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Eshraghi B, Babaei L, Aghajani M, Aghajani A. Late-onset periorbital edema in patients with a history of facial hyaluronic acid injection: A review on diagnosis and management. J Plast Reconstr Aesthet Surg 2024; 99:271-279. [PMID: 39395232 DOI: 10.1016/j.bjps.2024.09.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Revised: 08/23/2024] [Accepted: 09/13/2024] [Indexed: 10/14/2024]
Abstract
BACKGROUND Hyaluronic acid (HA) injections for soft tissue augmentation, particularly in the facial area, have become increasingly popular. Nevertheless, a growing number of reports indicate complications associated with this procedure, posing challenges for practitioners. One commonly encountered complication is periorbital edema. OBJECTIVE To review the existing literature on late-onset periorbital edema following HA injections, focusing on clinical presentation, proposed mechanisms, risk factors, diagnostics, and management strategies. METHODS A literature search was conducted to find articles describing findings on malar edema and eyelid edema following HA injections. The gathered data were categorized and juxtaposed to provide a clearer understanding of this phenomenon. RESULTS Incidence rates of periorbital edema post-HA injection vary, with delayed onset occurring weeks to years later. The manifestation involves diffuse edema in the eyelids and malar area, sometimes worsened by trigger factors like infections. Pathophysiology discussions distinguish between inflammatory and non-inflammatory causes, highlighting lymphatic and venous flow disturbances. Risk factors include filler characteristics, injection depth, and patient predispositions. Proper patient evaluation using ultrasonography aids in treatment planning, which could involve corticosteroids, hyaluronidase for HA removal, and subsequent cosmetic procedures like radiofrequency (RF) microneedling. Surgical interventions should be considered after HA dissolution, especially in cases requiring lower blepharoplasty. CONCLUSION Late periorbital edema post-facial HA injections, once rare, is now frequently seen. Understanding and addressing this complication is essential for optimizing patient care and outcomes in clinical practice. Treatment typically involves adjusting hyaluronidase dosage for HA removal. Additional procedures like blepharoplasty, RF needling, or filler reinjection may enhance post-treatment appearance.
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Affiliation(s)
- Bahram Eshraghi
- Isfahan eye research center, Department of Ophthalmology, Isfahan University of medical sciences, Isfahan, Iran
| | - Leila Babaei
- Isfahan eye research center, Department of Ophthalmology, Isfahan University of medical sciences, Isfahan, Iran
| | - Mahdi Aghajani
- Isfahan eye research center, Department of Ophthalmology, Isfahan University of medical sciences, Isfahan, Iran
| | - Ali Aghajani
- Isfahan eye research center, Department of Ophthalmology, Isfahan University of medical sciences, Isfahan, Iran.
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Miotti G, De Marco L, Quaglia D, Grando M, Salati C, Spadea L, Gagliano C, Musa M, Surico PL, Parodi PC, Zeppieri M. Fat or fillers: The dilemma in eyelid surgery. World J Clin Cases 2024; 12:2951-2965. [PMID: 38898854 PMCID: PMC11185368 DOI: 10.12998/wjcc.v12.i17.2951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/22/2024] [Accepted: 05/11/2024] [Indexed: 06/04/2024] Open
Abstract
The aging of the periocular region has always aroused great interest. A fresh, young, and attractive sight determined an ever-greater attention to surgical and non-surgical techniques to obtain this result. In particular, the change in the concept of a young look, considered then "full", led to the increasing use of surgical (fat grafting) or medical (hyaluronic acid) filling techniques. Eyelid rejuvenation became increasingly popular in the field of cosmetic treatments, with a focus on achieving a youthful and refreshed appearance. Among the various techniques available, the choice between using fat grafting or fillers presented a clinical dilemma. In particular, what surgery considered of fundamental importance was a long-lasting result over time. On the other hand, aesthetic medicine considered it fundamental not to have to resort to invasive treatments. But what was the reality? Was there one path better than the other, and above all, was there a better path for patients? The minireview aims to explore the physiopathology, diagnosis, treatment options, prognosis, and future studies regarding this dilemma. We analyzed the literature produced in the last 20 years comparing the two techniques. Current literature reveals advancements in biomaterials, stem cell research and tissue engineering held promise for further enhancing the field of eyelid rejuvenation. The choice between fat grafting and fillers in eyelid cosmetic treatments presented a clinical dilemma. Understanding physiopathology, accurately diagnosing eyelid aging, exploring treatment options, assessing prognosis, and conducting future studies were essential for providing optimal care to patients seeking eyelid rejuvenation.
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Affiliation(s)
- Giovanni Miotti
- Department of Plastic Surgery, University Hospital of Udine, Udine 33100, Italy
| | - Luca De Marco
- Department of Plastic Surgery, University Hospital of Udine, Udine 33100, Italy
| | - Davide Quaglia
- Department of Plastic Surgery, University Hospital of Udine, Udine 33100, Italy
| | - Martina Grando
- Department of Internal Medicine, Azienda Sanitaria Friuli Occidentale, San Vito al Tagliamento 33078, Italy
| | - Carlo Salati
- Department of Ophthalmology, University Hospital of Udine, Udine 33100, Italy
| | - Leopoldo Spadea
- Eye Clinic, Policlinico Umberto I, “Sapienza” University of Rome, Rome 00142, Italy
| | - Caterina Gagliano
- Department of Medicine and Surgery, University of Enna “Kore”, Enna 94100, Italy
- Eye Clinic Catania University San Marco Hospital, Viale Carlo Azeglio Ciampi, Catania 95121, Italy
| | - Mutali Musa
- Department of Optometry, University of Benin, Benin 300283, Nigeria
- Department of Ophthalmology, Africa Eye Laser Centre, Km 7, Benin 300105, Nigeria
| | - Pier Luigi Surico
- Schepens Eye Research Institute of Mass Eye and Ear, Harvard Medical School, Boston, MA 02114, United States
| | - Pier Camillo Parodi
- Department of Plastic Surgery, University Hospital of Udine, Udine 33100, Italy
| | - Marco Zeppieri
- Department of Ophthalmology, University Hospital of Udine, Udine 33100, Italy
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Barańska-Rybak W, Świerczewska Z, Lemiec A, Walker L. Triamcinolone Injection in the Treatment of Malar Edema. Dermatol Pract Concept 2024; 14:dpc.1402a117. [PMID: 38810029 PMCID: PMC11136127 DOI: 10.5826/dpc.1402a117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2023] [Indexed: 05/31/2024] Open
Abstract
INTRODUCTION Tear-through deformities can be a detectable sign of facial aging. Over recent years, minimally invasive procedures such as hyaluronic acid filler injections have been shown to be effective in improving this area. Malar edema is the accumulation of fluid over the malar eminence persisting for 1 month or more. Given its nature, the management remains problematic. The most commonly reported treatment modality is injection with hyaluronidase. OBJECTIVES To determine the safety and efficacy of triamcinolone injection in the treatment of malar edema. METHODS A total of 15 female patients with malar edema, with a mean age of 43.77 years, were treated with triamcinolone injections. The volume injected was chosen by the investigator. Prior to the triamcinolone injection, all patients had been treated with hyaluronidase, which turned out to be ineffective in all cases. Patients were asked to note all adverse effects. RESULTS Satisfactory results were achieved after a single treatment session for 14 patients and after two treatments for one patient. Overall, injections with triamcinolone were well tolerated and no adverse reactions were reported. CONCLUSIONS Injection with triamcinolone appears to be a safe and effective option for the management of malar edema following hyaluronic acid filler injection. Nevertheless, further research with larger patient groups is compulsory.
