Periocular mass lesions secondary to dermatologic fillers: Report of 3 cases

The Posthyaluronidase Syndrome: Dosing Strategies for Hyaluronidase in the Dissolving of Facial Filler and Independent Predictors of Poor Outcomes

Background

Hyaluronic acid dermal fillers are used extensively in periocular aesthetic medicine, and the incidence of filler-related complications is increasing. This study aimed to investigate the optimal dosing strategy for hyaluronidase and to identify predictors of poor outcomes.

Methods

We performed a retrospective review of 157 orbits of 90 patients treated with hyaluronidase over a 4-year period. Demographic data, indication, and details of hyaluronidase treatment and outcomes were recorded.

Results

The primary indication for dissolving filler was swelling in 52%, lumpiness in 20%, and before surgical blepharoplasty in 17%. The most frequently used hyaluronidase concentration was 150 U per mL in 66%, followed by 75 U per mL in 31%, 37.5 U per mL in 3%, and 100 U per mL in 1%. Outcomes were characterized as follows: 59% with a satisfactory result; 24% as insufficient treatment requiring further hyaluronidase; and 18% complaining of facial changes such as hollowing, indicating a post hyaluronidase syndrome. There was no statistical difference in outcomes between the 75 and 150 U per mL dosage groups (P = 0.625). A significant correlation was identified between posthyaluronidase syndrome and duration of filler in situ (P = 0.00019) and volume of filler (P = 0.000017).

Conclusions

The posthyaluronidase syndrome may be related to previous filler volume and duration, rather than the concentration or dose of hyaluronidase used. All patients should be informed about the risks of adverse effects after hyaluronidase treatment; patients with longer histories of filler use and higher total volumes should be advised of the increased risk.

Imaging Features and Complications of Facial Cosmetic Procedures

Facial aesthetic procedures have become increasingly popular and complex, making knowledge of facial anatomy crucial for achieving desired outcomes without complications. Some of the most common procedures include blepharoplasty, bichectomy, face-lifts, facial implants, thread lifting, and fillers. Blepharoplasty and bichectomy are surgical procedures that respectively aim to restore youthful contours to the periorbita and create a slimmer lower face by removing Bichat fat from the maxillofacial region. Facial implants are used for aesthetic augmentation of the skeletal structure and restoration of facial contour by using biomaterials or autogenous bone grafts. Face-lift surgeries involve incisions and removal of excess skin, and thread lifts involve less invasive procedures performed by inserting threads beneath the skin, with the aim to lift the skin and thus reduce wrinkles and sagging. Fillers improve wrinkles and loss of facial volume, with biologic types made from animal, human, or bacterial sources (such as hyaluronic acid), while synthetic fillers include substances such as paraffin, silicone, calcium hydroxyapatite, polymethylmethacrylate microspheres, polyacrylamide hydrogel, hydroxyethyl-ethyl methacrylate, and poly-l-lactic acid. Synthetic fillers can be classified as rapidly resorbable (<12 months), slowly resorbable (<24 months), or permanent. Imaging modalities such as US, CT, and MRI can help identify and analyze each type of facial aesthetic procedure or filler, as well as their possible complications such as foreign-body granuloma, noninflammatory nodule, late intermittent persistent edema, filler migration, infection, or complications after removal of the buccal fat pad. ©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center The online slide presentation from the RSNA Annual Meeting is available for this article.

Multiple Cases of Facial Disfigurement From Filler Use and One Injector

PURPOSE

To present a case of facial disfigurement from an injectable permanent filler and describe the consequences to patients exposed to the same injector (common source outbreak).

METHODS

Case report and discussion of a common source outbreak after a group of persons developed complications years after permanent filler given by one injector.

RESULTS

A 39-year-old transgender model underwent polymethylmethacrylate (Artefill) facial filler injections to the lips, cheeks, and chin in 2018. A year later, the patient presented to the emergency room with severe facial swelling and difficulty breathing. Treatments have included 4 surgeries to remove filler and scar tissue and chronic low-dose oral steroid therapy. Upon questioning the patient, 6 additional people suffered from similar facial swelling years after injection by the same injector. The injector cannot be located.

