Avoiding and Treating Blindness From Fillers: A Review of the World Literature

Morphological and functional abnormalities of ophthalmic artery in patients with ophthalmic vascular accidents

Background

By observing and comparing the morphological and functional differences of the ophthalmic artery (OA) in patients with ocular vascular accidents (OVAs) due to iatrogenic embolism or non-iatrogenic occlusion, we propose a classification system based on the characteristics of OA on invasive digital subtraction angiography (DSA).

Methods

All patients undergoing ophthalmic arterial DSA within 1 week after the OVAs between January 2017 and December 2021 were enrolled and divided into different types, and the differences between iatrogenic embolism and non-iatrogenic occlusion categories were compared.

Results

A total of 27 eyes of 27 patients were included in this study. Based on the results of carotid/intracranial arterial DSA, the morphological and functional abnormalities of OA with OVAs can be divided into five types. The proportion of males (7.14%), ocular ischemic syndrome (OIS) (0.00%) and neovascular glaucoma (NVG) (0.00%) in the iatrogenic embolism category was significantly lower than that (84.62, 61.54, and 69.23%, respectively) of the non-iatrogenic occlusion category (p < 0.001, p = 0.001, p < 0.001, respectively). However, the proportion of no light perception (NLP) (100%), anterior segment ischemia (ASI) (71.43%), and orbital involvement (ophthalmoplegia and ptosis, 42.86%) eventually occurring in the former was significantly greater than that in the latter (23.08, 0.00, 0.00%, respectively) (p < 0.001, p < 0.001, p = 0.010, respectively).

Conclusion

Ocular vascular accidents can be divided into five types based on the characteristics of OA on DSA.

Arterial Vascularization of the Forehead in Aesthetic Dermatology Procedures: A Review

Background: The growing popularity of aesthetic procedures on the face raises the question of their safety. The forehead region is crucial aesthetically, but due to its abundant vascularization, it is also one of the most dangerous areas for dermatologic procedures, especially in the glabella area. The purpose of this article is to review the literature on the arterial vascularization of the forehead to identify potential high-risk zones for aesthetic dermatology procedures. Methods: A database search (PubMed, Web of Science, Scopus, and Embase) was conducted, and the titles and abstracts of all identified studies were screened, followed by full-text evaluation. Results: We identified 714 articles during the database search, and 25 articles were included in the review. The included studies used cadaveric dissection and computed tomography applied to cadavers as well as Doppler ultrasonography on volunteers to evaluate the forehead arteries (supratrochlear (STrA), supraorbital (SOA), central (CA), paracentral artery (PCA), and frontal branch of superficial temporal artery(FBSTA)). A total of 1714 cases involving the forehead arteries were analyzed. The included arteries were observed over a relatively large area, and their locations varied. The CA and PCA in cadaver studies were observed in an area of 0.2 to 10.8 mm and 0.8 to 16.2 mm, respectively, on the entire path from the glabellar point to the frontal prominence point. The distances from the midline in cadaveric studies at various measurement points ranged from 0.6 to 28.0 mm for the superficial branch of the STrA and 13.6 to 40.7 mm for the deep branch of STrA. In case of SOA, the distance from the midline ranged from 23 to 32 mm. Measurements from the midline in Doppler studies ranged from 0 to 23 mm for STrA and from 10 to 50 mm for the SOA. In studies using computed tomography, STrA was observed at a distance of 11 to 21 mm and the SOA at a distance of 21 to 32 mm, both lateral to the midline. Conclusions: Medical professionals should be aware of zones where frontal arteries are more likely to be encountered. The glabella region appears to be one of the most dangerous areas for dermatologic procedures. It is believed that the supratrochlear, supraorbital, and the paracentral arteries may cause ophthalmic complications due to occlusion of the ophthalmic artery, while this risk for the frontal branch of the superficial temporal artery seems to be low but cannot be completely excluded.

Adverse Effects Associated with Dermal Filler Treatments: Part II Vascular Complication

Vascular complications arising from dermal filler treatments pose significant risks, including ischemia, tissue necrosis, and severe outcomes like blindness and pulmonary embolism. This study investigates the mechanisms of vascular complications, categorizing them into extravascular compression and intravascular emboli. Extravascular compression occurs when injected fillers compress adjacent blood vessels, leading to ischemia and potential necrosis, while intravascular emboli result from fillers entering blood vessels, causing blockages. The study emphasizes the importance of anatomical knowledge, careful injection techniques, and early intervention. Management strategies include the use of hyaluronidase to dissolve HA fillers, vasodilators to improve blood circulation, and hyperbaric oxygen therapy. The regions most susceptible to complications align with major arterial pathways, particularly the nasolabial folds and nasal region. The study also highlights the need for meticulous injection techniques, the use of cannulas over needles in high-risk areas, and the aspiration test to detect vessel penetration. Early detection and immediate intervention are crucial to mitigate adverse outcomes. Continuous education and training for practitioners, along with advancements in filler materials and injection methods, are essential for improving the safety of cosmetic procedures. This comprehensive understanding aids in preventing and managing vascular complications, ensuring better patient outcomes. The field of dermal filler treatments is advancing with new techniques and technologies, such as High-Resolution Ultrasound, Infrared Imaging, self-crossing hyaluronic acid filler, biodegradable microspheres, and microinjection.

Safe Zones for Facial Fillers: Anatomical Study of SubSMAS Spaces in Asians

The study "Spaces of the Face for Filler Procedures: Identification of subSMAS Spaces Based on Anatomical Study" explores the anatomy of facial spaces crucial for safe and effective filler injections. By delineating the subSMAS (sub-superficial musculoaponeurotic system) spaces, this research highlights how these virtual compartments, bordered by fat, muscles, fascia, and ligaments, facilitate independent muscle movement and reduce the risk of damaging critical structures. The thicker and more robust skin of East Asians necessitates deeper filler injections, emphasizing the significance of accurately identifying these spaces. A cadaver study with dyed gelatin validated the existence and characteristics of these subSMAS spaces, confirming their safety for filler procedures. Key spaces, such as the subgalea-frontalis, interfascial and temporalis, and prezygomatic spaces, were examined, illustrating safe zones for injections. The findings underscore the importance of anatomical knowledge for enhancing facial aesthetics while minimizing complications. This study serves as a guide for clinicians to perform precise and safe filler injections, providing a foundation for further research on the dynamic interactions of these spaces and long-term outcomes.

Aesthetic Temporal Augmentation with the Pedicled Temporoparietal Fascia Flap

INDRODUCTION

The contour of the temple area can significantly influence the overall facial shape and proportions. To date, various methods and techniques have been used to augment the deficient temporal fossa; however, each of these approaches has certain inherent limitations. The present study aimed to transfer the temporoparietal fascia flap (TPFF) to the frontotemporal regions for aesthetic temporal augmentation.

