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Rahman E, Philipp-Dormston WG, Webb WR, Rao P, Sayed K, Sharif AQMO, Yu N, Ioannidis S, Tam E, Rahman Z, Mosahebi A, Goodman GJ. "Filler-Associated Acute Stroke Syndrome": Classification, Predictive Modelling of Hyaluronidase Efficacy, and Updated Case Review on Neurological and Visual Complications. Aesthetic Plast Surg 2024:10.1007/s00266-024-04202-y. [PMID: 38971925 DOI: 10.1007/s00266-024-04202-y] [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: 04/01/2024] [Accepted: 06/09/2024] [Indexed: 07/08/2024]
Abstract
INTRODUCTION The rising use of soft tissue fillers for aesthetic procedures has seen an increase in complications, including vascular occlusions and neurological symptoms that resemble stroke. This study synthesizes information on central nervous system (CNS) complications post-filler injections and evaluates the effectiveness of hyaluronidase (HYAL) treatment. METHODS A thorough search of multiple databases, including PubMed, EMBASE, Scopus, Web of Science, Google Scholar, and Cochrane, focused on publications from January 2014 to January 2024. Criteria for inclusion covered reviews and case reports that documented CNS complications related to soft tissue fillers. Advanced statistical and computational techniques, including logistic regression, machine learning, and Bayesian analysis, were utilized to dissect the factors influencing therapeutic outcomes. RESULTS The analysis integrated findings from 20 reviews and systematic analyses, with 379 cases reported since 2018. Hyaluronic acid (HA) was the most commonly used filler, particularly in nasal region injections. The average age of patients was 38, with a notable increase in case reports in 2020. Initial presentation data revealed that 60.9% of patients experienced no light perception, while ptosis and ophthalmoplegia were present in 54.3 and 42.7% of cases, respectively. The statistical and machine learning analyses did not establish a significant linkage between the HYAL dosage and patient recovery; however, the injection site emerged as a critical determinant. CONCLUSION The study concludes that HYAL treatment, while vital for managing complications, varies in effectiveness based on the injection site and the timing of administration. The non-Newtonian characteristics of HA fillers may also affect the incidence of complications. The findings advocate for tailored treatment strategies incorporating individual patient variables, emphasizing prompt and precise intervention to mitigate the adverse effects of soft tissue fillers. 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)
- Eqram Rahman
- Research and Innovation Hub, Innovation Aesthetics, London, WC2H9JQ, UK.
| | | | | | - Parinitha Rao
- The Skin Address, Aesthetic Dermatology Practice, Bengaluru, India
| | - Karim Sayed
- Nomi Oslo, Oslo, Norway
- University of South-Eastern Norway, Drammen, Norway
| | - A Q M Omar Sharif
- Shaheed Suhrawardy Medical College, Sher e Bangla Nagar, Dhaka, Bangladesh
| | - Nanze Yu
- Peking Union Medical College Hospital, Beijing, China
| | | | | | - Zakia Rahman
- Stanford Dermatology, Stanford University School of Medicine, Redwood City, CA, USA
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Bruce CN, Esmaili N. Isolated Ophthalmoplegia After Periorbital Hyaluronic Acid Filler Injection. Ophthalmic Plast Reconstr Surg 2024; 40:e80-e82. [PMID: 38231591 DOI: 10.1097/iop.0000000000002595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
Facial filler injections are the second most commonly performed in-office cosmetic procedure. Vision loss is the most feared complication of hyaluronic acid (HA) filler injection, but isolated ophthalmoplegia can also occur. We report the case of a 45-year-old woman who developed nausea and diplopia following HA filler injection to the bilateral periorbital region. She presented with a left hypertropia and left-sided motility deficit without vision involvement. MRI of the orbits demonstrated mild enhancement and enlargement of the left inferior rectus and inferior oblique muscles. Treatment consisted of hyaluronidase injection and oral steroids. HA filler can cause isolated ocular misalignment and diplopia without associated vision loss. Patients should be counseled on these risks before undergoing soft tissue augmentation of the face with HA filler.
