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Liu K, Li K, Wang X, Sun J, Shen SGF. Facial vascular visualization enhancement based on optical detection technology. Dentomaxillofac Radiol 2024; 53:382-389. [PMID: 38775663 PMCID: PMC11358639 DOI: 10.1093/dmfr/twae020] [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: 11/21/2023] [Revised: 04/07/2024] [Accepted: 05/07/2024] [Indexed: 08/30/2024] Open
Abstract
OBJECTIVE This study aims to develop a facial vascular enhancement imaging system and analyze vascular distribution in the facial region to assess its potential in preventing unintended intravascular injections during cosmetic facial filling procedures. METHODS A facial vascular enhancement imaging system based on optical detection technology was designed, and volunteers were recruited. The system was utilized to detect and analyze vascular distribution in various anatomical regions of the faces. The vascular visualization-enhanced (VVE) images generated by the system were compared with visible light images to validate the vascular visualization capability of the system. Additionally, the reliability of vascular visualization was assessed by comparing the observed vascular patterns in the VVE images with those in near-infrared light images. RESULTS Thirty volunteers were recruited. The VVE images produced by the system demonstrated a significant capacity to identify vascular morphology and yielded a higher vessel count compared to visible light images, particularly in the frontal, orbital, perioral, mental, temporal, cheek, and parotid masseter regions (P < .05). The temporal region exhibited the highest vascular density, followed by the cheek region and then the frontal region. Reliability analysis of vascular visualization enhancement indicated that the system's imaging of facial vasculature not only demonstrated reliability but also enhanced physicians' visual perception. CONCLUSION Blood vessel distribution varies across facial regions. The facial vascular enhancement imaging system facilitates real-time and clear visualization of facial vasculature, offering immediate visual feedback to surgeons. This innovation holds promise for enhancing the safety and effectiveness of facial filling procedures.
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Affiliation(s)
- Kai Liu
- Department of Oral and Craniomaxillofacial Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
- College of Stomatology, Shanghai Jiao Tong University, Shanghai 200011, China
- National Center for Stomatology, Shanghai 200011, China
- National Clinical Research Center for Oral Diseases, Shanghai 200011, China
- Shanghai Key Laboratory of Stomatology, Shanghai 200011, China
| | - Kai Li
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai 200093, China
| | - Xudong Wang
- Department of Oral and Craniomaxillofacial Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
- College of Stomatology, Shanghai Jiao Tong University, Shanghai 200011, China
- National Center for Stomatology, Shanghai 200011, China
- National Clinical Research Center for Oral Diseases, Shanghai 200011, China
- Shanghai Key Laboratory of Stomatology, Shanghai 200011, China
| | - Jiuai Sun
- School of Medical Imaging, Shanghai University of Medicine and Health Sciences, Shanghai 201318, China
| | - Steve G F Shen
- Department of Oral and Craniomaxillofacial Surgery, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
- College of Stomatology, Shanghai Jiao Tong University, Shanghai 200011, China
- National Center for Stomatology, Shanghai 200011, China
- National Clinical Research Center for Oral Diseases, Shanghai 200011, China
- Shanghai Key Laboratory of Stomatology, Shanghai 200011, China
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Meer E, Lopez J, Lu J, Winn BJ, Grob SR. The role of oculoplastic surgeons in minimally invasive cosmetic injectables. Curr Opin Ophthalmol 2024; 35:382-390. [PMID: 38934244 DOI: 10.1097/icu.0000000000001068] [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: 06/28/2024]
Abstract
PURPOSE OF REVIEW In recent years, the field of aesthetic medicine has witnessed a paradigm shift with an increasing demand for minimally invasive cosmetic procedures, including cosmetic injectables. This review aims to delineate the distinctive role played by oculoplastic surgeons in the administration of cosmetic injectables, comparing their expertise to that of nonphysician practitioners. RECENT FINDINGS Complications arising from cosmetic injections are discussed, including skin discoloration, inflammation, necrosis, vision loss, retinal pathology, and central nervous system adverse effects. Injector expertise, patient factors, type of filler, location of injection, and management strategies are reviewed. Findings highlight diverse practitioner involvement, common adverse effects like skin necrosis and vision loss, with hyaluronic acid fillers being prominent. Areas at the highest risk for ocular complication include the glabella and nose with potential management involving dissolving fillers and reducing pressure. Emphasis is placed on expert injector selection and patient awareness. SUMMARY The administration of cosmetic injectables requires a profound understanding of facial anatomy, vasculature, and potential complications. In contrast to nonphysician practitioners, oculoplastic and aesthetic surgeons bring a level of anatomical precision and clinical acumen that is essential for navigating the complexities of cosmetic injectables. Emphasis on training and collaboration among practitioners will be essential in advancing the field while prioritizing patient safety and satisfaction.
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Affiliation(s)
| | | | - Jonathan Lu
- Department of Ophthalmology
- Division of Oculofacial Plastic and Orbital Surgery, Department of Ophthalmology, University of California, San Francisco
| | - Bryan J Winn
- Department of Ophthalmology
- Division of Oculofacial Plastic and Orbital Surgery, Department of Ophthalmology, University of California, San Francisco
- Ophthalmology Section, Surgical Service, San Francisco Veterans Affairs Healthcare System, San Francisco, California, USA
| | - Seanna R Grob
- Department of Ophthalmology
- Division of Oculofacial Plastic and Orbital Surgery, Department of Ophthalmology, University of California, San Francisco
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Zhou LC, Dong YX, Cao MB, Li JY, Peng T, Zhang SY, Zhou YW, Shu HN, Luo SK. The Safety of Injections in the Infraorbital Region. Aesthetic Plast Surg 2024; 48:2231-2238. [PMID: 38528128 DOI: 10.1007/s00266-024-03976-5] [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: 01/27/2024] [Accepted: 02/27/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Infraorbital filler injection is a commonly used minimally invasive cosmetic procedure on the face, which can cause vascular complications. OBJECTIVE In this study, we aimed to explore the anatomical structure of the infraorbital vasculature and to establish an accurate protocol for infraorbital filler injection. METHODS The vascular structure of the infraorbital region was evaluated in 84 hemifacial specimens using computed tomography. Four segments (P1-P4) and five sections (C1-C5) were considered. We recorded the number of identified arteries in each slice and at each location and the number of deep arteries. Furthermore, we also measured the infraorbital artery (IOA) distribution. RESULTS At P1-P4, the lowest number of arteries was detected in segment P4, with a 317/1727 (18.4%) and 65/338 (2.3%) probability of total and deep arterial identification, respectively. The probabilities of encountering an identified artery at the five designated locations (C1-C5) were 277/1727 (16%), 318/1727 (18.4%), 410/1727 (23.7%), 397/1727 (23%), and 325/1727 (18.8%), respectively. The probability of an IOA being identified at C2 was 68/84 (81%). CONCLUSION We described an effective filler injection technique in the infraorbital region to minimize the associated risks. 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)
- Ling-Cong Zhou
- Department of Plastic and Reconstructive Surgery, Guang Dong Second Provincial People's Hospital, The Affiliated Guangdong Second Provincial General Hospital of Jinan University, 466 Middle Xin Gang Road, Guangzhou, 510317, Guangdong, China
- Department of Plastic and Cosmetic Surgery, Yueyang Central Hospital, Yueyang, Hunan, China
| | - Yun-Xian Dong
- Department of Plastic and Reconstructive Surgery, Guang Dong Second Provincial People's Hospital, The Affiliated Guangdong Second Provincial General Hospital of Jinan University, 466 Middle Xin Gang Road, Guangzhou, 510317, Guangdong, China
| | - Mi-Bu Cao
- Department of Plastic and Reconstructive Surgery, Guang Dong Second Provincial People's Hospital, The Affiliated Guangdong Second Provincial General Hospital of Jinan University, 466 Middle Xin Gang Road, Guangzhou, 510317, Guangdong, China
| | - Jun-Yu Li
- Department of Plastic and Reconstructive Surgery, Guang Dong Second Provincial People's Hospital, The Affiliated Guangdong Second Provincial General Hospital of Jinan University, 466 Middle Xin Gang Road, Guangzhou, 510317, Guangdong, China
| | - Tong Peng
- Department of Plastic and Reconstructive Surgery, Guang Dong Second Provincial People's Hospital, The Affiliated Guangdong Second Provincial General Hospital of Jinan University, 466 Middle Xin Gang Road, Guangzhou, 510317, Guangdong, China
| | - Si-Yi Zhang
- Department of Plastic and Reconstructive Surgery, Guang Dong Second Provincial People's Hospital, The Affiliated Guangdong Second Provincial General Hospital of Jinan University, 466 Middle Xin Gang Road, Guangzhou, 510317, Guangdong, China
| | - Yang-Wu Zhou
- Department of Plastic and Cosmetic Surgery, Yueyang Central Hospital, Yueyang, Hunan, China
| | - Hai-Ning Shu
- Department of Plastic and Cosmetic Surgery, Yueyang Central Hospital, Yueyang, Hunan, China
| | - Sheng-Kang Luo
- Department of Plastic and Reconstructive Surgery, Guang Dong Second Provincial People's Hospital, The Affiliated Guangdong Second Provincial General Hospital of Jinan University, 466 Middle Xin Gang Road, Guangzhou, 510317, Guangdong, China
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Akhavan AA, Pang JH, Morrison SD, Satterwhite T. Gender Affirming Facial Surgery-Anatomy and Procedures for Facial Masculinization. Oral Maxillofac Surg Clin North Am 2024; 36:221-236. [PMID: 38458858 DOI: 10.1016/j.coms.2024.01.001] [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] [Indexed: 03/10/2024]
Abstract
For some patients, feminine facial features may cause significant gender dysphoria. Multiple nonsurgical and surgical techniques exist to masculinize facial features. Nonsurgical techniques include testosterone supplementation and dermal fillers. Surgical techniques include soft tissue manipulation, synthetic implants, regenerative scaffolding, or bony reconstruction. Many techniques are derived from experience with cisgender patients, but are adapted with special considerations to differing anatomy between cisgender and transgender men and women. Currently, facial masculinization is less commonly sought than feminization, but demand is likely to increase as techniques are refined and made available.