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Affiliation(s)
- Wioletta Barańska-Rybak
- Department of Dermatology, Venereology and Allergology, Faculty of Medicine, Medical University of Gdańsk, Poland
| | - Zuzanna Świerczewska
- Department of Dermatology, Venereology and Allergology, Faculty of Medicine, Medical University of Gdańsk, Poland
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Wilde CL, Jiang K, Lee S, Ezra DG. The Posthyaluronidase Syndrome: Dosing Strategies for Hyaluronidase in the Dissolving of Facial Filler and Independent Predictors of Poor Outcomes. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5765. [PMID: 38655103 PMCID: PMC11037726 DOI: 10.1097/gox.0000000000005765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 03/06/2024] [Indexed: 04/26/2024]
Abstract
Background Hyaluronic acid dermal fillers are used extensively in periocular aesthetic medicine, and the incidence of filler-related complications is increasing. This study aimed to investigate the optimal dosing strategy for hyaluronidase and to identify predictors of poor outcomes. Methods We performed a retrospective review of 157 orbits of 90 patients treated with hyaluronidase over a 4-year period. Demographic data, indication, and details of hyaluronidase treatment and outcomes were recorded. Results The primary indication for dissolving filler was swelling in 52%, lumpiness in 20%, and before surgical blepharoplasty in 17%. The most frequently used hyaluronidase concentration was 150 U per mL in 66%, followed by 75 U per mL in 31%, 37.5 U per mL in 3%, and 100 U per mL in 1%. Outcomes were characterized as follows: 59% with a satisfactory result; 24% as insufficient treatment requiring further hyaluronidase; and 18% complaining of facial changes such as hollowing, indicating a post hyaluronidase syndrome. There was no statistical difference in outcomes between the 75 and 150 U per mL dosage groups (P = 0.625). A significant correlation was identified between posthyaluronidase syndrome and duration of filler in situ (P = 0.00019) and volume of filler (P = 0.000017). Conclusions The posthyaluronidase syndrome may be related to previous filler volume and duration, rather than the concentration or dose of hyaluronidase used. All patients should be informed about the risks of adverse effects after hyaluronidase treatment; patients with longer histories of filler use and higher total volumes should be advised of the increased risk.
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Affiliation(s)
- Caroline L. Wilde
- From Moorfields Eye Hospital NHS Trust, London, United Kingdom
- The Ezra Clinic, London, United Kingdom
| | - Kailun Jiang
- From Moorfields Eye Hospital NHS Trust, London, United Kingdom
| | - Sieun Lee
- Mental Health and Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Daniel G. Ezra
- From Moorfields Eye Hospital NHS Trust, London, United Kingdom
- The Ezra Clinic, London, United Kingdom
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Kyriazidis I, Spyropoulou GA, Zambacos G, Tagka A, Rakhorst HA, Gasteratos K, Berner JE, Mandrekas A. Adverse Events Associated with Hyaluronic Acid Filler Injection for Non-surgical Facial Aesthetics: A Systematic Review of High Level of Evidence Studies. Aesthetic Plast Surg 2024; 48:719-741. [PMID: 37563436 DOI: 10.1007/s00266-023-03465-1] [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: 01/10/2023] [Accepted: 06/11/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Hyaluronic acid (HA) dermal fillers are widely used in aesthetic medicine. While generally safe, potential complications can arise. OBJECTIVE This systematic review aims to identify and classify potential complications linked to the use of HA dermal fillers, as informed by high-quality, low-risk-of-bias studies. METHODS This review follows the Cochrane review standards for clinical systematic reviews. This systematic review analyzed 48 high level of evidence studies on the use of hyaluronic acid (HA) dermal fillers in non-surgical facial aesthetics and the adverse events that occurred.The inclusion criteria were randomized control studies on HA dermal fillers and their complications. Excluded were case reports, case series, observational studies, and other non-randomized research due to their inability to provide generalized conclusions and their inherent publication bias. RESULTS Adverse events were classified into three categories: expected reactions, product or technique-related adverse events, and severe adverse events. Most adverse events were short-lived injection site reactions, which resolved spontaneously. Specific HA fillers and injection techniques influenced the occurrence of adverse events, which generally resolved within weeks without treatment. Severe adverse events were rare, persisting for months and requiring active medical intervention. DISCUSSION This classification system can enhance understanding, prevention, and treatment of HA filler complications, and support patient education. The common complications were injection site reactions, with persistent symptoms treated with topical steroids, NSAIDs, or hyaluronidase. Severe complications included severe edema, angioedema and others, often necessitating specific treatments. CONCLUSION HA dermal fillers are generally safe and effective, with most adverse events being transient and mild to moderate in severity. Severe adverse events, although rare, do occur and are generally non-treatment related. Informed consent, patient education, and professional training are crucial for safe and successful outcomes. Level of Evidence II This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Ioannis Kyriazidis
- Department of Plastic Surgery, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Papageorgiou General Hospital, 56403, Thessaloniki, Greece.
