Complications of injectable fillers, part 2: vascular complications

Hyaluronic Acid Filler Emergency Kit

Widespread use of facial filler has led to a rise in reports of associated complications. The aim of this kit is to encompass all needed items to treat the patient and to be organized and prepared to provide correct treatment in urgent situations. A search was performed to gather information on the treatment of complications that occur after injection of soft tissue fillers. The search included reports published in English up to June 2018. We focused on reports of complications arising from emergent/urgent situations following the use of hyaluronic acid injectables; these included filler embolization resulting in impending skin necrosis, blindness or partial loss of vision, and anaphylaxis. We collated treatment of emergent complications from our search of published articles. There were 2 described protocols for filler complications in the literature. One protocol, the “old” protocol, was based on a low dose of hyaluronidase with longer intervals of injections and ancillary treatment. This protocol did not show good results in comparison with the “new” protocol, which was needed to improve these results. The new protocol demonstrated that a high dose of hyaluronidase had better efficacy; this protocol involves hourly injections with no ancillary treatment required except for aspirin. We propose a filler emergency kit (FEK) to deal with complications of hyaluronic acid fillers according to the new protocol to manage the stresses caused by these situations. Every physician needs to be prepared for any potential complication; therefore, there is a need to have a FEK as a crash kit in the clinic to avoid distressing the physician and the patient.

Clinical value of high-resolution (5-17 MHz) echo-color Doppler (ECD) for identifying filling materials and assessment of damage or complications in aesthetic medicine/surgery

PURPOSE

The purpose of this retrospective study is to evaluate the role of echo-color-Doppler (ECD) imaging in identifying a series of characteristics pursuant to aesthetic filling material such as their degree of absorbability and their potential complications which include their propensity to stimulate the formation of encapsulated foreign-body granulomas. In the latter case, ECD can be of aid by giving indication for surgical therapy.

MATERIALS AND METHODS

Over a 4-year period, we studied 180 patients (60 ♂) who underwent an aesthetic medical/surgical treatment. We used ECD to evaluate the implant material, its thickness, the injection site, the integrity of dermal layers and the presence of any associated complications.

RESULTS

In 97% (174/180) of our patients, we were able to identify the type of material used; furthermore, 57% of patients had a hyaluronic acid implant, 14% a lipofilling and 29% a non-absorbable filler (with 10% of silicone). In 6/180 (3%), we could not recognize the material used; 89% (161/180) of our patients presented post-injection complications; moreover, 67% showed peri-implant dermal-hypodermal thickening areas with adjacent lymphostasis, 6% displayed an abnormal implant site, and 17% showed inflammation with encapsulated foreign-body granulomas that required subsequent surgical excision. Biopsy samples were obtained from 37/180 patients (21%); among these, 31 patients had an ECD evidence of granuloma and on 6 patients we were not able to define the injected material. Histopathological examination identified 29 granulomas, 5 sterile abscesses and 3 chronic inflammations in the absence of granuloma. ECD showed an overall 78% diagnostic accuracy, with 90% sensitivity and 37% specificity in detecting filler granulomas.

CONCLUSION

ECD is a low-cost technique that allows to identify filling materials and to assess the complications of an esthetic medical/surgical treatment.

Facial Blanching after Local Anesthesia Injection: Clinico-anatomical Correlation-Review of Literature

Facial blanching as a complication of local anesthesia is reported in dentistry. Inadvertent arterial penetration and subsequent vasospasm has been accepted as the mechanism of this phenomenon. Most cases occur after inferior alveolar nerve block injection. In this article, five cases are reported after Gow-Gates injection, maxillary nerve block via greater palatine foramen, inferior alveolar nerve block, and maxillary buccal infiltration. It is the largest case series in this topic. Also, clinico-anatomical correlation between facial–mucosal blanching and the site of intra-arterial injection is explained. To the best of our knowledge, partial blanching of the face subsequent to buccal infiltration is reported for the first time in this article. Cutaneous surgeon should be aware of this complication and should not carry out unnecessary treatment.

Pathophysiology Study of Filler-Induced Blindness

Background

A number of authors have proposed retrograde arterial embolism as the responsible mechanism for filler-induced blindness. However, no previous human study has substantiated this proposed mechanism.

Objectives

The aim of this study was to investigate the pathophysiology of filler-induced blindness using a fresh cadaver perfusion technique.

Methods

A fresh cadaver head perfusion model that simulates both physiologic blood pressure and flow rate of the carotid artery, ophthalmic artery, and supratrochlear artery was used. The common carotid artery was cannulated and the internal jugular vein exposed for open venous drainage. A plasma-based perfusate was circulated through the cadaver head, which was connected to a perfusion system consisting of a roller pump, preload reservoir, and pressure monitor. The hyaluronic acid filler mixed with methylene blue was injected into the cannulated superficial branch of the supratrochlear artery. Cadaver dissection, angiographic study, and histology were used to investigate filler-induced blindness.

