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Xiao H, Kou W, Yang Y, Dai E, Zhang X, Wen Y, Peng J, Fei P, Zhao P. Administration Method and Potential Efficacy of Hyaluronidase for Hyaluronic Acid Filler-Related Vision Loss: A Systematic Review. Aesthetic Plast Surg 2024; 48:709-718. [PMID: 36574028 DOI: 10.1007/s00266-022-03215-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 11/19/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND With the global increase in the use of injectable fillers, more cases with serious adverse events such vision loss are being reported. This article aims to review the cases of hyaluronic acid (HA) filler-related vision loss and to discuss the potential efficacy of hyaluronidase (HYASE) treatment via different given methods. METHODS A total of 29 articles presenting 144 cases of HA filler-related vision loss were included in this study. RESULTS Most cases of HA filler-related vision impairment were reported from China, followed by Korea. The majority of cases were seen in women. The nose, forehead and glabella were the most commonly injection sites. All cases had vision impairment and nearly all cases were unilateral with immediate onset of visual signs and symptoms. Ophthalmic artery occlusion (OAO) and central retinal artery occlusion (CRAO) were the two most commonly involved arterial obstruction patterns featured with a very poor prognosis followed by branch retinal artery occlusion (BRAO), the most favorable involved arterial pattern for a better prognosis. HYASE given subcutaneously and intra-arterially helped with visual recovery to different degrees, while retrobulbar HYASE seemed to be less helpful. CONCLUSION Complications after HA-based filler injection are extremely rare but can cause disastrous visual impairment. HYASE given subcutaneously and intra-arterially helped with visual recovery to different extents, and the efficacy might be reinforced when performed together, while retrobulbar HYASE seemed to be less helpful. However, to accurately access the efficacy of HYASE via different administration methods, further randomized controlled trials are needed. LEVEL OF EVIDENCE III 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 .
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Affiliation(s)
- Haodong Xiao
- Department of Ophthalmology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Floor 11, Building 19, 1665 Kongjiang Rd., Shanghai, 200092, China
| | - Wei Kou
- Ruijin Hospital Affiliated Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yuan Yang
- Department of Ophthalmology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Floor 11, Building 19, 1665 Kongjiang Rd., Shanghai, 200092, China
| | - Erkuan Dai
- Department of Ophthalmology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Floor 11, Building 19, 1665 Kongjiang Rd., Shanghai, 200092, China
| | - Xuerui Zhang
- Department of Ophthalmology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Floor 11, Building 19, 1665 Kongjiang Rd., Shanghai, 200092, China
| | - Yanjun Wen
- Department of Ophthalmology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Floor 11, Building 19, 1665 Kongjiang Rd., Shanghai, 200092, China
| | - Jie Peng
- Department of Ophthalmology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Floor 11, Building 19, 1665 Kongjiang Rd., Shanghai, 200092, China
| | - Ping Fei
- Department of Ophthalmology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Floor 11, Building 19, 1665 Kongjiang Rd., Shanghai, 200092, China.
| | - Peiquan Zhao
- Department of Ophthalmology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Floor 11, Building 19, 1665 Kongjiang Rd., Shanghai, 200092, China.
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Gonchar IV, Alfertshofer M, Nikolis A, Hong WJ, Biesman B, Cotofana S. Is constant needle motion during soft tissue filler injections a safer procedure? A theoretical mathematical model for evaluating patient safety. J Cosmet Dermatol 2023; 22:2964-2970. [PMID: 37712576 DOI: 10.1111/jocd.15998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 09/04/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND The safety rationale behind the constant needle motion injection technique is based on the assumption that due to the constant needle motion and simultaneous soft tissue filler material administration a smaller amount of product per area may be injected into an artery if an artery within the range of the moving needle is inadvertently entered. OBJECTIVE To perform mathematical calculations for determining the probability for causing intra-arterial product administration when constantly moving the needle during facial aesthetic soft tissue filler injections. METHODS This study was designed as a theoretical investigation into the probabilities for causing adverse events due to intravascular injection of soft tissue filler material when constantly moving a 27-G needle during facial soft tissue filler administration. RESULTS It was revealed that with a higher number of conducted injection passes a greater soft tissue area can be covered by the needle. The odds of encountering an artery within the covered soft tissue volume and the odds of injecting any volume greater than zero into the arterial blood stream increases with the number of performed injection passes. This increase is greatest between 1 and 10 performed injection passes. CONCLUSION This model demonstrates that the constant needle motion technique increases the probability of encountering an artery within the treatment area and thus increases the odds for intra-arterial product administration. The constant needle motion technique does not increase safety but rather may increase the odds of causing intra-arterial product administration with the respective adverse consequences for the patient.