| | - Georgia-Alexandra Spyropoulou
- Department of Plastic Surgery, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Papageorgiou General Hospital, 56403, Thessaloniki, Greece
| | | | - Anna Tagka
- First Department of Dermatology and Venereology, Andreas Syggros Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Hinne A Rakhorst
- Department of Plastic, Reconstructive and Hand Surgery, Medisch Spectrum Twente/Ziekenhuisgroep Twente, Haaksbergerstraat, Enschede, The Netherlands
| | - Konstantinos Gasteratos
- Department of Plastic Surgery, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Papageorgiou General Hospital, 56403, Thessaloniki, Greece
| | - Juan Enrique Berner
- Plastic Surgery Department, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
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Liu X, Gao Y, Ma J, Li J. The Efficacy and Safety of Hyaluronic Acid Injection in Tear Trough Deformity: A Systematic Review and Meta-analysis. Aesthetic Plast Surg 2024; 48:478-490. [PMID: 37684413 DOI: 10.1007/s00266-023-03613-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 08/12/2023] [Indexed: 09/10/2023]
Abstract
BACKGROUND Hyaluronic acid (HA) injection is an effective method to correct tear trough deformity. Nevertheless, the quantitative data of cosmetic results and complications of HA injection in tear troughs remained unemployed. The purpose of this meta-analysis was to synthesize the current quantitative data on the aesthetic outcomes and adverse effects of tear trough deformity correction with HA injection. METHODS This meta-analysis consulted PubMed, Embase, Web of Science, Scopus and Cochrane databases based on the search terms published before September 2022. Data extracted was analyzed to evaluate the satisfaction rates and complications of HA injection. Meta-analysis was performed using the random-effect model for overall and subgroup analysis. RESULTS This meta-analysis comprised 31 reports involving 2556 participants. The pooled overall satisfaction rate was 91.0% (95% CI 84.9-95.7%). The pooled rates of swelling/edema and bruising/ecchymosis were 19.2% (95% CI 10.4-29.9%) and 18.4% (95% CI 10.1-28.4%), respectively. The pooled rates of redness/erythema, contour irregularity/lump and blue discoloration/Tyndall effect were 7.1% (95% CI 1.5-15.6%), 5.3% (95% CI 1.8-10.2%) and 0.9% (95% CI 0.0-2.5%), respectively. CONCLUSIONS The present meta-analysis manifested a low risk of complication rate and a high satisfaction rate in tear trough rejuvenation with HA injection. LEVEL OF EVIDENCE I 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)
- Xuanchen Liu
- Department of Facial and Cervical Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuan Gao
- Department of Facial and Cervical Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiguang Ma
- Department of Facial and Cervical Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jie Li
- Department of Facial and Cervical Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Dong R, Jin Q, Zhi J, Jin M, Gao Y, Nan M, Jin Z, Jin C. Analysis of the efficacy of blunt separation combined with uncrosslinked sodium hyaluronate composite solution for the treatment of tear trough deformity in Asians. J Cosmet Dermatol 2023. [PMID: 38130178 DOI: 10.1111/jocd.16151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 11/28/2023] [Accepted: 12/13/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Filling therapy is becoming increasingly popular for correcting tear trough deformities (TTD). However, its therapeutic effect and retention time are limited. AIMS To improve the clinical efficacy and safety of TTD treatment in Asians, we used a blunt separation technique to break the adhesion site of periorbital subcutaneous tissue, and while repairing skin dermis after injury, it was combined with uncrosslinked hyaluronic acid compound solution to promote collagen regeneration and treat TTDs. PATIENTS/METHODS Twenty-six Chinese patients (21 women and 5 men) with TTD, with a mean age of 34.54 ± 9.21 (range, 20-56) years, were enrolled. Symptom improvement, recurrence rates, treatment safety, and patient satisfaction were evaluated. RESULTS All patients' tear trough rating scale (TTRS) scores decreased significantly immediately after treatment. The TTRS scores at 1, 3, and 6 months, and 1 year after treatment demonstrated significant differences from those before treatment (all p < 0.05). All patients' experienced mild pain, erythema, and swelling during the treatment. Three patients developed postinjection bruising after treatment, which lasted for 6-7 days and subsequently disappeared. No other adverse reactions were observed during the follow-up. There were no recurrent cases, and patient satisfaction was very high. CONCLUSIONS Blunt separation combined with an uncrosslinked sodium hyaluronate composite solution is safe and effective for treating TTDs in Asians with few side effects and has good clinical application prospects.
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Affiliation(s)
- Richeng Dong
- Department of Dermatology, Suzhou Mylike Cosmetic Hospital, Suzhou, Jiangsu, China
| | - Qingmei Jin
- Department of Dermatology, Suzhou Mylike Cosmetic Hospital, Suzhou, Jiangsu, China
| | - Jiahui Zhi
- Department of Dermatology, Suzhou Mylike Cosmetic Hospital, Suzhou, Jiangsu, China
| | - Meilin Jin
- Department of Medical Cosmetology, Yanbian University Hospital, Jilin, China
| | - Yang Gao
- Department of Medical Cosmetology, Yanbian University Hospital, Jilin, China
| | - Meilan Nan
- Department of Medical Cosmetology, Yanbian University Hospital, Jilin, China
| | - Zhehu Jin
- Department of Medical Cosmetology, Yanbian University Hospital, Jilin, China
| | - Chenglong Jin
- Department of Dermatology, Suzhou Mylike Cosmetic Hospital, Suzhou, Jiangsu, China
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Schelke L, Liplavk O, Cotofana S, Shah-Desai S, Velthuis P. Periorbital venous stasis may be involved with filler induced malar edema-A duplex ultrasound-imaging-based case series. J Cosmet Dermatol 2023; 22:3246-3251. [PMID: 37786282 DOI: 10.1111/jocd.16012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 08/26/2023] [Accepted: 09/17/2023] [Indexed: 10/04/2023]
Abstract
INTRODUCTION Filler injections in the periocular region are regarded as a challenging and advanced maneuver in a high-risk area. Adverse events as malar edema due to filler treatment may occur. To evaluate the possible reasons, the ultrasound images, and medical data of patients that were prospectively referred with malar edema were evaluated. MATERIALS AND METHODS A total of 17 patients (26 eyes) with malar edema after hyaluronic acid filler treatment were included. All cases were assessed with an 18 MHz linear ultrasound device. Exact location of the filler material was noted. Relations with clinical data were analyzed using chi-square tests. RESULTS Onset of malar edema after treatment showed a wide range from immediate (0 days) to 3 years. Most patients had an early onset N = 13 (76%), a minority showed late onset N = 4 (24%). In 23 eyes, the filler material was found to be located inside the SMAS. In 3 cases filler material was located on the periosteum of the orbital rim. After duplex-ultrasound guided filler removal, restored venous flow could be seen in the superficial and/or deep fatty layer often accompanied by flow piercing through the SMAS. Minutes after treatment, clinical improvement of malar edema was observed. CONCLUSION Malar edema after by filler treatments in the periocular region may be caused by veno-lymphatic compression by filler deposits.