METHODS

This was a retrospective study of 13 cases with temporal depression who underwent a TPFF procedure for aesthetic temporal augmentation. These cases were operated for three years, from January 1, 2020, to December 1, 2023, at Nanjing Second Hospital, Nanjing, China.

RESULTS

The data of bilateral temple width showed a measurement of 12.20 ± 0.53 cm (preoperative) and 14.36 ± 0.41 cm (postoperative), with a statistically significant difference (p < 0.001). There were no postoperative complications, including hematomas, infection, or facial nerve injuries. All patients were followed for 6 to 48 months (mean: 18 months) and exhibited cosmetic improvement. Overall, 10 patients were satisfied with the aesthetic results, while 3 were unsatisfied due to undercorrected depression. During the follow-up period, the temple volume was maintained. The frontal temple exhibited a smooth contour, and scalp baldness at the incision site was inconspicuous.

CONCLUSIONS

Compared with other methods, the pedicled TPFF flap transfer is a safe and effective technique for correcting depressions in the frontotemporal regions.

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 .

"Filler-Associated Acute Stroke Syndrome": Classification, Predictive Modelling of Hyaluronidase Efficacy, and Updated Case Review on Neurological and Visual Complications

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 .

Three-Dimensional Location of the Facial Artery in Relation to the Nasolabial Fold in Asian People: A Cadaveric CTA Study

BACKGROUND

Injection cosmetics have become popular in recent years. The nasolabial fold is one of the most important and dangerous regions in the midface, and its three-dimensional relationship with the facial artery remains unclear.

METHODS

Fifty-two cadavers infused with lead oxide contrast medium via the external carotid arteries were scanned by computed tomography (CT). The three-dimensional model was reconstructed using Mimics and Origin software, and the relevant data were calculated using validated algorithms.

RESULTS

There were three facial artery types according to its course in relation to the nasolabial fold. In the most common type, accounting for 83.7% of specimens, the facial artery evolves into an angular artery, with a horizontal distance between facial artery and nasolabial fold of - 1.90 ± 2.40, - 3.90 ± 2.95, - 5.18 ± 3.42, - 5.59 ± 3.53, - 5.59 ± 3.83, - 6.07 ± 4.10, - 6.92 ± 3.70, - 6.79 ± 3.37, - 4.52 ± 3.20, and - 2.76 ± 3.60 (mm) from the nasal ala to the oral commissure and a vertical distance of - 4.03 ± 2.56, - 3.27 ± 2.27, - 2.81 ± 2.57, - 2.1 ± 2.64, - 1.5 ± 3.32, - 0.71 ± 3.99, 0.92 ± 4.43, 0.4 ± 5.31, - 4.14 ± 5.14, - 7.05 ± 4.74 (mm).

CONCLUSIONS

The facial artery is vulnerable to damage when injecting filler in the nasolabial fold. For the upper 1/3 of the nasolabial fold, the supraperiosteal layer is recommended for injection, while for the lower 2/3 of the nasolabial fold, the dermal layer along the nasolabial fold is recommended.

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 .

Ultrasonographic Evaluation of Facial Artery in the Nasolabial Fold for Gender Differences and Symmetry Between Hemifaces

OBJECTIVES

The aim of this study was to establish the relationship of facial artery with nasolabial fold by color Doppler sonography and to determine facial artery variations and their relationship with age, gender, or hemifaces.

METHODS

The study included 188 patients (94 women, 94 men) aged 18-60 years. Overall, 376 facial arteries in both hemifaces were evaluated for the course within nasolabial fold, symmetry, and relationship with gender.

RESULTS

The mean age of the patients was 39.29 ± 12.81 years. Type A (55.7%) was the most common type in both hemifaces. There was no significant relationship between the course of facial artery and age (P > .05). Asymmetrical course of facial artery was more common in females (54.3%). In both genders, type A was the type with highest symmetry detected.

CONCLUSIONS

Nasolabial fold is one of the important facial regions for filler injection. To prevent vascular injection, course of facial artery should be identified within the nasolabial fold. Type A was the most common type in both hemifaces and genders. Although the rates were close to each other, asymmetry in the course of the facial artery was observed in most of the patients. Ultrasonographic examination which is non-invasive and non-ionizing imaging method can be performed carefully before filler injection to determine vascular tissues.

Orbital compartment syndrome following tear trough filler injection

A patient was treated with tear trough filler and developed a retrobulbar haemorrhage. This was managed acutely with a lateral canthotomy and cantholysis with no lasting visual compromise. This is the first reported case of an orbital compartment syndrome following filler injection and highlights the potential blinding complications which can occur. There should be an increased awareness of this complication amongst practitioners administering tear trough filler.

Resolve and dissolve-An ultrasound-guided investigation on the effects of hyaluronidase on different soft tissue fillers

BACKGROUND

Nonsurgical cosmetic procedures, particularly the use of hyaluronic acid (HA)-based soft tissue fillers, are becoming increasingly popular. This trend has catalyzed the development of a plethora of HA-based products differing in product characteristics, thereby catering to an ever-widening spectrum of aesthetic applications. However, complications rise concomitant with the increasing number of procedures. Among the strategies to manage such adverse events is the enzymatic breakdown with hyaluronidase.

OBJECTIVE

To analyze the response of different HA-based soft tissue filler materials to hyaluronidase injections.

METHODS

A total of 11 different HA-based soft tissue fillers were evaluated using noninvasive ultrasound imaging to assess their behavior in response to hyaluronidase injections. The HA-based soft tissue fillers were categorized according to their product characteristics into a structuring, volumizing, and lip volumizing group. Standardized injections of 0.2 cc were performed in chicken breast to simulate human tissue. Ultrasound measurements of width, height, and calculated volume were performed immediately after filler injection, 1 h and 24 h following hyaluronidase injection.

RESULTS

Regardless of the soft tissue filler analyzed, the most significant volume reduction occurred within the first h after applying hyaluronidase, with a 64.1% decrease from the initial volume. After 24 h, the total volume reduction reached 81.7%. No statistically significant differences were found when comparing the three groups at each follow-up time period, except for the height measurement after 1 h. While width was statistically significant in all groups between the investigated follow-up groups, the volume reduction was only statistically significant in the groups with the highest and second highest G' values (i.e., Group 1-structuring, Group 2-volumizing).

CONCLUSION

The effectiveness of hyaluronidase in dissolving HA-based fillers is initially independent of product characteristics of HA-based fillers such as G-prime, with increased efficacy in fillers with higher G-prime values, as evidenced by significant volume reductions in such groups.