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Affiliation(s)
- Carleigh N Bruce
- Department of Ophthalmology and Visual Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
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Joo HJ, Kim DH. Posterior Ischemic Optic Neuropathy Following Skin Booster Injection. J Neuroophthalmol 2024:00041327-990000000-00621. [PMID: 38595300 DOI: 10.1097/wno.0000000000002138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Affiliation(s)
- Hye Jun Joo
- Department of Ophthalmology (HJJ, DHK), Seoul National University Hospital, Seoul, South Korea; and Department of Ophthalmology (DHK), Seoul National University College of Medicine, Seoul, South Korea
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Karlin J, Vranis N, Dayan E, Parsa K. Post-Hyaluronic Acid Recurrent Eyelid Edema: Pathophysiologic Mechanisms and a Proposed Treatment Protocol. Aesthet Surg J Open Forum 2023; 5:ojad102. [PMID: 38828092 PMCID: PMC11140515 DOI: 10.1093/asjof/ojad102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024] Open
Abstract
Background Hyaluronic acid (HA) filler injections for facial augmentation are commonly administered but can lead to post-hyaluronic acid recurrent eyelid edema (PHAREE). The pathophysiology of this condition has not been fully understood. Objectives To report the successful treatment of PHAREE using serial hyaluronidase and fractionated radiofrequency microneedling, with additional carbon dioxide laser skin resurfacing in selected patients. Methods Five patients with PHAREE were treated with serial hyaluronidase injections and fractionated radiofrequency microneedling, with 2 patients receiving carbon dioxide laser treatment. The patients were followed up for a minimum of 24 months. Results All patients reported a resolution of PHAREE signs/symptoms with no adverse effects or recurrence. One patient demonstrated complete resolution after a single treatment; 4 required a series of treatments. Conclusions The proposed treatment protocol may provide advantages over hyaluronidase alone for PHAREE. The impermeable malar septum, vulnerable eyelid lymphatics, and potential immunogenicity of HA fragments likely contribute to PHAREE pathophysiology. Further research on pathophysiologic mechanisms is warranted. Level of Evidence 4
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Affiliation(s)
| | | | | | - Kami Parsa
- Corresponding Author: Dr Kami Parsa, 465 N Roxbury Dr, Ste 1011, Beverly Hills, CA 90210, USA. E-mail:
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Chung CW, Shiuey EJ, Briceño CA, Lee V. Acute diplopia after glabellar hyaluronic acid filler injection. Am J Ophthalmol Case Rep 2023; 31:101860. [PMID: 37251111 PMCID: PMC10220458 DOI: 10.1016/j.ajoc.2023.101860] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 04/24/2023] [Accepted: 05/15/2023] [Indexed: 05/31/2023] Open
Abstract
Purpose Blindness is a well-known complication of filler injection in the glabellar region. Acute diplopia from filler injection without vision loss is a rare complication that typically results in clinical ophthalmoplegia which can have permanent sequelae. Here, we describe a patient who presented with acute diplopia with grossly intact full extraocular motility after glabella hyaluronic acid filler injection that resolved after 1 month. Observations A previously healthy 43-year-old woman underwent her first hyaluronic acid injection in the glabella and developed immediate binocular double vision with severe pain and skin mottling above her right eyebrow and central forehead. Hyaluronidase injections, nitroglycerin paste, and aspirin were immediately administered. On exam, there was significant skin mottling over the glabella, extending to the forehead and nose with a small incomitant horizontal and vertical misalignment. No changes to her vision were observed and extraocular motility was grossly full. The rest of her exam was unremarkable. Over the course of the following month, the patient's diplopia resolved, but she developed skin necrosis and scarring. Conclusions Importance: Proper knowledge of facial and periocular anatomy is critical for practitioners to safely perform filler injections and manage potential complications. Patients should be counseled about the potential rare risks of these elective procedures.
