Incidence of Vascular Obstruction After Filler Injections

A structured approach with Swiss cheese model to reduce vascular adverse events of filler injections

BACKGROUND

Filler injection is among the most popular nonsurgical aesthetic procedures worldwide. Though relatively noninvasive, filler injection can lead to severe vascular adverse events. Even though the incidence is rare, it may cause devastating and irreversible outcomes. A Swiss cheese model has been widely applied for risk analysis and management approach in medical field.

AIMS

In this review article, we adopt the Swiss cheese model and create a structured approach to prevent severe vascular complications caused by filler injections.

METHODS

We reviewed the current literature regarding the knowledge and techniques of preventing vascular adverse events in the filler injection.

RESULTS

We propose four structured strategies in this model to reduce the risk of severe vascular adverse events of filler injections, including clinical facial anatomy, safe filler injection principles, real time imaging and auxiliary instruments, and implication of checklist.

CONCLUSION

This review provides clinicians a structured approach before and during the filler injection procedure to reduce the risk of vascular adverse events and improve its safety and outcome.

Updated Filler Emergency Kit: Next-Generation Emergency Solution

INTRODUCTION

The rising popularity of facial filler injections has corresponded with an increase in reported complications. While a filler emergency kit was previously introduced, advancements in the field have highlighted certain limitations, prompting the development of the updated filler emergency kit (UFEK).

METHODS

The authors conducted literature research up to February 2023, focusing on PubMed and open web searches for articles referred to filler emergent complications: vascular occlusion, blindness and anaphylaxis. Approximately 1200 articles were obtained from PubMed and other sources, and 45 articles were reviewed.

RESULTS

The developed UFEK protocol delineates specific interventions meticulously tailored to address diverse emergent scenarios linked to soft tissue fillers complications. This protocol emphasizes the urgent requirement for timely and personalized interventions.

CONCLUSION

The UFEK offers a standardized, comprehensive and effective approach. This work contributes to the responsible and informed progression of the field of aesthetic medicine, providing more value and safety, both for clinicians and patients. 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 .

Oops I did it (again): Patient experiences of complications after non-invasive cosmetic procedures

Whereas several quantitative studies have measured the impact of complications after cosmetic procedures on patients' lives, little qualitative research is available. To address this gap, we interviewed 20 patients attending a special filler complication consultation hour in the Netherlands. We conducted a reflexive thematic analysis, which resulted in three main themes: (1) complications: a patient's journey; (2) complications: the impact of procedures gone wrong; and (3) complications: a filler-free future? Throughout the interviews, the multifaceted impact of the complications was illustrated, which ultimately also demonstrated participants' negotiation of (negative) experiences with complications after cosmetic procedures within a neoliberal, consumerist environment. Within this context, particular discourses were advanced as others were obscured and/or rejected. Most significantly, issues of stigmatization and shame were tangible throughout the interviews as participants felt they (must) accept responsibility for the consequences of their own consumerist decision to undergo cosmetic procedures. Moreover, the participants' decision to undergo further cosmetic procedures after their complication illustrate the normality, or even normativity, of contemporary beauty practices. A final note regards some important implications for the industry in relation to providing adequate complication care.

Periorbital venous stasis may be involved with filler induced malar edema-A duplex ultrasound-imaging-based case series

INTRODUCTION

Filler injections in the periocular region are regarded as a challenging and advanced maneuver in a high-risk area. Adverse events as malar edema due to filler treatment may occur. To evaluate the possible reasons, the ultrasound images, and medical data of patients that were prospectively referred with malar edema were evaluated.

MATERIALS AND METHODS

A total of 17 patients (26 eyes) with malar edema after hyaluronic acid filler treatment were included. All cases were assessed with an 18 MHz linear ultrasound device. Exact location of the filler material was noted. Relations with clinical data were analyzed using chi-square tests.

RESULTS

Onset of malar edema after treatment showed a wide range from immediate (0 days) to 3 years. Most patients had an early onset N = 13 (76%), a minority showed late onset N = 4 (24%). In 23 eyes, the filler material was found to be located inside the SMAS. In 3 cases filler material was located on the periosteum of the orbital rim. After duplex-ultrasound guided filler removal, restored venous flow could be seen in the superficial and/or deep fatty layer often accompanied by flow piercing through the SMAS. Minutes after treatment, clinical improvement of malar edema was observed.