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Affiliation(s)
- Arya Andre Akhavan
- Division of Plastic and Reconstructive Surgery, Rutgers New Jersey Medical School, 140 Bergen Street, Suite E1620, Newark, NJ 07103, USA; Align Surgical Associates, 2299 Post Street, Suite 207, San Francisco, CA 94115, USA
| | - John Henry Pang
- Align Surgical Associates, 2299 Post Street, Suite 207, San Francisco, CA 94115, USA
| | - Shane D Morrison
- Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, University of Washington, 1959 Northeast Pacific Street, Box 356165, Seattle, WA 98195, USA
| | - Thomas Satterwhite
- Align Surgical Associates, 2299 Post Street, Suite 207, San Francisco, CA 94115, USA; Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University Medical Center.
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Borzabadi-Farahani A, Mosahebi A, Zargaran D. A Scoping Review of Hyaluronidase Use in Managing the Complications of Aesthetic Interventions. Aesthetic Plast Surg 2024; 48:1193-1209. [PMID: 36536092 PMCID: PMC10999391 DOI: 10.1007/s00266-022-03207-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 11/19/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Hyaluronidase is used as an adjunct or main treatment to manage complications associated with cosmetic hyaluronic acid (HA) filler injections such as necrosis, blindness, hypersensitivity, delayed nodules, and poor aesthetic outcomes. OBJECTIVE To systematically map the available evidence and identify the gaps in knowledge on the effectiveness of hyaluronidase use in managing the aesthetic complications associated with HA injections (vascular occlusion, blindness, nodules, delayed hypersensivity, granuloma, poor aesthetic outcome). METHODS PubMed, Medline, Embase and Cochrane databases were used up to May 2022, to look for randomized clinical trials (RCTs), clinical trials, and retrospective case-control studies reporting on the use of hyaluronidase for managing the HA filler injection complications. RESULTS The database search yielded 395 studies; of those 5 RCTs (all carried out in the USA) were selected (53 subjects), indicating the effectiveness of hyaluronidase for removal of un-complicated injected HA nodules (forearm, upper arm, or back skin). The follow-ups ranged from 14 days to 4 years. The amount of HA filler injected into each site varied from 0.2 to 0.4 mL. A dose dependent response was observed for most HA fillers. No major adverse reactions were reported. Overall, for removal of every 0.1 mL of HA filler they injected 1.25-37.5 units of hyaluronidase (single injections). When 3 consecutive weekly hyaluronidase injection was used much lower doses of 0.375-2.25 unit was utilised. There was no evidence in a form of RCTs, clinical trials, and retrospective case-control studies on the removal/reversal of HA injections in the facial skin, or management of over-corrections, inflammatory nodules, or tissue ischemia/necrosis associated with HA filler injection. CONCLUSION Based on studies on the forearm, upper arm and back skin, hyaluronidase can be used for the reversal of uncomplicated HA filler injection nodule. However, further adequately powered studies are warranted to establish the ideal treatment protocol/dose of hyaluronidase for reversal of HA filler injections in the facial region or management of complications associated with aesthetic HA injection. 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)
- Ali Borzabadi-Farahani
- Division of Surgery & Interventional Science (Minimally Invasive Aesthetics), University College London (UCL), London, WC1E 6BT, UK.
- Crouch End Orthodontics, 72 Crouch End Hill, London, N8 8AG, England, UK.
| | - Afshin Mosahebi
- Department of Plastic Surgery, Royal Free Hospital, University College London, London, UK
| | - David Zargaran
- Department of Plastic Surgery, Royal Free Hospital, University College London, London, UK
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Nikolis A, Enright KM, Nguyen Q, Cotofana S. The Suitability of a Large Particle Hyaluronic Acid Filler for the Treatment of Temporal Hollowing. Dermatol Surg 2023; 49:1145-1151. [PMID: 37712833 DOI: 10.1097/dss.0000000000003916] [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: 09/16/2023]
Abstract
BACKGROUND Hyaluronic acid (HA) fillers may be manufactured to have distinctive physical properties that optimize their use for specific indications. Fillers manufactured with large gel calibration (particle size; HA-V) may be particularly suitable for volumizing large surface areas such as the temporal hollows. OBJECTIVE To investigate the safety and effectiveness of HA-V for the treatment of temporal hollows. MATERIALS AND METHODS A prospective, open-label, single-cohort, clinical trial was conducted. Twenty-six women who presented with bilateral temporal hollows at baseline were recruited. All subjects received treatment with HA-V and were observed at 4 to 5 in-person visits over 16 weeks. Subjective and objective measures of safety and efficacy parameters were collected through 2- and 3-dimensional imagery, questionnaires/scales (i.e., subject satisfaction, global aesthetic improvement, temporal hollowing severity), and adverse event diaries. RESULTS To achieve optimal correction, the investigator used an average of 1.70 syringes per subject, per side. All treatments were performed using a bolus injection technique to place the product on the periosteum (bone) of the temporal region. Following optimal correction, all subjects (100%) displayed improvement in their global aesthetic appearance, and 25 of 26 subjects (96.15%) displayed ≥1 grade improvement on the temporal volume scale. Subject satisfaction was high, with 91.3% of subjects being satisfied with the appearance of their temporal regions following optimal correction. CONCLUSION In this pivotal trial, HA-V was evidenced to have an excellent safety profile and proven efficacy up to 16 weeks, making it a suitable HA filler for volumization of the temporal region.
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Affiliation(s)
- Andreas Nikolis
- Erevna Innovations Inc., Clinical Research Unit, Westmount, Quebec, Canada
- Department of Plastic Surgery, McGill University, Montreal, Quebec, Canada
| | - Kaitlyn M Enright
- Erevna Innovations Inc., Clinical Research Unit, Westmount, Quebec, Canada
| | - Quynh Nguyen
- Département d'ophtalmologie, Université de Montréal, Montréal, Quebec, Canada
| | - Sebastian Cotofana
- Department of Medical Education at Albany Medical College, Albany, New York
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7
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Zhang L, Zhao Y, Gu Q, Feng X, Li J, Lai F, Pan L, Sun Y, Wu S. A roadmap for safety during facial filler injections: A fresh frozen cadaver study. J Plast Reconstr Aesthet Surg 2023; 86:155-164. [PMID: 37717300 DOI: 10.1016/j.bjps.2023.06.029] [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: 12/20/2022] [Accepted: 06/05/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Filler injections are commonly applied to reshape facial contouring. However, cadaveric injections of filler for facial contouring on the whole face, followed by anatomic analysis and measurement, have rarely been reported. This study aimed to provide comprehensive anatomical information, including topographies and roadmap of injection point entry, penetration depth, filler location, the hierarchy of facial structure, and vital vascular course. METHODS Thirty faces on fresh frozen cadaver heads were used for this anatomic study. The whole face was divided into seven facial zones and 14 injection points for penetration depth measurement and cadaveric injection. Static periosteum injections with a sharp-needle technique were performed. Specimens were then dissected to observe the precise locations of fillers and their relationships with surrounding anatomic structures. RESULTS The topography of penetration depth gradually increased from the upper face to the middle face, lower face, and temporal region. Most of the injected hyaluronic acid filler flowed backward to the loose areolar tissue layer between the superficial musculoaponeurotic system and periosteum or deep fascia. Multilevel layer distributions and anastomosis of the vessels were found in the face, especially in the glabella, dorsum nasi, and temporal regions. CONCLUSIONS This study can provide clinicians with a comprehensive reference for facial contouring injections: topographies of the injection point and penetration depth and the vascular anatomical structure in high-risk facial zones. The static periosteum injection with effective aspiration is recommended as a relatively safe technique. Clinicians are supposed to grasp the anatomy and injection technique to achieve maximum safety during filler injections.
