Use of Minimal Amounts of Hyaluronidase in the Ultrasound-Guided Treatment of Acute Vascular Occlusion by Hyaluronic Acid: A Preliminary Report

Background

Complications from hyaluronic acid (HA) fillers are increasingly frequent, given the very high number of treatments performed every day worldwide. They are routinely treated with high doses of hyaluronidase, which can cause significant local and general unwanted effects.

Objectives

The aim of our work is to demonstrate that when the origin of the complication is precisely identified and treated under ultrasound guidance, a few hyaluronidase units are enough to treat it effectively.

Methods

Five young female patients came to our observation for vascular lesions from injection of HA fillers performed in the immediately preceding days, in 4 cases, and a few weeks earlier in the fifth case. All lesions were accurately identified by ultrasound and treated with hyaluronidase.

Results

The 4 promptly treated patients fully recovered with a hyaluronidase dose of 87 ± 44 IU (range, 30-150 IU). The fifth patient, treated later, markedly improved regarding clinical picture and symptoms. No early or late side effects have been reported from this hyaluronidase dosage.

Conclusions

Our data confirm that if the lesion at the origin of the skin damage is precisely localized with ultrasound examination and treated under ultrasound guidance, a few units of hyaluronidase, injected directly into the HA accumulation, effectively resolve the skin damage. At the doses we used, which were much lower than those usually recommended, hyaluronidase proved to be not only effective but also free of any side effects.

Level of Evidence 5

Early ultrasound for diagnosis and treatment of vascular adverse events with hyaluronic acid fillers

BACKGROUND

Hyaluronic acid fillers are known for a reliable safety profile, but complications do occur, even serious vascular adverse events.

OBJECTIVE

To improve the treatment outcome after a vascular adverse event with use of hyaluronic acid filler treatments.

METHODS

Duplex ultrasonography is used to detect the hyaluronic acid filler causing the intra-arterial obstruction.

RESULTS

If treated in time, 1 single treatment of ultrasonographically guided injections of hyaluronidase into the filler deposit will prevent skin necrosis.

CONCLUSION

Because the use of duplex ultrasonography adds extra essential information, its use may become an integral part of the prevention and treatment of injection adverse events.

Risk of Recall Among Medical Devices Undergoing US Food and Drug Administration 510(k) Clearance and Premarket Approval, 2008-2017

IMPORTANCE

The US Food and Drug Administration (FDA) uses 510(k) clearance and premarket approval (PMA) pathways to ensure device safety before marketing. Premarket approval evaluates high-risk medical devices and requires clinical trials, whereas 510(k) clearance evaluates moderate-risk devices and relies on benchtop (nonclinical and biomechanical) and descriptive data. Existing literature suggests that the clinical trials required by PMA are associated with reduced risk of recall compared with devices granted 510(k) clearance. Several investigators have found weaknesses in pivotal PMA trials, raising safety concerns. Furthermore, methodological factors may have led to a previous underestimation of recall risk for devices with PMA.

OBJECTIVES

To compare risk of recall and high-risk recall between devices that received 510(k) clearance and those that received PMA and to compare the risk of recall between devices for medical specialties.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study compared devices with 510(k) clearance vs those with PMA that reached the market between January 1, 2008, and December 31, 2017. Two- to 12-year follow-up was obtained from the FDA's 510(k) and PMA medical device database. Orthopedic surgery was chosen arbitrarily as the reference category for analysis between specialties because no baseline exists. Statistical analysis was performed from February 1 to November 1, 2020.

MAIN OUTCOMES AND MEASURES

The FDA issues recalls for safety concerns. These recalls are stratified into class I, II, and III, with class I representing high-risk issues for serious harm or death. The main outcome was the hazard ratio of any recall and class I recall between devices with PMA and those with 510(k) clearance. The secondary outcome was the recall hazard ratio between specialties with respect to the reference category. A single Cox proportional hazards regression model evaluating the association of medical specialty and FDA approval pathway with the risk of recall was performed.