Results

Cannulation of the superficial branch of the supratrochlear artery was successful in all six cadavers. Emboli to the ophthalmic artery was successfully demonstrated in the three out of 6 fresh cadaver heads. The C-arm angiogram documented a cut-off sign in the ophthalmic artery due to hyaluronic acid filler emboli. An average intravascular volume of the intraorbital part of the supratrochlear artery was 50.0 µL. The average depth of location of the superficial branch of the supratrochlear artery from the epidermal surface was 1.5 mm.

Conclusions

Our cadaveric study demonstrated that retrograde hyaluronic acid filler emboli to the ophthalmic artery could be produced by the cannulation of the supratrochlear artery. The superficial location of the supratrochlear artery, the rich vasculature surrounding it, and the variability in the anatomy make this possible.

Complication Management following Rejuvenation Procedures with Hyaluronic Acid Fillers-an Algorithm-based Approach

BACKGROUND

Hyaluronic acid is an ideal facial filler, however, although established as both safe and effective, complications do occur. Treatment recommendations that combine both expert opinions and clinical trial data are currently lacking, partly due to difficulties with diagnoses, nonspecific diagnostic investigations, and certain disorders presenting with similar symptoms, thereby confounding diagnosis and treatment.

METHODS

The purpose of this article was to provide the aesthetic clinician with practical recommendations regarding complication diagnosis arising as a consequence of hyaluronic acid filler rejuvenation treatment. It also provides recommendations for their management using step-wise treatment algorithms that are based on published expert opinions, as well as the author's clinical experience.

RESULTS

Algorithms are provided for the most common categories of complication associated with hyaluronic acid filler treatment, that is, skin discoloration, edema, nodules, infection, and vascular compromise.

CONCLUSIONS

These guidelines are not intended to be complete or exhaustive but may prove informative for aesthetic clinicians who are responsible for treating patients with hyaluronic acid fillers. It may help to guide them on recognizing potential complications and it provides clear guidance on optimum treatment pathways.

Complications of glans penis augmentation

Despite the controversy regarding penile augmentation (PA), glans penis augmentation (GPA) is used in penile reconstructive surgery in selected patients with small glans penis. Since 2003, injectable hyaluronic acid (HA) gel has been used for GPA. The attractiveness of HA gel fillers and interest in this technique have led to the use of other fillers for GPA, particularly irreversible fillers that improve the longevity of HA gels. Conversely, indirect glans augmentation via implantation of dermofat grafts or scaffolds between the corpus spongiosum and the distal tip of the corpus cavernosum is used to overcome poor longevity of the gel and glans surface undulation, which are the primary limitations of GPA using HA gel. Unfortunately, these implants form hard painful lumps over time in most patients and are difficult to remove. Blunt dissection is an invasive procedure that may cause vascular compromise and consequent glans necrosis in a few patients. We present our review regarding the current status of GPA for a more comprehensive understanding of this subject. Additionally, we have discussed a few complicated cases that were referred to us.

The Role of Anastomotic Vessels in Controlling Tissue Viability and Defining Tissue Necrosis with Special Reference to Complications following Injection of Hyaluronic Acid Fillers

BACKGROUND

Most target areas for facial volumization procedures relate to the anatomical location of the facial or ophthalmic artery. Occasionally, inadvertent injection of hyaluronic acid filler into the arterial circulation occurs and, unrecognized, is irreparably associated with disastrous vascular complications. Of note, the site of complications, irrespective of the injection site, is similar, and falls into only five areas of the face, all within the functional angiosome of the facial or ophthalmic artery.

METHODS

Retrospective and prospective studies were performed to assess the site and behavior of anastomotic vessels connecting the angiosomes of the face and their possible involvement in the pathogenesis of tissue necrosis. In vivo studies of pig and rabbit, and archival human total body and prospective selective lead oxide injections of the head and neck, were analyzed. Results were compared with documented patterns of necrosis following inadvertent hyaluronic acid intraarterial or intravenous injection.

RESULTS

Studies showed that the location of true and choke anastomoses connecting the facial artery with neighboring angiosomes predicted the tissue at risk of necrosis following inadvertent intraarterial hyaluronic acid injection.

CONCLUSION

Complications related to hyaluronic acid injections are intimately associated with (1) the anatomical distribution of true and choke anastomoses connecting the facial artery to neighboring ophthalmic and maxillary angiosomes where choke vessels define the boundary of necrosis of an involved artery but true anastomoses allow free passage to a remote site; or possibly (2) retrograde perfusion of hyaluronic acid into avalvular facial veins, especially in the periorbital region, and thereby the ophthalmic vein, cavernous sinus, and brain.