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Affiliation(s)
- Ivan V Gonchar
- Department of Discrete Mathematics, Moscow Institute of Physics and Technology, Moscow, Russia
| | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Andreas Nikolis
- Clinical Research Unit, Erevna Innovations Inc, Montreal, Quebec, Canada
- Division of Plastic Surgery, McGill University, Montreal, Quebec, Canada
| | - Wei-Jin Hong
- Department of Plastic and Reconstructive Surgery, Guangdong Second Provincial General Hospital, Guangzhou, China
| | | | - Sebastian Cotofana
- Department of Dermatology, Erasmus Hospital, Rotterdam, The Netherlands
- Centre for Cutaneous Research, Blizard Institute, Queen Mary University of London, London, UK
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Mannino M, Lupi E, Bernardi S, Becelli R, Giovannetti F. Vascular complications with necrotic lesions following filler injections: Literature systematic review. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2023:101499. [PMID: 37178872 DOI: 10.1016/j.jormas.2023.101499] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/11/2023] [Accepted: 05/10/2023] [Indexed: 05/15/2023]
Abstract
INTRODUCTION Although the related risk of vascular necrosis due to filler injection is low, the outcomes can be severe when they occur. This systematic review aims to report the occurrence and treatment of vascular necrosis due to filler injection. MATERIALS AND METHODS The systematic review was performed according to PRISMA guidelines. RESULTS The results showed the most used treatment is a combination of pharmacologic therapy and hyaluronidase application, which is efficacy when applied in the first 4 h. In addition, even though management recommendations are available in literature, proper guidelines are unavailable due to the low number of complications occurrence. CONCLUSION Clinical and high-quality studies on treatment and management of filler injection combination are necessary to provide scientific evidence on what to do in case of vascular complication occurrence.
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Affiliation(s)
- Mario Mannino
- Maxillofacial Unit, University "La Sapienza", Rome, 00185, Italy
| | - Ettore Lupi
- Maxillofacial Unit, Ospedale "S. Salvatore", L'Aquila, 67100, Italy; Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, 67100, L'Aquila, Italy
| | - Sara Bernardi
- Department of Life, Health and Environmental Sciences, University of L'Aquila, 67100, L'Aquila, Italy.
| | - Roberto Becelli
- Maxillofacial Unit, University "La Sapienza", Rome, 00185, Italy
| | - Filippo Giovannetti
- Maxillofacial Unit, Ospedale "S. Salvatore", L'Aquila, 67100, Italy; Department of Life, Health and Environmental Sciences, University of L'Aquila, 67100, L'Aquila, Italy
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Buckley C, Montgomery TR, Szank T, Murray BA, Quigley C, Major I. Modification of hyaluronic acid to enable click chemistry photo-crosslinking of hydrogels with tailorable degradation profiles. Int J Biol Macromol 2023; 240:124459. [PMID: 37072064 DOI: 10.1016/j.ijbiomac.2023.124459] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/16/2023] [Accepted: 04/11/2023] [Indexed: 04/20/2023]
Abstract
Hyaluronic acid (HA) is a naturally occurring mucopolysaccharide that, due to its inherent bioactivity and extracellular matrix-like structure, has the potential to be utilised extensively in tissue engineering. However, this glycosaminoglycan lacks the properties required for cellular adhesion and photo-crosslinking by UV light, which significantly hinders this polymers applicability. This research presents a method for modifying hyaluronic acid via thiolation and methacrylation to generate a novel photo-crosslinkable polymer with improved physicochemical properties, biocompatibility and the potential to customize biodegradability according to the ratio of monomers used. A decrease in stiffness proportional to increasing thiol concentration was observed when testing the compressive strength of hydrogels. Conversely, it was noted that the storage moduli of hydrogels increased proportionally to thiol concentration indicating a greater degree of cross-linking with the addition of thiol. The addition of thiol to HA increased the biocompatibility of the material in both neuronal and glial cell lines and improved the degradability of methacrylated HA. Due to the enhanced physicochemical properties and biocompatibility imparted by the introduction of thiolated HA, this novel hydrogel system could have numerous bioengineering applications.