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Affiliation(s)
- Lei Zhang
- Department of Plastic and Reconstructive Surgery, Center of Plastic and Reconstructive Surgery; Zhejiang Plastic Surgery Hospital, Zhejiang Provincial People's Hospital, Affiliated of Hangzhou Medical College, Hangzhou, China
| | - Ye Zhao
- Department of Plastic and Reconstructive Surgery, Center of Plastic and Reconstructive Surgery; Zhejiang Plastic Surgery Hospital, Zhejiang Provincial People's Hospital, Affiliated of Hangzhou Medical College, Hangzhou, China
| | - Qinghao Gu
- Department of Plastic and Reconstructive Surgery, Center of Plastic and Reconstructive Surgery; Zhejiang Plastic Surgery Hospital, Zhejiang Provincial People's Hospital, Affiliated of Hangzhou Medical College, Hangzhou, China
| | - Xiao Feng
- Department of Plastic and Reconstructive Surgery, Center of Plastic and Reconstructive Surgery; Zhejiang Plastic Surgery Hospital, Zhejiang Provincial People's Hospital, Affiliated of Hangzhou Medical College, Hangzhou, China
| | - Jingyu Li
- Department of Plastic and Reconstructive Surgery, Center of Plastic and Reconstructive Surgery; Zhejiang Plastic Surgery Hospital, Zhejiang Provincial People's Hospital, Affiliated of Hangzhou Medical College, Hangzhou, China
| | - Fangyuan Lai
- Department of Plastic and Reconstructive Surgery, Center of Plastic and Reconstructive Surgery; Zhejiang Plastic Surgery Hospital, Zhejiang Provincial People's Hospital, Affiliated of Hangzhou Medical College, Hangzhou, China
| | - Lei Pan
- Department of Plastic and Reconstructive Surgery, Center of Plastic and Reconstructive Surgery; Zhejiang Plastic Surgery Hospital, Zhejiang Provincial People's Hospital, Affiliated of Hangzhou Medical College, Hangzhou, China
| | - Yi Sun
- Department of Plastic and Reconstructive Surgery, Center of Plastic and Reconstructive Surgery; Zhejiang Plastic Surgery Hospital, Zhejiang Provincial People's Hospital, Affiliated of Hangzhou Medical College, Hangzhou, China
| | - Sufan Wu
- Department of Plastic and Reconstructive Surgery, Center of Plastic and Reconstructive Surgery; Zhejiang Plastic Surgery Hospital, Zhejiang Provincial People's Hospital, Affiliated of Hangzhou Medical College, Hangzhou, China.
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Hwang K, Han SH. Digital Compression of the Origin of the Nasal Branch of the Ophthalmic Artery During Filler Augmentation: A Review of the Anatomical Literature and an Analysis of Plastinated Specimens. J Craniofac Surg 2023; 34:e692-e694. [PMID: 37590013 DOI: 10.1097/scs.0000000000009601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 07/04/2023] [Indexed: 08/18/2023] Open
Abstract
The aim of this study was to determine the exact site of digital compression on the origin of the nasal branch of the ophthalmic artery during filler augmentation, by conducting a review of anatomical literature and examining plastinated specimens. According to 4 textbooks (Gray's Anatomy, Whitnall's Anatomy on the Human Orbit, Wolff's Anatomy, and Duke-Elder's System of Ophthalmology), the dorsal nasal artery leaves the orbit by piercing the orbital septum between the trochlea and the medial palpebral ligament and anastomoses with the angular part of the facial artery. In plastinated arterial specimens, the ophthalmic artery exits the orbit and divides into the supratrochlear artery and the dorsal nasal artery at the upper border of the lacrimal fossa. The dorsal nasal artery then anastomoses with the angular part of the facial artery. Branches of the dorsal nasal artery anastomose with their counterparts on the opposite side. During filler augmentation of the nose, bilateral digital compression is applied to the origins of the nasal branches of the ophthalmic artery, specifically at the point where the ophthalmic artery pierces the orbital septum. Applying compression just above the medial palpebral ligament against the bone, directly above the lacrimal sac, using the index finger and thumb can help prevent the migration of injected droplets to the ophthalmic artery. This straightforward maneuver, grounded in anatomical understanding, aims to prevent the migration of injected droplets to the ophthalmic artery.
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Affiliation(s)
- Kun Hwang
- Department of Plastic Surgery, Armed Forces Capital Hospital, Bundang-gu, Seongnam-City, Gyeonggi-do, and Ewha Medical Academy, Ewha Womans University Medical Center
| | - Seung Ho Han
- Ewha Medical Academy, Ewha Womans University Medical Center, Seoul, Republic of Korea
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9
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Yu B, Zhou G, Fu Q, Yang Y, Li S, Zheng C, Chen M. Post-rhinoplasty complications with previous hyaluronic acid injection history: Cerebral infarction and vision loss. J Cosmet Dermatol 2023; 22:2677-2681. [PMID: 37042561 DOI: 10.1111/jocd.15775] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 03/31/2023] [Indexed: 04/13/2023]
Abstract
BACKGROUND Rhinoplasty is becoming increasingly frequent as the pursuit of aesthetics by people accelerates. In recent years, the proportion of people opting for rhinoplasty injections has gradually increased. This has led to numerous reports citing catastrophic postoperative complications such as skin necrosis, cerebral infarction, and visual impairment. AIM The aim of our report is to discuss the possible etiological factors for this post-rhinoplasty complication and provides a rationale for HA injection history as a risk factor in rhinoplasty. METHODS We report a rare case that received nasal HA injections in the past without any untoward incident. She opted for a second rhinoplasty 2 years after her initial nasal HA injections. This second intervention led to post-injection loss of vision in one eye and cerebral infarction. Following clinical and radiological examination, digital subtraction angiography (DSA) and superselective intra-arterial thrombolysis were performed. RESULTS The patient did not develop disuse exotropia or ocular atrophy, but the left eye remained without light perception, which implies that intra-arterial thrombolytic therapy may be a positive and effective method to maintain the normal appearance of the eye. CONCLUSION It is advisable for patient safety to maintain a long interval of time between hyaluronidase injection and repeat rhinoplasty. Clinicians should become familiar with the anatomical peculiarities of the patient and be gentle during the rhinoplasty procedure.
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Affiliation(s)
- Boya Yu
- Department of Plastic and Reconstructive Surgery, the Fourth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Guiwen Zhou
- Department of Plastic and Reconstructive Surgery, the Fourth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Qiang Fu
- Department of Plastic and Reconstructive Surgery, the Fourth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yi Yang
- Department of Plastic and Reconstructive Surgery, the Fourth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Shiyi Li
- Department of Plastic and Reconstructive Surgery, the Fourth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Can Zheng
- Department of Plastic and Reconstructive Surgery, the Fourth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Minliang Chen
- Department of Plastic and Reconstructive Surgery, the Fourth Medical Center of Chinese PLA General Hospital, Beijing, China
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10
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Zhuang J, Zheng Q, Su X, Jiang L, Hu J. Clinical Manifestations and Prognosis of Embolism Caused by Filler Injection in Different Facial Regions. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5225. [PMID: 37650096 PMCID: PMC10465098 DOI: 10.1097/gox.0000000000005225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 07/12/2023] [Indexed: 09/01/2023]
Abstract
Background Embolism is a serious complication after facial filling, with a usually poor prognosis of the symptoms after embolism. The authors systematically reviewed reported cases of facial vascular embolism, explored the relationship between the location and material used for facial filling and occurrence of vascular embolism, and assessed the prognosis of complications after vascular embolism. Methods This study provides a systematic review of published cases of vascular embolism after facial filling. A summary of the filling materials and filling sites for each case, the adverse reactions and embolized blood vessels, a recording of the time when each patient experienced adverse reactions and started treatment, and a presentation of their prognosis are provided. Results The frontal, eyebrow, and nose are common filling sites causing facial embolism. The main clinical manifestations after embolism were visual impairment, skin necrosis, and ptosis. The prognosis of visual impairment after embolization was poor, whereas skin necrosis and ptosis generally improved after treatment. Conclusions This article aimed to review the clinical manifestations, therapies, and prognosis of embolism after facial filling. A better understanding of these complications can help clinicians to detect the occurrence of complications as early as possible and give patients timely treatment.