The infraorbital artery: Clinical relevance in esthetic medicine and identification of danger zones of the midface

BACKGROUND

Over the past decade, cosmetic injections of dermal fillers or fat have become a popular procedure in facial rejuvenation in an overconsuming society. However, complications such as arterial embolism and occlusion can occur even with experienced injectors, especially in high-risks zones namely the glabella, the nasal dorsum or the nasolabial fold. The aim of this study was to define the vascular danger zones of the infraorbital area in order to provide guidelines helping avoid them.

MATERIALS AND METHODS

The infraorbital artery, its main branches and their anastomoses with neighbouring vessels were studied in 18 fresh cadavers. Mimetic injections of inked hyaluronic acid were performed in the infraorbital area in the interest of analyzing its distribution and to determine potential vascular risks towards the infraorbital artery and its branches.

RESULTS

The infraorbital artery and its branches were located in common injection regions and anastomosed to the supratrochlear artery, the dorsal nasal artery and the angular artery through the nasal branch of the infraorbital artery. Two danger zones could be depicted: injections can be risky when performed too superficially in the midcheek area, and likewise risky when performed in a periosteal layer in infraorbital hollow or tear-trough correction, because of an obvious possibility of retrograde embolism.

CONCLUSION

The infraorbital artery can be involved in anatomic mechanism of arterial occlusion, further blindness and stroke, among the related neighbouring arteries. Based on the findings of this study, injections to the periosteum layer in tear-trough correction and above the periosteum on the zygomatic arch is not advised.

The Risk of Skin Necrosis Following Hyaluronic Acid Filler Injection in Patients With a History of Cosmetic Rhinoplasty

BACKGROUND

As the number of patients using dermal filler for face augmentation increases, the number of adverse events associated with injection may increase. Unpredictable repositioning of blood vessels and a more tenuous blood supply in the operated nose may increase the risk of ischemia, necrosis, and vascular embolism following the filler injection.

OBJECTIVES

To highlight the importance of the patient's history of previous cosmetic procedures including rhinoplasty in the emergence of vascular complications.

METHODS

Our medical records over a two-year period were reviewed retrospectively to identify all patients who were treated at our center for vascular complications associated with facial hyaluronic acid filler injections. In each case, the subject's demographic data (gender and age), habitual status, past medical and surgical history, the symptoms and clinical presentation at the first visit, the time interval between the injection and the onset of symptoms, injected filler material and brand, injection sites, the introduced treatment, and photographs were reviewed carefully.

RESULTS

A total of seven patients were identified, each developing skin necrosis following injection of the hyaluronic acid filler. All patients reported a cosmetic rhinoplasty more than three years ago.

CONCLUSIONS

Our finding confirms the conjecture previously made in the literature and suggests that the distinctive vascularity of the nose and the surrounding area may cause filler augmentation induced vascular complications in patients whose vascular circulation has already been compromised by a previous nose surgery.

LEVEL OF EVIDENCE 5

Ultrasonography-guided Cannula Method for Hyaluronic Acid Filler Injection with Evaluation using Laser Speckle Flowgraphy

Hyaluronic acid (HA) is present in the connective tissues of the skin and decreases with age. HA fillers are popular as facial rejuvenation treatments. They are generally considered safe; however, complications, such as cutaneous necrosis and blindness due to vascular embolism, sometimes occur. Because vascular embolisms are likely associated with the deep placement of HA fillers, a strategy that involves injection into superficial regions (the conventional method) is commonly used to reduce risks. However, deep injections to achieve revolumization are becoming common, even in high-risk areas for intravascular infusion. We aimed to study the usefulness of the ultrasonography-guided cannula method for preventing intravascular infusion of HA fillers. An HA filler was injected into the region just under the dermis on the left side of the face of a 38-year-old man using the conventional method, and another HA filler was injected into the periosteum on the right side using the ultrasonography-guided cannula method. The skin blood flow on both sides was compared using laser speckle flowgraphy (LSFG). The ultrasonography-guided method was successful in detecting the cannula and the blood vessel, and the HA filler was safely injected into a deep region. Using LSFG, a difference in skin blood flow between the 2 methods was detected. The ultrasonography-guided cannula method was effective in aiding the safe injection of an HA filler in a deep high-risk area and maintained skin blood flow. LSFG may be adopted to evaluate skin blood flow after HA filler injections.

