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Díaz-Aguayo I, Urdiales-Gálvez F, Benítez PA, Carvajal-Larrate A, Farollch-Prats L, Hospido A, Mira M, Uva L, Zuluaga L. Aesthetic management of lips and perioral region with Hylacross® and Vycross® hyaluronic-acid based fillers: A document of recommendations. J Cosmet Dermatol 2024; 23:2843-2856. [PMID: 38751134 DOI: 10.1111/jocd.16358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 03/20/2024] [Accepted: 04/22/2024] [Indexed: 08/29/2024]
Abstract
BACKGROUND Lip volumization and perioral rejuvenation with hyaluronic-acid (HA) based dermal fillers are generating increasing interest and demand. However, this topic is still having many unmet needs nowadays. This document aimed to provide tips and recommendations that may help clinicians to achieve optimal and more predictable aesthetic outcomes. METHODS A multidisciplinary group of aesthetic medicine doctors from Spain and Portugal reviewed the tools used for assessing the patient and aesthetic outcomes, as well as the different techniques and products used in lips/perioral rejuvenation. RESULTS The consensus panel provided specific recommendations focusing on the basic information to collect before performing the aesthetic procedure; comprehensive approach to lips/perioral region rejuvenation; clinical and aesthetic assessment tools; product and technique selection; patient profile and needs; and safety issues (complications/adverse-events). CONCLUSIONS The rapid evolution of techniques and tools for assessing the patient and aesthetic outcomes, as well as the development of new HA-based fillers makes it necessary to update the clinical recommendations that guide the daily practice of clinicians, particularly those who have less experience with these procedures. This document addressed relevant subjects related to lip/perioral-region rejuvenation to perform the correct procedure, with the appropriate HA-based, on the right patient; to help specialists to obtain optimal and predictable aesthetic outcomes.
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Affiliation(s)
| | | | | | | | | | | | - Mar Mira
- Clínica Mira + Cueto, Madrid, Spain
| | - Luís Uva
- Clinica Personal Derma, Lisbon, Portugal
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Park SJ, Yoo KH. One-Year Safety Evaluation of New Hyaluronic Acid Fillers (YYS Series): A Prospective, Multicenter, Observational Study. Dermatol Surg 2024; 50:731-738. [PMID: 38595129 PMCID: PMC11288390 DOI: 10.1097/dss.0000000000004190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
BACKGROUND With the continuous increasing availability of new filler products, each hyaluronic acid filler brand has distinctive pharmacokinetics, which may be associated with different complications. Therefore, the long-term safety of new generations of fillers should be evaluated. OBJECTIVE This prospective, multicenter, observational, postmarketing study ( ClinicalTrials.gov identifier: NCT04738019) aimed to investigate the incidence of delayed-onset nodules and adverse reactions after the injection of new hyaluronic acid fillers (YYS series) into the facial skin. METHODS Subjects scheduled to receive an injection YYS series filler were followed up for 52 weeks. The authors aimed to determine the incidence of a self-reported delayed-onset nodule-a visible or palpable nodule or mass at the injection site that was detected beyond the 14th day following the injection-during the 1-year follow-up period. RESULTS Among the 1,022 subjects who received an injection of the YYS series, the incidences of delayed-onset nodules were 0% for YYS 360, YYS 540, and YYS 720. A 0.21% incidence (1 delayed hypersensitivity reaction) of a delayed-onset adverse reaction was noted for YYS 720, although none were reported for YYS 360 and YYS 540. CONCLUSION In this study, a notably low frequency of adverse reactions associated with the YYS series was observed.
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Affiliation(s)
- Su Jung Park
- Department of Dermatology, College of Medicine, Chung-Ang University, Seoul, Republic of Korea
| | - Kwang Ho Yoo
- Department of Dermatology, College of Medicine, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong-si, Republic of Korea
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Hong GW, Hu H, Chang K, Park Y, Lee KWA, Chan LKW, Yi KH. Review of the Adverse Effects Associated with Dermal Filler Treatments: Part I Nodules, Granuloma, and Migration. Diagnostics (Basel) 2024; 14:1640. [PMID: 39125515 PMCID: PMC11311355 DOI: 10.3390/diagnostics14151640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 07/24/2024] [Accepted: 07/26/2024] [Indexed: 08/12/2024] Open
Abstract
The increase in the use of filler treatments within minimally invasive cosmetic surgery has correspondingly escalated the variety and frequency of associated side effects. Initially, unregulated procedures led to primary side effects such as infections, foreign body reactions, and granuloma formation. However, severe vascular complications like skin and tissue necrosis and blindness have emerged as recognized risks. Side effects from filler treatments can range from mild to life-threatening, including edema, pain, tenderness, numbness, bleeding, bruising, hematoma, redness, erythema, pigmentation, allergic reactions, itching, pruritus, the Tyndall effect, asymmetry, irregularity, migration, skin and soft tissue infections, nodules, granulomas, and vascular compromise. These side effects are categorized into early and delayed types. Many complications, particularly those related to vascular abnormalities, are frequently linked to procedural issues, emphasizing the importance of understanding filler properties, injection techniques, and facial anatomy. Preventing side effects is ideal, but early detection and treatment are crucial. Recognizing potential side effects based on their timing and understanding appropriate preemptive treatment methods is essential. This discussion addresses non-vascular side effects, highlighting their onset, symptoms, and management strategies. The comprehensive understanding and careful management of these side effects are vital for minimizing complications and ensuring patient safety in filler treatments.
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Affiliation(s)
- Gi-Woong Hong
- Samskin Plastic Surgery Clinic, Seoul 06577, Republic of Korea
| | - Hyewon Hu
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 FOUR Project, Yonsei University College of Dentistry, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea;
| | | | | | | | | | - Kyu-Ho Yi
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 FOUR Project, Yonsei University College of Dentistry, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea;
- Maylin Clinic (Apgujeong), Seoul 06001, Republic of Korea
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Silikovich F, Kroumpouzos G. Nonsurgical Rhinoplasty: Results from a Retrospective Study of Rino-4-Puntos Technique with Hyaluronic Acid. Aesthetic Plast Surg 2024:10.1007/s00266-024-04263-z. [PMID: 39060796 DOI: 10.1007/s00266-024-04263-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Accepted: 07/15/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND Nonsurgical rhinoplasty (NSR) utilizing hyaluronic acid (HA) filler injections is increasingly used to address nose shape issues. While refinements have been proposed, the technique lacks standardization. OBJECTIVES Our study aimed to evaluate the aesthetic outcome, longevity of results, safety, and patient satisfaction with the novel Rino-4-Puntos (R4P) NSR technique. METHODS This is a retrospective study of consecutive individuals treated with R4P between January 2021 and July 2023. All participants had one of the four indications: rectification of the dorsum (21%), triangulation of the tip (32%), projection (25%), and strengthening of the columella (22%). Each patient received two hyaluronic acid (HA) fillers: one with intermediate G prime (G') at Points 1-3 and another with high G' at Point 4, which is further divided into Points 4.1, 4.2, 4.3, and 4.4. The injection points were as follows: P1 (radix, 0.05-0.15 mL, supraperiosteal), P2 (supratip, 0.025 mL, suprachondrial), P3 (tip, 0.15 mL, deep fat), P4 (columella, 0.30 mL, supraperiosteal [4.1], or deep fat [4.2, 4.3, and 4.4]). RESULTS Four hundred individuals (n = 284 [71%] females) are included. The mean filler volume used was 0.65 ± 0.17 mL. Injecting small boluses (≤ 0.05 mL) in the midline at deep planes minimized the risk of adverse effects, as no vascular complications occurred. Ninety-three percent of participants considered the overall outcome at least satisfactory ("good," "very good," or "excellent"). The treatment effect was maintained for a median of 11 months. CONCLUSIONS The R4P technique refines NSR by combining enhanced aesthetic outcome, longevity, and safety. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Fernando Silikovich
- Concepto 4 Puntos Clinic, Av Monroe 2270 1405, Belgrano, B1428, Buenos Aires, Argentina.
| | - George Kroumpouzos
- Department of Dermatology, Warren Alpert Medical School at Brown University, Providence, RI, USA.