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Affiliation(s)
- Jun Zhuang
- From the Department of Ear Reconstruction, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qiaoyuan Zheng
- College of Clinical Medicine, Fudan University, Xuhui District, Shanghai, China
| | - Xueshang Su
- Department of Cicatrix Minimally Invasive Treatment Center, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Liya Jiang
- Department of Cosmetic Injection Center, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jintian Hu
- From the Department of Ear Reconstruction, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Cosmetic Injection Center, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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11
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Anatomic Study of Fillers: Mimetic Injections for Maximum Safety. Plast Reconstr Surg 2023; 151:172e-173e. [PMID: 36576840 DOI: 10.1097/prs.0000000000009757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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12
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Invited Discussion on "Comparison of Effectiveness and Safety of a Botulinum Toxin Mono Therapy and a Combination Therapy with Hyaluronic Acid Filler for Improving Glabellar Frown". Aesthetic Plast Surg 2022; 46:1881-1883. [PMID: 35608681 DOI: 10.1007/s00266-022-02927-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 04/28/2022] [Indexed: 11/01/2022]
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13
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Nguyen HH, Tran HTT, Duong QH, Nguyen MD, Dao HX, Le DT. Significant Vision Recovery from Filler-Induced Complete Blindness with Combined Intra-Arterial Injection of Hyaluronidase and Thrombolytic Agents. Aesthetic Plast Surg 2022; 46:907-911. [PMID: 34767060 DOI: 10.1007/s00266-021-02658-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 10/23/2021] [Indexed: 10/19/2022]
Abstract
With the increase of cosmetic injectable hyaluronic acid (HA), there have been more cases with serious complications, including skin necrosis, blindness, and cerebral embolism. Patients who have recovered from HA filler-induced total vision loss are extremely rare. We report a case of a 27-year-old female who developed severe ocular pain on the right side and total vision loss following a 1.0 ml HA filler injection in the nasal dorsum. She arrived at our hospital 4 hours later. Her visual acuity was no light perception (NLP), and she exhibited eyelid ptosis, ophthalmoplegia, and frontal and nasal ecchymosis. She was promptly treated with subcutaneous and retrobulbar hyaluronidase injections, as well as intra-arterial 1500 IU hyaluronidase injections into the right ophthalmic artery with DSA assistance. Her vision improved from NLP to counting fingers at 1.0 meters. Unfortunately, 13 hours later, she felt an intense headache, and her vision again decreased to NLP. We immediately performed an injection of 1500 IU hyaluronidase combined with 8 mg alteplase for intra-arterial thrombolysis (IAT) into the right ophthalmic artery. Her vision improved immediately afterward. After 3 months, her visual acuity had significantly recovered from NLP (admission vision status) to 20/50 (Snellen chart with glasses). Similarly, skin, conjunctival, eye movement, and ptosis symptoms completely recovered. This case demonstrates that reversal of complete blindness due to embolism of the ophthalmic and central retinal arteries could be accomplished through multidisciplinary therapies, especially IAT using fibrinolytic agents combined with hyaluronidase followed by an anticoagulant regimen.Level of evidence VThis 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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Affiliation(s)
- Ha H Nguyen
- Department of Maxillofacial - Plastic - Aesthetic Surgery, Viet-Duc University Hospital, 40 Trang Thi, Hanoi, Vietnam.
| | - Huyen T T Tran
- Department of Maxillofacial - Plastic - Aesthetic Surgery, Viet-Duc University Hospital, 40 Trang Thi, Hanoi, Vietnam
| | - Quan H Duong
- Department of Maxillofacial - Plastic - Aesthetic Surgery, Viet-Duc University Hospital, 40 Trang Thi, Hanoi, Vietnam
| | - Minh D Nguyen
- Medical Imaging & Nuclear Medicine Center, Viet Duc University Hospital, Hanoi, Vietnam
| | - Hai X Dao
- Medical Imaging & Nuclear Medicine Center, Viet Duc University Hospital, Hanoi, Vietnam
| | - Dung T Le
- Medical Imaging & Nuclear Medicine Center, Viet Duc University Hospital, Hanoi, Vietnam
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14
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Abstract
ABSTRACT With the sudden emergence of new medical aesthetic fillers, the number of fillers injected worldwide has exploded, but there are also worrying risks in the pursuit of beauty. At present, many cases of blindness caused by injection of aesthetic fillers have been reported. Most of the cases are caused by irreversible vascular embolism. This is a rare yet greatly feared complication of using facial cosmetic fillers. This article reviewed and analyzed the literature and summarized the changes in the anatomical structure of facial blood vessels related to blindness during facial injection.
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Affiliation(s)
- Dan Li
- From the Department of Plastic and Burn Surgery, the First Affiliated Hospital Chongqing Medical University, Chongqing, China
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15
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Consensus Recommendations on the Use of Hyaluronic Acid-Based Fillers for Nonsurgical Nasal Augmentation in Asian Patients. Plast Reconstr Surg 2022; 149:384-394. [PMID: 35077414 DOI: 10.1097/prs.0000000000008722] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Nonsurgical nasal augmentation using dermal fillers such as hyaluronic acid is increasing in popularity because of its less invasive nature and shorter downtime compared with traditional surgery. However, the complexity of the nasal vasculature makes it a high-risk procedure without proper training. Appropriate patient and product selection and safer standardized injection techniques are warranted to minimize complications and to achieve reproducible aesthetic results. In this article, recommendations for nonsurgical nasal augmentation using hyaluronic acid fillers are outlined, with focus on the dorsum, tip, and columella. METHODS A consensus meeting was conducted to develop recommendations on nonsurgical nasal augmentation in Asian patients using hyaluronic acid-based fillers. Literature review was performed using PubMed and Google Scholar. Relevant studies were included to formulate recommendations. Consensus statements were graded using the criteria outlined by the Grading of Recommendations Assessment, Development and Evaluation Working Group. RESULTS Nonsurgical nasal augmentation is an advanced procedure that warrants in-depth knowledge of the nasal anatomy. The panel recommends thorough preinjection assessment and counseling to fully align the patient's expectations with aesthetic goals. Injections must be deep and at the level of the periosteum or perichondrium to minimize risk of intravascular injection. Aliquots of hyaluronic acid must be introduced using slow, low-pressure, and low-volume injections. Optimal aesthetic effect is achieved with hyaluronic acid dermal fillers that are highly elastic, cohesive, and with good adaptability to their environment. CONCLUSIONS Hyaluronic acid injections are safe and effective in nonsurgical nasal augmentation. In-depth knowledge of vascular anatomy and proper injection techniques using suitable products are necessary to achieve aesthetic goals safely. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.
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16
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Goodman GJ, Magnusson MR, Callan P, Roberts S, Hart S, Lin F, Rahman E, McDonald CB, Liew S, Porter C, Corduff N, Clague M. Aspiration Before Tissue Filler-An Exercise in Futility and Unsafe Practice. Aesthet Surg J 2022; 42:89-101. [PMID: 33512439 PMCID: PMC8670299 DOI: 10.1093/asj/sjab036] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Aesthetic physicians rely on certain anecdotal beliefs regarding the safe practice of filler injections. These include a presumed safety advantage of bolus injection after a negative aspiration. OBJECTIVES The authors sought to review and summarize the published literature on inadvertent intravascular injection of hyaluronic acid and to investigate whether the technique of aspiration confers any safety to the practitioner and the patient. METHODS Pertinent literature was analyzed and the current understanding of the safety of negative and positive aspiration outlined. RESULTS The available studies demonstrate that aspiration cannot be relied on and should not be employed as a safety measure. It is safer to adopt injection techniques that avoid injecting an intravascular volume with embolic potential than utilize an unreliable test to permit a risky injection. CONCLUSIONS To prevent intravascular injection, understanding "injection anatomy" and injection plane and techniques such as slow, low-pressure injection are important safety measures. Assurance of safety when delivering a bolus after negative aspiration does not appear to be borne out by the available literature. If there is any doubt about the sensitivity or reliability of a negative aspiration, there is no role for its utilization. Achieving a positive aspiration would just defer the risk to the next injection location where a negative aspiration would then be relied on. LEVEL OF EVIDENCE: 4
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Affiliation(s)
| | | | | | | | | | | | - Eqram Rahman
- Royal Free Hospital, University College London, United Kingdom
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17
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Cai B, Yuan R, Zhu GZ, Zhan WF, Luo CE, Kong XX, Luo SK. Deployment of the Ophthalmic and Facial Angiosomes in the Upper Nose Overlaying the Nasal Bones. Aesthet Surg J 2021; 41:NP1975-NP1985. [PMID: 33421060 DOI: 10.1093/asj/sjab003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Nasal filler placement is associated with a high risk of blindness. The arterial supply to the upper nose overlaying the nasal bones is poorly understood. OBJECTIVES The aim of this study was to visualize and analyze the deployment of the ophthalmic and facial angiosomes in the upper nose to help prevent blindness following nasal filler injections. METHODS The arterial systems of 62 cadaveric heads were filled with lead oxide contrast agent, and computed tomography (CT) images were acquired and reconstructed in 3 dimensions. RESULTS Twenty-six of the cadaveric noses examined demonstrated clear CT images of the facial and ophthalmic angiosomes in the upper nose. The Type 1 upper nose (15.4%) is supplied by 2 independent ophthalmic angiosomes that communicate indirectly through a choke anastomosis. The Type 2 upper nose (38.5%) is supplied by 2 ophthalmic angiosomes with a true anastomosis between them. The Type 3 upper nose (46.1%) is supplied by both ophthalmic and facial angiosomes with true anastomoses across the dorsal midline. These true anastomoses are mediated by the radix arcade in 46% of the noses and involve the dorsal nasal artery in 65% of the cases. The anastomoses all cross the upper dorsal midline and are directly linked to the ophthalmic angiosome. CONCLUSIONS The deployment and anastomosis of the facial and ophthalmic angiosomes in the upper nose fall into 3 major patterns. About 85% of the noses have true anastomotic arteries that cross the upper dorsal midline and are directly linked to the ophthalmic circulation. Dorsum filler injection poses a significant risk of blindness.
