to be mild and transient. Serious adverse events are rare. Early adverse reactions to hyaluronic acid fillers include vascular infarction and compromise; inflammatory reactions; injection-related events; and inappropriate placement of filler material. Among late reactions are nodules, granulomas, and skin discoloration. Most adverse events can be avoided with proper planning and technique. Detailed understanding of facial anatomy, proper patient and product selection, and appropriate technique can further reduce the risks. Should adverse reactions occur, the clinician must be prepared and have tools available for effective treatment.

CONCLUSIONS

Adverse reactions with hyaluronic acid fillers are uncommon. Clinicians should take steps to further reduce the risk and be prepared to treat any complications that arise.

Periorbital Surgery: Forehead, Brow, and Midface

Periorbital rejuvenation requires a careful understanding of the interplay between the eyelids, brow, forehead, and midface. Reversing periorbital signs of aging requires a correction of volume loss, soft tissue ptosis, and skin changes. Many surgical and nonsurgical techniques exist to treat the aging periorbital region; however, careful consideration of the patient's complaints and existing anatomy is critical to achieving a safe and esthetically pleasing outcome.

Safe Planes for Injection Rhinoplasty: A Histological Analysis of Midline Longitudinal Sections of the Asian Nose

BACKGROUND

Dorsal nasal augmentation is an essential part of injection rhinoplasty on the Asian nose. Aesthetic physicians require detailed knowledge of the nasal anatomy to accurately and safely inject filler.

METHODS

One hundred and thirty-five histological cross sections were examined from 45 longitudinal strips of soft tissue harvested from the midline of the nose, beginning from the glabella to the nasal tip. Muscles and nasal cartilage were used as landmarks for vascular identification.

RESULTS

At the nasal tip, a midline longitudinal columellar artery with a diameter of 0.21 ± 0.09 mm was noted in 14 cadavers (31.1 %). At the infratip, subcutaneous tissue contained cavernous tissue similar to that of the nasal mucosa. The feeding arteries of these dilated veins formed arteriovenous shunts, into which retrograde injection of filler may be possible. All of the nasal arteries present were identified as subcutaneous arteries. They coursed mainly in the superficial layer of the subcutaneous tissues, with smaller branches forming subdermal plexuses. A substantial arterial anastomosis occurred at the supratip region, in which the artery lay in the middle of the subcutaneous tissue at the level of the major alar cartilages. These arteries had a diameter ranging between 0.4 and 0.9 mm and were found in 29 of 45 specimens (64.4 %). This was at the level midway between the rhinion above the supratip and the infratip. This anastomotic artery also crossed the midline at the rhinion superficial to the origin of the procerus on the lower end of the nasal bone. Here the arterial diameter ranged between 0.1 and 0.3 mm, which was not large enough to cause arterial emboli. Fascicular cross sections of the nasalis muscle directly covered the entire upper lateral cartilage. The subdermal tissue contained few layers of fat cells along with the occasional small artery. The procerus arose from the nasal bone and was continuous with the nasalis in 16 cadavers (35.6 %). There was fatty areolar tissue between the procerus and the periosteal layer and no significant arteries present. The procerus ascended beyond the brow to insert into the frontalis muscle with very few cutaneous insertions. The supratrochlear vessels and accompanying nerve were occasionally found on the surface of the frontalis muscle.

CONCLUSION

Most nasal arteries found in the midline are subcutaneous arteries. Filler should be injected deeply to avoid vascular injury leading to compromised perfusion at the dorsum or filler emboli at the nasal tip.

LEVEL OF EVIDENCE V

This journal requires that the authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Hyaluronidase Caveats in Treating Filler Complications

BACKGROUND

Most of the complications associated with hyaluronic acid (HA) fillers can be addressed by hyaluronidase. Extensive experience with this enzyme was accumulated in ophthalmology and anesthesia. In dermatologic use multiple aspects still remain controversial.