- GK Dermatology PC, 541 Main St, Suite 320, South Weymouth, MA, 02190, USA.
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Hong GW, Hu H, Chang K, Park Y, Lee KWA, Chan LKW, Yi KH. Adverse Effects Associated with Dermal Filler Treatments: Part II Vascular Complication. Diagnostics (Basel) 2024; 14:1555. [PMID: 39061692 PMCID: PMC11276034 DOI: 10.3390/diagnostics14141555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 07/09/2024] [Accepted: 07/15/2024] [Indexed: 07/28/2024] Open
Abstract
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.
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Affiliation(s)
- Gi-Woong Hong
- Samskin Plastic Surgery Clinic, Seoul 06577, Republic of Korea;
| | - Hyewon Hu
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 FOUR Project, Yonsei University College of Dentistry, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea;
| | | | | | | | | | - Kyu-Ho Yi
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 FOUR Project, Yonsei University College of Dentistry, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea;
- Maylin Clinic (Apgujeong), Seoul 06001, Republic of Korea
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Baranska-Rybak W, Lajo-Plaza JV, Walker L, Alizadeh N. Late-Onset Reactions after Hyaluronic Acid Dermal Fillers: A Consensus Recommendation on Etiology, Prevention and Management. Dermatol Ther (Heidelb) 2024; 14:1767-1785. [PMID: 38907876 PMCID: PMC11265052 DOI: 10.1007/s13555-024-01202-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 05/31/2024] [Indexed: 06/24/2024] Open
Abstract
Hyaluronic acid (HA) dermal fillers, generally considered low-risk, can lead to rare late-onset reactions (LORs) manifesting between 3 and 4 months postinjection, occasionally even as early as 24 h postinjection. The Complication Assessment and Risk Evaluation (CARE) board was established to review these reactions. In this publication, the authors aims to explore the etiological hypotheses underlying LORs, associated risk factors, prevention, and management approaches suggested by the CARE board. The CARE board identified three etiological hypotheses contributing to LORs. Firstly, the physicochemical structure of the filler, particularly low molecular weight HA, which may trigger an immune response. Secondly, infection, potentially introduced during injection or by dormant biofilm activation. Lastly, an imbalance in the host immune system, caused by factors like autoimmune diseases or viral infections, may lead to extended foreign body reactions, delayed type IV hypersensitivity, or adjuvant-based reactions. Based on these hypotheses, the board categorized various risk factors as patient-related (e.g., recent dental treatment, current medical status, active autoimmune disease), product-related (e.g., molecular weight), and procedure-related (e.g., aseptic technique and trauma). To reduce the risk of LORs, the CARE board recommends diligent patient selection, including comprehensive medical history assessment and informed consent. Practitioners should maintain an effective aseptic technique, and choose an appropriate product and injection depth for the anatomical location. Post-procedure, patients should receive education on proper filler care. Management of LORs depends on the suspected etiology, and the CARE board has proposed an algorithm to determine the most appropriate treatment. Hyaluronidase is recommended for noninflammatory reactions in the absence of active infection, while watchful waiting and/or steroid treatment may be preferred for inflammatory reactions. Hyaluronidase is not recommended as a first-line treatment for infections, which require drainage, bacterial culture, and antibiotic treatment. However, the board emphasizes the need for individualized evaluation and treatment in all cases.
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Affiliation(s)
- Wioletta Baranska-Rybak
- Department of Dermatology, Venereology and Allergology, Medical University of Gdansk, Ul. Smoluchowskiego 17, 80-214, Gdańsk, Poland.
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Nicola AG, Pricop MO, Ramos-Medina B. Clinical Management With High-Frequency Ultrasound of Recurrent Submental Abscess Formation After Filler Placement: Bacterial Contamination or Immune-Mediated Adverse Event? Cureus 2024; 16:e58878. [PMID: 38659708 PMCID: PMC11040211 DOI: 10.7759/cureus.58878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2024] [Indexed: 04/26/2024] Open
Abstract
The authors present a case of a 29-year-old female patient with a recurrent submental abscess formation after chin augmentation with highly reticulated hyaluronic acid filler. We evaluate the possible cause of this complication and the result after clinical management with ultrasound-guided injection of hyaluronidase. We highlight the prevention, assessment and treatment with real-time imaging of hyaluronidase injection in the affected area, as a predictable approach for both the patient and the physician.
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Affiliation(s)
- Andrada-Gabriela Nicola
- Oral and Maxillofacial Surgery, University of Medicine and Pharmacy Victor Babes, Timisoara, ROU
| | - Marius Octavian Pricop
- Oral and Maxillofacial Surgery, University of Medicine and Pharmacy Victor Babes, Timisoara, ROU
| | - Benito Ramos-Medina
- Oral and Maxillofacial Surgery, Hospital Universitario Santa Lucia, Cartagena, ESP
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Moellhoff N, Kuhlmann C, Frank K, Kim BS, Conte F, Cotofana S, Piccolo NS, Pallua N. Arterial Embolism After Facial Fat Grafting: A Systematic Literature Review. Aesthetic Plast Surg 2023; 47:2771-2787. [PMID: 37563433 PMCID: PMC10784353 DOI: 10.1007/s00266-023-03511-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 06/30/2023] [Indexed: 08/12/2023]
Abstract
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 .
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Affiliation(s)
- Nicholas Moellhoff
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Ziemssenstraße 5, 80336, Munich, Germany.
| | - Constanze Kuhlmann
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Ziemssenstraße 5, 80336, Munich, Germany
| | - Konstantin Frank
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Ziemssenstraße 5, 80336, Munich, Germany
| | - Bong-Sung Kim
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zürich, Switzerland
| | - Francesco Conte
- Medical Faculty Rhenish, Westphalian Technical University, Aachen, Germany
- Pallua-Clinic Duesseldorf, Duesseldorf, Germany
| | - Sebastian Cotofana
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Nelson S Piccolo
- Division of Plastic Surgery, Pronto Socorro para Queimaduras, Goiânia, Brazil
- International Society of Plastic Regenerative Surgeons, Arlington Heights, IL, USA
| | - Norbert Pallua
- Medical Faculty Rhenish, Westphalian Technical University, Aachen, Germany
- Pallua-Clinic Duesseldorf, Duesseldorf, Germany
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Neamatallah T. Delayed inflammatory reaction to hyaluronic acid lip filler after the Pfizer-BioNTech COVID-19 vaccine: A case report. Heliyon 2023; 9:e18274. [PMID: 37539264 PMCID: PMC10395472 DOI: 10.1016/j.heliyon.2023.e18274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 07/07/2023] [Accepted: 07/13/2023] [Indexed: 08/05/2023] Open
Abstract
Hypersensitivity reactions can be a side effect to any vaccine, but they are usually rare. The COVID-19 vaccination may cause hypersensitivity, and several cases of delayed hypersensitivity (DH) to hyaluronic acid (HA) dermal filler have been documented. The current report presents a case of a 36-year-old female patient with DH to HA dermal filler after receiving the Pfizer-BioNTech COVID-19 vaccine. Symptoms, including dryness, swelling, and a painless nodule, appeared after the first and second doses of the vaccine. The patient was treated with intralesional hyaluronidase and triamcinolone in the outpatient clinic. Although HA is relatively safe and routinely used in aesthetic medicine, DH reactions must be considered. Therefore, an appropriate patient history should be obtained, and physicians should provide counselling on the potential reactions to avoid these adverse effects.