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Affiliation(s)
- Ciara Buckley
- PRISM Research Institute, Technological University of the Shannon, Athlone N37 HD68, Ireland
| | - Therese R Montgomery
- School of Science and Computing, Atlantic Technological University, Galway H91 T8NW, Ireland
| | - Tomasz Szank
- Biosciences Research Institute, Technological University of the Shannon, Athlone N37 HD68, Ireland
| | - Brian A Murray
- Department of Science, Technological University Dublin- Tallaght Campus, Dublin D24 FKT9, Ireland
| | - Cormac Quigley
- School of Science and Computing, Atlantic Technological University, Galway H91 T8NW, Ireland
| | - Ian Major
- PRISM Research Institute, Technological University of the Shannon, Athlone N37 HD68, Ireland.
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Sanches SCDC, Ré MI, Silva-Júnior JOC, Ribeiro-Costa RM. Organogel of Acai Oil in Cosmetics: Microstructure, Stability, Rheology and Mechanical Properties. Gels 2023; 9:gels9020150. [PMID: 36826320 PMCID: PMC9956281 DOI: 10.3390/gels9020150] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/07/2022] [Accepted: 12/11/2022] [Indexed: 02/16/2023] Open
Abstract
Organogel (OG) is a semi-solid material composed of gelling molecules organized in the presence of an appropriate organic solvent, through physical or chemical interactions, in a continuous net. This investigation aimed at preparing and characterizing an organogel from acai oil with hyaluronic acid (HA) structured by 12-hydroxystearic acid (12-HSA), aiming at topical anti-aging application. Organogels containing or not containing HA were analyzed by Fourier-transform Infrared Spectroscopy, polarized light optical microscopy, thermal analysis, texture analysis, rheology, HA quantification and oxidative stability. The organogel containing hyaluronic acid (OG + HA) has a spherulitic texture morphology with a net-like structure and absorption bands that evidenced the presence of HA in the three-dimensional net of organogel. The thermal analysis confirmed the gelation and the insertion of HA, as well as a good thermal stability, which is also confirmed by the study of oxidative stability carried out under different temperature conditions for 90 days. The texture and rheology studies indicated a viscoelastic behavior. HA quantification shows the efficiency of the HA cross-linking process in the three-dimensional net of organogel with 11.22 µg/mL for cross-linked HA. Thus, it is concluded that OG + HA shows potentially promising physicochemical characteristics for the development of a cosmetic system.
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Affiliation(s)
| | - Maria Inês Ré
- IMT Mines Albi-Carmaux, CNRS UMR 5302, Centre RAPSODEE, Campus Jarlard, Université de Toulouse, CEDEX 09, 81013 Albi, France
| | - José Otávio Carréra Silva-Júnior
- Laboratory R&D Pharmaceutical and Cosmetic, Faculty of Pharmaceutical Sciences, Federal University of Pará, Belém 66075-110, Brazil
| | - Roseane Maria Ribeiro-Costa
- Laboratory of Pharmaceutical Nanotechnology, College of Pharmacy, Federal University of Pará, Belém 66075-110, Brazil
- Correspondence: ; Tel.: +55-91-3201-7203
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Soares DJ. Bridging a Century-Old Problem: The Pathophysiology and Molecular Mechanisms of HA Filler-Induced Vascular Occlusion (FIVO)-Implications for Therapeutic Interventions. Molecules 2022; 27:5398. [PMID: 36080164 PMCID: PMC9458226 DOI: 10.3390/molecules27175398] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 01/10/2023] Open
Abstract
Biocompatible hyaluronic acid (HA, hyaluronan) gel implants have altered the therapeutic landscape of surgery and medicine, fostering an array of innovative products that include viscosurgical aids, synovial supplements, and drug-eluting nanomaterials. However, it is perhaps the explosive growth in the cosmetic applications of injectable dermal fillers that has captured the brightest spotlight, emerging as the dominant modality in plastic surgery and aesthetic medicine. The popularity surge with which injectable HA fillers have risen to in vogue status has also brought a concomitant increase in the incidence of once-rare iatrogenic vaso-occlusive injuries ranging from disfiguring facial skin necrosis to disabling neuro-ophthalmological sequelae. As our understanding of the pathophysiology of these injuries has evolved, supplemented by more than a century of astute observations, the formulation of novel therapeutic and preventative strategies has permitted the amelioration of this burdensome complication. In this special issue article, we review the relevant mechanisms underlying HA filler-induced vascular occlusion (FIVO), with particular emphasis on the rheo-mechanical aspects of vascular blockade; the thromboembolic potential of HA mixtures; and the tissue-specific ischemic susceptibility of microvascular networks, which leads to underperfusion, hypoxia, and ultimate injury. In addition, recent therapeutic advances and novel considerations on the prevention and management of muco-cutaneous and neuro-ophthalmological complications are examined.