OBJECTIVE

To elucidate questions with regard to hyaluronidase use in HA-induced complications, including appropriate dosage, timing, and technique of delivery, differences in the activity of hyaluronidases of different origins, interaction between the enzymes and different HA gels, and safety issues.

MATERIALS AND METHODS

Extensive review of the relevant literature was conducted. The conclusions are based on this review and personal author's experience.

RESULTS

FDA-approved hyaluronidases provide predictable results and can be used interchangeably. A physician has to be closely familiar with specific characteristics of other hyaluronidases. Different brands of HA fillers have different sensitivity to degradation by hyaluronidase. For filler overcorrection or misplacement, low dose of the enzyme has to be injected directly into the palpable HA mass. In case of vascular accident, flushing of the ischemic area with high doses of hyaluronidase is required. Hypersensitivity reactions to hyaluronidase are so far not reported in dermatologic literature.

CONCLUSION

With increased popularity of HA fillers, hyaluronidase had become an indispensable tool in dermatology office. It is safe and reliable for treatment of HA-induced complications.

Understanding, Avoiding, and Managing Severe Filler Complications

Any injectable filler may elicit moderate-to-severe adverse events, ranging from nodules to abscesses to vascular occlusion. Fortunately, severe adverse events are uncommon for the majority of fillers currently on the market. Because these are rare events, it is difficult to identify the relevant risk factors and to design the most efficacious treatment strategies. Poor aesthetic outcomes are far more common than severe adverse events. These in contrast should be easily avoidable by ensuring that colleagues receive proper training and follow best practices.

"Walk the Rim, Feel the Bone" Technique in Superior Sulcus Filling

Superior sulcus filler injection is a nonsurgical method to rejuvenate the upper face. Blindness and stroke are devastating complications of facial filler injection. This study describes an injection technique that minimizes the risk of blindness and includes a case study demonstrating the cosmetic benefits of this procedure. To avoid retrograde injection of filler embolus into the ophthalmic artery, we advocate a "'walk the rim, feel the bone" approach. Small boluses of hyaluronic acid filler are given in preperiosteal plane, avoiding the superior orbital foramen.

Delayed immunologic complications due to injectable fillers by unlicensed practitioners: our experiences and a review of the literature

For a number of years, there have been unauthorized practitioners who have been illegally injecting substances. In this series of cases, delayed type hypersensitivity reactions occurred after having unknown material fillers injected by unlicensed practitioners. When injecting an unknown material, there can be a severe immune reaction due to the unknown number of antigens in the material, and therefore may act as a much stronger superantigen than conventional filler materials. It appears that the adverse effects in these cases are more severe and have tendency to break out after a longer period of time in comparison with those caused by approved fillers, likely due to operative technique and use of unverified materials. It is important to recognize the danger of such illegal procedures and to increase awareness of the public, as this has evolved into a significant public health issue.

Location of injected polymethylmethacrylate microspheres influences the onset of late adverse effects: an experimental and histopathologic study

Polymethylmethacrylate (PMMA) has been widely used in the correction of wrinkles because of its long-lasting cosmetic improvements. However, side effects and complications may occur, and its clinical appearance on the oral mucosa can be similar to that of inflammatory or neoplastic disease. The aim of this research was to compare the clinical and histopathologic responses to PMMA injected by two different methods. Twenty-two rats received an injection of PMMA using the tunneling technique (gold standard), with subcutaneous deposition of the filler in the face, or a variation of the technique with transcutaneous submucosal deposition of the filler in the cheek. The tissue reaction was analyzed clinically every 24 hours during the first week, then once a week for the following 3 months. Histologic evaluation was based on the local inflammatory response to the filler. No clinical changes were observed during the initial evaluation period (0-14 days). After 14 days, only the submucosal group showed extra-oral enlargement (n=4, 18.2%). Histopathologic analysis revealed nodule formation in four animals (18.2%) in the submucosal group, with no nodules observed in the subcutaneous group. The data obtained in this study demonstrate that the technique used to deliver the filler may influence the risk of adverse reactions.