Course and Relation of the Facial Vessels-An Anatomical Study

Background and Objectives: Facial vascular anatomy plays a pivotal role in both physiological context and in surgical intervention. While data exist on the individual course of the facial artery and vein, to date, the spatial relationship of the vasculature has been ill studied. The aim of this study was to assess the course of facial arteries, veins and branches one relative to another. Materials and Methods: In a total of 90 halved viscerocrania, the facial vessels were injected with colored latex. Dissection was carried out, the relation of the facial vessels was studied, and the distance at the lower margin of the mandible was measured. Furthermore, branches including the labial and angular vessels were assessed. Results: At the base of the mandible, the facial artery was located anterior to the facial vein in all cases at a mean distance of 6.2 mm (range 0-15 mm), with three cases of both vessels adjacent. An angular vein was present in all cases, while an angular artery was only present in 34.4% of cases. Conclusions: The main trunk of the facial artery and vein yields a rather independent course, with the facial artery always located anterior to the vein, while their branches, especially the labial vessels, demonstrate a closer relationship.

Anatomy of the temporal region to guide filler injections

Hollow temples are not typically considered aesthetically pleasing, and hollowness worsens with the aging process. When filling this region with fillers, there are several anatomical considerations, with injection techniques varying depending on the layer targeted. Specifically, injections between the superficial temporal fascia and the superficial layer of the deep temporal fascia are performed using a cannula, while periosteal layer injections involve the use of a needle to reach the bone before inserting fillers. Detailed anatomical insights encompass the boundaries of the temporal fossa and cautionary notes regarding blood vessels, supported by specific studies on veins and arteries in the temporal region. Complications, including vessel injuries, are discussed alongside an exploration of various injection techniques. This review provides a comprehensive exploration of anatomical considerations and the specific methodologies employed in temple augmentation with fillers.

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

Consideration of the diameter of superficial temporal arteries related to filler injections in the temporal region

BACKGROUND

The concavity of the temple due to adipose tissue atrophy from aging accentuates the zygomatic arch and lateral orbital rim, leading to an aged appearance. The use of hyaluronic acid filler in the temporal region has gained popularity due to its procedural simplicity and consistent outcomes.

OBJECTIVE

To evaluate the safety of administering hyaluronic acid filler in the temporal region concerning the frontal branch of the superficial temporal artery, which is at risk of injury.

METHODS

Empirical observations were conducted on the internal diameter of the frontal branch of the superficial temporal artery, a critical anatomical site for potential injury.

RESULTS

A significant proportion of the artery segments exhibited an internal diameter below 1 mm. Given that the outer diameter of an 18-gauge cannula is 1.27 mm, this method can be considered a relatively secure approach for enhancing the temporal region.

CONCLUSION

The use of an 18-gauge cannula for hyaluronic acid filler administration in the temporal region appears to be a safe and effective method, with the potential risk to the frontal branch of the superficial temporal artery being minimal.

Causes and management of sight threatening complications of dermal filler injections: A review

Injectable dermal fillers continue to increase in popularity in aesthetic medicine. Although rare, vision loss secondary to filler injections is a devastating complication associated with a poor visual prognosis. The mechanism for vision loss is thought to be related to retrograde embolization of the dermal filler from peripheral vessels in the face into the ophthalmic arterial system. Early recognition and prompt management are essential if vision is to be salvaged. The use of retrobulbar hyaluronidase is still contentious, however when administered by a specialist, this treatment gives the best chance at visual recovery and should be considered for all 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.

Why Do Nasolabial Folds Appear? Exploring the Anatomical Perspectives and the Role of Thread-Based Interventions

The classification of nasolabial folds into three types, each with distinct causative factors and mechanisms, is explored. Age-related changes in facial skin and connective tissues are examined in detail, revealing variations across different facial regions due to variances in tissue firmness and thickness. The innovative 'Reverse Technique,' involving cog threads to enhance tissue traction and effectiveness in thread-lifting procedures, is introduced. Detailed technical guidelines, anatomical considerations, and safety measures are provided, emphasizing the importance of identifying optimal vectors and fixing points to achieve maximum lifting effects while minimizing potential risks, particularly those associated with vascular structures. Additionally, the 'Cross Technique using volumizing thread' is discussed, designed to smooth tissue boundaries and rejuvenate sagging areas. Facial anatomy, including the positioning of arteries and ligaments, is underscored as essential for ensuring the safety and efficacy of procedures. In conclusion, this review stands as a comprehensive guide for practitioners, offering insights into innovative thread-lifting methods and their applications in addressing nasolabial folds. The primary focus is on achieving optimal aesthetic results while prioritizing patient safety.

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 .

Laser Speckle Contrast Imaging Guides Needling Treatment of Vascular Complications from Dermal Fillers

BACKGROUND

Although laser Doppler imaging (LDI) accurately delineates a hypoperfused area to help target hyaluronidase treatment, laser speckle contrast imaging (LSCI) is more appropriate for assessing microvascular hemodynamics and has greater reproducibility than LDI. This study investigated the use of LSCI in the evaluation and treatment of six patients who developed vascular complications after facial dermal filler injections.

METHODS

The areas of vascular occlusion were accurately defined in real time by LSCI and were more precise than visual inspections or photographic evidence for guiding needling and hyaluronidase treatment.

RESULTS

All patients had achieved satisfactory outcomes as early as Day 2 of treatment and no procedure-related complications were reported after a median follow-up of 9.5 (7-37) days.

CONCLUSION

LSCI accurately and noninvasively delineated vascular occlusions in real time among patients experiencing complications of facial dermal filler injections. Moreover, LSCI was more accurate than visual and photographic evaluations. Clinicians can use LSCI to reliably follow-up therapeutic outcomes after salvage interventions for vascular occlusions.

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 .

Disastrous cerebral and ocular vascular complications after cosmetic facial filler injections: a retrospective case series study

Soft tissue filler injections are among the most popular facial rejuvenation methods. Cerebral infarction and ophthalmic artery occlusion are rare and catastrophic complications, especially when facial cosmetic fillers are injected by inexperienced doctors. Radiologists and plastic surgeons need to increase their awareness of the complications associated with fillers, which allows early diagnosis and intervention to improve patient prognosis. Regarding the mechanism by which vascular occlusion occurs after facial filler injections, a retrograde embolic mechanism is currently the predominant theory. Numerous case reports have been presented regarding complications associated with injections of facial aesthetics. However, the small sample sizes of these studies did not allow for an adequate assessment of the clinical and imaging manifestations based on the location of the occlusion and the type of filler, and detailed elaboration of multiple cerebral infarctions is also lacking. Therefore, this study aimed to investigate the clinical and radiological features of severe cerebral and ocular complications caused by cosmetic facial filler injections. In addition, we discuss the pathogenesis, treatment, and prognosis of these patients. The clinical, computed tomography (CT), magnetic resonance imaging (MRI), and digital subtraction angiography (DSA) findings were described and analysed. Radiological examinations are crucial for demonstrating severe complications, and brain MRI is especially strongly suggested for patients with cosmetic filler-induced vision loss to identify asymptomatic cerebral infarctions. Extreme caution and care should be taken during facial injections by plastic surgeons.