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Affiliation(s)
- Danny J. Soares
- American Foundation for Aesthetic Medicine (AFFAM), Fruitland Park, FL 34731, USA;
- College of Medicine, University of Central Florida, Orlando, FL 32827, USA
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Wang Z, Sun J, Li Y, Song G, Su H, Yu W, Gong Q. Cloning, expression, and characterization of a glycosaminoglycan lyase from Vibrio sp. H240. Enzyme Microb Technol 2021; 154:109952. [PMID: 34871823 DOI: 10.1016/j.enzmictec.2021.109952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 11/04/2021] [Accepted: 11/15/2021] [Indexed: 11/29/2022]
Abstract
Glycosaminoglycan lyase is an effective tool for the functional studies of glycosaminoglycans and for the preparation of oligosaccharides. In this study, a new glycosaminoglycan lyase HCLaseV with a molecular weight of 90 kDa was cloned, expressed, and characterized from Vibrio sp. H240. The lyase belonged to the polysaccharide lyase (PL)- 8 family. HCLaseV showed enzyme activities toward chondroitin sulfate A, chondroitin sulfate B, chondroitin sulfate C, and hyaluronic acid. HCLaseV exhibited the highest activity against HA at pH 7.0 and 40 °C. HCLaseV was an endo-type enzyme whose degradation end-product was unsaturated disaccharides. Ca2+ inhibited the activity of HCLaseV to a certain extent, which was different from most of the enzymes in the PL-8 family. Mutagenesis studies showed that the Ca2+ inhibition might be related to the Asn244 residue. The sequence homology was evaluated by mutagenesis studies, and the catalytic residues in HCLaseV were presumed to be His278, Trp485, and Tyr287. These characteristics are helpful for further basic research and application.
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Affiliation(s)
- Zheng Wang
- School of Medicine and Pharmacy, Ocean University of China, 5 Yushan Road, Qingdao 266003, PR China; Laboratory for Marine Drugs and Bioproducts of Qingdao National Laboratory for Marine Science and Technology, 1 Wenhai Road, Qingdao 266237, PR China; Provincial Key Laboratory of Glycoscience and Glycotechnology, Ocean University of China, 5 Yushan Road, Qingdao 266003, PR China; Key Laboratory of Marine Drugs, Ministry of Education, Ocean University of China, 5 Yushan Road, Qingdao 266003, PR China
| | - Junhao Sun
- School of Medicine and Pharmacy, Ocean University of China, 5 Yushan Road, Qingdao 266003, PR China; Laboratory for Marine Drugs and Bioproducts of Qingdao National Laboratory for Marine Science and Technology, 1 Wenhai Road, Qingdao 266237, PR China; Provincial Key Laboratory of Glycoscience and Glycotechnology, Ocean University of China, 5 Yushan Road, Qingdao 266003, PR China; Key Laboratory of Marine Drugs, Ministry of Education, Ocean University of China, 5 Yushan Road, Qingdao 266003, PR China
| | - Yunlu Li
- School of Medicine and Pharmacy, Ocean University of China, 5 Yushan Road, Qingdao 266003, PR China; Laboratory for Marine Drugs and Bioproducts of Qingdao National Laboratory for Marine Science and Technology, 1 Wenhai Road, Qingdao 266237, PR China; Provincial Key Laboratory of Glycoscience and Glycotechnology, Ocean University of China, 5 Yushan Road, Qingdao 266003, PR China; Key Laboratory of Marine Drugs, Ministry of Education, Ocean University of China, 5 Yushan Road, Qingdao 266003, PR China
| | - Guanrui Song