CONCLUSION

Malar edema after by filler treatments in the periocular region may be caused by veno-lymphatic compression by filler deposits.

Retrospective Study of Vascular Complications Caused by Hyaluronic Acid Injection

BACKGROUND

Complications from intravascular embolization of hyaluronic acid (HA) are not only no longer uncommon but also devastating. This study aimed to examine clinical aspects of patients referred to our hospital for care following complications from intravascular filler embolization.

METHODS

We retrospectively reviewed data from all patients referred to our medical center for the management of complications associated with intravascular embolization of HA fillers including demographics, medical history, clinical features, and treatment between November 2013 and June 2022.

RESULTS

A total of 116 patients with vascular complications (27 cases with vision loss and 89 cases with skin necrosis) were assessed. The highest risk injection sites for skin necrosis included the nasal region (58/115, 50.4%), temple (16/115, 13.9%), and forehead (11/115, 9.6%) and for vision loss included the nasal region (18/30, 60.0%) and forehead (7/30, 23.3%). In skin necrosis cases, a needle (60/89, 67.4%) carried a higher risk than that of a cannula (29/89, 32.6%), whereas in vision loss cases, nasal dorsum injections using a cannula (16/27, 59.3%) carried a higher risk than that observed using a needle (11/27, 40.7%). No treatment was completely successful in reversing these complications.

CONCLUSION

Intravascular embolization of HA filler is a serious complication. Although some combination treatments have been proposed, there is no standard protocol for treating severe complications.

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 http://www.springer.com/00266 .

Investigating the Anatomic Location of Soft Tissue Fillers in Noninflammatory Nodule Formation: An Ultrasound-Imaging-Based Analysis

INTRODUCTION

Noninflammatory nodules may be persistent to dissolve. To evaluate the possible reasons, a case series of ultrasound images and medical data of patients who were prospectively referred with noninflammatory nodules were evaluated.

MATERIALS AND METHODS

A total of 27 patients with nodules but without signs of inflammation were included. All cases were assessed with an 18-MHz linear ultrasound device. Exact location of the filler material was noted. Relations with clinical data were analyzed using chi-square tests.

RESULTS

Early onset of complaints (<2 weeks) was found in 16 patients and late onset (>2 weeks) in 11. All patients had multiple nodules. In all cases, the filler nodule was found to be located inside the fascia. Extension to the subcutaneous tissue was seen in 8 cases and to the deeper planes in 5. In 14 cases, the filler material was completely located inside layers of the fascia, and migration was observed in 5 cases.

DISCUSSION

Accumulation of filler material in the superficial musculoaponeurotic system or fascia may be an important cause for the occurrence of persistent noninflammatory nodules, either by initial faulty injection technique or by later accumulation through the pathway generated with a needle or cannula. Ultrasound-guided injections are helpful to dissolve the nodule.

Use of the high-dose pulsed hyaluronidase protocol in the management of impending skin necrosis associated with hyaluronic acid fillers: a systematic review

Impending skin necrosis resulting from inadvertent intravascular injection of hyaluronic acid (HA) fillers can lead to tissue loss and significant scarring. In recent years, management trends have shifted from multimodal approaches to the sole use of high doses of hyaluronidase. The aim of this systematic review was to evaluate the effectiveness of the high-dose pulsed hyaluronidase management protocol in preventing skin necrosis and possible subsequent scarring. An online search of the bibliographic databases PubMed and Embase yielded 3039 articles. A total of 72 studies reporting 186 cases were found to be eligible for inclusion. The selection and evaluation process was done according to the PRISMA criteria. Included studies were assessed using the JBI and STROBE critical appraisal tools. The analysis of treatment outcomes was done according to the timing of treatment initiation and the type of intervention used. This review found that an immediate intervention using the high-dose pulsed hyaluronidase management protocol provided predictable and satisfactory outcomes. Initiating the protocol within 24 h of filler injection halted the progression of necrosis and prevented permanent sequelae. The conclusions are limited by the lack of a high level of evidence, since the only available sources of data are case reports and case series.