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Affiliation(s)
- L Schelke
- Department of Dermatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - O Liplavk
- Department of Dermatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - S Cotofana
- Department of Dermatology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Centre for Cutaneous Research, Blizard Institute, Queen Mary University of London, London, United Kingdom
| | | | - P Velthuis
- Department of Dermatology, Erasmus University Medical Center, Rotterdam, The Netherlands
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Berros P, Atlan L, Hubschman S, Converset S, Enright KM, Nikolis A. Novel Treatment Protocol for Combined Tear Trough Ligament Stretching and Injection. Plast Reconstr Surg 2023; 152:808e-816e. [PMID: 36912918 DOI: 10.1097/prs.0000000000010410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
BACKGROUND Complex anatomical changes have been the main challenges for optimal treatment results of tear trough deformities through hyaluronic acid (HA) injections. The authors present a novel technique consisting of a preinjection tear trough ligament stretching (TTLS-I) leading to its release, and compared its efficacy, safety, and patient satisfaction to tear trough deformity injection (TTDI). METHODS This was a 4-year, retrospective, single-center cohort study of 83 TTLS-I patients, with a follow-up period of 1 year. One hundred thirty-five TTDI patients served as a comparison group. Outcome analyses included the analysis of possible risk factors for adverse outcome and comparative statistics between the complication and satisfaction rates of the two groups. RESULTS TTLS-I patients received significantly less HA (0.3 cc; range, 0.2 to 0.3 cc) than TTDI patients did (0.6 cc; range, 0.6 to 0.8 cc; P < 0.001). The injected HA amount was a significant predictive factor for complications ( P < 0.05). Complication rates assessed during the follow-up visit for hematomas, edema, and the need for corrective hyaluronidase injection were low in both groups, with no significant differences between the groups. TTDI patients had significantly higher rates (5.1%) of lump surface irregularities during follow-up, compared with 0% in the TTLS-I group ( P < 0.05). After 1 year of follow-up, 98.8% of TTLS-I patients were satisfied, whereas 95.6% of TTDI patients were satisfied, with no significant difference between groups. CONCLUSIONS TTLS-I is a novel, safe, and effective treatment method, necessitating significantly less HA compared with TTDI. Moreover, it leads to very high satisfaction rates and very low complication rates. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
| | | | - Sasha Hubschman
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine
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Wilde CL, Gupta A, Lee S, Ezra DG. Tear Trough Filler Using the Three-point Tangent Technique: Lessons from 1452 Tear Trough Applications. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5060. [PMID: 37305194 PMCID: PMC10256367 DOI: 10.1097/gox.0000000000005060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 03/29/2023] [Indexed: 06/13/2023]
Abstract
This study describes a novel three-point tangent technique for tear trough filler and the results from the largest series to date. Methods A retrospective case review was performed for all patients treated between 2016 and 2020. Patient demographics, filler details and complications were recorded. The injection technique involves using a blunt cannula to deliver filler along three linear tangents bespoke to each patient. Results A total of 1452 applications of filler to the orbits of 583 patients were recorded. The median patient age was 41 years (range 19-77), and 84% were women. The mean volume of applied filler at the first appointment was 0.34 mL to each orbit (range 0.1--1.5); 82% reported no complication, 10% reported swelling with a median duration of 4 weeks (range 1-52), 4.3% experienced bruising, 4.6% reported contour irregularities, and 3.3% experienced a Tyndall effect. Retrobulbar hemorrhage occurred in one patient (0.17%), which was managed immediately with no lasting visual compromise. Volume of filler injected was significantly associated with a risk of edema (P < 0.00001) and contour irregularities (P = 0.012). In total, 50% of cases of edema resolved spontaneously after 4 weeks. Filler was dissolved in 1.9% of orbits. Patients with a history of dissolving were significantly more likely to require dissolving after subsequent reinjection (P = 0.043). Conclusions The three-point tangent technique is a safe and effective method. Increasing volume of filler administered is associated with complications of edema and contour irregularities. Edema is the most common complication and resolves spontaneously in half of patients by 4 weeks.
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Affiliation(s)
- Caroline L. Wilde
- From the Moorfields Eye Hospital NHS Trust, London, United Kingdom
- The Ezra Clinic, London, United Kingdom
| | - Ankur Gupta
- From the Moorfields Eye Hospital NHS Trust, London, United Kingdom
| | - Sieun Lee
- Mental Health & Clinical Neuroscience, School of Medicine, University of Nottingham, United Kingdom
| | - Daniel G. Ezra
- From the Moorfields Eye Hospital NHS Trust, London, United Kingdom
- The Ezra Clinic, London, United Kingdom
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Abstract
BACKGROUND Hyaluronic acid soft-tissue augmentation fillers are commonly injected into multiple areas of the face, including the tear trough. Despite well-documented risks, there is no standardized, evidence-based approach to inject filler in this area, be it using a hypodermic needle or a microcannula. The authors, therefore, sought to establish a preference between the two methods to facilitate progression toward standardization and prevention of adverse events. METHODS This is a systematic review of articles discussing hyaluronic acid tear trough injection techniques performed in vivo and related outcomes. Searches were conducted across The Cochrane Library, PubMed, Scopus, Web of Science, and Embase to yield relevant articles published before February of 2020. All selected articles incorporated discrete patient cases and were analyzed by a variety of variables assessing evidence strength, outcomes, technique, and patient safety. RESULTS After appraisal, 42 articles met eligibility criteria: 20 using needles, 12 using cannulas, and 10 focusing on adverse events. Level III was the most commonly awarded evidence grade, corresponding to retrospective, nonexperimental descriptive studies. There were no statistically significant differences in reported aesthetic results, patient satisfaction, or incidence of adverse events across the needle-based and cannula-based articles. Some technique trends, such as targeted anatomical plane and needle position, emerged in subsequent articles. CONCLUSION Given that there were no statistically significant differences in patient safety or outcomes, an evidence-based preference for needle or cannula injection into the tear trough cannot be made at this time. Current inconsistencies make tear trough injection procedures difficult to replicate, making standardization based on avoidance of adverse events not feasible.
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12
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Aguilar-González M, Davó-Cabrera J, Rausell-Fontestad N, Botella-Estrada R, España-Gregori E, Pérez-López M. Does hyaluronidase injected in periocular area change skin ultrastructure: standardized in vitro analysis. J Cosmet Dermatol 2022; 21:4323-4327. [PMID: 35451166 DOI: 10.1111/jocd.15014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 04/12/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Treatment with hyaluronic acid (HA) fillers as a strategy for rejuvenation has experienced a significant growth in recent years, accompanied by a parallel increase in its complications, the treatment of which, such as hyaluronidase, we must be aware of. PATIENTS/METHODS 14 patients (28 eyes) had indication for upper blepharoplasty surgery in the Hospital Universitario y Politécnico La Fe. After surgery, periocular skin of one eye of each patient was infiltrated with 300 U of hyaluronidase (14 cases) while the skin of the fellow eye was preserved untreated (14 controls). All samples were studied by the Pathology department and finally 6 variables (skin structure alteration, degeneration of elastic fibers, deposits, collagen fibers destructuring, inflammation, other findings) were analyzed. RESULTS No differences in skin structure, elastic fibers and collagen dermal fibers were found between hyaluronidase treated skin and controls. A significant association between ex vivo application of hyaluronidase in periocular skin and the presence of amorphous extracellular deposits within the dermis was found. CONCLUSIONS Hyaluronidase applied ex vivo to periocular skin led to presence of deposits within the extracellular matrix compared to control eyelid skin but elastin and collagen dermis structure remained unaltered.