- School of Medicine and Pharmacy, Ocean University of China, 5 Yushan Road, Qingdao 266003, PR China; Laboratory for Marine Drugs and Bioproducts of Qingdao National Laboratory for Marine Science and Technology, 1 Wenhai Road, Qingdao 266237, PR China; Provincial Key Laboratory of Glycoscience and Glycotechnology, Ocean University of China, 5 Yushan Road, Qingdao 266003, PR China; Key Laboratory of Marine Drugs, Ministry of Education, Ocean University of China, 5 Yushan Road, Qingdao 266003, PR China
| | - Hai Su
- School of Medicine and Pharmacy, Ocean University of China, 5 Yushan Road, Qingdao 266003, PR China; Laboratory for Marine Drugs and Bioproducts of Qingdao National Laboratory for Marine Science and Technology, 1 Wenhai Road, Qingdao 266237, PR China; Provincial Key Laboratory of Glycoscience and Glycotechnology, Ocean University of China, 5 Yushan Road, Qingdao 266003, PR China; Key Laboratory of Marine Drugs, Ministry of Education, Ocean University of China, 5 Yushan Road, Qingdao 266003, PR China
| | - Wengong Yu
- School of Medicine and Pharmacy, Ocean University of China, 5 Yushan Road, Qingdao 266003, PR China; Laboratory for Marine Drugs and Bioproducts of Qingdao National Laboratory for Marine Science and Technology, 1 Wenhai Road, Qingdao 266237, PR China; Provincial Key Laboratory of Glycoscience and Glycotechnology, Ocean University of China, 5 Yushan Road, Qingdao 266003, PR China; Key Laboratory of Marine Drugs, Ministry of Education, Ocean University of China, 5 Yushan Road, Qingdao 266003, PR China
| | - Qianhong Gong
- School of Medicine and Pharmacy, Ocean University of China, 5 Yushan Road, Qingdao 266003, PR China; Laboratory for Marine Drugs and Bioproducts of Qingdao National Laboratory for Marine Science and Technology, 1 Wenhai Road, Qingdao 266237, PR China; Provincial Key Laboratory of Glycoscience and Glycotechnology, Ocean University of China, 5 Yushan Road, Qingdao 266003, PR China; Key Laboratory of Marine Drugs, Ministry of Education, Ocean University of China, 5 Yushan Road, Qingdao 266003, PR China.
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Aaron M, Qing Huang Y, Bouffard D, Costa JP, Côté B. A case of cutaneous necrosis due to intra-articular hyaluronic acid and treated with hyaluronidase. SAGE Open Med Case Rep 2021; 9:2050313X211025110. [PMID: 34262769 PMCID: PMC8252361 DOI: 10.1177/2050313x211025110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 04/05/2021] [Indexed: 11/25/2022] Open
Abstract
A 66-year-old woman presented to the hospital with cutaneous necrosis of her right ankle and foot. Her symptoms began immediately after an intra-articular injection of hyaluronic acid for ankle osteoarthritis, which was performed 6 days before. Histopathology showed an intra-vascular hyaluronic acid embolus. The initial treatment approach was conservative, but the patient’s clinical state degraded. She was thus treated with sub-cutaneous hyaluronidase, the enzyme that degrades hyaluronic acid, which yielded a moderate improvement even though it was administered 22 days after the initial hyaluronic acid injection. Although hyaluronic acid embolism and subsequent cutaneous necrosis are well-known complications of dermal fillers, there are few reported cases of embolism following intra-articular injection. To our knowledge, this is the first time hyaluronidase has been used in this setting.