Physiochemical Characteristics of Calcium Hydroxylapatite (CaHA)

The clinical performance of fillers in soft tissue augmentation depends upon their physiochemical properties, anatomical areas injected, interaction with the recipient, and the skill and experience of the physician. Scientific measures of filler properties facilitate appropriate selection of treatments for optimal treatment outcomes, and inform adjustments to treatments that improve patient safety and aesthetic outcomes. The rheological properties of calcium hydroxylapatite (CaHA), elastic modulus (G') and viscosity, coupled with its capacity to offer both immediate results and continued stimulation of collagen type I deposition, support its distinction as an ideal treatment for the volume loss characteristic of aging. Furthermore, the comparatively higher G' of CaHA offers a physiochemical basis for the clinical performance observed by the authors, especially in regions such as the temple and chin, where the force exerted by CaHA against bone permits expansion of overlaying tissue, permitting it to behave as a liquid implant.

Ischemic oculomotor nerve palsy due to hyaluronic acid filler injection

Hyaluronic acid (HA) is the most popular agent today for intradermal injections to improve wrinkles and other cosmetic defects. Ischemic necrosis due to injection of HA is one of the serious complications. Because there are many vascular branches around the nose, caution and care should be given during facial filler injection. Although the incidence is rare, blindness and permanent visual loss may occur. We describe a 29-year-old woman presented with painful erythematous swelling with violaceous patch on right periocular area and glabella after HA filler injection. After injecting the filler, she felt pain and dizziness, and her vision became blurred. She immediately received hyaluronidase around the HA filler inject area and during hospitalized for 10 days, she was successfully treated with systemic steroid, vasodilator, prophylactic antibiotics, and LLLT (low-level laser therapy) without any defects.

Vascular Complications After Chin Augmentation Using Hyaluronic Acid

Vascular complications after hyaluronic acid (HA) filling of the chin have rarely been reported. In this report, two cases of vascular occlusion after HA augmentation of the mentum are presented. The first case involved local skin necrosis that resulted from a massive microcirculatory embolism and/or external compression of the chin skin microvasculature. The second case involved vascular compromise in the tongue that resulted from HA injection in the chin. The diagnosis was established on the basis of interventional angiography findings. Concerning the pathogenesis, we hypothesized that the filler embolus flowed into the branches of the deep lingual artery through the rich vascular anastomoses among the submental, sublingual, and deep lingual arteries, after being accidentally injected into the submental artery (or its branches). 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 .

Semi-interpenetrating network hyaluronic acid microgel delivery systems in micro-flow

Macroscopic hydrogels are commonly used as injectable scaffolds or fillers, however they may easily obstruct blood vessels, which poses risks and limits their clinical use. In the present study, three types of hyaluronic acid (HA)-based hydrogel micro-particles with non-covalent, covalent semi-interpenetrating and conventional 3D molecular networks, have been designed, fabricated and characterized. The micro-particles are spherical, biconcave or irregular in shape and their diameter ranged between 2.5 and 3.5 µm; their suspensions exhibit a tuneable viscosity, shear-thinning behaviour, dynamic stability and dispersity in microfluidic flow as a result of their specific particulate nature, providing thus a well-controlled injectable platform. Hydrogel particle suspensions also demonstrate an enhanced safety profile, in terms of the dispersity, cell safety, and hemocompatibility. In addition, Rhodamine 6G has successfully been loaded and released from the particles as a model for drug delivery. Functionalisation of hydrogel microparticles using synthetic polymers has been proven to be a cost-effective way to achieve desirable rheological properties and flow dynamic stability with improved physicochemical properties and biocompatibility in vitro, showing promise as a multifunctional biomedical material for various advanced surgical devices and therapies.

Successfully Managing Impending Skin Necrosis following Hyaluronic Acid Filler Injection, using High-Dose Pulsed Hyaluronidase

Facial fillers are becoming increasingly popular as aesthetic procedures to temporarily reduce the depth of wrinkles or to contour faces. However, even in the hands of very experienced injectors, there is always a small possibility of vascular complications like intra-arterial injection of filler substance. We present a case report of a patient who developed features of vascular obstruction in right infraorbital artery and tell-tale signs of impending skin necrosis, after hyaluronic acid filler injection by an experienced injector. The diagnosis of a vascular complication was made quickly with the help of clinical features like blanching, livedo reticularis, and poor capillary refill. Patient was treated promptly with “high-dose pulsed hyaluronidase protocol” comprising three 1,000-unit pulses of hyaluronidase, administered hourly. There was no further increase in size of the involved area after the first dose of hyaluronidase. All of the involved area, along with 1 cm overlapping in uninvolved skin area, was injected during each injection pulse, using a combination of cannula and needle. Complete reperfusion and good capillary filling were achieved after completion of 3 pulses, and these were taken as the end-point of high-dose pulsed hyaluronidase treatment. Immediate skin changes after filler injections, as well as after hyaluronidase injections and during the 3-week recovery period, were documented with photographs and clinical notes. Involved skin was found to have been fully recovered from this vascular episode, thus indicating that complete recovery of the ischemic skin changes secondary to possible intra-arterial injection could be achieved using high-dose pulsed hyaluronidase protocol.