The Research Trend of Soft Tissue Filler Injection from 2000 to 2022: A Bibliometric and Visualized Analysis

Background

The demand for soft tissue filler injections has experienced a significant increase in recent years. Therefore, this study used bibliometric analysis to identify prominent research areas and emerging trends within the field.

Methods

Publications concerning research on soft tissue filler injections were collected from the Web of Science Core Collection database. Subsequently, VOSviewer 1.6.18 and CiteSpace 6.2.R4 software were used to analyze the co-authorship, co-occurrence, and citations of countries, institutions, authors, hotspot keywords, and journals associated with these studies.

Results

A total of 1370 records pertaining to filler injection research conducted between 2000 and 2022 were identified. The United States (524 publications) emerged as the country with the highest number of publications in this field, with Mayo Clinic (37 publications) making the most substantial contribution. Dermatologic Surgery emerged as the leading journal in this field, publishing the highest number of research articles (151 publications) and also being the most frequently co-cited. Cotofana proved to be the most prolific author with 51 publications, and Lemperle emerged as the most frequently co-cited author with 628 citations (including total link strength: 6587). The most popular keywords, in descending order of popularity, were "dermal filler," "injection," "soft-tissue augmentation," "complications," and "hyaluronic acid."

Conclusions

The findings of this study offer a comprehensive overview of the main directions in filler injection research. Furthermore, they underscore the imperative of intensifying efforts to prevent complications linked to filler injections.

Adverse Events Associated with Hyaluronic Acid Filler Injection for Non-surgical Facial Aesthetics: A Systematic Review of High Level of Evidence Studies

BACKGROUND

Hyaluronic acid (HA) dermal fillers are widely used in aesthetic medicine. While generally safe, potential complications can arise.

OBJECTIVE

This systematic review aims to identify and classify potential complications linked to the use of HA dermal fillers, as informed by high-quality, low-risk-of-bias studies.

METHODS

This review follows the Cochrane review standards for clinical systematic reviews. This systematic review analyzed 48 high level of evidence studies on the use of hyaluronic acid (HA) dermal fillers in non-surgical facial aesthetics and the adverse events that occurred.The inclusion criteria were randomized control studies on HA dermal fillers and their complications. Excluded were case reports, case series, observational studies, and other non-randomized research due to their inability to provide generalized conclusions and their inherent publication bias.

RESULTS

Adverse events were classified into three categories: expected reactions, product or technique-related adverse events, and severe adverse events. Most adverse events were short-lived injection site reactions, which resolved spontaneously. Specific HA fillers and injection techniques influenced the occurrence of adverse events, which generally resolved within weeks without treatment. Severe adverse events were rare, persisting for months and requiring active medical intervention.

DISCUSSION

This classification system can enhance understanding, prevention, and treatment of HA filler complications, and support patient education. The common complications were injection site reactions, with persistent symptoms treated with topical steroids, NSAIDs, or hyaluronidase. Severe complications included severe edema, angioedema and others, often necessitating specific treatments.

CONCLUSION

HA dermal fillers are generally safe and effective, with most adverse events being transient and mild to moderate in severity. Severe adverse events, although rare, do occur and are generally non-treatment related. Informed consent, patient education, and professional training are crucial for safe and successful outcomes. Level of Evidence II 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 .

The Needle Versus Cannula Debate in Soft Tissue Augmentation

In recent years, injectables have become increasingly popular in cosmetic procedures. The choice between using a needle or a cannula depends on several factors, including the site of injection, the filler type, the patient's preferences, and the practitioner's skills. Although needles are easy to use, cost-effective, and best for treating superficial rhytids, they may cause tissue injury. Cannulas are safer, particularly when injecting deep to the bone, and can provide more even distribution of filler material when filling large zones. An in-depth understanding of the facial anatomy and ongoing training are crucial for practitioners to develop and improve technical abilities.

Cosmetic Filler-Induced Vascular Occlusion: A Rising Threat Presenting to Emergency Departments

Vascular emergencies from cosmetic filler-induced vascular occlusion represent an iatrogenic etiology that poses a threat to patients, with sequelae that range from disfiguring skin necrosis to blindness and stroke. As cosmetic fillers continue to grow in popularity, the importance of early identification, triaging, and management of these rare but potentially disabling injuries has motivated efforts to educate the public and professional audiences. In this practice review article, we outline components of acute care pertaining to these injuries based on evolving practice guidelines and best evidence recommendations.

[Effectiveness and interest of retrobulbar hyaluronidase injections in the treatment of blindness complicating facial hyaluronic acid injections: A literature review]

INTRODUCTION

Hyaluronic acid injections are becoming increasingly common among both the general public and the medical community, but they are not without risks. The occurrence of blindness, although rare, is a tragic event for both the patient and the practitioner. One of the treatments proposed in the literature is to inject hyaluronidase as close as possible to the site of ischemia, retrobulbarly. The aim of our study is to evaluate the effectiveness and potential benefits of retrobulbar hyaluronidase injections.

MATERIALS AND METHODS

A literature review was conducted using the PubMed database. Only articles addressing retrobulbar hyaluronidase injections for the treatment of blindness following hyaluronic acid injections were included.

RESULTS

We identified 12 case reports or series, comprising a total of 16 patients. Among these 16 patients, 3 regained their vision. Hyaluronidase was injected between 20minutes and 7days after the onset of the complication, with injected doses ranging from 3×150IU to 3×1500IU.

DISCUSSION

Literature reveals only 3 cases of successful treatment out of the 16 reported injections. The time interval before retrobulbar injection, as well as the dose and the experience of the injecting practitioner, may influence the success rate of this treatment. Other treatments, such as intravascular hyaluronidase injections, remain to be explored.

Does injecting small amounts of fillers prevent the development of secondary blindness?

INTRODUCTION

Inadvertent entry of filler products into the supratrochlear, supraorbital, or dorsal nasal arteries, among other branches of the ophthalmic artery, might result in an immediate and devastating loss of vision. We wanted to examine how much filler could block the ophthalmic artery.

MATERIALS AND METHODS

Twenty-nine fresh cadavers were examined. We exposed the arterial supply to the opthalmic artery by dissecting the orbital area. Thereafter, 17 filler injections were introduced into the supratrochlear, supraorbital, and dorsal nasal arteries each. The amount of filler injection that completely blocked the ophthalmic artery was measured. Additionally, one of the head specimens was processed using phosphotungstic acid-based contrast enhancement micro-computed tomography to analyze each arteries to obstruct its whole ophthalmic artery.