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Affiliation(s)
- Michelle Aaron
- Department of Dermatology, Université de Montréal, Montreal, QC, Canada.,Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Yu Qing Huang
- Department of Internal Medicine, Université de Montréal, Montreal, QC, Canada
| | - Danielle Bouffard
- Department of Pathology, Université de Montreal, Montréal, QC, Canada
| | - Jean-Pascal Costa
- Department of Internal Medicine, Université de Montréal, Montreal, QC, Canada
| | - Benoît Côté
- Department of Dermatology, Université de Montréal, Montreal, QC, Canada.,Centre hospitalier de l'Université de Montréal, Montreal, QC, Canada
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Rouanet C, Kestemont P, Winter C, Lerhe B, Savoldelli C. Management of vascular complications following facial hyaluronic acid injection: High-dose hyaluronidase protocol: A technical note. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2021; 123:262-265. [PMID: 34157447 DOI: 10.1016/j.jormas.2021.05.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 03/07/2021] [Accepted: 05/03/2021] [Indexed: 12/01/2022]
Abstract
Aesthetic medicine has experienced major developments in recent years, which is illustrated by the increasing number of hyaluronic acid injected in the area of facial rejuvenation. Although considered low risk, it can rarely result in arterial embolization with potentially major aesthetic and functional consequences. These vascular complications range from livedo to skin necrosis to permanent blindness. In such cases the management is urgent. Early care leads to a successful recovery but most of the time the diagnosis is delayed. Several treatments have been suggested and the use of hyaluronidase is decisive. There is no official guideline on the use of hyaluronidase. The aim of this article is to propose a protocol to clarify the management of vascular complications of HA with high doses of hyaluronidase based on the literature and our clinical experience of 35 patients treated.
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Affiliation(s)
- Cédric Rouanet
- Department of ENT and Maxillofacial surgery, Head and Neck Institute, University Hospital of Nice, France
| | - Philippe Kestemont
- Department of ENT and Maxillofacial surgery, Head and Neck Institute, University Hospital of Nice, France; Clinique Saint-George, Nice, France
| | | | - Barbara Lerhe
- Department of ENT and Maxillofacial surgery, Head and Neck Institute, University Hospital of Nice, France
| | - Charles Savoldelli
- Department of ENT and Maxillofacial surgery, Head and Neck Institute, University Hospital of Nice, France.
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Histological and Quantitative Appraisal of the Intradermal and Subcutaneous Distribution of the Hyaluronic Acid Injected into the Nasolabial Fold. Aesthetic Plast Surg 2021; 45:710-717. [PMID: 32198637 DOI: 10.1007/s00266-020-01681-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 03/08/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Histological analysis of hyaluronic acid (HA) applied in the nasolabial fold (NLF) studied gel distribution into the dermis and subcutaneous fat, correlating density of NLF tissues, with cohesivity, concentration and degradation of HA. METHOD Ten patients received two injection points on each NLF. They were intradermal near the nasal ala and subcutaneous near the oral commissure. Injection points received 0.1 ml of 24 mg/ml HA cross-linked by BDDE 2.0 ppm through a bolus technique injection without retrograde backflow. Biopsies were taken 72 h and 9 months after application to histological analysis. RESULTS Dermis density fragmented the gel into small nodules, spreading it into the reticular dermis. Seventy-two hours after application, average diameter of the small nodules was 0.30 mm and at month nine 0.05 mm. Softness of the subcutaneous fat and high concentration of HA created a single and compact nodule. Seventy-two hours after application, average of nodule diameters was 1.05 mm and at month nine 0.49 mm. HA biodegradation occurred on the external surface of the gel. The single nodule offered small contact surface to enzymes, slowing gel degradation. The sum average of the diameters of the small nodules offered a large contact surface to enzymes, accelerating gel degradation. CONCLUSION Permanence of the HA into the tissues depended on the relationship between the gel distribution and its degradation. Due to the small contact surface of the single nodule to enzymes, permanence of the HA into the subcutaneous fat was more extended than into the dermis. LEVEL OF EVIDENCE IV 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 .
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Arlette JP, Ashenhurst M, Hill V, Jiang K. Prevention and Management of Filler Induced Iatrogenic Stroke of the Eye. J Cutan Med Surg 2021; 25:543-552. [PMID: 33653128 DOI: 10.1177/1203475421999340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In the past few decades, minimally-invasive esthetic treatments and the use of injectable Hyaluronic Acid Gels and other filling agents to treat facial esthetics have increased dramatically. Although extremely rare, a filler can cause ocular and orbital ischemia by retrograde flow from the ophthalmic artery when injected in any of the anastomosis of the face. Once filler reaches the central retinal artery, blindness is inevitable, and no treatment is effective. While the risk of blindness happening with any filler injection is rare, the life-altering irreversible consequence of a procedure that was anticipated to be simple and beautifying is a reality that each injector must be prepared for with every injection. The parameters associated with an iatrogenic stroke of the eye are the site of injection, the injection technique, patient characteristics, and the material injected. Understanding the interplay of each of these variables might help us reduce the possibility of blindness during the injection of a soft-tissue cosmetic filler. Here, we explore the causes of Hyaluronic Acid Gels Filler embolic phenomena, review the natural course of the process, and discuss appropriate immediate interventions. We also (1) propose an education plan for injectors and describe how to carry out a focused ophthalmologic examination and procedural activities for a referral to an ophthalmologist, (2) outline steps to prevent emboli during filler injection, and (3) how to manage and support a patient with a sudden loss of vision during or immediately after a Hyaluronic Acid Gels filler treatment.