Foam sclerotherapy of segments of the saphenous vein with adjuvant hyaluronan compression

Background: Thermal, mechano-chemical and chemical methods of vein closure are increasingly less effective in saphenous veins with diameters above 10 mm. Furthermore, increasing vein size is associated with unpleasant inflammatory reactions, in particular in locations close to sensitive structures like the skin. External compression media are not able to prevent these unwanted sequela in a tolerable way. As a possible solution, perivenous hyaluronan compression was evaluated combined with microfoam sclero-therapy.

Methods: 34 patients (25 f, 9 m, 43–71 yr/o) with saphenous insufficiency (GSV), dia -meters 10.1–23.1 mm (M: 14.1 mm), distance to skin: >10 mm, received a vein lumen compression oft thigh- or calf segments by perivenous injection of a NASHA gel mediated by a coaxial paravenous catheter prior to catheter-applied microfoam sclerotherapy (aethoxysklerol 1 %). Injection of both, hyaluronan and microfoam, were performed during catheter withdrawal. The aim of hyaluronan compression was a 2/3 reduction oft the native vein cross section. For comparison, adjacent segments were compressed with common tumescent fluid. Segments for both modalities had similar diameter and were randomized. Due to department rules, the junction segment was closed with endovenous lasers to warrant elimination of reflux. No textile compression media were applied. Clinical controls including ultrasound were performed after 2, 8, 26 and 54 weeks.

Results: All treated vein segments showed total occlusion after 2 weeks (first visit). The lumen reduction was 54–81 % (M: 68.4 %) in segments with hyaluronan compression and 8–29 % (M: 19.2 %) in segments with tumes-cent fluid. Time needed for hyaluronan compression was 1.1–3.5 min (M: 2.2 min) and for tumescence 0.8–2.7 min (M: 1.8 min) per 10 cm-segment. Clinical investigations up to 8 weeks did not reveal any symptoms, visible inflammations or stainings in segments covered with hyaluronan, while tumescent-compressed segments had such findings in 20/34 cases (58.8 %). Perivenous hyaluronan did not induce any discomfort or side effects during follow-up.

Conclusions: Even large saphenous veins can be effectively and safely treated by microfoam sclerotherapy without any postinterventional symptoms when the vein lumen is reduced by perivenous injection of hyaluronan gel. However, it takes additional interventional effort to achieve this goal. Future applications could also include combinations with thermal or gluing device or support novel foams like Varithena or biomatrix sclerofoam when treating very large veins or venous aneurysms, and furthermore serve in vein shaping fort the purpose of establishing laminar flow or modifying pressure relations (venoplasty).

Adverse Drug Reactions

Adverse events and adverse drug reactions are common in clinical practice. Side effects range from the common to the rare and may be confused with other mucocutaneous manifestations resulting from several medications to treat infections, other medical conditions, and in the clinical setting of oncologic treatment. The objective of this chapter to review current data on adverse drug reactions, here classified as (i) severe adverse drug reactions, (ii) uncomplicated cutaneous adverse drug reactions, and (iii) adverse drug reactions caused by chemotherapy drugs, particularly those cases whereby the dermatologist is requested to issue a report and asked to comment on the safety and viability of readministration of a specific drug. We describe aspects associated with these events, presenting a detailed analysis of each of them.

Dermal filler-associated malar edema: Treatment of a persistent adverse effect

A 72-year-old Caucasian female presented for evaluation of bilateral lower eyelid "fluid filled" bags that had been present and slowly worsening for 7 years. She reported a history of lower eyelid blepharoplasty in her 40s, as well as hyaluronic acid tear trough fillers 8 years prior to presentation. Her malar edema completely resolved following injection of hyaluronidase. To our knowledge, this is the longest reported interval for presentation and treatment of hyaluronic acid associated malar edema.

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 .