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Schelke LW, Decates TS, Cartier H, Cotofana S, Velthuis PJ. Investigating the Anatomic Location of Soft Tissue Fillers in Noninflammatory Nodule Formation: An Ultrasound-Imaging-Based Analysis. Dermatol Surg 2023; 49:588-595. [PMID: 36942950 PMCID: PMC10227930 DOI: 10.1097/dss.0000000000003756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
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.
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Affiliation(s)
- Leonie W. Schelke
- Department of Dermatology, Erasmus University Medical Center, Roterdam, The Netherlands
| | - Tom S. Decates
- Department of Dermatology, Erasmus University Medical Center, Roterdam, The Netherlands
| | | | - Sebastian Cotofana
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Peter J. Velthuis
- Department of Dermatology, Erasmus University Medical Center, Roterdam, The Netherlands
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López PV, García PT, López-Pitalúa JA, Pinto H. Side effects after hyaluronic acid facial injection in adults during COVID-19 pandemic. J Cosmet Dermatol 2023; 22:1714-1719. [PMID: 37082890 DOI: 10.1111/jocd.15780] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/06/2023] [Accepted: 04/05/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Different causes may be responsible for delayed inflammatory reactions after hyaluronic acid injections, among them several mechanisms of SARS-CoV-2. AIMS The study's objective was to assess the percentage of adverse reactions after hyaluronic acid injections in a cohort of adult patients with a test for SARS-CoV-2 or vaccinated during the COVID-19 pandemic. PATIENTS/METHODS An observational, retrospective, comparative, multi-center, non-interventional in a real-life setting study was carried out with patients treated with facial injections of hyaluronic acid from May to September 2021, with a test to discard SARS-COV 2 or that had been vaccinated. RESULTS Sixty-three patients were included. Seven (11.1%) were vaccinated patients without a test for SaRS-CoV-2 and 56 (88.9%) with antigenic or PCR screening tests (18 [32.1%] negative and 39 [69.6%] positives for COVID-19). The mean age was 51.3 (SD 12.71; range 23-70), and 57 (90.5%) were female. Twenty-three patients (36.5%) had a history of adverse events with hyaluronic acid injections. During the study, 15 adverse events were reported; 11 patients (73.3%) had a history (p = 0.0018); two patients (13.3%) had been vaccinated; 13 (86.7%) had performed a SARS-CoV2 test (six [46.2%] negatives, and seven [53.8%] with a positive result; p = 0.5969). All adverse study events were resolved, and none had sequelae. CONCLUSION Adverse events after hyaluronic acid facial injections were higher among patients with a history but not among those diagnosed with COVID-19. The new scenario related to COVID-19 infections or vaccinations would require readapting criteria for applying hyaluronic acid injections.
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Affiliation(s)
| | | | | | - Hernán Pinto
- i2e3 Biomedical Research Institute, Barcelona, Spain
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12
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Reply to Comments on "Treatment of Delayed-onset Inflammatory Reactions to Hyaluronic Acid Filler: An Algorithmic Approach". PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4661. [PMID: 36817272 PMCID: PMC9937105 DOI: 10.1097/gox.0000000000004661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
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Ehlinger-David A, Gorj M, Braccini F, Loreto F, Grand-Vincent A, Garcia P, Taieb M, Benadiba L, Catoni I, Mathey ER, Deutsch JJ, Bahadoran P, Vincent T, David M, Cartier H, Nadra K, Moellhoff N, Fanian F. A prospective multicenter clinical trial evaluating the efficacy and safety of a hyaluronic acid-based filler with Tri-Hyal technology in the treatment of lips and the perioral area. J Cosmet Dermatol 2023; 22:464-472. [PMID: 35718985 PMCID: PMC10087550 DOI: 10.1111/jocd.15169] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/16/2022] [Accepted: 05/30/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Age-related changes of facial soft tissue cause clinical signs of facial aging such as lip atrophy, marionette lines, and an accentuated nasolabial fold. These changes can be modified using dermal fillers. AIMS To evaluate efficacy, longevity, and safety of a cross-linked hyaluronic acid-based filler with Tri-Hyal technology in the treatment of lips, nasolabial folds, and marionette lines. MATERIALS AND METHODS This prospective, multi-center trial evaluated injections of three different areas (lips, nasolabial fold alone, or with marionette wrinkles) with a soft tissue filler containing 25 mg/ml cross-linked hyaluronic acid and 0.3% lidocaine. Primary endpoint was the aesthetic correction 3 weeks after one injection session without touch-up. Follow-up was 18 months. Assessments were performed using the Global Aesthetic Score (GAS), clinical scoring based on photographic scales, high-frequency ultrasound imaging, and the Global Aesthetic Improvement Scale (GAIS). RESULTS In total, 100 subjects were injected. GAS improved significantly for all treatment indications at 3 weeks (p < 0.0001). Success rates were highest for nasolabial folds (98.4%), followed by marionette lines (94.4%) and lips (73.5%). After 18 months post-injection, success was observed in 91%, 88%, and 33% of subjects injected into nasolabial folds, marionette lines, and lips, respectively. GAIS scored highest for nasolabial folds (SGAIS: 71%; IGAIS: 40%), followed by marionette lines (SGAIS: 56%; IGAIS: 33%) and lips (SGAIS: 30%; IGAIS: 22%) at 18 months follow-up. CONCLUSIONS The filler demonstrated high efficacy and safety in all indications. Regional differences in longevity were evident. Thus, the necessity of regional retreatments should be discussed with patients before injection.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Nicholas Moellhoff
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
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Ortiz Middleton E. Evidence-based clinical guide for the management of peripheral vascular occlusion with hyaluronic acid, report of 6 successful cases. ADVANCES IN ORAL AND MAXILLOFACIAL SURGERY 2022. [DOI: 10.1016/j.adoms.2022.100367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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15
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de Wit A, Siebenga PS, Wijdeveld RW, Koopmans PC, van Loghem JAJ. A split-face comparative performance evaluation of injectable hyaluronic acid-based preparations HCC and CPM-HA20G in healthy females. J Cosmet Dermatol 2022; 21:5576-5583. [PMID: 35699361 DOI: 10.1111/jocd.15157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 04/29/2022] [Accepted: 05/18/2022] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Skin revitalizers are used for skin quality improvement purposes. Hyaluronan hybrid cooperative complexes (HCC, Profhilo®, IBSA Pharmaceuticals) are an anti-aging treatment with a large amount of pure hyaluronic acid (HA) based on stable, cooperative, and hybrid complexes. Cohesive polydensified matrix Hyaluronic Acid (CPM-HA20, Belotero Revive®, Merz Pharmaceuticals GmbH) is a slightly cross-linked HA (20 mg/ml) with glycerol (17.5 mg/ml). AIMS To evaluate the performance of HCC and CPM-HA20G for skin quality improvement in healthy female subjects. METHODS This was a split-face, single-blinded study that enrolled 24 healthy female subjects. Injections were given on three separate occasions. HCC was injected on the right cheek, while CPM-HA20G was injected on the left cheek. A battery of skin property measurements was used to evaluate the skin. Skin properties and overall satisfaction were analyzed using mixed models with the values at baseline, at week 1, week 8, and week 14 as an outcome and a random effect of subject and fixed effects of treatment, visit, and the treatment by visit interaction. RESULTS Both products showed evidence of effect relative to baseline on surface hydration (AU), elasticity (N/m) TEWL (g/m2 h), and melanin (AU). CPM-HA20G also showed significant evidence of effect relative to baseline on water content (%), and HCC on pore count (n) and hemoglobin (AU). Satisfaction reported by the subjects themselves showed positive trends of satisfaction over time for multiple skin properties. There were no significant differences between the tested products in the observed skin characteristics over time. CONCLUSION These devices are effective and safe treatments for skin quality improvement, especially moisturization, with high patient satisfaction and generally mild and transient side effects.