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Affiliation(s)
| | - Juan Davó-Cabrera
- Department of Oculoplastic and Orbital Surgery, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Nuria Rausell-Fontestad
- Department of Pathological Anatomy, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | | | - Enrique España-Gregori
- Department of Oculoplastic and Orbital Surgery, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Marta Pérez-López
- Department of Oculoplastic and Orbital Surgery, Hospital Universitario y Politécnico La Fe, Valencia, Spain
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Siperstein R. Infraorbital Hyaluronic Acid Filler: Common Aesthetic Side Effects with Treatment and Prevention Options. Aesthet Surg J Open Forum 2022; 4:ojac001. [PMID: 35386936 PMCID: PMC8982019 DOI: 10.1093/asjof/ojac001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background Infraorbital hollows can give a fatigued or aged appearance, which can be treated by volumizing the segmented transition from the tear trough to the cheek with hyaluronic acid filler. Due to thin skin and the complex anatomy of the infraorbital area, both short- and long-term side effects (SEs) from this treatment are very common. While some patients are clear surgical candidates vs filler candidates, in real-world practice, many, if not most, patients are on a continuum where either procedure is appropriate, and the treatment decision is individualized based on each person’s risk vs benefit profile. Objectives Common aesthetic SEs from hyaluronic acid filler treatment in the infraorbital area will be reviewed, including their etiology, prevention, detection, and treatment. Methods The author’s experience from injecting the infraorbital areas of more than 800 patients in private clinical practice and observations from both short- and long-term follow-ups over 8 years is leveraged to provide detailed guidance. Results Recommendations on injection techniques, patient selection, and patient education are presented along with algorithms for the prevention and management of bruising, short- and long-term swelling, bumps, and blue discoloration (which is usually secondary to swelling from the filler rather than just the filler alone placed or migrating too superficially). Conclusions For nearly all patients, complete dissolution of filler with hyaluronidase is not required to address the issue, and the guidelines provided here will assist clinicians in the management of SEs to increase patient satisfaction with their treatment and aesthetic outcome. Level of Evidence: 5
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Trinh LN, McGuigan KC, Gupta A. Delayed Complications following Dermal Filler for Tear Trough Augmentation: A Systematic Review. Facial Plast Surg 2021; 38:250-259. [PMID: 34666405 DOI: 10.1055/s-0041-1736390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Tear trough deformity is a popular target for the treatment with filler injections. The side effects are generally mild and transient. However, delayed complications may occur. We aim to perform a thorough systematic review of the published literature related to delayed complications after tear trough filler injections. A search of published literature was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in June 2021 and included PubMed, ScienceDirect, and Embase databases. The Medical Subject Headings (MeSH) terms used included the following terms: delayed complications, nodules, granulomas, swelling, discoloration, dermal filler, hyaluronic acid (HA), polyacrylamide, calcium hydroxyapatite (CaHA), poly-L-lactic acid (PLLA), eyelid, periorbital, periocular, and tear trough. Twenty-eight articles consisting of 52 individual cases were included in the final analysis. 98% (51/52) of patients were female and had an average age of 48.3 years. HA was the most reported product (71.2%, 37/52), followed by PLLA (4/52, 7.7%), and CaHA (4/52, 7.7%). The most common delayed complication with any dermal filler was swelling (42.3%, 22/52) followed by lumps or nodules (25.0%, 13/52). Xanthelasma-like reaction (17.3%, 9/52), migration (7.7%, 4/52), discoloration (3%, 3/52) also occurred. The average time of onset of any complication was 16.8 months with xanthelasma-like reaction appearing soonest (mean: 10 months) and discoloration appearing latest (mean: 52 months). Most swelling cases were caused by HA. Semi-permanent fillers such as PMMA and synthetic fillers such as PLLA were more likely to be associated with lumps and nodules than other complications. It is important that clinicians who perform tear trough augmentation with dermal fillers have a thorough understanding of the risks of the procedure to diagnose and manage them promptly as well as provide patients with accurate information regarding the potential adverse effects.
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Affiliation(s)
- Lily Nguyen Trinh
- School of Medicine, Tulane University School of Medicine, New Orleans, Louisiana.,Department of Otolaryngology-Head and Neck Surgery, Mass Eye and Ear, Boston, Massachusetts
| | - Kelly C McGuigan
- School of Medicine, Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, Pennsylvania
| | - Amar Gupta
- Department of Otolarynology, Private Practice-Head and Neck Surgery, Los Angeles, California
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Comparing Water Absorption of Food and Drug Administration-Approved Hyaluronic Acid Fillers. Dermatol Surg 2021; 47:1237-1242. [PMID: 34347694 DOI: 10.1097/dss.0000000000003108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND To compare the water absorption of 12 FDA-approved hyaluronic acid (HA) facial fillers in vitro in conditions relevant to in vivo injection. OBJECTIVE The goal of this study was to provide long-term insight into an improved, tailored facial rejuvenation approach and to understand sequelae that could affect preoperative surgical planning. METHODS In 2 experiments, 12 FDA-approved HA fillers were loaded into test tubes with nonpreserved normal saline and then placed in a 94.5°F-96°F environment for 1 month to allow water absorption by passive diffusion. The test tubes were centrifuged so that the hydrated filler could pass to the bottom of the tube. The tubes were centrifuged for 12 minutes at 1,200 revolutions per minute in the first experiment and for 7 minutes in the second experiment. A blue dye was then instilled to demarcate the filler/saline interface. RESULTS There was variation in the water absorption of different HAs. Low absorption occurred in non-animal-stabilized hyaluronic acid. CONCLUSION The pattern of water absorption was similar in the 2 experiments. The results inform us about in vivo conditions and provide guidance for filler selection.