New High Dose Pulsed Hyaluronidase Protocol for Hyaluronic Acid Filler Vascular Adverse Events

The purpose of this article is to update the changes to the author's protocols used to manage acute filler related vascular events from those previously published in this journal. For lack of a better term, this new protocol has been called the High Dose Pulsed Hyaluronidase (HDPH) protocol for vascular embolic events with hyaluronic acid (HA) fillers. The initial protocol used involved many different modalities of treatment. The current protocol is exceedingly simple and involves solely the use of hyaluronidase in repeated high doses. Despite the simplicity of the treatment, it has proven itself to be very successful over the past two years of clinical use. There has been no partial or complete skin loss associated with this protocol since its implementation if the protocol was implemented within 2 days of the ischemic event onset. The protocol involves diagnosis and repeated administration of relatively high doses hyaluronidase (HYAL) into the ischemic tissue repeated hourly until resolution (as detected clinically through capillary refill, skin color, and absence of pain). The dosage of HYAL varies as the amount of ischemic tissue, consistent with the new underlying hypothesis that we must flood the occluded vessels with a sufficient concentration of HYAL for a sufficient period of time in order to dissolve the HA obstruction to the point where the products of hydrolysis can pass through the capillary beds. Although vascular embolic events are rare, it is important to note that the face has higher risk and lower risk areas for filler treatment, but there are no "zero risk" areas with respect to filler treatments. Even with good anatomic knowledge and correct technique, there is still some nonzero risk of vascular embolic events (including highly skilled, experienced injectors). However, with careful low pressure, low volume injection technique, and adequate preparation for treatment of acute vascular events, the risk is quite manageable and the vast majority of adverse events are very treatable with an excellent prognosis, with a few exceptions. This new protocol offers excellent results, but requires further research to determine optimal parameters for various HA fillers.

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.

Ocular Complications Following Autologous Fat Injections into Facial Area: Case Report of a Recovery from Visual Loss After Ophthalmic Artery Occlusion and a Review of the Literature

With the increase in popularity of the use of cosmetic fillers in plastic and esthetic surgery, the possibility of severe ocular complications should not be neglected. Of the fillers used, autologous fat is the most common to cause permanent visual deterioration, one of the most severe complications associated with the use of cosmetic fillers. Here we present the first report of a complete recovery of visual acuity from an instance of visual loss with no light perception caused by ophthalmic artery occlusion of the right eye following autologous fat injection in the facial area. Immediate ophthalmological intervention and comprehensive therapy with prostaglandins and vinpocetine made it possible to restore retinal perfusion and achieve complete recovery of visual acuity. Awareness of the iatrogenic artery occlusions associated with facial fillers and the need for immediate treatment should be popularized among injectors to prevent devastating consequences, such as permanent vision loss.

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.

Filler Rhinoplasty Evaluated by Anthropometric Analysis

BACKGROUND

There are no reports of objectively evaluating the efficacy of filler rhinoplasty by anthropometric techniques.

OBJECTIVE

To objectively demonstrate the effectiveness of filler rhinoplasty by anthropometric analysis.

MATERIALS AND METHODS

A total of 242 patients who revisited the clinic within 2 months of undergoing hyaluronic acid filler rhinoplasty were analyzed based on the injection site, injected volume, and the change in anthropometry.

RESULTS

Among the 242 patients, 112 (46.3%) were in the nasal dorsum augmentation group, 8 (3.3%) were in the tip rotation group, and 122 (50.4%) were in the whole nose augmentation group. Average injection volume was 1 ± 0.4 mL for nasal dorsum and 0.9 ± 0.3 mL for tip rotation, whereas 1.6 ± 0.5 mL was used for whole nose augmentation. On follow-up, the radix height, nasofrontal angle, and nasolabial angle (NLA) had increased by 78.3%, 5.7 ± 4.1°, and 9.4 ± 4.5°, respectively, whereas the modified nasofacial angle had decreased by 1.9 ± 2.9°. Three cases (1.2%) of vascular complications were encountered.

CONCLUSION

Filler rhinoplasty is a simple and effective treatment modality producing outcomes comparable with surgical augmentation rhinoplasty. Among various anthropometric measurements, the nasal radix height was the most useful for evaluating dorsum augmentation, whereas the NLA was the best for nasal tip rotation.

Novel Anatomic Description of the Course of the Inferior Palpebral Vein for Minimally Invasive Aesthetic Treatments

BACKGROUND

The inferior palpebral vein (IPV) receives tributaries from the inferior palpebral part of the orbicularis oculi muscle (OOc). The aim of this study was to elucidate the venous distribution pattern of the IPV for dermal filler injection.

MATERIAL AND METHODS

Fifty hemifaces from 34 cadavers were used in this study. The various distribution patterns of the IPV were classified according to its relationship with the angular vein (AV) and facial veins.

RESULTS

The IPV can be classified into the following 4 types: Type I (58.0%), in which the origin of the IPV is located beneath the lateral part of the OOc; Type II (12.0%), in which the origin of the IPV is located beneath the inferior part of the OOc; Type III (8.0%), in which the origin of the IPV is located beneath both the lateral and inferior parts of the OOc; and Type IV (22.0%), in which the IPV is undeveloped.