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Affiliation(s)
| | | | | | | | - Jani A J van Loghem
- UMA Institute, Amsterdam, The Netherlands.,University of Amsterdam, Amsterdam, The Netherlands
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16
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Treatment of Delayed-onset Inflammatory Reactions to Hyaluronic Acid Filler: An Update. Plast Reconstr Surg Glob Open 2022; 10:e4570. [PMID: 36246076 PMCID: PMC9555884 DOI: 10.1097/gox.0000000000004570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Abstract
BACKGROUND Delayed-onset reactions are increasingly relevant given the growing use of hyaluronic acid dermal fillers. There is poor understanding of the phenomenon's etiology and incidence. OBJECTIVE To highlight differences between the dermal filler products with an emphasis on delayed-onset reaction incidence, pathogenesis, prevention, and treatment. METHODS A literature review was performed for delayed-onset reactions following hyaluronic acid dermal filler injection using PubMeb and Embase. Articles were included based on relevance, quality, and the predetermined definition of "delayed-onset reaction" (>30 days post injection). A total of 28 studies were included in the data analysis. RESULTS A total of 13,136 subjects from 28 studies treated with 15 filler types were included in the analysis. VYC-15L dermal filler injections carried the highest risk of delayed reaction with a mean incidence of 3.83% ( n = 46/1,202), followed by VYC-20L (0.92%) and VYC-17.5L (0.88%). The mean incidence of delayed reactions among all filler types was 1.13%. CONCLUSION Incidence of delayed reaction to hyaluronic fillers ranges from 0% to 3.83% (mean = 1.13%) and varies by filler type. The exact etiology of these delayed reactions remains disputed. Future studies should report reaction description, precise timeline, and posttreatment immunologic history to better delineate the incidence of delayed-onset hypersensitivity reactions.
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Affiliation(s)
- Ryan E Kokoska
- All authors are affiliated with the Department of Dermatology, Indiana University School of Medicine, Indianapolis, Indiana
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18
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Lai D, Liu H, Kong L, Cheng S. Delayed complication of botulinum toxin and hyaluronic acid filler injections: A case report. J Cosmet Dermatol 2022; 21:2374-2378. [PMID: 35460324 DOI: 10.1111/jocd.15016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 03/11/2022] [Accepted: 04/19/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Botulinum toxin and hyaluronic acid (HA) filler injections are popular minimally invasive cosmetic procedures owing to their convenience, efficiency, and durability; however, adverse reactions often occur. MATERIALS AND METHODS We describe the delayed hypersensitivity reaction that occurred after sequential injections of botulinum toxin and HA filler. RESULTS The histopathologic and dermatoscopic findings suggested a delayed hypersensitivity reaction with the formation of a dermal foreign body granuloma. The rash resolved 2 months following treatment with antihistamines and topical steroids cream. CONCLUSION We assume that local trauma during the blepharoplasty stimulated an immune response, which was the basis for this complication.
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Affiliation(s)
- Dihui Lai
- Department of Dermatology, Beijing ChuiYangLiu Hospital, Beijing, China
| | - Hongmei Liu
- Department of Dermatology, MEIYAN Aesthetic Plastic Medical Clinic, Beijing, China
| | - Linghong Kong
- Department of Pathology, Beijing ChuiYangLiu Hospital, Beijing, China
| | - Shaowei Cheng
- Department of Dermatology, Beijing ChuiYangLiu Hospital, Beijing, China
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19
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de la Guardia C, Virno A, Musumeci M, Bernardin A, Silberberg MB. Rheologic and Physicochemical Characteristics of Hyaluronic Acid Fillers: Overview and Relationship to Product Performance. Facial Plast Surg 2022; 38:116-123. [PMID: 35114708 PMCID: PMC9188840 DOI: 10.1055/s-0041-1741560] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Injections with hyaluronic acid (HA) fillers for facial rejuvenation and soft-tissue augmentation are among the most popular aesthetic procedures worldwide. Many HA fillers are available with unique manufacturing processes and distinct in vitro physicochemical and rheologic properties, which result in important differences in the fillers' clinical performance. The aim of this paper is to provide an overview of the properties most widely used to characterize HA fillers and to report their rheologic and physicochemical values obtained using standardized methodology to allow scientifically based comparisons. Understanding rheologic and physicochemical properties will guide clinicians in aligning HA characteristics to the facial area being treated for optimal clinical performance.
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Affiliation(s)
- Carola de la Guardia
- Medical Affairs, Allergan Aesthetics, an AbbVie company, Marlow, United Kingdom of Great Britain and Northern Ireland
| | - Ada Virno
- Clinical Development, Allergan Aesthetics, an AbbVie company, Rome, Italy
| | - Maria Musumeci
- Medical Affairs, Allergan Aesthetics, an AbbVie company, Marlow, United Kingdom of Great Britain and Northern Ireland
| | | | - Michael B Silberberg
- Medical Affairs, Allergan Aesthetics, an AbbVie company, Marlow, United Kingdom of Great Britain and Northern Ireland
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20
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Vargas-Laguna E, García-Gavín J, Bárcena-Ruiz E. Safety in Dermatologic Procedures: Vascular Occlusion by Filling Materials. ACTAS DERMO-SIFILIOGRAFICAS 2021. [DOI: 10.1016/j.adengl.2021.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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21
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Owczarczyk-Saczonek A, Zdanowska N, Wygonowska E, Placek W. The Immunogenicity of Hyaluronic Fillers and Its Consequences. Clin Cosmet Investig Dermatol 2021; 14:921-934. [PMID: 34295171 PMCID: PMC8291382 DOI: 10.2147/ccid.s316352] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/03/2021] [Indexed: 12/24/2022]
Abstract
Hyaluronic acid (HA) is a glycosaminoglycan, a natural component of the extracellular matrix. The identical structure of the molecule in all living organisms is its main advantage, as it translates into the minimal probability of immunogenicity. Therefore, it is the closest to the ideal preparation used as a filler, due to its biocompatibility and stability at the site of implantation. This paper includes the discussion of the potential mechanisms of adverse immune reactions to HA along with the mechanisms of reaction following vaccinations against SARS-CoV-2. Based on the literature, we tried to systematize adverse immune reactions with systemic manifestations to HA. The occurrence of unpredictable reactions to hyaluronic acid indicates that they may not be treated as neutral or non-allergenic. The modifications of the chemical structure of HA, additives and individual tendencies in a patient may be the cause of unpredictable reactions, leading to serious health consequences. Preparations of unknown origin, poorly purified, or including bacterial DNA are particularly dangerous. Therefore, long-lasting follow-up of the patient and the selection of a preparation approved by the FDA or EMA are of high importance. Patients are often unaware of the consequences of cheaper procedures performed by persons without suitable knowledge with the use of unregistered products, so the public should be educated and legal regulations should be introduced.