RESULTS

The supratrochlear, supraorbital, and dorsal nasal arteries had mean volumes in milliliter (mean ± standard deviation) of 0.0397 ± 0.010 mL, 0.0409 ± 0.00932 mL, and 0.0368 ± 0.00732 mL, respectively. However, the arteries did not differ significantly.

CONCLUSION

Even a modest amount of filler injection can completely block the ophthalmic artery, resulting in visual loss.

Arterial Embolism After Facial Fat Grafting: A Systematic Literature Review

BACKGROUND

While autologous fat grafting of the face is considered a generally safe procedure, severe complications such as arterial embolism (AE) have been reported.

OBJECTIVE

To summarize data on injection-related visual compromise, stroke, and death caused by arterial embolism after facial fat transplantation.

MATERIALS AND METHODS

Plastic surgery societies were contacted for reports on AE after autologous facial fat injection. In addition, a systematic literature review was performed. Data extracted included study design, injection site/technique, symptoms, management, outcome, and etiology.

RESULTS

61 patients with a mean age of 33.56 ± 11.45 years were reported. Injections targeted the glabella or multiple facial regions (both n = 16/61, 26.2%) most commonly, followed by injections in the temples (n = 10/61, 16.4%) and the forehead (n = 9/61, 14.8%). The mean volume injected was 21.5 ± 21.5 ml. Visual symptoms were described most frequently (n = 24/58, 41.4%) followed by neurological symptoms (n = 20/58, 34.5%), or both (n = 13/58, 22.4%). Ophthalmic artery (OA, n = 26/60, 43.3%), anterior or middle cerebral artery (CA, n = 11/60, 18.3%) or both (n = 14/60, 23.3%) were most frequently occluded. Outcome analysis revealed permanent vision loss in all patients with OA occlusion (n = 26/26, 100%), neurological impairment in most patients with CA occlusion (n = 8/10, 80%), and vision loss in most patients suffering from both OA and CA occlusion (n = 7/11, 63.6%). Six patients died following embolisms.

CONCLUSIONS

AE causes severe complications such as blindness, stroke, and death. Due to a lack of high-quality data, no evidence-based treatment algorithms exist. To increase patient safety, a database collecting cases and complications should be established.

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 .

Iatrogenic ophthalmic artery occlusion after platelet-rich plasma dermal filler documented with ultra-widefield imaging

PURPOSE

To report a case of iatrogenic ophthalmic artery occlusion (OAO) secondary to platelet-rich plasma (PRP) dermal filler injection for facial rejuvenation documented with ultra-widefield imaging.

METHODS

Case report.

RESULTS

A 45-year-old woman developed a sudden and painful vision loss in the left eye (LE) after a dermal filler injection of PRP in the left glabellar region. She immediately received intravenous corticosteroids with no improvements. Two weeks later a complete ophthalmological examination including visual acuity (VA), fundus examination, ultra-widefield fundus autofluorescence and fluorescein angiography, and optical coherence tomography was performed. A diagnosis of iatrogenic OAO in the LE with profound ocular ischemia was made and VA remained no light perception. Monthly follow-up visits were scheduled to ascertain the onset of any ocular complication.

CONCLUSIONS

Dermal filler injections of PRP can lead to rare but devastating side effects with permanent visual loss. Considering that there is currently no validated treatment strategy, prevention could be the real key of iatrogenic OAO management.

Deep Temporal Artery Anatomy: Implications for Improving the Safety of Deep Temporal Injections

BACKGROUND

Knowledge of the anatomy of the deep temporal artery (DTA) is critical to ensure safe filling of the deep temporal region. However, current treatment guidelines still focus on how to avoid the superficial temporal artery and the middle temporal vein, and an understanding of the safety of avoiding DTA injury is lacking.

OBJECTIVE

The purpose of this study was to determine the positioning and course of the DTA to help clinicians safely perform the injection and filling in the temporal region.

METHODS

Computed tomography (CT) scans and dissections of the skulls of 34 fresh frozen cadavers perfused with lead oxide were performed. Reconstruction and trajectory analysis of all DTA branches were performed using Mimics and MATLAB software.

RESULTS

In this study, the DTA was identified in all samples, which originated from the maxillary artery of the external carotid artery system. According to image reconstruction and anatomical observations, the distribution of the anterior and posterior branches of the DTA had two different distribution patterns. The anatomical level of the DTA is located between the temporal muscle and the periosteal layer. Compared with observations in previous studies, the anterior branch of the DTA is slightly different, and we found that its course is closer to the frontal area in Asian specimens.

CONCLUSION

The anatomical information on the DTA described in this study may help improve awareness of the safety of temporal injection by aesthetic physicians.

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 Table of Contents or online Instructions to Authors www.springer.com/00266. .

External carotid artery to ophthalmic artery flow associated with internal carotid artery stenosis

PURPOSE

One of the most devastating complications of facial filler injection is sudden ischemic blindness. However, its mechanisms and predisposing factors are poorly understood. The purpose of this study was to investigate the prevalence of external carotid artery (ECA) to ophthalmic artery (OA) anterograde flow in patients with internal carotid artery (ICA) stenosis and in a control population without carotid disease.

METHODS

In this cross-sectional cohort study, two groups of patients who underwent catheter cerebral angiography over a 5-year period were identified: patients with symptomatic ICA stenosis and a control group of patients with refractory epistaxis undergoing embolization. Angiograms were reviewed by an interventional neuroradiologist. The primary outcome measure was the presence of ECA to OA flow, defined as choroidal blush before filling of the circle of Willis. Secondary outcome measures included the percentage and location of ICA stenosis and ECA anastomotic branches involved.

RESULTS

The study included 149 patients with ICA stenosis and 69 control patients. ECA to OA flow was more prevalent in patients with ICA stenosis (34.9%) compared to controls (2.9%) (p < .001). Logistic regression demonstrated that for each 10% increase in ICA stenosis over 70%, there was 2.8 times increased risk of ECA to OA flow (p < .001).

CONCLUSIONS

ECA to ICA anterograde flow can be demonstrated in approximately 3% of control patients and in over 1/3 of patients with symptomatic carotid stenosis. This provides a plausible pathway for small filler particles to pass with blood flow from the facial to the ophthalmic circulation.

An experimental study of the vascular embolism caused by recombinant type III collagen implants and hyaluronic acid

BACKGROUND

There are significant differences in the reported incidence of vascular complications that result from the injection of different soft tissue fillers. This study aimed to compare the risk of vascular embolism after recombinant type III collagen implants and hyaluronic acid (HA) injection into arteries.

METHODS

Different concentrations of recombinant type III collagen and Restylane were injected into the central ear artery of rabbits, to construct an immediate embolization model. We screened for vascular recanalization and tissue necrosis at 30 min, 1 day, and 7 days after injection, and histopathology examination was processed on Day 7.