CONCLUSION

The course of the IPV can be approximated by connecting the lateral orbital rim to the C point (the meeting point between the IPV and the AV). The lateral rim can be palpated and the location of the C point is suggested as a columnar area inferior to the pupil.

Literature Review of Cosmetic Procedures in Men: Approaches and Techniques are Gender Specific

The proportion of men receiving non-surgical cosmetic procedures has risen substantially in recent years. Various physiologic, anatomic, and motivational considerations differentiate the treatments for male and female patients. Nevertheless, research regarding approaches to the male cosmetic patient is scarce. We sought to provide an overview and sex-specific discussion of the most popular cosmetic dermatologic procedures pursued by men by conducting a comprehensive literature review pertaining to non-surgical cosmetic procedures in male patients. The most common and rapidly expanding non-surgical interventions in men include botulinum toxin, filler injection, chemical peels, microdermabrasion, laser resurfacing, laser hair removal, hair transplantation, and minimally invasive techniques for adipose tissue reduction. Important sex-specific factors associated with each of these procedures should be considered to best serve the male cosmetic patient.

An Anatomical Analysis of the Supratrochlear Artery: Considerations in Facial Filler Injections and Preventing Vision Loss

BACKGROUND

Embolia cutis medicamentosa (ECM) is a rare phenomenon attributed to intra-arterial drug injection. Glabellar filler injections can result in potentially devastating visual loss from inadvertent retrograde arteriolar embolization due to the extensive vasculature within the upper face. The minimum amount of filler necessary to potentiate this complication has not yet been reported.

OBJECTIVES

We aim to determine the volume of filler necessary to occupy the supratrochlear artery from the glabella to the bifurcation of the ophthalmic and central retinal arteries. We specifically examine the volume of the supratrochlear artery from the glabella to orbital apex.

METHODS

The study was approved by Duke University Institutional Review Board and involved surgical dissection of six fresh tissue cadaver heads (12 hemifaces). The arterial system in each cadaver head was injected with latex for visualization. The supratrochlear arteries were isolated anteriorly from the glabella to the orbital apex posteriorly. Intra-orbital vessel radius and length were measured. The vessel volume was calculated by water displacement of the intra-arterial latex.

RESULTS

The vessel volumes ranged from 0.04 to 0.12 mL. The average vessel volume was calculated as 0.085 mL, the average length as 51.75 mm, and the average radius as 0.72 mm.

CONCLUSIONS

Vascular occlusion from filler injections can lead to devastating visual consequences due to inadvertent retrograde intra-arterial embolization. Our findings indicate that the average entire volume of the supratrochlear artery from the glabella to the orbital apex is 0.085 mL. Injectors should be aware that a bolus of this critical volume may lead to a significant adverse outcome.

Nasal Reshaping with Hyaluronic Acid: An Alternative or Complement to Surgery

BACKGROUND

Rhinoplasty has traditionally been preferred for correction of nasal defects. Long-term clinical experience with hyaluronic acid (HA) injection as an alternative or complement to rhinoplasty is presented.

METHODS

A retrospective review of the author's clinical experience with HA gel for nasal reshaping from 1997 to 2012 was conducted, with treatments performed during 1998, 2005, and 2012 selected for detailed review.

RESULTS

More than 250 patients were treated for nasal reshaping with HA since 1997. In addition to being a complement to surgery, HA injection successfully addressed nasal defects that would have been difficult to correct surgically. The effect persisted for >1 year in most patients (>5 y in some patients), with individual variations. No serious complications occurred. When comparing the 3 years reviewed in detail, new indications for nasal reshaping with HA gel became evident over time, which was also reflected by the increase in number of patients treated (1998: n = 2; 2005: n = 22; 2012: n = 51). Of these patients, 55 (73%) received HA injection instead of rhinoplasty, 20 (27%) received HA injection after rhinoplasty, and 5 (7%) underwent rhinoplasty after HA injection. The mean injection volume was 0.4 mL HA gel/treatment. All patients were satisfied with the primary outcome of treatment. Retreatment was performed in 32 patients (43%).

CONCLUSIONS

Injection of HA gel is a valuable tool for nasal reshaping. It can also be used for correction of minor postrhinoplasty defects in appropriate patients.

Engorgement of the Angular and Temporal Veins Following Periorbital Hyaluronic Acid Gel Injection

PURPOSE

To study angular and temporal vein engorgement following periorbital hyaluronic acid gel (HAG) injection.