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Affiliation(s)
- Agnieszka Owczarczyk-Saczonek
- Department of Dermatology, Sexually Transmitted Diseases and Clinical Immunology, University of Warmia and Mazury in Olsztyn, Olsztyn, Poland
| | - Natalia Zdanowska
- Department of Dermatology, Sexually Transmitted Diseases and Clinical Immunology, University of Warmia and Mazury in Olsztyn, Olsztyn, Poland
| | - Ewa Wygonowska
- Department of Dermatology, Sexually Transmitted Diseases and Clinical Immunology, University of Warmia and Mazury in Olsztyn, Olsztyn, Poland
| | - Waldemar Placek
- Department of Dermatology, Sexually Transmitted Diseases and Clinical Immunology, University of Warmia and Mazury in Olsztyn, Olsztyn, Poland
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22
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Michon A. Hyaluronic acid soft tissue filler delayed inflammatory reaction following COVID-19 vaccination - A case report. J Cosmet Dermatol 2021; 20:2684-2690. [PMID: 34174156 PMCID: PMC8447415 DOI: 10.1111/jocd.14312] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 06/02/2021] [Accepted: 06/16/2021] [Indexed: 12/02/2022]
Abstract
Background The use of hyaluronic acid soft tissue fillers in aesthetic medicine exploded in recent years for many reasons, including being relatively safe. Incidence of delayed inflammatory reactions (DIRs) to hyaluronic acid soft tissue fillers range between 0.3% and 4.25%. These reactions are mediated by T‐lymphocytes and can be triggered by flu‐like illnesses, including SARS‐CoV‐2 infection. Vaccination may also induce hypersensitivity. Aim In this case report, we present two cases of delayed reaction after hyaluronic acid soft tissue filler treatment of the tear trough area and following mRNA vaccination against SARS‐Cov‐2, also known as COVID‐19, months later. Patients A 39‐year old female who previously had her tear trough area treated with hyaluronic acid soft tissue filler developed swelling days after getting the mRNA Pfizer‐BioNTech COVID‐19 vaccine. Another patient, a 61‐year‐olf female, developed intermittent facial swelling in areas previously treated with hyaluronic acid soft tissue fillers days after receiving her first dose of the mRNA Pfizer‐BioNTech COVID‐19 vaccine. Results As demonstrated in our case report, vaccination against COVID‐19 may induce DIRs in patients who previously had hyaluronic soft tissue fillers. Conclusion Delayed inflammatory reactions to hyaluronic acid soft tissue fillers are uncommon and usually self‐limited, with frequent spontaneous resolution. However, considering the ongoing pandemic and the worldwide demand for vaccines against COVID‐19, the aesthetic providers should be conscious of the risks posed by the interaction of such vaccines in patients who previously had or seeking hyaluronic acid soft tissue filler injections.
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Affiliation(s)
- Alain Michon
- The Ottawa Skin Clinic, Ottawa, ON, Canada.,Institut du Savoir Montfort, Montfort Hospital, Ottawa, ON, Canada.,Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
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23
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Zheng Z, Lei X, Yang Y, Tan X, Cheng B, Huang W. Changes in Human Fat Injected Alongside Hyaluronic Acid in the Backs of Nude Mice. Aesthet Surg J 2021; 41:NP631-NP642. [PMID: 33326559 DOI: 10.1093/asj/sjaa351] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Cross-linked hyaluronic acid (HA) is an active anti-aging cosmetic filler. The combination of cross-linked HA and preadipocytes or adipose-derived stem cells has been previously investigated, but the effects of agglomerated cross-linked HA injection on the vascularization of fat grafts remain unclear. OBJECTIVES The aim of this study was to explore the effects of agglomerated cross-linked HA injection on the vascularization of fat grafts. METHODS The backs of nude mice were divided into 4 regions that received different treatments: nothing (control group), agglomerated Biohyalux (HA group), agglomerated fat (FAT group), and lumps formed by the sequential injection of Biohyalux and fat (HA/FAT group). Samples were collected after 1 month for weighing and hematoxylin and eosin staining, immunohistochemistry, image analysis, and Western blotting. RESULTS The weight of fat and the mean number of adipocytes in the HA/FAT group did not significantly differ from those in the FAT group. No living tissue was found in agglomerated HA. Some tiny HA particles were surrounded by tissue rich in blood vessels. The expression levels of CD31 and vascular endothelial growth factor (VEGF) in the HA/FAT group were higher than those in the FAT group, but the difference was only significant for VEGF expression. CONCLUSIONS Cross-linked HA had minimal effect on the early retention rate of surrounding fat grafts, but enhanced their vascularization. Fat grafts should be not injected into lumps of cross-linked HA. Therefore, agglomerated cross-linked HA should be dissolved before fat transplantation.
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Affiliation(s)
- Zhifang Zheng
- Department of Anatomy, School of Basic Medicine Sciences, Southern Medical University, Guangzhou, China
| | - Xiaoxuan Lei
- Department of Plastic Surgery, General Hospital of Southern Theater Command, Guangzhou, China
| | - Yu Yang
- Department of Plastic Surgery, General Hospital of Southern Theater Command, Guangzhou, China
| | - Xi Tan
- Department of Plastic Surgery, General Hospital of Southern Theater Command, Guangzhou, China
| | - Biao Cheng
- Department of Plastic Surgery, General Hospital of Southern Theater Command, Guangzhou, China
| | - Wenhua Huang
- Department of Anatomy, School of Basic Medicine Sciences, Southern Medical University, Guangzhou, China
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24
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Vargas-Laguna E, García-Gavín J, Bárcena-Ruiz E. Safety in Dermatologic Procedures: Vascular Occlusion by Filling Materials. ACTAS DERMO-SIFILIOGRAFICAS 2021; 112:S0001-7310(21)00177-0. [PMID: 33984311 DOI: 10.1016/j.ad.2021.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/08/2021] [Accepted: 04/15/2021] [Indexed: 11/22/2022] Open
Abstract
Ischemic events are the most serious complications of facial antiaging treatment with dermal fillers. Ischemia can cause Nicolau syndrome, blindness, or even stroke. This article discusses how to prevent ischemic complications and what steps to take should a dermatologic emergency develop. A thorough understanding of facial anatomy is important. Preferred procedural techniques involve the use of cannulas and retrograde injection. When ischemia is detected in the skin, hyaluronidase should be injected, preferably through a cannula. If ocular ischemia occurs, the patient should be transferred to a hospital with stroke code activation.