RESULTS

At 30 min after injection, complete recanalization of the central ear artery was observed in 17 rabbits in the C1 group while none in the HA group. On Day 1 after injection, complete recanalization of the CEA main trunk was observed in all rabbits in the collagen group while 50% in the HA group. There was a significant difference between the C1 group and the HA group in terms of vascular recanalization and skin necrosis.

CONCLUSION

Under the present experimental conditions, the risk of causing vascular embolism was much lower with collagen than with Restylane. Different doses of collagen at different injection rates have the same safety profile.

Complications of toxins and fillers in facial aesthetics

Dermal filler and botulinum toxin injections are among the most performed non-invasive procedures for rejuvenation and contouring, internationally. Although most dermal fillers and approved botulinum toxins are well tolerated with a high safety profile, adverse events and/or complications can happen. Injection-related sequelae and side effects are usually rare, mild, transient, and self-limiting in nature. However, devastating and life-changing complications, such as intravascular occlusion, skin necrosis, permanent visual impairment, and stroke, have been reported. Risk reduction measures include an in-depth knowledge of anatomy, physiology, and pharmacology, correct patient selection, correct identification of clinical indications, and, fundamentally, the importance of appropriate skill and training. In this paper, some of the complications are discussed and advice on how to minimise adverse events and complications from these injectables is provided.

An Experimental Model Exhibiting Anterograde and Retrograde Vascular Occlusion of Facial Fillers to Avoid Vision Loss

Background

Facial filler injection techniques that help decrease the risk of vascular occlusion are an important growing area of study. This study demonstrates a model of injecting fillers into a simulated bifurcated arterial system, using different sized needle gauges at a constant injection pressure.

Methods

Three facial fillers were injected into a bifurcated intravenous tubing with continuous irrigation at a constant pressure to simulate a vascular system. Videography was used to observe for retrograde flow through the simulated supratrochlear artery to the bifurcation point, where the filler was redirected by anterograde flow into the branch representing the ophthalmic artery.

Results

Filler injection with retrograde flow to the bifurcation occurred with all the 27G needle trials. In comparison, the 30G needle trials were only able to reach the bifurcation point in three of the nine trials. The average time to the bifurcation point with subsequent ophthalmic artery anterograde flow with the 27G and 30G needles were 8.44 (95% confidence interval ±2.06) and 33.33 (95% confidence interval ±16.56) seconds, respectively.

Conclusions

Larger 27G needles consistently reached retrograde flow and the bifurcation point faster than 30G needles. This study suggests thinner needles may be less likely to cause retrograde occlusion.

A Computed Tomographic Investigation of the Ophthalmic Artery Volume and Its Relevance to Soft Tissue Filler Injections

BACKGROUND

The measured intraarterial volume of cadaveric ophthalmic arteries was utilized for safety recommendations during facial soft tissue filler injections. However, its clinical practicability and model applicability have become questionable.

OBJECTIVES

To measure the volume of the ophthalmic artery in living individuals by utilizing computed tomography (CT) imaging technology.

METHODS

A total of 40 Chinese patients (23 males, 17 females) were included in this study with a mean age of 61.0 (14.2) years and a mean body mass index of 23.7 (3.3) kg/m2. Patients were investigated with CT imaging technology to evaluate the length, diameter, and volume of the bilateral ophthalmic arteries as well as the length of the bony orbits, resulting in a total of 80 investigated ophthalmic arteries and orbits.

RESULTS

Independent of gender, the average length of the ophthalmic artery was 80.6 (18.7) mm, the calculated volume of the ophthalmic artery was 0.16 (0.05) mL and the minimal and maximal internal diameter of the ophthalmic artery were 0.50 (0.05) mm and 1.06 (0.1) mm, respectively.

CONCLUSIONS

Based on the results obtained from the investigation of 80 ophthalmic arteries it must be concluded that current safety recommendations should be reevaluated. The volume of the ophthalmic artery appears to be 0.2 mL rather than 0.1 mL as previously reported. In addition, it appears impractical to limit the volume of soft tissue filler bolus injections to 0.1 mL due to the aesthetic requirements of each individual patient and treatment plan.

The Course and Variation of the Facial Vein in the Face-Known and Unknown Facts: An Anatomical Study

Background and Objectives: The facial vein is the main collector of venous blood from the face. It plays an important role in physiological as well as pathological context. However, to date, only limited data on the course and tributaries of the facial vein are present in contemporary literature. The aim of this study was to provide detail on the course and the tributaries of the facial vein. Materials and Methods: In 96 sides of 53 body donors, latex was injected into the facial vein. Dissection was carried out and the facial vein and its tributaries (angular vein, ophthalmic vein, nasal veins, labial veins, palpebral veins, buccal and masseteric veins) were assessed. Results: The facial vein presented a textbook-like course in all cases and crossed the margin of the mandible anterior to the masseter in 6.8% of cases, while being located deep to the zygomaticus major muscle in all cases and deep to the zygomaticus minor in 94.6% of cases. Conclusions: This work offers detailed information on the course of the facial vein in relation to neighboring structures, which shows a relatively consistent pattern, as well as on its tributaries, which show a high variability.

Ophthalmic Complications of Periorbital and Facial Aesthetic Procedures: A Literature Review

The emergence and popularity of cosmetic facial procedures may lead to significant ophthalmic complications such as ocular motility dysfunction and visual disability. Here, we present a scoping review to identify common ophthalmic complications in some facial plastic surgeries and cosmetic injections, and to develop clinical approaches for prophylaxis and management in terms of direct attention and awareness of non-ophthalmologists toward such scenarios and appropriate intervention. This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The following keywords were used to search PubMed, Scopus, Web of Science, and Google Scholar: "facial laser", "facial fillers", "facial injections", "hyaluronic acid", "local facial injections of botulinum toxin", "rhinoplasty", "blepharoplasty blindness", "ophthalmoplegia", "diplopia", "ptosis", "ophthalmic artery occlusion", "posterior ciliary artery occlusion", and "ocular ischemic syndrome". A total of 37 articles published between 1989 and 2021 were included, of which 21 were case reports. The most common ophthalmic complication was vision loss (0.0008%). The risk of ophthalmic complications including ocular pain, sudden unilateral or bilateral vision loss, flashes of light, ptosis, and ophthalmoplegia increase with injection in common anatomical regions like the glabella, nose, and supraorbital and nasolabial folds. The incidence of adverse events ranges from 5% to 18% in rhinoplasty. The most common complications after blepharoplasty were dry eye syndrome and diplopia, caused by eyelid ptosis. Eyelid, cornea, lens, and retina injuries are ophthalmic complications that occur after facial laser treatment. Ophthalmic complications after non-ophthalmic and cosmetic procedures are becoming increasingly common. The cumulative reported cases of ophthalmic complications after hyaluronic acid filler injection from 2016 to 2020 showed different types of adverse events, with the most common being decreased visual acuity, unilateral vision loss, and ptosis, with varying outcomes of each complication ranging from partial resolution to complete recovery. These complications must be recognized early, and prompt treatment must be established.