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Affiliation(s)
- Bing Cai
- Department of Plastic and Reconstructive Surgery, Department of Radiology, Guang Dong Second Provincial General Hospital, Guangzhou City, China
| | - Rong Yuan
- Department of Plastic and Reconstructive Surgery, Department of Radiology, Guang Dong Second Provincial General Hospital, Guangzhou City, China
| | - Guo-Zhang Zhu
- Department of Plastic and Reconstructive Surgery, Department of Radiology, Guang Dong Second Provincial General Hospital, Guangzhou City, China
| | - Wen-Feng Zhan
- Department of Radiology, Guang Dong Second Provincial General Hospital, Guangzhou City, China
| | - Cheng-En Luo
- Department of Plastic and Reconstructive Surgery, Department of Radiology, Guang Dong Second Provincial General Hospital, Guangzhou City, China
| | - Xiang-Xue Kong
- Department of Plastic and Reconstructive Surgery, Department of Radiology, Guang Dong Second Provincial General Hospital, Guangzhou City, China
| | - Sheng-Kang Luo
- Department of Plastic and Reconstructive Surgery, Department of Radiology, Guang Dong Second Provincial General Hospital, Guangzhou City, China
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18
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Hwang CJ, Chon BH, Perry JD. Blindness After Filler Injection: Mechanism and Treatment. Facial Plast Surg Clin North Am 2021; 29:359-367. [PMID: 33906767 DOI: 10.1016/j.fsc.2021.02.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Dermal fillers remain popular for facial rejuvenation but with its increasing use, the potential for more complications including blindness is present. This article focuses on the mechanism of filler-associated blindness, possible treatments, and future directions. Unfortunately, to date there is no proven treatment to reverse filler-induced blindness or visual compromise. It is essential for all injectors to discuss the potential ocular risks including blindness with their patients and obtain informed consent before filler injection.
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Affiliation(s)
- Catherine J Hwang
- Oculofacial Plastic Surgery, Department of Ophthalmology, Cole Eye Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
| | - Brian H Chon
- Oculofacial Plastic Surgery, Department of Ophthalmology, Cole Eye Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Julian D Perry
- Oculofacial Plastic Surgery, Department of Ophthalmology, Cole Eye Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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19
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Xu X, Zhou G, Fu Q, Zhang L, Yu Y, Dong Y, Liang L, Chen M. Efficacy of intra-arterial thrombolytic therapy for vision loss resulting from hyaluronic acid filler embolization. J Cosmet Dermatol 2021; 20:3205-3212. [PMID: 33825341 PMCID: PMC8596545 DOI: 10.1111/jocd.14111] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 03/11/2021] [Accepted: 03/18/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The incidence of hyaluronic acid (HA) embolism has increased markedly in recent years. HA embolism can lead to serious complications such as blindness, eye and eyelid movement disorders, skin necrosis, and cerebral embolism. However, there is a lack of robust clinical evidence regarding the benefits of treatment of HA embolism with intra-arterial thrombolytic therapy (IATT). METHODS In the present study, we enrolled 45 patients with decreased visual acuity, including 40 patients with symptoms of vision loss and eight patients with symptoms of intracranial embolism. The patients underwent emergency IATT via hyaluronidase and papaverine injections, followed by conventional sequential therapy. RESULTS In the 45 patients with symptoms of vision loss, 16 (36%) exhibited improvements in final visual acuity, even when the clinical application of the thrombolytic treatments was performed beyond the recommended window for optimal treatment. The facial skin necrosis of all patients was restored to near normal appearance. Notably, for eight patients with suspected symptoms of intracranial infarction we performed cerebral angiography and IATT, and in two patients obtained partial recanalization of the obstruction, the symptoms of heavy headache and binocular distension pain were improved in one patient with intracranial embolism after IATT treatment. CONCLUSION Our results indicate that IATT is feasible for patients with vision loss induced by HA embolism. IATT combined with conventional sequential therapy was beneficial in the recovery from other serious HA embolism complications. Nevertheless, the underlying pathophysiological mechanism needs to be clarified in future animal experiments.
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Affiliation(s)
- Xiao Xu
- Department of Ophthalmology of The Third Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Guiwen Zhou
- Department of Burns and Plastic Surgery of The Forth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Qiang Fu
- Department of Burns and Plastic Surgery of The Forth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Lixia Zhang
- Department of Burns and Plastic Surgery of The Forth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Youtao Yu
- Department of Interventional of The Forth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Ying Dong
- Department of Ophthalmology of The Forth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Liming Liang
- Department of Burns and Plastic Surgery of The Forth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Minliang Chen
- Department of Burns and Plastic Surgery of The Forth Medical Center of Chinese PLA General Hospital, Beijing, China
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20
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Arlette JP, Ashenhurst M, Hill V, Jiang K. Prevention and Management of Filler Induced Iatrogenic Stroke of the Eye. J Cutan Med Surg 2021; 25:543-552. [PMID: 33653128 DOI: 10.1177/1203475421999340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In the past few decades, minimally-invasive esthetic treatments and the use of injectable Hyaluronic Acid Gels and other filling agents to treat facial esthetics have increased dramatically. Although extremely rare, a filler can cause ocular and orbital ischemia by retrograde flow from the ophthalmic artery when injected in any of the anastomosis of the face. Once filler reaches the central retinal artery, blindness is inevitable, and no treatment is effective. While the risk of blindness happening with any filler injection is rare, the life-altering irreversible consequence of a procedure that was anticipated to be simple and beautifying is a reality that each injector must be prepared for with every injection. The parameters associated with an iatrogenic stroke of the eye are the site of injection, the injection technique, patient characteristics, and the material injected. Understanding the interplay of each of these variables might help us reduce the possibility of blindness during the injection of a soft-tissue cosmetic filler. Here, we explore the causes of Hyaluronic Acid Gels Filler embolic phenomena, review the natural course of the process, and discuss appropriate immediate interventions. We also (1) propose an education plan for injectors and describe how to carry out a focused ophthalmologic examination and procedural activities for a referral to an ophthalmologist, (2) outline steps to prevent emboli during filler injection, and (3) how to manage and support a patient with a sudden loss of vision during or immediately after a Hyaluronic Acid Gels filler treatment.
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Affiliation(s)
- John P Arlette
- 70401 Department of Surgery, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Michael Ashenhurst
- Department of Surgery, Division of Ophthalmology, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Vivian Hill
- Department of Surgery, Division of Ophthalmology, University of Calgary, Alberta, Canada
| | - Kailun Jiang
- Department of Surgery, Division of Ophthalmology, Cumming School of Medicine, University of Calgary, Alberta, Canada
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21
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Wang K, Rong X, Dang J, Yang J, Zheng H, Hou M, Li H, Jiang C, Xiong S, Qiu L, Yu Z, Yi C. Severe Vascular Complications Caused by Facial Autologous Fat Grafting: A Critical Review. Ann Plast Surg 2021; 86:S208-S219. [PMID: 33443884 DOI: 10.1097/sap.0000000000002691] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Vascular embolism is the most severe complication after autologous fat grafting. With a worldwide increase in fat grafting, there has been a rise in severe vascular complications, such as ophthalmic artery embolism, cerebral artery embolism, and even death. This article aims to review the role of fat in causing severe vascular complications and the association between fat grafting and severe vascular complications. METHODS A critical review was conducted by appraising the cases of severe vascular complications associated with facial fat grafting reported globally. Repeated cases that were reported in multiple publications were further screened. RESULTS The final search yielded 50 publications in English that met the inclusion criteria for review. A total of 113 cases of fat-induced severe vascular complications in the literature were identified. The number of cases reported yearly has increased over time, with even more significant increases since 2010. The glabella and temple are the most common sites of severe vascular complications described in the literature. In addition, only one case of ophthalmic artery embolism and one case of cerebral artery embolism have been treated successfully. CONCLUSIONS Given the increase in reported cases of severe vascular complications, both doctors and patients should pay careful attention to the risks of facial fat grafting. Because of the unclear mechanism of vascular embolism and the lack of guidelines for prevention and treatment, the effective cure rate is unsatisfactory. We propose that preventing vascular embolism is a priority in fat grafting and that timely, multidisciplinary treatment should be performed when severe vascular complications occur. It is necessary in future studies to explore the mechanisms of vascular embolism and effective treatment strategies to promote the development of fat grafting.
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Affiliation(s)
- Kai Wang
- From the Department of Plastic and Reconstructive Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
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22
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Abstract
BACKGROUND Injectable fillers have become an integral part of facial rejuvenation, but vascular occlusion is a dreaded complication of such injections. OBJECTIVE To determine the force required by the fingertip onto the plunger of the syringe to cause retrograde migration. METHODS In this cadaver study, twelve 2-cm arterial segments and 4 fillers were tested. Injection pressure required to force a column of filler for 1 cm was measured. Five oculoplastics specialists were subsequently recruited and asked to inject the filler at a typical injection pressure. RESULTS The nonhyaluronic acid filler required significantly more pressure to cause propagation of the material compared with all other fillers (p < .01). None of the other fillers differed significantly from each other. Typical injection pressures generated by experienced injectors were significantly lower than that required to cause propagation of filler at the desired velocity and significantly lower than mean arterial pressure. Measured pressure required to cause filler propagation was well within the normal range of the finger strength that can be generated by humans. CONCLUSION Typical injection pressures from fingertip to plunger are lower than required to cause propagation of filler intravascularly.