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Affiliation(s)
- E Vargas-Laguna
- Servicio de Dermatología, Hospital Severo Ochoa, Madrid, España.
| | - J García-Gavín
- Servicio de Dermatología, Clínica Gavín Dermatólogos, Vigo, España
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25
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Benslimane F. Personal Strategy to Avoid Fat Embolism During Fat Grafting: Brisk Withdrawal of Cannula While Injection. Aesthetic Plast Surg 2021; 45:718-729. [PMID: 33403423 DOI: 10.1007/s00266-020-02066-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 11/21/2020] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Complications of fat grafting by means of injection may lead to unwanted passage of substrate into vessel lumens resulting in catastrophic complications. Likewise, a similar trend of complications is observed with non-autologous fillers regardless of an almost generalized use of blunt cannulas, the latter being implicated in the majority of serious vascular complications of hyaluronic acid injection. This report is the product of investigation to review all cases that underwent an original technique of fat injection: "The smart fat injection" during the cannula's brisk withdrawal technique. The aim of this research was to document the safety of this technique by searching if fat embolism had occurred and if yes, its incidence in this group of fat injection surgeries. METHOD This retrospective review included 3039 patients who underwent the smart fat injection at the facial or corporeal level between 2001 and 2019. The study focused on the search for complications linked to fat yet also cruorical embolism, as the latter may resemble the clinical symptoms of fat embolism. RESULTS The assessment of the 3039 patients who underwent the smart fat injection during cannula's brisk withdrawal, resulted in none presenting clinically detectable fat or a cruorical embolism. CONCLUSION This report documents the safety of the smart fat injection developed over a period of 22 years. It further explains the rationale of the technique for avoiding fat embolism while simultaneously enhancing fat take. This technique should not be implemented without appropriate in vitro training. LEVEL OF EVIDENCE V 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 .
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26
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False Sense of Safety: Blunt Cannulas Cause the Majority of Severe Vascular Complications in Hyaluronic Acid Injection. Plast Reconstr Surg 2020; 146:240e-241e. [DOI: 10.1097/prs.0000000000007022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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27
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van Loghem J, Funt D, Pavicic T, Goldie K, Yutskovskaya Y, Fabi S, Siebenga P, Thuis J, Hkeik J, Kadouch J, Prager W, Azib N, Casabona G, Dayan S, Bay Aguilera S, Snozzi P, Saeed P. Managing intravascular complications following treatment with calcium hydroxylapatite: An expert consensus. J Cosmet Dermatol 2020; 19:2845-2858. [PMID: 32185876 PMCID: PMC7687073 DOI: 10.1111/jocd.13353] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 02/17/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Inadvertent intra-arterial injection of dermal fillers including calcium hydroxylapatite (CaHA) can result in serious adverse events including soft tissue necrosis, permanent scarring, visual impairment, and blindness. When intra-arterial injection occurs, immediate action is required for optimal outcomes, but the infrequency of this event means that many physicians may never have experienced this scenario. The aim of this document is to provide evidence-based and expert opinion recommendations for the recognition and management of vascular compromise following inadvertent injection of CaHA. METHODS An international group of experts with experience in injection of CaHA and management of vascular complications was convened to develop a consensus on the optimal management of vascular compromise following intra-arterial CaHA injection. The consensus members were asked to provide preventative advice for the avoidance of intravascular injection and to produce a treatment protocol for acute and delayed presentation. To ensure all relevant treatment options were included, the recommendations were supplemented with a PubMed search of the literature. RESULTS For prevention of intra-arterial CaHA injection, consensus members outlined the importance of a thorough knowledge of facial vascular anatomy and patient history, as well as highlighting potential risk zones and optimal injection techniques. Individual sections document how to recognize the symptoms of vascular occlusion leading to vision loss and tissue necrosis as well as detailed treatment protocols for the management of these events. For impending tissue necrosis, recommendations are provided for early and delayed presentations with treatment protocols for acute and follow-up treatment. A separate section details the treatment options for open and closed wounds. CONCLUSIONS All physicians should be prepared for the eventuality of intra-arterial injection of a dermal filler, despite its rarity. These consensus recommendations combine advice from aesthetic experts with the latest reports from the published literature to provide an up-to-date office-based protocol for the prevention and treatment of complications arising from intra-arterial CaHA injection.
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Affiliation(s)
- Jani van Loghem
- Falck ClinicAesthetic Medicine CentreAmsterdamThe Netherlands
| | - David Funt
- Mount Sinai School of MedicineNew YorkNYUSA
- Mount Sinai School of MedicineGarden CityNYUSA
- Mount Sinai School of MedicineWoodmereNYUSA
| | - Tatjana Pavicic
- Private Practice for Dermatology and AestheticsMunichGermany
| | | | - Yana Yutskovskaya
- Dermatovenerology and Cosmetology DepartmentPacific State MedicalUniversity of HealthMoscowRussia
| | - Sabrina Fabi
- Department of DermatologyUniversity of CaliforniaSan DiegoCAUSA
| | - Pieter Siebenga
- Falck ClinicAesthetic Medicine CentreAmsterdamThe Netherlands
| | - Job Thuis
- Falck ClinicAesthetic Medicine CentreAmsterdamThe Netherlands
| | | | - Jonathan Kadouch
- ReSculpt ClinicPractice for Aesthetic DermatologyAmsterdamThe Netherlands
| | - Welf Prager
- Prager & Partner Dermatologische PraxisHamburgGermany
| | | | | | - Steve Dayan
- Division of Facial Plastic and Reconstructive SurgeryDepartment of OtolaryngologyUniversity of Illinois at ChicagoChicagoILUSA
| | - Shino Bay Aguilera
- Department of DermatologyNova Southeastern University College of Osteopathic MedicineFort LauderdaleFLUSA
| | | | - Peerooz Saeed
- Falck ClinicAesthetic Medicine CentreAmsterdamThe Netherlands
- Departments of Ophthalmology and EndocrinologyOrbital CenterAcademic Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
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28
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Caldas Pozuelo C, Domínguez De Dios J, Mota Rojas X. Multiple oral granulomatous nodules to hyaluronic acid filler. J Cosmet Dermatol 2020; 19:3453-3455. [PMID: 32979892 DOI: 10.1111/jocd.13734] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/06/2020] [Accepted: 09/08/2020] [Indexed: 11/26/2022]
Abstract
A 74-year-old Caucasian woman presented with a 2-week history of multiple nodules in both lips and perioral region that caused her mild discomfort while eating. The patient reported hyaluronic acid infiltration on both lips 5 months prior to presentation. The examination revealed multiple, well-defined, millimetric, and firm nodules on both lips and oral mucosa. An excisional biopsy of one of the nodules was performed under local anesthesia. Histopathological analysis demonstrated acute eosinophilic inflammation, fibrosis, and granulomas on mucoid material, positive for colloidal iron stain and Alcian blue stain, alongside a minor salivary gland showed mild atrophy, fibrosis, and fat infiltration. Enhancement of the aged lip using hyaluronic acid, to restore the bulkiness and elasticity that have been lost with age, is very common. Nevertheless, soft tissue fillers are used in a wide age range. Hyaluronic acid represents 78% of the dermal filler injections in the United States, been the second most popular nonsurgical cosmetic procedure after botulinum toxin injection. Foreign body granulomatous reaction is a rare delayed complication that has been well documented elsewhere and it has been associated with poor injection technique. Although it also has been related to hypersensitivity reactions that may be caused by impurities developed during the bacterial fermentation process, treatment of granulomatous reactions with hyaluronidase is recommended.