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Affiliation(s)
- Caroline W. Chung
- Scheie Eye Institute, University of Pennsylvania, Philadelphia, PA, USA
| | - Eric J. Shiuey
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - César A. Briceño
- Scheie Eye Institute, University of Pennsylvania, Philadelphia, PA, USA
| | - Vivian Lee
- Scheie Eye Institute, University of Pennsylvania, Philadelphia, PA, USA
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Peng YP, Lin YW, Yang YY. Aspiration before tissue filling with hyaluronic acid-safety enhancement by using a lidocaine-primed syringe. J Cosmet Dermatol 2023; 22:2457-2463. [PMID: 37098936 DOI: 10.1111/jocd.15759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 02/18/2023] [Accepted: 03/24/2023] [Indexed: 04/27/2023]
Abstract
OBJECTIVE Most of the doctors would regularly aspirate the plunger of a syringe before injection to make sure that the needle would not be mis-inserted into vessels. Yet pulling the plunger back only cannot guarantee the injecting status is safe. Injecting all of the non-fluid fillers, including colloidal hyaluronic acid (HA) into the vessel may cause "No blood return while pulling back the plunger," which is defined as false-negative aspiration. METHODS In the first experiment, HA syringes were inserted into vessel simulators in vitro with standard needle sizes and residual dosages. In the second experiment, the lidocaine-primed syringe were inserted into the vessel simulator instead to observe its aspiration. RESULTS There was no difference using different sizes of needles or dosages except for group 0.1 mL and the lidocaine-primed syringe. The rest of the groups need to wait more seconds to observe the blood return. CONCLUSIONS The time lag does exist in every single aspiration and 88% of the blood return would happen in 10 s. We suggested that operators should aspirate regularly before giving an injection with at least 10 s of waiting or use the lidocaine-primed syringe instead. Blood returns could mostly be recognized in both ways.
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Affiliation(s)
- Yu-Pin Peng
- Dr. Pong Dermatologic and Aesthetic Clinic, 7F-5, No.305, Sec.3, Zhongxiao E Rd., Da'an Dist, Taipei City, 106, Taiwan
| | - Yi-Wen Lin
- Department of Dermatology, The First Affiliated Hospital of Jinan University, 613 Huangpu W Avenue, Guangzhou, Guangdong, 510630, China
| | - Yu-Yen Yang
- Department of Aesthetic Surgery, The First Affiliated Hospital of Jinan University, 613 Huangpu W Avenue, Guangzhou, Guangdong, 510630, China
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Wanitphakdeedecha R, Ng JNC, Phumariyapong P, Nokdhes YN, Patthamalai P, Tantrapornpong P, Suphatsathienkul P, Apinuntham C, Yan C, Nanchaipruek Y, Thongjaroensirikul P, Maneeprasopchoke P, Techapichetvanich T, Eimpunth S, Manuskiatti W, Thanachaipiwat S, Panich U. A pilot study comparing the efficacy of autologous cultured fibroblast injections with hyaluronic acid fillers for treating nasolabial folds. Sci Rep 2023; 13:6616. [PMID: 37095274 PMCID: PMC10126053 DOI: 10.1038/s41598-023-33786-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 04/19/2023] [Indexed: 04/26/2023] Open
Abstract
Autologous cultured fibroblast injections for soft tissue augmentation are a potential alternative to other filler materials. No studies have compared autologous fibroblast injections and hyaluronic acid (HA) fillers for treating nasolabial folds (NLFs). To compare the efficacies and safeties of autologous cultured fibroblast injections and HA fillers for treating NLFs. This prospective, evaluator-blinded, pilot study enrolled 60 Thai female adult patients diagnosed with moderate to severe NLFs. They were randomized to receive either 3 treatments of autologous fibroblasts at 2-week intervals or 1 treatment with HA fillers. The primary outcome was the clinical improvement of the NLFs graded by 2 blinded dermatologists immediately after injection and at 1-, 3-, 6-, and 12-month follow-ups. Objective measurement of the NLF volume was evaluated. Patient self-assessment scores, pain scores, and adverse reactions were recorded. Of the 60 patients, 55 (91.7%) completed the study protocol. The NLF volumes improved significantly in the autologous fibroblast group at all follow-ups relative to baseline (P = 0.000, 0.004, 0.000, 0.000, and 0.003). The patients in the autologous fibroblast group rated more noticeable NLF improvements than those in the HA filler group (3-month follow-up, 58.41% vs. 54.67%; 6-month follow-up, 52.50% vs. 46%; 12-month follow-up, 44.55% vs. 31.33%). No serious adverse reactions were recorded. Autologous fibroblast injections are safe and effective for treating NLFs. These injections also promise sustained growth of living cells, possibly leading to a greater persistence than shown by other fillers.