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23
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Ten B, Kara T, Kaya Tİ, Yılmaz MA, Temel G, Balcı Y, Türsen Ü, Esen K. Evaluation of facial artery course variations and depth by Doppler ultrasonography. J Cosmet Dermatol 2020; 20:2247-2258. [PMID: 33171021 DOI: 10.1111/jocd.13838] [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: 06/09/2020] [Revised: 10/23/2020] [Accepted: 11/02/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND As deep nasolabial folds (NLF) are associated with facial aging, there is an increasing demand for esthetic correction with filler injections. Understanding the anatomy of the angular artery (AA) and facial artery (FA) around the NLF region is essential for ensuring the safety of dermal filler injections into the NLF. The purpose of this study was to provide detailed vascular anatomical information on the course and depth of AA and FA around NLF using Doppler ultrasound on live cases. METHODS FA was observed from the origin level adjacent to the mandible corpus to the end of its terminal branch AA in 168 hemifaces of 84 cases with Doppler ultrasonography. RESULTS We made a classification of the FA course based on the NLF. The minimum and maximum depths of the FA along its course were measured in 84 cases. The results showed that its course may be highly superficial (2.5 mm at the mandibular origin, 3.7 mm at the cheilion, 3.7 mm at the nasal ala) or it may follow a very deep course near the periosteum (15.0 mm at the mandibular origin, 18.7 mm at the cheilion, 23.5 mm at the nasal ala). FA depth was varied between 5.98 mm and 6.62 mm at the mandibular origin, between 8.36 mm and 9.20 mm at the cheilion, between 9.52 mm and 10.51 mm at the nasal ala at a 95% confidence interval. CONCLUSIONS This study suggests that there is no absolutely safe depth or region for nasolabial fold filler injections.
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Affiliation(s)
- Barış Ten
- Department of Radiology, Mersin University Faculty of Medicine, Mersin, Turkey
| | - Taylan Kara
- Department of Radiology, Mersin University Faculty of Medicine, Mersin, Turkey
| | - Tamer İrfan Kaya
- Department of Dermatology, Mersin University Faculty of Medicine, Mersin, Turkey
| | - Mustafa Anıl Yılmaz
- Department of Dermatology, Mersin University Faculty of Medicine, Mersin, Turkey
| | - Gülhan Temel
- Department of Biostatistics, Mersin University Faculty of Medicine, Mersin, Turkey
| | - Yüksel Balcı
- Department of Radiology, Mersin University Faculty of Medicine, Mersin, Turkey
| | - Ümit Türsen
- Department of Dermatology, Mersin University Faculty of Medicine, Mersin, Turkey
| | - Kaan Esen
- Department of Radiology, Mersin University Faculty of Medicine, Mersin, Turkey
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24
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Grusha YO, Sheptulin VA. [Ophthalmological complications after contour plastic]. Vestn Oftalmol 2020; 136:108-112. [PMID: 33084287 DOI: 10.17116/oftalma2020136061108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Ophthalmological complications after filler injections for aesthetic improvement in various regions of human face are extremely rare. Among them, blindness is considered the most dangerous and almost irreversible. Over 100 cases of vision loss, described by specialists from different countries of Asia, Europe and North America, give evidence that real statistics may be significantly higher. While autologous fat is the most frequent cause of blindness, partial vision recovery was described after hyaluronic acid filler and calcium hydroxyapatite injections. This article attempts to summarize the data from available publications and inform the specialists about the potential risk areas, clinical manifestations, as well as preventive and treatment methods in case such complications do develop.
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Affiliation(s)
- Y O Grusha
- Research Institute of Eye Diseases, Moscow, Russia.,I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
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25
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Localization and Topography of the Arteries on the Middle Forehead Region for Eluding Complications Following Forehead Augmentation: Conventional Cadaveric Dissection and Ultrasonography Investigation. J Craniofac Surg 2020; 31:2029-2035. [PMID: 32604295 DOI: 10.1097/scs.0000000000006644] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Forehead augmentation with filler injection is one of the most dangerous procedures associated with iatrogenic intravascular injection resulting in the severe complications. Nonetheless, few studies have determined the explicit arterial localization and topography related to the facial soft tissues and landmarks. Therefore, this study aimed to determine an arterial distribution and topography on the middle forehead region correlated with facial landmarks to grant an appropriate guideline for enhancing the safety of injection. Nineteen Thai embalmed cadavers were discovered with conventional dissection and 14 Thai healthy volunteers were investigated with ultrasonographic examination on the middle forehead. This study found that at the level of mid-frontal depression point, the transverse distance from the medial canthal vertical line to the superficial and deep branches of supraorbital artery were 9.1 mm and 15.1 mm, respectively. Whereas the depths from the skin of these arteries were 4.1 mm and 4.3 mm, respectively. Furthermore, the frontal branch of superficial temporal artery was detectable in 42.1% as an artery entering the forehead area. At the level of lateral canthal vertical line, the vertical distance of frontal branch was 31.6 mm, and the depth from skin of the artery was 2.7 mm. In conclusion, a proper injection technique could be performed based on an intensive arterial distribution and topography, and ultrasonographic examination before the injection is also suggested in order to restrict the opportunity of severe complications.
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26
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Evaluation of Intraarterial Thrombolysis in Treatment of Cosmetic Facial Filler-Related Ophthalmic Artery Occlusion. Plast Reconstr Surg 2020; 145:42e-50e. [PMID: 31881603 DOI: 10.1097/prs.0000000000006313] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND With an increase in recent years in the number of people receiving cosmetic facial injection treatments of hyaluronic acid, the incidence of hyaluronic acid embolism has also increased commensurately. Hyaluronic acid embolism leads to serious complications, including blindness, eye and eyelid movement disorders, skin necrosis, and cerebral embolism. However, there is a lack of robust clinical evidence regarding the benefits of treatment for hyaluronic acid embolism by intraarterial thrombolysis therapy. METHODS This study included 24 patients with a decrease in visual acuity and other complications induced by facial hyaluronic acid injection. Patients underwent emergency intraarterial thrombolysis therapy by injection of hyaluronidase (500 to 1500 units) alone or hyaluronidase (750 to 1500 units) combined with urokinase (100,000 to 250,000 units), followed in both cases by a general symptomatic treatment and nutritional therapy. RESULTS Ten (42 percent) of 24 patients ultimately had improvements to visual acuity, even when the clinical application of the thrombolytic treatments had passed the recommended window for optimal treatment. In all cases, patients' facial skin necrosis was restored to nearly normal appearance. In addition, the authors found that hyaluronidase combined with urokinase was a more effective therapy than hyaluronidase alone. CONCLUSIONS The authors' results indicate that intraarterial thrombolysis therapy is beneficial to patients suffering from blindness induced by hyaluronic acid embolism. The therapy was shown to be worthy of clinical application because it alleviated the impairment to patients' vision and was also beneficial in the recovery from other serious complications, including eye movement disorder, eye edema, headaches, and skin necrosis. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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27
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Agorgianitis L, Panagouli E, Tsakotos G, Tsoucalas G, Filippou D. The Supratrochlear Artery Revisited: An Anatomic Review in Favor of Modern Cosmetic Applications in the Area. Cureus 2020; 12:e7141. [PMID: 32257686 PMCID: PMC7105260 DOI: 10.7759/cureus.7141] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
The supratrochlear artery represents a terminal branch of the ophthalmic artery. Cosmetic interventions may traumatize it, resulting in a circulation in the lesion in glabellar region and in the medial aspect of the forehead. This review article aims to synopsise the existing knowledge of the anatomy of the supratrochlear artery in close correlation with minimally invasive cosmetic procedures in the facial area such as soft-tissue filler injections. Their possible adverse effects and their safe application based on the topographic anatomy were included. A literature review was performed in PubMed/Medline online medical database. The superficial course of the supratrochlear artery, as well as the rich, variable anastomotic network that it forms with the supraorbital, angular and dorsal nasal artery raise clinical questions in the case of soft-tissue filler injections in the nasoglabellar and central forehead area. Accidental cannulation of the supratrochlear artery and ultimately, the risk of embolization of the central retinal artery in a retrograde fashion might lead to injury with questionable cosmetic results. Although the risk of complications from the use of soft tissue fillers is considered rare, once happen, the results could be devastating for the quality of life. Thus, the comprehension of the anatomy of the supratrochlear artery is paramount for the health practitioners.