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Affiliation(s)
| | | | - Xenia Mota Rojas
- Department of Otolaryngology, Hospital Álvaro Cunqueiro, Vigo, Spain
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29
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Ors S. The Effect of Hyaluronidase on Depth of Necrosis in Hyaluronic Acid Filling-Related Skin Complications. Aesthetic Plast Surg 2020; 44:1778-1785. [PMID: 32424534 DOI: 10.1007/s00266-020-01759-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 04/30/2020] [Indexed: 01/03/2023]
Abstract
AIM In this clinical study, 16 female patients with vascular compression and occlusion-related ischemia and skin necrosis after hyaluronic acid filling injection were analyzed retrospectively. Dose, timing, and efficacy of hyaluronidase use in skin necrosis are discussed. PATIENTS AND METHODS In a total of 841 cases, aged between 18 and 60 years, hyaluronic acid filling injections were performed. All patients were followed up for 3-24 months. Filling injected areas include nasolabial (391 cases), lip (225 cases), glabella-forehead (90 cases), infraorbital (46 cases), malar region (25 cases), chin (24 cases), and nose (40 cases). Skin complications occurred in four cases during the application and in 12 cases 6-24 h after the procedure. Only palliative treatment was performed in six cases, while hyaluronidase was used in 10 cases in addition to palliative treatment. Hyaluronidase injection was performed 30 s after filling injection in four cases and 6-24 h after the injection in the remaining six cases. A total of 1500 units of hyaluronidase was applied to each case in average. RESULTS Recovery period of the patients who received palliative treatment only lasted 40-60 days. The area of necrosis was limited in these patients who did heal well only with some change of pigmentation and no obvious scar. In the patient group who received hyaluronidase in addition to palliative treatment, a large necrosis area was observed at the same time in four patients. Despite the hyaluronidase treatment in this group, recovery period was 20-90 days. The affected and necrosis areas were large. The cause of ischemia depended both on occlusion and on compression. While four patients healed with a scar, the remaining 12 patients healed without any significant scar. CONCLUSIONS Hyaluronidase injection provides earlier recovery of limited skin necrosis. Immediate hyaluronidase injection allows small damage to heal in a short time; however, it does not completely eliminate large necrosis, although it limits the necrotic area. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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30
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Unexpected Bone Resorption in Mentum Induced by the Soft-Tissue Filler Hyaluronic Acid: A Preliminary Retrospective Cohort Study of Asian Patients. Plast Reconstr Surg 2020; 146:147e-155e. [DOI: 10.1097/prs.0000000000006979] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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31
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Zhao P, Zhao W, Zhang K, Lin H, Zhang X. Polymeric injectable fillers for cosmetology: Current status, future trends, and regulatory perspectives. J Appl Polym Sci 2020. [DOI: 10.1002/app.48515] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Peng Zhao
- Center for Medical Device EvaluationNational Medical Products Administration Beijing 100081 People's Republic of China
| | - Wanlu Zhao
- National Engineering Research Center for BiomaterialsSichuan University Chengdu Sichuan 610065 People's Republic of China
| | - Kai Zhang
- National Engineering Research Center for BiomaterialsSichuan University Chengdu Sichuan 610065 People's Republic of China
- Institute of Regulatory Science for Medical DeviceSichuan University Chengdu Sichuan 610065 People's Republic of China
| | - Hai Lin
- National Engineering Research Center for BiomaterialsSichuan University Chengdu Sichuan 610065 People's Republic of China
| | - Xingdong Zhang
- National Engineering Research Center for BiomaterialsSichuan University Chengdu Sichuan 610065 People's Republic of China
- Institute of Regulatory Science for Medical DeviceSichuan University Chengdu Sichuan 610065 People's Republic of China
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Alegre-Sánchez A, Bernárdez C. A new nonhydrophilic agarose gel as subdermal filler for facial rejuvenation: Aesthetic results and patient satisfaction. J Cosmet Dermatol 2020; 19:1900-1906. [PMID: 32500943 DOI: 10.1111/jocd.13529] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/20/2020] [Accepted: 05/28/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND A wide range of fillers are already available for facial rejuvenation. Most of them are based on the use of reticulated or nonreticulated hyaluronic acid. AIMS The main objective of this study is to present the advantages, efficacy, and safety profile of a new agarose gel filler without reticulating agents, for different facial areas. PATIENT/METHODS A total of 41 patients were treated with different concentrations of the agarose gel filler (1%; 1,5%; 2,5% and 3,5%). Mean age of the participants was 44.62 years. 67.7% (31/41) of the patients were female. Typically, each anatomic area was injected with half of the syringe volume (0.7 + 0.1 mL of lidocaine 2%) per side. One week after one-session treatment, Global Aesthetic Improvement Scale (GAIS) was obtained and satisfaction surveys were filled by patients. RESULTS Clinical improvement was noted immediately, with no progressive volume gain over following days. In the GAIS, 90% of the cases scored as "significant or great improvement." Patient satisfaction was very high with 83% of them evaluating the results as 8 or higher in a scale 1-10. Only one late-onset nodule was observed some weeks after injection, that resolved completely with corticosteroid injection. CONCLUSIONS This new agarose gel filler represents an effective and safe alternative for facial rejuvenation with fillers. Among its advantages, it can be highlighted the absence of reticulating agents and its nonhydrophilic nature.
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Affiliation(s)
- Adrián Alegre-Sánchez
- Grupo Pedro Jaén Dermatology Clinic, Madrid, Spain.,University Hospital Ruber Juan Bravo, Madrid, Spain
| | - Claudia Bernárdez
- Grupo Pedro Jaén Dermatology Clinic, Madrid, Spain.,University Hospital Ruber Juan Bravo, Madrid, Spain
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Horriat N, Woods TR, Medina A. An unusual and delayed complication of hyaluronic acid filler injection: a case report. CASE REPORTS IN PLASTIC SURGERY AND HAND SURGERY 2020; 7:68-72. [PMID: 33457452 PMCID: PMC7782608 DOI: 10.1080/23320885.2020.1769481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
48-year-old female with facial granulomatous nodules and fungal/bacterial infection after hyaluronic acid injection. She underwent anti-fungal/antibacterial therapy and local excision. The proposed mechanisms include inflammatory foreign body reaction and pathogen contamination. Providers must exercise caution with the use of facial fillers and demonstrate expertise in avoiding and managing potential complications.