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16
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Gorbea E, Kidwai S, Rosenberg J. Nonsurgical Tear Trough Volumization: A Systematic Review of Patient Satisfaction. Aesthet Surg J 2021; 41:NP1053-NP1060. [PMID: 33693530 DOI: 10.1093/asj/sjab116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Nonsurgical rejuvenation of the tear trough area via the use of injectable filler material has become a popular procedure in facial rejuvenation. This procedure offers immediate, albeit temporary, results with minimal recovery time. OBJECTIVES The aim of this systematic review was to report on patient satisfaction and complication rates to further guide practitioners. METHODS PubMed, Cochrane, and Scopus libraries were queried for articles containing relevant terms. Articles with more than 5 patients who reported on satisfaction and/or complications from the procedure were included for review. In addition to these variables, we noted other aspects of injection, including filler material, technique, and needle or cannula delivery. Studies that did not otherwise fulfill inclusion criteria for statistical analysis but reported on intravascular injection-related complications were cited. RESULTS Initial query resulted in 1655 studies which were assessed for duplicates and inclusion/exclusion criteria. After screening, 28 articles were included for analysis. In total, 1956 patients were captured who had been injected with 1 of 4 materials: hyaluronic acid (1535), calcium hydroxyapatite (376), autologous fibroblast/keratin gel (35), and collagen-based filler (10). Short- and long-term satisfaction rates were 84.4% and 76.7%, respectively. Minor complications were common (44%). Secondarily, we found the use of cannula for filler injection of this region to be associated with a lower rate of ecchymosis (7% vs 17%, P < 0.05). CONCLUSIONS Filler injection volumization of tear trough deformity is an effective technique for facial rejuvenation associated with high patient satisfaction. Multiple filler materials offer acceptable satisfaction and complication profiles. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Enrique Gorbea
- Department of Otolaryngology, Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sarah Kidwai
- Department of Otolaryngology-Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Joshua Rosenberg
- Department of Otolaryngology, Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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17
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Alghoul MS, Vaca EE, Bricker JT, Mioton LM. Enhancing the Lateral Orbital "C-Angle" With Calcium Hydroxylapatite: An Anatomic and Clinical Study. Aesthet Surg J 2021; 41:952-966. [PMID: 32719841 DOI: 10.1093/asj/sjaa218] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Deliberate injection of specific facial subunits may improve aesthetic outcomes in facial rejuvenation. We contend that the lateral orbital area (LOA) is a key anatomic subunit in the perception of eye attractiveness, with a C-shaped distribution of fat contributing to the formation of a distinct angle in the lateral orbit. OBJECTIVES The aim of this study was to describe the anatomy of the LOA that constitutes the C-shaped angle and to investigate the safety and cosmetic outcomes of nonsurgical enhancement of that area with calcium hydroxylapatite (CaHA). METHODS Four injected fresh-frozen cadaver heads were dissected. Twenty patients were enrolled in a prospective clinical study. Participants were seen on the day of injection, and at 2 weeks and 3 months postinjection. Two-dimensional and 3D photographs were analyzed to quantify the volumetric changes between pretreatment and postinjection time points. Secondary outcomes included Global Aesthetic Improvement Scale score and subject satisfaction at 3 months. RESULTS Cadaver dissections revealed distinct fat compartments and a zone of adhesion forming the C-shaped area around the lateral orbit. In the clinical study, a mean of 1.88 mL of CaHA was injected into each lateral periorbital region. There was 97% and 76% volume retention at 2 weeks and 3 months, respectively, with 70% of patients being "very satisfied" at 3 months. The average Global Aesthetic Improvement Scale rating at 3 months was 3.95. There were no complications. CONCLUSIONS The LOA is a distinct facial subunit that can be enhanced safely by CaHA injection with good cosmetic outcomes. Focusing on the C-angle can improve periorbital aesthetics. LEVEL OF EVIDENCE: 4
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Affiliation(s)
| | - Elbert E Vaca
- Northwestern Feinberg School of Medicine Plastic Surgery Program, Chicago, IL
| | | | - Lauren M Mioton
- Northwestern Feinberg School of Medicine Plastic Surgery Program, Chicago, IL
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18
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Trinh LN, Grond SE, Gupta A. Dermal Fillers for Tear Trough Rejuvenation: A Systematic Review. Facial Plast Surg 2021; 38:228-239. [PMID: 34192769 DOI: 10.1055/s-0041-1731348] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
There is significant variation in treatment parameters when treating the infraorbital region. Thorough knowledge of these pertinent factors, choice of the optimal filling material, and proper understanding of the anatomy of this unforgiving region will contribute to a safe, effective, and natural result. We aim to conduct a systematic review of published literature related to soft tissue fillers of the tear trough and infraorbital region. A search of published literature was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and included PubMed, Embase, and Science Direct databases. The Medical Subject Headings (MeSH) terms used were "tear trough" OR "infraorbital" AND "dermal filler" OR "hyaluronic acid" OR "poly-L-lactic acid" OR "calcium hydroxyapatite" OR "Restylane" OR "Radiesse" OR "Perlane" OR "Juvéderm" OR "Belotero." Different combinations of these key terms were used. The initial search identified 526 articles. Six additional articles were identified through references. Two-hundred twenty-five duplicates were removed. A total of 307 studies were screened by title and abstract and 258 studies were eliminated based on inclusion and exclusion criteria. Forty-nine articles underwent full-text review. The final analysis included 23 articles. Patient satisfaction was high, and duration of effect ranged from 8 to 12 months. Restylane was most commonly used. Injection technique varied, but generally involved placing filler pre-periosteally, deep to orbicularis oculi muscle, anterior to the inferior orbital rim via serial puncture or retrograde linear threading with a 30-gauge needle. Topical anesthetic was most commonly used. Side effects were generally mild and included bruising, edema, blue-gray dyschromia, and contour irregularities. Nonsurgical correction of the tear trough deformity with soft tissue filler is a minimally invasive procedure with excellent patient satisfaction with long-lasting effects. It is essential to have a fundamental understanding of the relevant anatomy and ideal injection technique to provide excellent patient outcomes and prevent serious complications.
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Affiliation(s)
- Lily N Trinh
- Department of Otolaryngology-Head and Neck Surgery, Tulane University, School of Medicine, New Orleans, Louisiana
| | | | - Amar Gupta
- Department of Otolaryngology-Head and Surgery, St. Elizabeth's Medical Center, Brighton, Massachusetts
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19
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Dubinsky-Pertzov B, Bernardini FP, Or L, Gazit I, Hartstein ME. Late-Onset Upper Eyelid and Brow Edema as a Long-Term Complication of Hyaluronic Acid Filler Injection. Aesthet Surg J 2021; 41:NP464-NP471. [PMID: 32427315 DOI: 10.1093/asj/sjaa126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Late-onset upper eyelid edema is an uncommonly recognized complication of hyaluronic acid (HA)-based filler injection to the supraorbital area. OBJECTIVES The authors sought to report their experience in diagnosing and managing late-onset upper eyelid edema. METHODS This was a noncomparative, retrospective study of a series of 17 consecutive patients who presented with upper eyelid edema 6 to 24 months after uneventful HA filler injection in the supraorbital area. RESULTS The study group included 17 female patients. The average time of presentation was 13.9 months. Thirteen patients (76.4%) were satisfied after hyaluronidase and requested no further treatment (observation only); 4 patients (23.5%) elected to receive HA filler re-treatment, with satisfactory results. All patients were followed-up for at least 6 months after the re-treatment. CONCLUSIONS The incidence of late-onset upper eyelid edema is likely to increase as the number of patients undergoing HA filler injection to the supraorbital area increases. Our study emphasizes the importance of recognizing this condition and suggests a suitable noninvasive treatment with satisfying results for both the patient and the physician. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Biana Dubinsky-Pertzov
- Department of Ophthalmology, Shamir Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Lior Or
- Department of Ophthalmology, Shamir Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Inbal Gazit
- Department of Ophthalmology, Shamir Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Morris E Hartstein
- Department of Ophthalmology, Shamir Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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20
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Nagendran ST, Ali MJ, Dogru M, Malhotra R. Complications and Adverse Effects of Periocular Aesthetic Treatments. Surv Ophthalmol 2021; 67:741-757. [PMID: 33933438 DOI: 10.1016/j.survophthal.2021.04.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 04/17/2021] [Accepted: 04/19/2021] [Indexed: 10/21/2022]
Abstract
The popularity and variety of temporary and permanent periocular aesthetic treatments has increased over the past decade. Patients frequently present to eye clinics with ocular complications and side effects following these treatments, their severity ranging from ocular irritation from dry eyes to visual loss from vascular occlusion. A careful, thorough history is essential, as many patients may not associate aesthetic procedures with ocular complications, and some may be embarrassed to disclose this information. All ophthalmologists should understand the potential ocular sequelae of these treatments and be able to initiate treatment in sight-threatening cases. Wesummarises the current literature on ophthalmic complications of the most common periocular aesthetic treatments.