RESULTS

During the study period, 28 246 devices received 510(k) clearance and 310 devices (10.7%) received PMA; 3012 devices (10.7%) with 510(k) clearance and 84 devices (27.1%) with PMA were recalled. A total of 216 devices (0.8%) with 510(k) clearance and 16 devices (5.2%) with PMA had class I recalls. Devices with PMA compared with those with 510(k) clearance had a hazard ratio for recall of 2.74 (95% CI, 2.19-3.44; P < .001) and a hazard ratio for high-risk recall of 7.30 (95% CI, 4.39-12.13; P < .001). Only radiologic devices were associated with an increased risk of recall (hazard ratio, 1.57; 95% CI, 1.32-1.87; P < .001), whereas 6 specialties were assocated with a decreased risk compared with the orthopedic reference category: general and plastic surgery, otolaryngology, obstetrics and gynecology, physical medicine, hematology, and general hospital.

CONCLUSIONS AND RELEVANCE

This study suggests that high-risk medical devices approved via PMA are associated with a greater risk of recall than previously reported. Most recalls are for devices with 510(k) clearance, also raising safety concerns. Strengthening postmarketing surveillance strategies and pivotal trials may improve device safety.

Ultrasound to Improve the Safety and Efficacy of Lipofilling of the Temples

BACKGROUND

Autologous fat is known for a reliable and natural safety profile, but complications do occur-even serious vascular adverse events.

OBJECTIVES

The authors sought to examine doppler-ultrasound (DUS) imaging for the harvesting and subsequent facial implantation of autologous fat tissue.

METHODS

All patients underwent lipofilling treatment of the temporal fosse of the face. DUS examination was performed for preprocedural vascular mapping and imaging of previously injected (permanent) fillers. In addition, the injection of autologous fat was performed DUS-guided.

RESULTS

Twenty patients (all female; mean age, 57.9 years; range, 35-64 years). DUS examination showed that 16 of the 20 patients (80%) had been injected with resorbable or nonresorbable fillers elsewhere in the past. The temporal artery could be visualized and avoided in all cases. An average of 1.1 cc of autologous fat was injected in the temporal fossa per side. One case of edema and nodules was described, but no other adverse events were reported.

CONCLUSIONS

The utilization of DUS can add valuable information to a lipofilling procedure and should be considered an integral part of a safe lipofilling treatment.

LEVEL OF EVIDENCE: 4

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.

Transparency and Dermatologic Device Approval by the US Food and Drug Administration

Importance

The US Food and Drug Administration approves Class III medical devices via the premarket approval pathway, often requiring clinical data on safety and efficacy. Manufacturers can submit incremental device changes via supplemental applications, which are not subjected to such vetting measures and can cause understudied changes that lead to drift from a device's original design.

Objectives

To characterize the postapproval changes to Class III dermatologic devices and to evaluate inconsistencies in the use of the premarket approval pathway.

Design, Setting, and Participants

This study was a cross-sectional retrospective cohort analysis of a public US Food and Drug Administration database for premarket approval of devices. Included were dermatologic devices approved by the US Food and Drug Administration between January 1, 1980, and November 1, 2016, through the premarket pathway for device approval.

Main Outcomes and Measures

Original devices were identified, and their supplements were characterized chronologically, by review track, and by modification category.

Results

The 27 dermatologic devices studied consisted of 14 injectables, 11 photodynamic therapies, a dermal replacement matrix, and a diagnostic imaging instrument. Supplemental applications are increasingly used: the data-requiring panel-track pathway was the least common approach (2.8% [16 of 562 supplements]), while the 30-day track, which does not require clinical data, was most frequently used (42.5% [239 of 562 supplements]). Four devices (14.8%) underwent low-risk recalls (Class II or Class III), and 10 devices (37.0%) were voluntarily withdrawn.

Conclusions and Relevance

As manufacturers make increasing use of supplemental applications, minor device changes may occur without supporting clinical data, which could pose a safety risk to patients.