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Affiliation(s)
- Narges Horriat
- Division of Plastic Surgery, Department of Surgery, School of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Tina R Woods
- Division of Oral Pathology, Department of Oral Maxillofacial Surgery and Pathology, School of Dentistry, University of Mississippi Medical Center, Jackson, MS, USA
| | - Abelardo Medina
- Division of Plastic Surgery, Department of Surgery, School of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
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Artzi O, Cohen JL, Dover JS, Suwanchinda A, Pavicic T, Landau M, Goodman GJ, Ghannam S, Al Niaimi F, van Loghem JAJ, Goldie K, Sattler S, Cassuto D, Lim TS, Wanitphakdeedecha R, Verner I, Fischer TC, Bucay V, Sprecher E, Shalmon D. Delayed Inflammatory Reactions to Hyaluronic Acid Fillers: A Literature Review and Proposed Treatment Algorithm. Clin Cosmet Investig Dermatol 2020; 13:371-378. [PMID: 32547150 PMCID: PMC7244356 DOI: 10.2147/ccid.s247171] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 04/18/2020] [Indexed: 12/28/2022]
Abstract
Background and Objectives There is a wide diversity of opinions regarding the management of delayed inflammatory reactions (DIRs) secondary to hyaluronic acid (HA)-based fillers. The plethora of approaches has led the authors to conduct a review regarding management and treatment of DIRs as well as establish therapeutic guidelines for this purpose. Materials and Methods A review of the literature was performed through databases such as PubMed using keywords including HA-fillers and complications, delayed HA filler sequelae and therapy, soft tissue and dermal filler reactions and management. Additionally, a survey comprised of questions regarding the management and treatment of DIRs was sent to 18 physicians highly experienced with soft-tissue filler injections in 10 countries. Their answers and recommendations were analyzed and debated amongst these panelists. Results Sixteen panelists favored antibiotic therapy as first-line treatment for DIRs, specifically dual antibiotic therapy consisting of a fluoroquinolone along with a tetracycline or macrolide for a period of 3-6 weeks. The majority refrained from the use of intralesional (IL) or systemic steroids except in the case of disfiguring or recalcitrant reactions. IL hyaluronidase was recommended by 13 panelists; however, some preferred a watchful waiting approach for a period of 48 hours to 2 weeks prior to IL hyaluronidase, and in cases where antibiotics did not lead to improvement. Conclusion A consensus was reached and summarized to propose a clear, easy-to-follow, stepwise algorithm for the treatment of DIRs.
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Affiliation(s)
- Ofir Artzi
- Department of Dermatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Joel L Cohen
- AboutSkin Dermatology and AboutSkin Research, , Greenwood Village and Lone Tree, CO, USA
| | - Jeffrey S Dover
- SkinCare Physicians, Chestnut Hill, MA, USA.,Dermatology, Yale University School of Medicine, New Haven, CT, USA.,Dermatology, Brown Medical School, Rhode Island, USA
| | - Atchima Suwanchinda
- Department of Dermatology, School of Anti-Aging and Regenerative Medicine, Mae Fah Luang University, Bangkok, Thailand.,Division of Dermatology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Tatjana Pavicic
- Private Practice for Dermatology and Aesthetics Dr. Tatjana Pavicic, Munich 80539, Germany
| | | | | | - Sahar Ghannam
- Associate Prof. of Dermatology, Alexandria University, Alexandria, Egypt
| | | | | | - Kate Goldie
- Medical Director European Medical Aesthetics Ltd, London W1G 8QN, UK
| | | | | | | | | | - Ines Verner
- Verner Clinic, Tel Aviv, Israel.,Department of Dermatology, University of Rome, Guglielmo Marconi, Italy
| | - Tanja C Fischer
- Skin and Laser Center, Potsdam, Germany.,School of Medicine, University of Frankfurt, Germany
| | - Vivian Bucay
- Bucay Center for Dermatology and Aesthetics, UTHSC, San Antonio, TX, USA
| | - Eli Sprecher
- Department of Dermatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Human Molecular Genetics & Biochemistry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dana Shalmon
- Department of Dermatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Philipp-Dormston WG, Goodman GJ, De Boulle K, Swift A, Delorenzi C, Jones D, Heydenrych I, Trindade De Almeida A, Batniji RK. Global Approaches to the Prevention and Management of Delayed-onset Adverse Reactions with Hyaluronic Acid-based Fillers. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2730. [PMID: 32440404 PMCID: PMC7209845 DOI: 10.1097/gox.0000000000002730] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 02/04/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Delayed-onset adverse reactions to hyaluronic acid (HA) fillers are uncommon but have received increased attention, particularly with regard to late-onset nodules. Globally, there is a need for comprehensive prevention and management strategies. METHODS Experts with clinical practices in diverse regions of the world and extensive experience in managing complications related to HA fillers convened to propose and evaluate approaches to prevent delayed-onset adverse reactions after HA filler administration and manage late-onset nodules. RESULTS The expert panel agreed to define delayed-onset adverse reactions as those presenting more than 4 weeks posttreatment, with swelling, induration, and nodulation being the most common clinical signs. The panel recommended 5 general key approaches for the prevention of delayed-onset reactions (patient selection, anatomic location of injection/product selection, aseptic technique, injection procedure/filler, and posttreatment care). Strategies recommended for managing late-onset nodules included oral antibiotics, oral steroids, nonsteroidal anti-inflammatory drugs if needed, hyaluronidase for noninflammatory nodules (recognizing the limitations and regional availability of this treatment), intralesional antibiotics, intralesional immunosuppressive drugs such as steroids and fluorouracil, and surgical excision as a last resort. The panel noted that late-onset nodules may vary in both clinical presentation and etiology, making them challenging to address or prevent, and stressed individualized treatment based on clinical presentation. Regional differences in aseptic protocols, antibiotic selection, and steroid formulations were described. CONCLUSION Insights from global experts on approaches to prevent and manage delayed-onset adverse reactions following HA filler administration, including late-onset nodules, support clinicians worldwide in optimizing patient outcomes and safety.
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Affiliation(s)
- Wolfgang G. Philipp-Dormston
- From the Department of Dermatology, Witten/Herdecke University, Witten, Germany
- Klinik Links vom Rhein, Cologne, Germany
| | - Greg J. Goodman
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Clayton, Victoria, Australia
| | | | | | | | - Derek Jones
- Skin Care and Laser Physicians of Beverly Hills, Beverly Hills, Calif
| | - Izolda Heydenrych
- Cape Town Cosmetic Dermatology Centre, Cape Town, South Africa
- Stellenbosch University, Cape Town, South Africa
| | - Ada Trindade De Almeida
- Clinica de Dermatologia, Hospital do Servidor Público Municipal de São Paulo, São Paulo, Brazil
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Jung GS. Filler rhinoplasty based on anatomy: The dual plane technique. JPRAS Open 2019; 20:94-100. [PMID: 32158877 PMCID: PMC7061673 DOI: 10.1016/j.jpra.2019.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 04/04/2019] [Indexed: 11/25/2022] Open
Abstract
Filler rhinoplasty is susceptible to spreading because of the way the nose protrudes away from the face. Often, the well-defined appearance immediately after the procedure is poorly maintained, and the nasion area develops a bulbous appearance. Therefore, I developed a “dual plane technique” to prevent spreading and to maintain the desired shape of the filler rhinoplasty. Dual plane injections were administered in 96 patients. Based on the anatomy of the nose, a highly elastic filler was injected in the deep fat layer and a moderately elastic filler was injected in the superficial fat compartments. The retrograde linear threading technique was used to inject the fillers to prevent mixing with each other. Afterwards, the highly elastic hyaluronic acid filler was injected from the anterior nasal spine into the supracartilaginous layer by a retrograde linear threading technique. All patients were followed up for at least 3 months, during which time there were no major complications and aesthetic satisfaction was high. The dual plane technique is an injection technique based on the anatomical base. Different types of filler can be used according to the plane and filler rheology to obtain an aesthetically pleasing result.
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Affiliation(s)
- Gyu Sik Jung
- GLAD Plastic Surgery Clinic, 31 Dongsung-ro 5-gil, 3rd floor, Jung-gu, Daegu 41941, Republic of Korea
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