CONCLUSIONS

Care must be taken in giving all facial fillers, particularly permanent ones. When one source patient is identified, questioning the patient's knowledge of others affected is critical to help manage an epidemic problem and to report a rogue injector. Physicians have a duty to investigate and report such cases.

Infraorbital mass long after dermal filler injection: A report of two cases

BACKGROUND

Hyaluronic acid fillers have been increasingly used throughout the world in the management of aging skin in the periocular region and other areas.

OBJECTIVE

To evaluate very late-term orbital mass formation secondary to Hyaluronic acid filler injection into the inferior eyelid.

METHODS

We report two cases that presented with a subcutaneous palpable mass localized at the right medial lower infraorbital area. Following clinical and radiological examination, surgical excision was required for the differential diagnosis of tumor.

RESULTS

After pathologic examination and the finding of a foreign-body granulomatous reaction, both patients recalled that hyaluronic acid filler had once been injected into their lower eyelids approximately 10 years prior. This is consistent with the fact that dermal-filler-related granuloma formation may occur even years later in the differential diagnosis of mass lesions.

CONCLUSION

It is suggested that patients be informed about the possible but rare mass effect in the infraorbital region. Clinicians should also attend to delayed hypersensitivity reactions, since patients may not recall details due to the length of time since injection.

A Case of Orbital Granuloma Secondary to Dermal Filler Injection

A foreign body granulomatous reaction is a rare complication of the subcutaneous injection of fillers. We describe a 57-year-old female that presented with a six-month history of a non-painful, right lower eyelid mass. She had a dermal filler in the zygomatic region several months before the onset of her symptoms. Anterior orbitotomy and pathology revealed multinuclear giant cells consistent with a hyaluronic acid-based filler. This case describes the clinical presentation, histopathologic features, and treatment of an orbital granuloma secondary to dermal filler injection. Our case was uncommon because the zygomatic filler migrated across the orbital septum. Additionally, transconjunctival orbitotomy was used instead of a hyaluronidase injection due to the inferior location of the granuloma.

Filler Migration to the Orbit

BACKGROUND

Dermal filler injections continue to grow in popularity as a method of facial rejuvenation. This increase in the number of injections performed has resulted in an increasing number of types of filler-related complications.

OBJECTIVES

We report a series of cases where dermal filler injected in the face migrated to the orbit. Treatment methods and possible mechanisms of this newly reported complication are discussed.

METHODS

A retrospective, multicenter analysis was performed on patients with dermal filler migration to the orbit after facial filler injections.

RESULTS

Seven patients (6 females, 1 male; age range, 42-67 years) presented with orbital symptoms after filler injection and were subsequently found to have dermal filler in the orbit. Four out of 7 patients underwent orbitotomy surgery, 1 patient underwent lacrimal surgery, 1 patient had strabismus surgery, and 1 patient was treated with hyalurodinase injections. All patients have remained stable postoperatively.

CONCLUSIONS

Orbital complications secondary to migrated filler may occur long after the initial procedure. Because the site of the complication is distant from the injection site, patients and physicians may not immediately make the connection. Furthermore, this may lead to unnecessary examinations and a delay in diagnosis while looking for standard orbital masses. Dermal fillers should therefore be considered in the differential diagnosis of patients presenting with new-onset orbital masses.

LEVEL OF EVIDENCE: 4

Delayed migration of soft tissue fillers in the periocular area masquerading as eyelid and orbital pathology

Soft tissue fillers used for facial rejuvenation can cause complications. We present two cases of late migration of injected fillers mimicking other pathology in the periocular area. Case 1 is a 52-year-old woman referred with chronic bilateral upper lid swelling, mimicking blepharochalasis syndrome, 5¹/₂ years after undergoing injection of hyaluronic acid filler in both brows. Extensive blood investigations were normal. Bilateral, sequential upper lid biopsy revealed migrated hyaluronic acid filler, which was successfully treated with hyaluronidase. Case 2 is a 62-year-old woman who presented with a right lower lid mass 8 years after undergoing injection of polyalkylimide gel into both cheeks. CT scanning confirmed an intermediate density soft tissue mass overlying the inferior orbital rim. Histology from surgical excision reported chronic granulomatous inflammation due to migrated polyalkylimide gel. An awareness of late migration of fillers causing eyelid swelling and masses in the periocular area will prevent unnecessary investigations and facilitate prompt management.