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Affiliation(s)
- Sonali T Nagendran
- Corneoplastic Unit, Queen Victoria Hospital NHS Trust, East Grinstead, United Kingdom
| | - Mohammad Javed Ali
- Govindram Seksaria Institute of Dacryology, L.V. Prasad Eye Institute, Hyderabad, India
| | - Murat Dogru
- Department of Ophthalmology, Keio University School of Medicine, Tokyo, Japan
| | - Raman Malhotra
- Corneoplastic Unit, Queen Victoria Hospital NHS Trust, East Grinstead, United Kingdom.
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21
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The use of periocular fillers in aesthetic medicine. J Plast Reconstr Aesthet Surg 2021; 74:1602-1609. [PMID: 33546985 DOI: 10.1016/j.bjps.2020.12.079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 12/08/2020] [Accepted: 12/20/2020] [Indexed: 11/22/2022]
Abstract
The periocular area is the first to display signs of ageing. Dermal fillers are an increasingly popular, minimally invasive method for facial rejuvenation. The eye is anatomically delicate and complex. Therefore, special consideration must be taken if dermal fillers are employed. This article examines the literature to assess the efficacy and safety of dermal fillers around the eye as well as the management of complications secondary to dermal filler use, such as oedema, granuloma formation, filler migration, xanthelasma, skin necrosis and visual loss. Hyaluronic acid (HA) is the most popular and commonly employed dermal filler for periocular use. It is effective, with good observer improvement and patient satisfaction (p<0.0001). Ninety percent of adverse events are mild in nature and self-resolve within 1 month. Malar oedema is a delayed complication unique to the periocular area, occurring in 11% of patients. This can be managed with use of hyaluronidase if a HA filler has been employed. Other complications, such as granuloma formation, filler migration and xanthelasma, have also been reported with variable management outcomes. Vascular adverse events include skin necrosis and visual loss. No Level 1 evidence exists for the management of visual loss. Two cases of visual restoration have been identified in the literature; however, this is rare.
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22
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Shah-Desai S, Joganathan V. Novel technique of non-surgical rejuvenation of infraorbital dark circles. J Cosmet Dermatol 2020; 20:1214-1220. [PMID: 32881282 DOI: 10.1111/jocd.13705] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 08/07/2020] [Accepted: 08/25/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Infraorbital dark circles are a common esthetic concern which can be challenging to treat given their multifactorial nature. Under-eye dark circles are seen in all skin types, with a strong familial component in darker skin types. Other major contributing factors include soft tissue and bony changes, skin changes, lifestyle contributions, and allergies. Involutional periorbital volumetric changes cause volume loss in the tear trough, naso-jugal and palpebro-malar grove, skin and subcutaneous tissues with tethering of the eyelid skin to the tear trough ligament, giving a sunken and hollow appearance to the lower lid. Associated prolapse of the orbital fat and thin skin can worsen the appearance of a dark circle. Hyaluronic acid fillers placed in the pre-periosteal plane in the tear trough, palpebro-malar and naso-jugal grooves, give good results in patients with thick eyelid skin and negligible fat prolapse. However, in patients with thin skin and moderate fat prolapse, authors have reported worsening outcomes with risk of Tyndall (blue-gray discoloration) and contour irregularities from visible lumps. AIMS To describe a novel technique to improve dark circles caused by a diffuse valley-type pre-septal tear trough deformity in patients with thin eyelid skin. METHODS Retrospective case note review of 330 eyelids treated with microdroplet subdermal placement of filler in the preseptal tear trough area by a single surgeon. CONCLUSION This novel technique shows good esthetic outcomes in patients with dark circles, with good longevity and a low risk of complications.
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Reddy S, Nguyen TA, Gharavi N. Complications associated with infraorbital filler injection. J COSMET LASER THER 2020; 22:226-229. [PMID: 33794721 DOI: 10.1080/14764172.2021.1909067] [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: 10/21/2022]
Abstract
Soft tissue augmentation with injectable fillers is increasingly being performed, and providers must be prepared to understand and treat complications. Periorbital skin presents unique challenges due to its thin nature, easily evident pigmentary and textural irregularities, and anatomical considerations including vasculature and subcutaneous layers. The most common complications of infraorbital filler include ecchymosis, malar edema, blue-gray hue, and contour irregularities. Uncommon complications include infection and biofilm formation, skin necrosis, and blindness. This purpose of this review is to highlight the infraorbital anatomy, complications of filler injection in this region, and techniques to avoid these complications.
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Affiliation(s)
- Shivani Reddy
- Department of Dermatology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | - Tuyet A Nguyen
- Department of Dermatology, California Skin Institute, Los Angeles, CA, USA
| | - Nima Gharavi
- Department of Dermatology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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24
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Kołodziejczak A, Rotsztejn H. The eye area as the most difficult area of activity for esthetic treatment. J DERMATOL TREAT 2020; 33:1257-1264. [DOI: 10.1080/09546634.2020.1832189] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Anna Kołodziejczak
- Department of Cosmetology and Aesthetic Dermatology, Faculty of Pharmacy, Medical University of Lódź, Łódź, Poland
| | - Helena Rotsztejn
- Department of Cosmetology and Aesthetic Dermatology, Faculty of Pharmacy, Medical University of Lódź, Łódź, Poland
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25
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Decates TS, Kruijt Spanjer EC, Saini R, Velthuis PJ, Niessen FM. Unilateral facial edema after filler injection of the lower eyelid. Dermatol Ther 2020; 33:e13539. [PMID: 32384211 PMCID: PMC7507173 DOI: 10.1111/dth.13539] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/10/2020] [Accepted: 04/28/2020] [Indexed: 12/22/2022]
Abstract
The use of hyaluronic acid (HA) gel fillers for rejuvenation of the face has been increasing in popularity over the years. This nonsurgical, temporary technique is commonly used in the periocular region to restore volume. The aim of this study was creating awareness in the potential causes of edema after hyaluronic acid gel filler injections under the eyes. A 32‐year‐old woman presented for a cosmetic consultation to address unilateral swelling of the left check. She states she had an HA filler injected in the tear trough on both sides. Extensive evaluation and ultrasound were performed by physicians of different specialties. Intra‐oral and radiological examination revealed a tooth‐related cause known as apical periodontitis. Removal of this tooth resulted in complete resolution of the patient's presenting symptoms. Familiarity with all the potential causes of adverse events after injections with hyaluronic acid gel fillers accelerates the treatment and healing of the patient with complications. Reporting this case should raise awareness about possible teeth‐related complications.