The growing importance of ultrasonography in cosmetic dermatology: An update after the 23rd IMCAS Annual World Congress (2022)

BACKGROUND

Ultrasound (US) has been used for many years in the field of medicine. Many specialties have embraced US as a quick, painless, and relatively inexpensive tool to assist the clinician in determining anatomy, pathology, and aid in diagnostic or therapeutic procedures. US allows for precise mapping of cutaneous and subcutaneous structures in the face, in particular vascular structures. The use of US leads to reduced chances of complications and clinical failures, rendering more safety and high quality.

METHODS

US is considered the first-imaging technique for dealing with fillers and managing their potential complications. US can be deployed for vascular mapping, safe placement of fillers, and directed low-dose hyaluronidase reversal of vascular adverse events. It is a noninvasive imaging modality that provides a good definition for studying the skin, deeper layers, and blood flow in real time. In other words, we go from static to dynamic anatomy. In addition, US can guide with the application of botulinum toxin, in order to define the muscular planes. US may contribute to a more personalized procedure, better cosmetic results, and help to avoid complications. In general, physicians tend to use it for prevention. Last, for research purposes, US examination provides valuable information on the behavior, longevity, and interaction of the filler within the tissues.

CONCLUSION

This new approach for US-guided treatments is a very practical and an effective method in cosmetic dermatology. As doctors, we owe it to our patients to do our best to prevent any harm. We feel that in near future, US will be an essential diagnostic tool in any dermatology or cosmetic doctor's office to both ensure safety and provide legal protection for the professional.

Bridging a Century-Old Problem: The Pathophysiology and Molecular Mechanisms of HA Filler-Induced Vascular Occlusion (FIVO)-Implications for Therapeutic Interventions

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.

Superselective Ophthalmic Artery Thrombolytic Therapy for Hyaluronic Acid Embolization: A Case Report

Blindness caused by embolization of fillers is a rare but catastrophic complication after cosmetic injection. Vision improvement is rarely reported among the various studies on potential clinical treatments. In this case, the patient suffered from ophthalmic artery occlusion with no light perception 48 h after hyaluronic acid injection. After two intra-arterial thrombolytic therapy sessions and traditional sequential therapy, ocular appearance was restored to normal, blood supply to the retina and visual function were improved, and visual acuity was restored to hand motion levels. Our results suggest that intra-arterial thrombolytic therapy with hyaluronidase and papaverine has a positive effect on hyaluronic acid-induced visual loss and is worthy of clinical promotion.

Hyperbaric Oxygen Therapy in Managing Minimally Invasive Aesthetic Procedure Complications: A Report of Three Cases

Introduction

Minimally invasive aesthetic procedures such as filler injections and thread lifts have gained popularity recently. Complications from these aesthetic procedures are difficult to avoid. This increasing public health concern requires a combination of effective therapeutic modalities. Hyperbaric oxygen therapy (HBOT) has generated favorable results in treating a diversity of wounds, inflammation, and infection.

Case Presentations

Three cases with complications arising from aesthetic procedures were described in this report. The patients were all female, with ages ranging from the late-twenties to mid-fifties. Two patients experienced complications from filler injections, one of which progressed to a parotid gland infection due to a placental extract filler while the other was caused by a hyaluronic acid filler. The third patient had notable excoriations and inflammation on both cheeks following a thread lift procedure. Alongside antibiotics and other symptomatic therapies, the patients received multiple, 90-minute HBOT sessions at 2.4 ATA over the course of one to two weeks. The wounds were frequently monitored to evaluate the healing progress.

Discussion

Complications from facial rejuvenation procedures can be disastrous. They expose the patient to the risk of developing vascular occlusions and skin infections that require prompt and effective treatment. Multiple treatment options (eg, frequently massaging the affected area, warm compresses, aspirin, and antibiotics) have been used to treat these complications. HBOT serves a valuable purpose in restoring adequate tissue perfusion in cases of filler-induced vascular occlusion and infection. Moreover, HBOT assists in restoring tissue injury and reducing inflammation following thread lift procedures.

Conclusion

HBOT has proven helpful as a treatment adjunct toward counteracting the effects of minimally invasive aesthetic procedures in several cosmetic-related cases.