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Affiliation(s)
- John P Arlette
- 70401 Department of Surgery, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Michael Ashenhurst
- Department of Surgery, Division of Ophthalmology, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Vivian Hill
- Department of Surgery, Division of Ophthalmology, University of Calgary, Alberta, Canada
| | - Kailun Jiang
- Department of Surgery, Division of Ophthalmology, Cumming School of Medicine, University of Calgary, Alberta, Canada
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Jones DH, Fitzgerald R, Cox SE, Butterwick K, Murad MH, Humphrey S, Carruthers J, Dayan SH, Donofrio L, Solish N, Yee GJ, Alam M. Preventing and Treating Adverse Events of Injectable Fillers: Evidence-Based Recommendations From the American Society for Dermatologic Surgery Multidisciplinary Task Force. Dermatol Surg 2021; 47:214-226. [PMID: 33543879 DOI: 10.1097/dss.0000000000002921] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Derek H Jones
- Skin Care and Laser Physicians of Beverly Hills, Los Angeles, California
| | | | - Sue Ellen Cox
- Aesthetic Solutions, Assoc Clinical Faculty, UNC Department of Dermatology, Consulting Associate, Duke University Department Dermatology, Chapel Hill, North Carolina
| | | | - M Hassan Murad
- Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota
| | - Shannon Humphrey
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, Canada
| | - Jean Carruthers
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, Canada
| | - Steven H Dayan
- Denova Research, Clinical Assistant Professor, University of Illinois, Chicago, Illinois
| | - Lisa Donofrio
- Department of Dermatology, Yale University School of Medicine, New Haven, Connecticut
| | - Nowell Solish
- Department of Dermatology, University of Toronto, Toronto, Canada
| | | | - Murad Alam
- Departments of Dermatology, Otolaryngology, and Surgery, Northwestern University, Chicago, Illinois
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13
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Zeltzer A, Geeroms M, Antoniazzi E, Giunta G, De Baerdemaeker R, Hendrickx B, Hamdi M. The "ART" of facial filler injections: Avoid, recognize, and treat hyaluronic acid-induced complications. J Cosmet Dermatol 2020; 19:2229-2236. [PMID: 32649055 DOI: 10.1111/jocd.13611] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 07/06/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hyaluronic acid (HA) fillers are frequently used for cosmetic purposes as volumizers or as wrinkle fillers. One of the major advantages of hyaluronic acid use is the possibility to neutralize it by using hyaluronidase should complications occur. PATIENT A case of a 21-year-old female patient is presented, in whom a hyaluronic acid injection-induced vascular occlusion was seen four days after the initial injection, with increasing pain and severe signs of ischemia. METHOD Treatment consisted of an immediate hyaluronidase injection, supplemented with administration of acetylsalicylic acid, piracetam, low molecular weight heparin (LMWH), corticosteroids, analgesics, prophylactic antibiotics, application of topical nitroglycerin and warmth, smoking cessation, and hyperbaric oxygen therapy. RESULTS The initial progress and evolution of the deformity with possible therapeutic options are being discussed. CONCLUSION The "ART" (avoid, recognize, and treat) in handling filler complications is presented, as a new universal guideline for clinical aesthetic practitioners and injectors.
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Affiliation(s)
- Assaf Zeltzer
- Department of Plastic and Reconstructive Surgery, Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Maxim Geeroms
- Department of Plastic and Reconstructive Surgery, Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Elisa Antoniazzi
- Department of Plastic and Reconstructive Surgery, Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Gabriele Giunta
- Department of Plastic and Reconstructive Surgery, Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Randy De Baerdemaeker
- Department of Plastic and Reconstructive Surgery, Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Benoit Hendrickx
- Department of Plastic and Reconstructive Surgery, Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
| | - Moustapha Hamdi
- Department of Plastic and Reconstructive Surgery, Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium
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