METHODS

In this retrospective study, the authors reviewed the photographs of 805 patients who had periorbital HAG injection at Jules Stein Eye Institute Oculoplastic Clinic between January 2004 and January 2014. HAG injections were used to fill the orbital hollow, zygomatic hollow, septal confluence hollow, and cheek. The inclusion criteria were patients who had at least 1 pre-, immediate post-, and late postinjection photographs. Immediate postinjection photographs were taken right after HAG injection, and late postinjection photographs were taken at the following visit before any injection. The exclusion criteria were patients with any previous ocular surgery 6 months before filler injection, patients with orbital diseases, and patients who had HAG injections for functional purposes. The photographs were evaluated for the presence of angular and temporal vein engorgement at any of the injections during the follow-up visits. The photographs of eyes with vein engorgement were graded on a scale of 0 (no engorgement), 1 (mild engorgement), 2 (moderate engorgement), and 3 (severe engorgement).

RESULTS

There were 78 eligible patients (156 orbits; 68 females and 10 males) with average age of 59.4 ± 13.4 years. The authors found 18 orbits of 12 patients (15.4%; 6 unilateral and 6 bilateral) with angular vein engorgement at least 1 time after HAG injection during the follow-up visits. The frequency of temporal vein engorgement was 9.1%. The mean ± SD of angular vein grading for engorgement increased from 0.72 ± 0.51 on preinjection photographs to 1.45 ± 0.88 on immediate postinjection photographs (p = 0.0001) and 0.89 ± 0.50 on late postinjection photographs (p = 0.04). The mean ± SD of angular vein grading for engorgement was 0.67 ± 0.55 on the first preinjection photographs, which increased to 1.10 ± 0.50 on the last late postinjection photographs. The difference was statistically significant (p = 0.001).

CONCLUSIONS

Angular and temporal vein engorgement occurred following HAG injection in the periorbital region. The engorgement occurred immediately after injections and decreased considerably but not completely in the following visit.

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.

Efficacy and Safety of a Hyaluronic Acid Filler to Correct Aesthetically Detracting or Deficient Features of the Asian Nose: A Prospective, Open-Label, Long-Term Study

BACKGROUND

There is increasing interest among patients and plastic surgeons for alternatives to rhinoplasty, a common surgical procedure performed in Asia.

OBJECTIVES

To evaluate the safety, efficacy, and longevity of a hyaluronic acid filler in the correction of aesthetically detracting or deficient features of the Asian nose.

METHODS

Twenty-nine carefully screened Asian patients had their noses corrected with the study filler (Juvéderm VOLUMA [Allergan plc, Dublin, Ireland] with lidocaine injectable gel), reflecting individualized treatment goals and utilizing a standardized injection procedure, and were followed for over 12 months.

RESULTS

A clinically meaningful correction (≥1 grade improvement on the Assessment of Aesthetic Improvement Scale) was achieved in 27 (93.1%) patients at the first follow-up visit. This was maintained in 28 (96.6%) patients at the final visit, based on the independent assessments of a central non-injecting physician and the patients. At this final visit, 23 (79.3%) patients were satisfied or very satisfied with the study filler and 25 (86.2%) would recommend it to others. In this small series of patients, there were no serious adverse events (AEs), with all treatment-related AEs being mild to moderate, transient injection site reactions, unrelated to the study filler.

CONCLUSIONS

Using specific eligibility criteria, individualized treatment goals, and a standardized injection procedure, the study filler corrected aesthetically detracting or deficient features of the Asian nose, with the therapeutic effects lasting for over 12 months, consistent with a high degree of patient satisfaction. This study supports the safety and efficacy of this HA filler for specific nose augmentation procedures in selected Asian patients. LEVEL OF EVIDENCE 3: Therapeutic.

Retinal Branch Artery Embolization Following Hyaluronic Acid Injection: A Case Report

Injection of hyaluronic acid (HA) filler is a common aesthetic procedure. Impairment of vision, although rare, is a devastating complication of this procedure, which may not be reversible. We report on a patient who experienced visual acuity impairment and ischemic oculomotor nerve palsy after injection of HA into the nasal dorsum. In this case, clinical signs improved within 14 days of treatment. We also provide a review of the mechanism, clinical features, risk factors, and prevention and treatment strategies relating to embolization of ocular circulation after injection of HA. Vision loss is a rare but devastating complication of injection of hyaluronic acid (HA) in the face. Visual acuity seldom recovers completely. We report on a 22-year-old Asian woman who experienced obstruction of a branch of the retinal artery after injection of HA to augment her nose. The patient's visual acuity declined shortly after the procedure, and ophthalmoplegia occurred. Combination treatment was administered to restore the perfusion and oxygen supply to the retina and optic nerve. Within 14 days of rigorous treatment, the patient experienced improvement in visual acuity, extraocular movement, and visual field defects. LEVEL OF EVIDENCE 5: Risk.