Hyaluronic Acid Filler Injection Guided by Doppler Ultrasound

Doppler ultrasound can be used to detect almost all arteries of the face before injecting the hyaluronic acid (HA) filler. The relatively more dangerous sites of filler injection are the glabellar wrinkle, forehead, temple, nose, and nasolabial fold area, and it is recommended to map the vasculature of these areas by Doppler ultrasound before performing filler injection. The Doppler ultrasound detection method is included as a video. Internal carotid arterial branches, the supratrochlear, supraorbital, and dorsal nasal arteries, and external carotid arterial branches, the superficial temporal and facial arteries, are very important arteries when injecting HA filler; thus, Doppler ultrasound detection is recommended.

Tear Trough Filler Using the Three-point Tangent Technique: Lessons from 1452 Tear Trough Applications

This study describes a novel three-point tangent technique for tear trough filler and the results from the largest series to date.

Methods

A retrospective case review was performed for all patients treated between 2016 and 2020. Patient demographics, filler details and complications were recorded. The injection technique involves using a blunt cannula to deliver filler along three linear tangents bespoke to each patient.

Results

A total of 1452 applications of filler to the orbits of 583 patients were recorded. The median patient age was 41 years (range 19-77), and 84% were women. The mean volume of applied filler at the first appointment was 0.34 mL to each orbit (range 0.1--1.5); 82% reported no complication, 10% reported swelling with a median duration of 4 weeks (range 1-52), 4.3% experienced bruising, 4.6% reported contour irregularities, and 3.3% experienced a Tyndall effect. Retrobulbar hemorrhage occurred in one patient (0.17%), which was managed immediately with no lasting visual compromise. Volume of filler injected was significantly associated with a risk of edema (P < 0.00001) and contour irregularities (P = 0.012). In total, 50% of cases of edema resolved spontaneously after 4 weeks. Filler was dissolved in 1.9% of orbits. Patients with a history of dissolving were significantly more likely to require dissolving after subsequent reinjection (P = 0.043).

Conclusions

The three-point tangent technique is a safe and effective method. Increasing volume of filler administered is associated with complications of edema and contour irregularities. Edema is the most common complication and resolves spontaneously in half of patients by 4 weeks.

Adverse Events Reported From Hyaluronic Acid Dermal Filler Injections to the Facial Region: A Systematic Review and Meta-Analysis

Dermal filler injections are one of the most popular cosmetic procedures in the United States. Of the many options available, hyaluronic acid (HA) dermal fillers like Juvederm or Restylane are often used. Despite their use and popularity, adverse events are known to occur from these procedures. Although most outcomes may be mild and resolve over time, rare instances of severe complications cannot be ignored, as these effects may be irreversible. Healthcare practitioners and patients must be aware of these risks, as these cosmetic procedures can affect the patient's quality of life. The aim of this study was to evaluate the incidence of adverse events (AEs) reported from the use of hyaluronic acid dermal fillers in the facial region. A systemized search of randomized controlled trials was conducted using Cochrane Central, Embase, Medical Literature Analysis and Retrieval System Online (MEDLINE), and the Web of Science databases. After screening for eligibility and conducting a critical appraisal of the articles, 19 studies were retained for the final review. The meta-analysis results included different side effects by facial location, i.e., nasolabial fold (NLF) vs. other (midface, perioral line, and lip region). The midface includes the anteromedial cheek region, the zygomaticomalar region, and the submalar region. The adverse events were swelling, pain, erythema, bruising, lumps and bumps, firmness, tenderness, itching, and skin discoloration. A significant difference was found in the proportion of individuals experiencing swelling, lumps or bumps, and firmness at the nasolabial fold site versus the midface, perioral line, and lip region. There was no significant difference in the proportion of individuals experiencing pain, erythema, bruising, tenderness, itching, or skin discoloration at the nasolabial fold site versus the other sites. The study highlights the prevalence of common AEs that can result from HA dermal fillers like Juvederm or Restylane, thus emphasizing the importance of healthcare professionals explaining the risk and benefits to patients.

The Deep Temporal Arteries: Anatomical Study with Application to Augmentations Procedures of the Temple

The aim of this study was to determine the anatomical features of the deep temporal arteries (DTAs) and thereby provide clinical information for the temple augmentation procedure. Forty-two adult hemifaces from 15 Korean and 6 Thai cadavers (12 males, 9 females; mean age at death, 79.6 years) with no history of trauma or surgical procedure on the temple area were used for anatomical study. A detailed dissection was performed to identify the locations of the anterior and posterior deep temporal arteries (ADTA and PDTA) with reference to the vertical plane passing through the zygomatic tubercle. Fifty-eight healthy Korean participants (31 males and 27 females; mean age, 24.7 years) were included in the ultrasonographic study. The distance from the bone to the DTAs was measured at the level of the zygomatic tubercle (H_Zt ) and the eyebrow (H_Eb ). The DTAs were not found within 7.2-12.6 mm posterior to the zygomatic tubercle; instead, the locations varied widely at the H_Eb . The distances between the bone and the ADTA were 1.7 ± 1.2 mm (mean ± SD) and 1.3 ± 0.8 mm, and those between the bone and the PDTA were 2.1 ± 1.2 mm and 2.0 ± 1.4 mm at H_Zt and H_Eb , respectively. Our findings indicate that at H_Zt , the area 1 cm posterior to the zygomatic tubercle may be a safe area for deep temple augmentation procedures. However, because the distribution patterns of the DTAs at H_Eb and depth of the DTAs are variable, additional care is required to minimize the risks of the procedure.

Acute unilateral vision loss and bilateral cerebral infarction following cosmetic filler injection

The current case report describes acute unilateral vision loss and bilateral cerebral infarction as devastating complications following cosmetic injection of hyaluronic acid to the nasal bridge in a 34-year-old female. The patient reported the onset of sudden eye pain, headache, and vision loss in her right eye. At the initial visit to the hospital, the patient had no light perception in the right eye. Examinations revealed marked ptosis and complete ophthalmoplegia with no proptosis. At the time of the patient's hospital evaluation, computed tomography, and magnetic resonance imaging were ordered. Few mottled materials (denser than blood) were observed in the cavernous sinus with a density of 106 Hounsfield units (HU), yet no air was depicted in the cavernous sinus. MRI scan revealed multiple areas of bilateral intracranial infarcts. Although cosmetic injection of hyaluronic acid has been documented as a safe procedure, vision loss remains one of the most feared complications.