The case of the eyelid silicone granulomas

Foreign body granulomas can develop even several years after autologous fat or filler injection. In some instances the foreign body granulomas have been found at sites other than the original injection site. We present a case of a 48-year-old male with reported "hyaluronic acid fillers" injected into his upper and lower eyelids several years prior. He subsequently developed periorbital swelling with negative allergic and rheumatologic workup. The patient ultimately underwent a blepharoplasty for improvement of the swelling. Histopathology suggested silicone granulomas of the upper and lower eyelid. This case illustrates the importance of keeping foreign body granulomas on the differential for all patients with a history of facial dermal filler injections. Although hyaluronic acid is the most common dermal filler, providers should suspect the use of other dermal fillers including those not FDA approved particularly when common conservative treatment methods are not sufficient.

Long-term outcomes of surgically removed migrated polyalkylimide (bio-alcamid) filler to the periorbital area

Purpose

To report the long-term follow-up results after surgical excision of migrated Bio-Alcamid fillers to the Periorbita area.

Methods

A retrospective case series of all patients who underwent surgical removal of migrated Bio-Alcamid fillers to the Periorbita area with minimal follow-up of 1 year from January 2009 to January 2018 was done.

Results

16 female patients (24–52 y) presented with an upper or lower eyelid swelling 3–7 years following a filler injection in the nasal bridge, temporal or malar area. All patients had surgical excision of a granulomatous mass ranging in size from 1–3.5 cm. The histopathology report revealed a giant cell reaction in all patients. Follow–up periods ranged from 1 to 8 years. One patient developed lid retraction and another had recurrence 3 years later; the remaining had an unremarkable course.

Conclusions

Filler migration is one of the potential complications associated with Bio-Alcamid soft tissue injection. It is important for all physicians to assess nodules/masses/swelling in the facial area to be aware that soft tissue fillers may migrate to a location away from their intended site of injection years after the injection. Patients undergoing surgical excision tend to have favorable overall long-term outcomes in terms of aesthetics and incidence of recurrence.

Diagnosis of orbital mass lesions: clinical, radiological, and pathological recommendations

The orbit can harbor mass lesions of various cellular origins. The symptoms vary considerably according to the nature, location, and extent of the disease and include common signs of proptosis, globe displacement, eyelid swelling, and restricted eye motility. Although radiological imaging tools are improving, with each imaging pattern having its own differential diagnosis, orbital mass lesions often pose a diagnostic challenge. To provide an accurate, specific, and sufficiently comprehensive diagnosis, to optimize clinical management and estimate prognosis, pathological examination of a tissue biopsy is essential. Diagnostic orbital tissue biopsy is obtained through a minimally invasive orbitotomy procedure or, in selected cases, fine needle aspiration. The outcome of successful biopsy, however, is centered on its representativeness, processing, and interpretation. Owing to the often small volume of the orbital biopsies, artifacts in the specimens should be limited by careful peroperative tissue handling, fixation, processing, and storage. Some orbital lesions can be characterized on the basis of cytomorphology alone, whereas others need ancillary molecular testing to render the most reliable diagnosis of therapeutic, prognostic, and predictive value. Herein, we review the diagnostic algorithm for orbital mass lesions, using clinical, radiological, and pathological recommendations, and discuss the methods and potential pitfalls in orbital tissue biopsy acquisition and analysis.

A rare case of orbital granulomatous inflammation from explosive hydraulic oil masquerading as orbital cellulitis

The differential diagnosis for acute orbital inflammation is broad. We report a case of granulomatous orbital inflammation due to high-pressure oil injury to the orbit presenting as an atypical orbital cellulitis. Here we review the presentation and treatment of orbital inflammation from oil.

Periocular dermatoses

The periocular area may be affected by infectious or noninfectious diseases such as inflammatory dermatoses, systemic disease, drug reactions, benign and malignant lesions, traumatic lesions, and esthetic complications. We present a review of the most common periocular dermatoses.