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Affiliation(s)
- Rungsima Wanitphakdeedecha
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Pran-Nok Road, Bangkok Noi 10700, Bangkok, Thailand.
| | - Janice Natasha C Ng
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Pran-Nok Road, Bangkok Noi 10700, Bangkok, Thailand
| | - Phumithep Phumariyapong
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Pran-Nok Road, Bangkok Noi 10700, Bangkok, Thailand
| | - Ya-Nin Nokdhes
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Pran-Nok Road, Bangkok Noi 10700, Bangkok, Thailand
| | - Poramin Patthamalai
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Pran-Nok Road, Bangkok Noi 10700, Bangkok, Thailand
| | - Ploypailin Tantrapornpong
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Pran-Nok Road, Bangkok Noi 10700, Bangkok, Thailand
| | - Panittra Suphatsathienkul
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Pran-Nok Road, Bangkok Noi 10700, Bangkok, Thailand
| | - Chalermkwan Apinuntham
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Pran-Nok Road, Bangkok Noi 10700, Bangkok, Thailand
| | - Chadakan Yan
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Pran-Nok Road, Bangkok Noi 10700, Bangkok, Thailand
| | - Yanisorn Nanchaipruek
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Pran-Nok Road, Bangkok Noi 10700, Bangkok, Thailand
| | - Panwadee Thongjaroensirikul
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Pran-Nok Road, Bangkok Noi 10700, Bangkok, Thailand
| | - Pitchaya Maneeprasopchoke
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Pran-Nok Road, Bangkok Noi 10700, Bangkok, Thailand
| | - Thanya Techapichetvanich
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Pran-Nok Road, Bangkok Noi 10700, Bangkok, Thailand
| | - Sasima Eimpunth
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Pran-Nok Road, Bangkok Noi 10700, Bangkok, Thailand
| | - Woraphong Manuskiatti
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Pran-Nok Road, Bangkok Noi 10700, Bangkok, Thailand
| | - Saowalak Thanachaipiwat
- Department of Pharmacology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Uraiwan Panich
- Department of Pharmacology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Sheptulin VA, Grusha YO. Reversible Vision Loss Following Nonsurgical Filler Rhinoplasty. RUSSIAN OPEN MEDICAL JOURNAL 2022. [DOI: 10.15275/rusomj.2022.0406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The increase in the frequency and popularity of aesthetic filler injections is accompanied by a high risk of complications, including ophthalmological sequalae. Of these, loss of vision is considered the most dangerous and, in most cases, irreversible. We present a case report of a patient who experienced acute vision loss due to suspected partial occlusion of the ophthalmic artery following nonsurgical rhinoplasty with hyaluronic acid filler injection. It differs from others in that treatment in the form of a combination of multiple subcutaneous hyaluronidase injections into the periocular region, a single retrobulbar injection of hyaluronidase, and hyperbaric oxygen therapy led to a significant recovery of ophthalmic symptoms with only residual visual field defects remaining.
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Affiliation(s)
| | - Yaroslav O. Grusha
- M.M. Krasnov Institute of Eye Diseases, Moscow, Russia; I.M. Sechenov First Moscow State Medical University, Moscow, Russia
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Mella J, Oyer S. Nonsurgical rhinoplasty: prevention and management of associated complications. Curr Opin Otolaryngol Head Neck Surg 2022; 30:241-248. [PMID: 35906976 DOI: 10.1097/moo.0000000000000818] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Nonsurgical rhinoplasty (NSR) continues to grow in demand and popularity. Consequently, there has been a rise in the number of reported complications. This review will summarize and discuss the current evidence for the prevention and management of adverse events related to NSR with a specific emphasis on practical clinical applications. The review is based on recent systematic reviews and multidisciplinary expert consensus recommendations. RECENT FINDINGS First, NSR has overall favorable outcomes with rare complications. Second, vascular compromise is a rare event, but the number of reported severe complications is rising. Third, providers should be intimately familiar with preventive measures, early signs and symptoms, and appropriate management algorithms of all possible complications. Fourth, having a readily available 'toolbox' of recommended therapies may improve timely management of emergent complications. SUMMARY The number of complications associated with NSR is expected to rise congruent with the increased demand for the procedure. Although NSR has a favorable safety profile, complications can occur in the best of hands even when using appropriate risk reduction strategies. Early detection and appropriate treatment of known complications may eliminate or minimize sequelae and allow providers to continue to safely perform NSR.
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Affiliation(s)
- Jeffrey Mella
- University of Virginia, Department of Otolaryngology, Head and Neck Surgery, Facial Cosmetic and Reconstructive Surgery, Charlottesville, Virginia, USA
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