Multiple branch retinal artery occlusions following the new facial cosmetic filler (Poly-D, L-lactic Acid) injection a case report

BACKGROUND

Poly-D, L-lactic acid is (PDLLA) a new cosmetic filler. We reported the first case of PDLLA-related devastating complication of multiple branch retinal artery occlusion (BRAO).

CASE PRESENTATION

A 23-year-old female had sudden blindness after injection of PDLLA at the glabella. After emergency intraocular pressure-lowering medicine, ocular massage, steroid pulse therapy, heparin and alprostadil infusion, and subsequent treatments including acupuncture and 40 sessions of hyperbaric oxygen therapy, her best-corrected visual acuity improved from hand motion at 30 cm to 0.3 within 2 months.

CONCLUSION

Although safety of PDLLA was evaluated in animal studies and in 16,000 human cases, it could still cause rare but devastating retinal artery occlusion as in the present case. Proper and immediate therapies could still improve patient's vision and scotoma. Surgeons should keep in mind the possibility of iatrogenic filler-related retinal artery occlusion.

Clinical Anatomy of the Chin Evaluated by 3-Dimensional Tomography and Cadaveric Dissection: Implications for Safety and Optimal Injection Techniques in Chinese

BACKGROUND

Soft tissue fillers have been widely used for the correction of chin volume loss because of congenital conditions and aging.

OBJECTIVE

This study aimed to discuss anatomical concerns for chin filler injections, which may help to reduce the incidence of severe intravascular embolization complications and improve patient satisfaction.

METHODS AND MATERIALS

We scanned 40 cadaveric heads with a contrast agent using a 64-row spiral computed tomography scanner. The scan was visualized by a Philips IntelliSpace workstation and analyzed by Materialise's interactive m image control system software to measure and quantify the arterial data. Twenty of 40 cadavers were dissected to define the layers of tissue.

RESULTS

In total, 221 arteries passed through the sagittal plane of 40 specimens. The number of superficial arteries (163 of 221) was much greater than the number of deep arteries (58 of 221). The number of arteries gradually decreased with distance from the lower lip vermilion border plane, which formed the lower third of the face.

CONCLUSION

This study introduces a safe and effective technique for administering chin filler injections that minimizes risks and improves patient satisfaction.

Expert recommendations on supportive skin care for non-surgical and surgical procedures

A thorough knowledge of non-surgical procedures (laser, peelings, injections, threads) and surgical procedures (combined surgeries and skin grafts), including contraindications and potential risks and side effects, (e.g. infection, hypopigmentation, hyperpigmentation, and scarring) is essential to be able to reduce their incidence and ensure the patient receives the most benefit from the procedure. Individuals with darker skin and of high Fitzpatrick phototype are at higher risk of dyschromias, notably melasma and post-inflammatory hyperpigmentation, which may be treated using aesthetic procedures but may also arise as a complication of some procedures. A group of experts in cosmetic surgery and dermatology reviewed the published literature and discussed recommendations for optimizing outcomes with practical advice on supportive skincare before, during and after non-surgical or surgical procedures. A broad-spectrum sunscreen with a high sun protection factor against UVB and high protection against UVA, especially long UVA, is essential for all treatment modalities for the prevention and potential improvement of pigmentation disorders. Supportive skin care management to prepare, cleanse and protect the skin and post-procedure skin care with healing and anti-inflammatory ingredients are recommended to speed up regeneration and wound healing whilst minimizing scarring and downtime. Additionally, adjunctive skin care to procedures with antioxidant, anti-ageing and lightening properties may enhance skin benefits.

Ultrasound-Guided Targeted vs Regional Flooding: A Comparative Study for Improving the Clinical Outcome in Soft Tissue Filler Vascular Adverse Event Management

BACKGROUND

Adverse vascular event management following hyaluronic acid-based aesthetic injections relies on the administration of hyaluronidase which is capable of enzymatically degrading the injected product and improving clinical symptoms. Two protocols are currently available to manage such complications: "ultrasound-guided targeted" and "flooding".

OBJECTIVES

The aim of this study was to compare the 2 protocols in terms of the volume of hyaluronidase utilized, and the onset and degree of clinical improvement.

METHODS

A comparative case series of 39 patients was retrospectively evaluated. The patients were initially treated with the "flooding" protocol and then treated with the "ultrasound-guided targeted" protocol due to no or little improvement.

RESULTS

The "ultrasound-guided targeted" protocol utilized a mean [standard deviation] total of 122.5 [34] IU of hyaluronidase, whereas the "flooding" protocol utilized 1519.4 [1137] IU, which represents a statistically significant reduced amount of injected hyaluronidase (P = 0.028). There was no clinical improvement in 92.3% and only little improvement in 7.7% of the treated patients following the first applied "flooding" protocol, but there was a 100% immediate improvement when subsequently treated with the "ultrasound-guided targeted" protocol. Ultrasound imaging revealed that the application of hyaluronidase restored normal blood flow both in the perivascular space and in the superficially located subdermal soft tissues.

CONCLUSIONS

Despite its limitations in study design, this retrospectively evaluated case series revealed that the "ultrasound-guided targeted" protocol utilized less hyaluronidase and restored clinically visible symptoms faster. The effect of this protocol is best explained by the perforasome concept which will need to be investigated further in future studies.

LEVEL OF EVIDENCE: 4

Clinical outcomes after lip injection procedures-Comparison of two hyaluronic acid gel fillers with different product properties

BACKGROUND

Transient swelling is common after lip injections with hyaluronic acid (HA) based fillers. Swelling and other injection-site reactions may relate to the injection procedure itself, or to gel properties, which differ between fillers due to differences in manufacturing methods.

OBJECTIVES

To evaluate safety and effectiveness of lip injections with two HA fillers manufactured using different gel technologies.

METHODS

In a study sample of 40 subjects, treatment with two soft tissue filler product (HA_RK or HA_JUS ) was randomly assigned. Subjects were injected with 0.5 cc per upper and lower lip using a standardized injection procedure. Early-onset adverse events (AEs) were assessed by evaluation up to Day 14. Aesthetic improvement, subject satisfaction, and AEs post-Day 14 were assessed up to 24 weeks.

RESULTS

In subjects treated with HA_RK , the intensity of early onset swelling, erythema, and pain/tenderness was lower than in subjects treated with HA_JUS . Aesthetic improvement was achieved in both groups, and most subjects were satisfied with the appearance of their lips. Treatment-related AEs post-Day 14 mostly related to the implant site; most were mild-to-moderate, and none were serious.

CONCLUSIONS

The intensity of early-onset swelling, and other injection-site reactions was lower in subjects treated with HA_RK than in subjects treated with HA_JUS . Since both the injection volume and injection procedure were standardized, the difference in local tolerability between the two HA fillers may relate to differences in gel properties. Aesthetic improvement, subject satisfaction, and AE profiles post-Day 14, however, were similar between filler groups.