Granulomatous foreign-body reactions to permanent fillers: detection of CD123+ plasmacytoid dendritic cells

BACKGROUND

Soft-tissue augmentation with permanent fillers can lead to severe granulomatous foreign-body reactions (GFBRs), but the immune pathomechanism of this complication is still unknown. We performed conventional histologic examination and immunostaining for plasmacytoid dendritic cells (pDCs) in skin sections from patients with GFBR to 4 permanent filler agents, which have been widely used in recent decades.

METHODS

Twenty-one skin biopsies were studied from 19 patients with GFBR to polyalkylimide 4% gel (PAIG, n = 10), polyacrylamide 2.5% gel (PAAG, n = 2), hydroxyethyl methacrylate/ethyl methacrylate in hyaluronic acid (HEMA/EMA, n = 4), or liquid injectable silicone (n = 5). GFBRs were analyzed in hematoxylin and eosin stained sections and pDCs detected using CD123 antibodies. Anti-CD11c immunostaining was performed for comparison.

RESULTS

Grading of the inflammatory infiltrates observed histologically did not correlate with the clinical features of inflammation. Immunostaining for CD123 did not detect pDCs in 8 of 10 polyalkylimide gel, 1 of 2 polyacrylamide gel, and the 5 liquid injectable silicone biopsies. In contrast, all 4 HEMA/EMA biopsies contained collections of pDCs in lymphocytic infiltrates close to filler particles and adjacent sarcoidal granulomas.

CONCLUSIONS

Our data suggest that pDCs contribute to the sarcoidal granulomas associated with injected HEMA/EMA. Recruited pDCs may exert their pro-inflammatory effects by the release of interferon-α at the site of these filler deposits.

Identification and Complications of Cosmetic Fillers: Sonography First

Cosmetic fillers are frequently used these days for enhancing beauty and to treat wrinkles or sagging skin. However, information on the history of injections may be difficult to obtain, and there is a growing number of reports on complications with these agents. In contrast to other imaging techniques, sonography has been successfully used for detecting and identifying common types of cosmetic fillers and has become the first-line imaging modality to deal with these exogenous components.

Minimally invasive options for the brow and upper lid

Eyebrow and upper eyelid aging occurs in all tissue planes, and manifests most commonly in skin quality, tissue volume loss (soft tissue and bone), and tissue descent. All these involutional changes are amenable to less-invasive (nonsurgical) interventions with natural and aesthetically pleasing results. It is critical for aesthetic facial surgeons to familiarize themselves with these procedures because they are in high demand by patients. This article outlines current concepts of nonsurgical management options for brow and upper eyelid aging. The anatomy and age-related changes in these structures are reviewed, and minimally invasive techniques to address these changes are detailed.

Dermal filler complications: a clinicopathologic study with a spectrum of histologic reaction patterns

Although dermal fillers are generally accepted as safe and well-tolerable cosmetic tools, adverse reaction still forms a prognostic problem. The aim of this study was to demonstrate the clinicopathologic patterns of dermal filler complications in our center. A 5-year single-center study that included patients complained from filler complications and referred to the dermatopathology unit in Al-Azhar University for histologic assessment. The study included 38 female patients with an average age of 47 years. The mean onset of complications was 14.6 ± 5.27 months after injection. The injected material included hyaluronic acid (18.4%), silicone (52.6%), bovine collagen (15.8%) and polyacrylamide hydrogel (13.2%). Most lesions were located on the face (55.3%), less commonly on the hands (18.4%), buttocks (21%), and rarely on the vulva (5.3%). The clinical spectrum included indurated plaque (23.7%), nodular lesion (31.6%), inflammatory mass (15.8%), atrophic lesion (10.5%), skin discoloration (13.1%) and ulceration (5.3%). Histologically, granulomatous reaction was the major finding, either a foreign body granuloma (34.2%) or infectious granuloma (13.2%). Other histologic reactions included dermal pseudocysts with chronic inflammation (26.3%), dermal fibrosis (15.8%), and eosinophilic panniculitis (10.5%). Our results confirmed that dermal fillers could be manifested with variable clinical presentations and show different histologic reactions. Because of long-standing duration until complications occur, history taking is crucial and should be emphasized in every suspected patient. It is hoped that this article will increase awareness for recognition of these variable complications and help select the appropriate therapy.