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Affiliation(s)
- Loukas Agorgianitis
- Anatomy and Surgical Anatomy, National and Kapodistrian University of Athens, Athens, GRC
| | - Eleni Panagouli
- Anatomy, National and Kapodistrian University of Athens, Athens, GRC
| | - George Tsakotos
- Anatomy, School of Medicine, National and Kapodistrian University of Athens, Athens, GRC
| | - Gregory Tsoucalas
- Anatomy, School of Medicine-Democritus University of Thrace, Alexandroupolis, GRC
| | - Dimitrios Filippou
- Surgery, School of Medicine, National and Kapodistrian University of Athens, Athens, GRC
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Phumyoo T, Jiirasutat N, Jitaree B, Rungsawang C, Uruwan S, Tansatit T. Anatomical and Ultrasonography‐Based Investigation to Localize the Arteries on the Central Forehead Region During the Glabellar Augmentation Procedure. Clin Anat 2019; 33:370-382. [DOI: 10.1002/ca.23516] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/13/2019] [Accepted: 10/26/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Thirawass Phumyoo
- Department of Anatomy, Faculty of Medicine, and The Chula Soft Cadaver Surgical Training CenterChulalongkorn University and King Chulalongkorn Memorial Hospital Bangkok Thailand
- Department of Basic Medical ScienceFaculty of Medicine Vajira Hospital, Navamindradhiraj University Bangkok Thailand
| | | | - Benrita Jitaree
- Department of Anatomy, Faculty of Medicine, and The Chula Soft Cadaver Surgical Training CenterChulalongkorn University and King Chulalongkorn Memorial Hospital Bangkok Thailand
| | - Chalermquan Rungsawang
- Department of Anatomy, Faculty of Medicine, and The Chula Soft Cadaver Surgical Training CenterChulalongkorn University and King Chulalongkorn Memorial Hospital Bangkok Thailand
| | - Sukanya Uruwan
- Department of Anatomy, Faculty of Medicine, and The Chula Soft Cadaver Surgical Training CenterChulalongkorn University and King Chulalongkorn Memorial Hospital Bangkok Thailand
| | - Tanvaa Tansatit
- Department of Anatomy, Faculty of Medicine, and The Chula Soft Cadaver Surgical Training CenterChulalongkorn University and King Chulalongkorn Memorial Hospital Bangkok Thailand
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Tran AQ, Staropoli P, Rong AJ, Lee WW. Filler-Associated Vision Loss. Facial Plast Surg Clin North Am 2019; 27:557-564. [DOI: 10.1016/j.fsc.2019.07.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Clinical Observations and the Anatomical Basis of Blindness After Facial Hyaluronic Acid Injection. Aesthetic Plast Surg 2019; 43:1054-1060. [PMID: 31006827 PMCID: PMC7340666 DOI: 10.1007/s00266-019-01374-w] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 03/31/2019] [Indexed: 11/16/2022]
Abstract
Background Blindness or visual loss is the most serious complication resulting from facial hyaluronic acid (HA) injection. In this study, three recent clinical cases were analyzed, and the relevant anatomy of cadavers was evaluated to investigate the mechanism behind visual impairment due to HA injection. Methods Three patients with different extents of visual loss after HA injection were studied. Ophthalmic testing and corresponding treatments were performed, and the clinical progress was observed. In addition, thirty-six fresh Asian cadaver hemifaces were anatomized to investigate the morphology of the ophthalmic artery and its branches. The minimum dose of HA for central retinal artery embolism was calculated based on the ophthalmic arterial volumes of cadavers. Results Visual impairment was more severe in central retinal artery occlusion and combined intraocular branch occlusion than in posterior ciliary artery occlusion. During follow-up, no improvement was observed in terms of visual impairment. Cadaver study reconfirmed that the ophthalmic artery included facial and intraocular branches. The ophthalmic arterial volumes running from the supraorbital artery and supratrochlear artery to the central retinal artery were 0.083 cm3 and 0.089 cm3, respectively. Conclusions The severity of blindness caused by HA injection may be associated with the occlusion site. Our clinical observations indicate that conventional treatments, such as retrobulbar hyaluronidase injection, are insufficient to relieve visual impairment. Injecting as little as 0.08 ml of HA into the facial branch is enough to cause central retinal artery embolism. Limiting the volume per injection could represent a simple prophylactic strategy. 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266.
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Nonsurgical Rhinoplasty: A Graft-based Technique. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2241. [PMID: 31624669 PMCID: PMC6635207 DOI: 10.1097/gox.0000000000002241] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 03/08/2019] [Indexed: 11/29/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Nonsurgical rhinoplasty with hyaluronic acid (HA) has gained popularity due to its efficacy and minimal downtime. From a structural standpoint, it is like performing a tridimensional reshaping where only enhancement by grafts is allowed. To date, indications, technique, and products are still debated. The aim of this study is to describe the author’s experience with nonsurgical nasal reshaping, focusing on the indications and maneuvers to safely achieve, by mean of HA, the grafts previously described for surgical rhinoplasty. Materials and Methods: A total of 70 consecutive patients underwent nonsurgical rhinoplasty using the same type of HA. The rhinoplasty module of FACE-Q was administered to all patients before treatment and 15 days posttreatment. Statistical analysis was performed. Results: No complication was experienced. Two (2.8%) patients required a retouch after 15 days for further dorsal correction. There was a statistically significant difference between preoperative and postoperative values in all domains and overall scores of the rhinoplasty module of FACE-Q. Conclusions: The graft-based technique proved to be safe, effective, and reliable. It may allow correction of selected nasal defects with reduced cost and minimal downtime.
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External and Internal Diameters of the Facial Artery Relevant to Intravascular Filler Injection. Plast Reconstr Surg 2019; 143:1031-1037. [DOI: 10.1097/prs.0000000000005428] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Chatrath V, Banerjee PS, Goodman GJ, Rahman E. Soft-tissue Filler-associated Blindness: A Systematic Review of Case Reports and Case Series. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2173. [PMID: 31321177 PMCID: PMC6554164 DOI: 10.1097/gox.0000000000002173] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 01/08/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND With the increase in the use of soft-tissue fillers worldwide, there has been a rise in the serious adverse events such as vascular compromise and blindness. This article aims to review the role of fillers in causing blindness and the association between hyaluronic acid (HA) filler and blindness. METHODS The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were used to report this review. RESULTS A total of 190 cases of blindness due to soft-tissue fillers were identified, of which 90 (47%) cases were attributed to autologous fat alone, and 53 (28%) cases were caused by HA. The rest of the cases were attributed to collagen, calcium hydroxylapatite, and other fillers. CONCLUSIONS Autologous fat was the most common filler associated with blindness despite HA fillers being the most commonly used across the globe. However, the blindness caused by other soft-tissue fillers like collagen and calcium hydroxylapatite was represented. It was also evident through the review that the treatment of HA-related blindness was likely to have better outcomes compared with other fillers due to hyaluronidase use.
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Affiliation(s)
- Vandana Chatrath
- From the Postgraduate Medical Institute, Faculty of Medical Sciences, Anglia Ruskin University, Chelmsford, Essex, CM1 1SQ United Kingdom
- Delhi Dermatology Group, New Delhi, India
| | | | | | - Eqram Rahman
- Institute of Medical and Biomedical Education, St. George’s University of London, Cranmer Terrace, Tooting Broadway, SW17 0RE London, United Kingdom
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Abstract
PURPOSE OF REVIEW Fat embolism syndrome (FES) is a rare disorder with potentially devastating neurologic complications. This article reviews the history, pathophysiology, clinical features, diagnosis, and treatment of FES with a focus on its neurologic aspects. RECENT FINDINGS The neurologic complications of FES are more commonly recognized with current diagnostic testing and increase awareness of the disorder. FES may present initially with neurologic manifestations. Prompt diagnosis of FES and of its neurologic manifestations could be lifesaving. This includes respiratory support and management of neurological complications. The classic clinical triad of pulmonary insufficiency, neurologic disturbances, and petechial skin rash typically presents 24 to 72 h following an initial insult, most commonly a traumatic long bone fracture. Early onset (< 24 h) and delayed onset (> 72 h) have been described. Neurologic manifestations may include ischemic/hemorrhagic strokes, retinal ischemia, seizures, autonomic dysfunction, and diffuse brain injury. Diagnosis remains clinical. Management consists mainly of supportive care.
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Cho KH, Dalla Pozza E, Toth G, Bassiri Gharb B, Zins JE. Pathophysiology Study of Filler-Induced Blindness. Aesthet Surg J 2019; 39:96-106. [PMID: 29873688 DOI: 10.1093/asj/sjy141] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background A number of authors have proposed retrograde arterial embolism as the responsible mechanism for filler-induced blindness. However, no previous human study has substantiated this proposed mechanism. Objectives The aim of this study was to investigate the pathophysiology of filler-induced blindness using a fresh cadaver perfusion technique. Methods A fresh cadaver head perfusion model that simulates both physiologic blood pressure and flow rate of the carotid artery, ophthalmic artery, and supratrochlear artery was used. The common carotid artery was cannulated and the internal jugular vein exposed for open venous drainage. A plasma-based perfusate was circulated through the cadaver head, which was connected to a perfusion system consisting of a roller pump, preload reservoir, and pressure monitor. The hyaluronic acid filler mixed with methylene blue was injected into the cannulated superficial branch of the supratrochlear artery. Cadaver dissection, angiographic study, and histology were used to investigate filler-induced blindness. Results Cannulation of the superficial branch of the supratrochlear artery was successful in all six cadavers. Emboli to the ophthalmic artery was successfully demonstrated in the three out of 6 fresh cadaver heads. The C-arm angiogram documented a cut-off sign in the ophthalmic artery due to hyaluronic acid filler emboli. An average intravascular volume of the intraorbital part of the supratrochlear artery was 50.0 µL. The average depth of location of the superficial branch of the supratrochlear artery from the epidermal surface was 1.5 mm. Conclusions Our cadaveric study demonstrated that retrograde hyaluronic acid filler emboli to the ophthalmic artery could be produced by the cannulation of the supratrochlear artery. The superficial location of the supratrochlear artery, the rich vasculature surrounding it, and the variability in the anatomy make this possible.