Treatment algorithm of complications after filler injection: based on wound healing process

Soft tissue filler injection has been a very common procedure worldwide since filler injection was first introduced for soft tissue augmentation. Currently, filler is used in various medical fields with satisfactory results, but the number of complications is increasing due to the increased use of filler. The complications after filler injection can occur at any time after the procedure, early and delayed, and they range from minor to severe. In this review, based on our experience and previously published other articles, we suggest a treatment algorithm to help wound healing and tissue regeneration and generate good aesthetic results with early treatment in response to the side effects of filler. Familiarity with the treatment of these rare complications is essential for achieving the best possible outcome.

Complications After Facial Injections With Permanent Fillers: Important Limitations and Considerations of MRI Evaluation

BACKGROUND

Soft-tissue fillers have become more prevalent for facial augmentation in the last 2 decades, even though complications of permanent fillers can be challenging to treat. An investigative imaging tool could aid in assessing the nature and extent of these complications when clinical findings are ambiguous.

OBJECTIVES

The authors analyzed the value of magnetic resonance imaging (MRI) in the assessment of delayed-onset complications after injection of patients with permanent fillers.

METHODS

Thirty-two patients with complications related to facial fillers were evaluated in this prospective cohort study. Their medical history was documented, and MRI was conducted before treatment of the complications. Radiologists were informed of the injection sites but were blinded to the results of other clinical evaluations. Levels of agreement between clinical and radiologic findings were calculated with the Jaccard similarity coefficient.

RESULTS

A total of 107 site-specific clinicoradiologic evaluations were analyzed. The level of agreement was assessed as strong for deposits without complications and noninflammatory nodules (combined 85%), moderate for abscesses (60%), fair for low-grade inflammations (32%), and slight for migrations (9%). Results from the MRI examinations aided in subsequent treatment decisions in 11% of cases.

CONCLUSIONS

Study results show that MRI may be useful for diagnosing complications associated with fillers that have migratory potential, for depiction of the extent of deposits before treatment, and for follow-up of low-grade inflammation and abscesses after surgery.

LEVEL OF EVIDENCE

3.

Complications of injectable fillers, part 2: vascular complications

Accidental intra-arterial filler injection may cause significant tissue injury and necrosis. Hyaluronic acid (HA) fillers, currently the most popular, are the focus of this article, which highlights complications and their symptoms, risk factors, and possible treatment strategies. Although ischemic events do happen and are therefore important to discuss, they seem to be exceptionally rare and represent a small percentage of complications in individual clinical practices. However, the true incidence of this complication is unknown because of underreporting by clinicians. Typical clinical findings include skin blanching, livedo reticularis, slow capillary refill, and dusky blue-red discoloration, followed a few days later by blister formation and finally tissue slough. Mainstays of treatment (apart from avoidance by meticulous technique) are prompt recognition, immediate treatment with hyaluronidase, topical nitropaste under occlusion, oral acetylsalicylic acid (aspirin), warm compresses, and vigorous massage. Secondary lines of treatment may involve intra-arterial hyaluronidase, hyperbaric oxygen therapy, and ancillary vasodilating agents such as prostaglandin E1. Emergency preparedness (a "filler crash cart") is emphasized, since early intervention is likely to significantly reduce morbidity. A clinical summary chart is provided, organized by complication presentation.

Hydrogels for tissue engineering and regenerative medicine

Injectable hydrogels have become an incredibly prolific area of research in the field of tissue engineering and regenerative medicine, because of their high water content, mechanical similarity to natural tissues, and ease of surgical implantation, hydrogels are at the forefront of biomedical scaffold and drug carrier design.