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Affiliation(s)
- Ki-Hyun Cho
- Department of Plastic Surgery and the Cerebrovascular Center Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Edoardo Dalla Pozza
- Department of Plastic Surgery and the Cerebrovascular Center Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Gabor Toth
- Department of Plastic Surgery and the Cerebrovascular Center Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Bahar Bassiri Gharb
- Department of Plastic Surgery and the Cerebrovascular Center Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - James E Zins
- Department of Plastic Surgery and the Cerebrovascular Center Neurological Institute, Cleveland Clinic, Cleveland, OH
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Hom DB, Harmon J. Investigating Methods to Prevent Blindness From Facial Fat Injections. JAMA FACIAL PLAST SU 2018; 20:451-452. [PMID: 29978184 DOI: 10.1001/jamafacial.2017.2230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- David B Hom
- Division of Facial Plastic & Reconstructive Surgery, Department of Otolaryngology-Head & Neck Surgery, University of Cincinnati College of Medicine and Neurosensory Disorder Center at UC Gardner Neuroscience Institute, Cincinnati, Ohio
| | - Jeffrey Harmon
- Division of Facial Plastic & Reconstructive Surgery, Department of Otolaryngology-Head & Neck Surgery, University of Cincinnati College of Medicine and Neurosensory Disorder Center at UC Gardner Neuroscience Institute, Cincinnati, Ohio
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Abstract
BACKGROUND During periorbital noninvasive and surgical procedures, there is the risk of iatrogenic injury to the emerging point of the ophthalmic artery. This study aimed to determine the three-dimensional location of the emerging point of the ophthalmic artery and to provide clinicians with anatomical information that would help them to avoid associated complications. METHODS Seventeen hemifaces of the emerging point of the ophthalmic artery from 10 Korean and seven Thai cadavers were dissected and scanned by a three-dimensional scanner. The emerging points of the ophthalmic artery of 30 healthy Korean volunteers were also detected using an ultrasound imaging system. RESULTS The transverse distance from the medial canthus to the emerging of the ophthalmic artery was 3.8 ± 1.0 mm medially, and the vertical distance was 14.0 ± 2.9 mm superiorly. The transverse distance from the midline was 16.5 ± 1.7 mm to the emerging point of the ophthalmic artery and 20.0 ± 2.0 mm to the medial canthus. The measured depth from the skin surface to the emerging point of the ophthalmic artery was 4.8 ± 1.7 mm by means of three-dimensional scanning and 4.5 ± 1.1 mm using ultrasound detection. The vertical distance from the inferior margin of the superior orbital rim to the emerging point of the ophthalmic artery was 5.3 ± 1.4 mm. CONCLUSION These data inform clinicians about the anatomical three-dimensional location of the emerging point of the ophthalmic artery, which will help them to avoid iatrogenic injury when they are performing periorbital clinical procedures.
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Hufschmidt K, Bronsard N, Foissac R, Baqué P, Balaguer T, Chignon-Sicard B, Santini J, Camuzard O. The infraorbital artery: Clinical relevance in esthetic medicine and identification of danger zones of the midface. J Plast Reconstr Aesthet Surg 2018; 72:131-136. [PMID: 30327185 DOI: 10.1016/j.bjps.2018.09.010] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 08/20/2018] [Accepted: 09/10/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Over the past decade, cosmetic injections of dermal fillers or fat have become a popular procedure in facial rejuvenation in an overconsuming society. However, complications such as arterial embolism and occlusion can occur even with experienced injectors, especially in high-risks zones namely the glabella, the nasal dorsum or the nasolabial fold. The aim of this study was to define the vascular danger zones of the infraorbital area in order to provide guidelines helping avoid them. MATERIALS AND METHODS The infraorbital artery, its main branches and their anastomoses with neighbouring vessels were studied in 18 fresh cadavers. Mimetic injections of inked hyaluronic acid were performed in the infraorbital area in the interest of analyzing its distribution and to determine potential vascular risks towards the infraorbital artery and its branches. RESULTS The infraorbital artery and its branches were located in common injection regions and anastomosed to the supratrochlear artery, the dorsal nasal artery and the angular artery through the nasal branch of the infraorbital artery. Two danger zones could be depicted: injections can be risky when performed too superficially in the midcheek area, and likewise risky when performed in a periosteal layer in infraorbital hollow or tear-trough correction, because of an obvious possibility of retrograde embolism. CONCLUSION The infraorbital artery can be involved in anatomic mechanism of arterial occlusion, further blindness and stroke, among the related neighbouring arteries. Based on the findings of this study, injections to the periosteum layer in tear-trough correction and above the periosteum on the zygomatic arch is not advised.
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Affiliation(s)
- K Hufschmidt
- Department of Plastic and Reconstructive Surgery, University Hospital Nice, Pasteur 2, 30, avenue de la Voie Romaine, 06000 Nice, France.
| | - N Bronsard
- Institut Universitaire Locomoteur et Sport (iULS), Hôpital Pasteur 2, University of Nice Sophia Antipolis (UNSA), Nice, France
| | - R Foissac
- Unit of Plastic and Esthetic Surgery, Clinic Saint George, 2 avenue de Rimiez, 06105 Nice, France
| | - P Baqué
- Department of General and Emergency Surgery, University Hospital Nice, Pasteur 2, 30, avenue de la Voie Romaine, 06000 Nice, France
| | - T Balaguer
- Department of Plastic and Reconstructive Surgery, University Hospital Nice, Pasteur 2, 30, avenue de la Voie Romaine, 06000 Nice, France
| | - B Chignon-Sicard
- Department of Plastic and Reconstructive Surgery, University Hospital Nice, Pasteur 2, 30, avenue de la Voie Romaine, 06000 Nice, France
| | - J Santini
- Head and Neck Institute, University Hospital of Nice, 31, avenue de Valombrose, 06000 Nice, France
| | - O Camuzard
- Department of Plastic and Reconstructive Surgery, University Hospital Nice, Pasteur 2, 30, avenue de la Voie Romaine, 06000 Nice, France
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Thanasarnaksorn W, Cotofana S, Rudolph C, Kraisak P, Chanasumon N, Suwanchinda A. Severe vision loss caused by cosmetic filler augmentation: Case series with review of cause and therapy. J Cosmet Dermatol 2018; 17:712-718. [PMID: 30006992 DOI: 10.1111/jocd.12705] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 06/22/2018] [Accepted: 06/01/2018] [Indexed: 12/01/2022]
Abstract
Hyaluronic acid (HA) injection is a popular nonsurgical, facial rejuvenating procedure. Due to the rapidly expanding use of HA injections, significant potential complications have also increased in frequency. Among these complications, the rare but most devastating one is arterial occlusion, which can result in skin necrosis or blindness. To describe the mechanisms behind vision loss secondary to hyaluronic acid injection and the efficacy of treatments to restore vision and associated ocular functionality. We reviewed six cases of patients from October 2011 to December 2017 who experienced vision loss after receiving facial HA injections and the subsequent treatments undertaken to attempt to reverse the vision loss and additional eye complications. Of the six patients, four received nose, one received forehead, and another one received temple injections. All six patients developed vision loss secondary to hyaluronic acid embolization in retinal or ophthalmic arteries. Additional complications included severe periorbital pain, ptosis, impairment of extraocular muscle functionality. Recovery of vision was dependent on the type, frequency, and duration of subsequent treatment. Vision loss is a rare but catastrophic complication caused by hyaluronic injection that occurs secondary to hyaluronic acid embolization in retinal or ophthalmic arteries due to retrograde flow from facial vascular anastomoses. We suggest the early supratrochlear/supraorbital hyaluronidase injection, ocular massage, and re-breathing into a plastic bag as safe, uncomplicated and effective methods to restore the retinal circulation and reverse vision loss.
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Affiliation(s)
- Wilai Thanasarnaksorn
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Samitivej Esthetics Institute, Samitivej Sukhumvit Hospital, Bangkok, Thailand
| | - Sebastian Cotofana
- Department of Medical Education, Albany Medical College, Albany, New York
| | - Christina Rudolph
- Department of Medical Education, Albany Medical College, Albany, New York
| | | | - Nongsak Chanasumon
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Atchima Suwanchinda
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,School of Anti-Aging and Regenerative Medicine, Mae Fah Luang University, Bangkok, Thailand
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