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Affiliation(s)
- Tom S Decates
- Department of Dermatology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Elmer C Kruijt Spanjer
- Department of Maxillo and Facial Surgery, Haaglanden Medisch Centrum, the Hague, Netherlands
| | - Renu Saini
- Meyer Dental Practice, the Hague, Netherlands
| | - Peter J Velthuis
- Department of Dermatology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Frank M Niessen
- Department of Plastic Surgery, Amsterdam University Medical Center, Amsterdam, Netherlands
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An Alternative Periorbital Treatment Option Using Calcium Hydroxyapatite for Hyperpigmentation Associated with the Tear Trough Deformity. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2633. [PMID: 32309082 PMCID: PMC7159963 DOI: 10.1097/gox.0000000000002633] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 12/09/2019] [Indexed: 01/17/2023]
Abstract
Background The nasojugal groove or tear trough (TT) area deformity produces visible, pigmented, difficult-to-treat hollows. Hyaluronic acid (HA) filler-based correction yields variable results and complications. We developed an alternative, minimally invasive treatment for this area. Methods Patients with significant, visible TT area pigmentation, and/or those requiring corrections for TT filler removal, were given lignocaine-diluted calcium hydroxyapatite (CaHA) fillers. CaHA boluses were placed deep on the bone, under the origin of the orbicularis retaining ligament, and under the sub-orbicularis oculi fat. Diluted CaHA was used as a subcutaneous biostimulatory wash. Efficacy and complications were assessed using the Global Aesthetic Improvement Scale and a modified Tear Trough Rating Scale, at 4 and 18 months. Results Twelve patients, between 25 and 52 years of age, were treated and showed immediate improvements in hyperpigmentation due to light reflection and some visibility of the filler through skin. Lower eyelid swelling and redness occurred a few days postinjection but resolved spontaneously. Over 4 to 6 months, hyperpigmentation and skin tone, thickness, and color improved noticeably. Global Aesthetic Improvement Scale and modified Tear Trough Rating Scale scores indicated that all patients experienced satisfactory improvements. Three prior HA patients required a second CaHA treatment at 4-6 months for a satisfactory correction, one of whom required a third CaHA "wash" at 10 months. Some mild redness was observed for up to 12 weeks in a few patients; however, no differences in the degree of redness were observed between those treated for dark circles or post-HA correction. One patient experienced a persistent, dull erythema for 8 months; another had overt erythema and swelling following a chest infection which resolved with antibiotics and hydrocortisone cream. No nodules developed in any patient. Conclusions We developed an alternative TT deformity treatment that leverages CaHA unique rheology and neocollagenesis-stimulating ability, which lifted and supported the prolapsing orbicularis retaining ligament, improved skin quality, and rejuvenated the periocular area without direct injections into the TT.
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Levy N, Benzaquen M, Le Roux MK, Arnaud M, Graillon N, Foletti JM. Self‐injection of a solution intended for topical use containing hyaluronic acid and vitamin B5. Clin Exp Dermatol 2020; 45:600. [DOI: 10.1111/ced.14168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/24/2019] [Indexed: 11/28/2022]
Affiliation(s)
- N. Levy
- Department of Maxillofacial Surgery Aix Marseille University APHM Hôpital de la Conception Marseille France
- Departments of Department of Ophthalmology Aix Marseille University APHM Hôpital Nord Marseille France
| | - M. Benzaquen
- Department of Dermatology Aix Marseille University APHM Hôpital Nord Marseille France
| | - M. K. Le Roux
- Department of Maxillofacial Surgery Aix Marseille University APHM Hôpital de la Conception Marseille France
| | - M. Arnaud
- Department of Maxillofacial Surgery Aix Marseille University APHM Hôpital de la Conception Marseille France
| | - N. Graillon
- Department of Maxillofacial Surgery Aix Marseille University APHM Hôpital de la Conception Marseille France
| | - J. M. Foletti
- Department of Maxillofacial Surgery Aix Marseille University APHM Hôpital de la Conception Marseille France
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Goldberg RA. Commentary on: Rehabilitation of the Dysmorphic Lower Eyelid From Hyaluronic Acid Filler: What to Do After a Good Periocular Treatment Goes Bad. Aesthet Surg J 2020; 40:206-207. [PMID: 30995303 DOI: 10.1093/asj/sjz084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Robert A Goldberg
- Dr Goldberg is a Professor of Ophthalmology, David Geffen School of Medicine at UCLA; and Chief, Orbital and Ophthalmic Plastic Surgery Division, UCLA Stein Eye Institute, Los Angeles, CA
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Park JY, Byun EJ, Kim HS. Rejuvenation of periocular region in Koreans: A multimodal approach combining botulinum toxin, fillers, and micro‐focused ultrasound with visualization for optimal results. Dermatol Ther 2019; 33:e13159. [DOI: 10.1111/dth.13159] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 10/29/2019] [Accepted: 11/01/2019] [Indexed: 12/22/2022]
Affiliation(s)
- Je Young Park
- Department of DermatologyOracle Dermatology Clinic, Seoul National University Seoul South Korea
| | - Eun Jung Byun
- Department of DermatologyIncheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea Incheon South Korea
| | - Hei Sung Kim
- Department of DermatologyIncheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea Incheon South Korea
- Department of Biomedicine & Health SciencesThe Catholic University of Korea Seoul South Korea
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30
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Hussain SN, Mangal S, Goodman GJ. The Tick technique: A method to simplify and quantify treatment of the tear trough region. J Cosmet Dermatol 2019; 18:1642-1647. [DOI: 10.1111/jocd.13169] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Revised: 05/15/2019] [Accepted: 05/15/2019] [Indexed: 11/27/2022]
Affiliation(s)
| | - Sonia Mangal
- Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Greg J. Goodman
- Department of Primary Care Monash University Clayton Vic. Australia
- Skin and Cancer Foundation Inc Clayton Vic. Australia
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Zoumalan CI. Managing Periocular Filler-Related Syndrome Prior to Lower Blepharoplasty. Aesthetic Plast Surg 2019; 43:115-122. [PMID: 30298348 DOI: 10.1007/s00266-018-1250-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Accepted: 09/22/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Hyaluronic acid (HA) fillers are extensively used in periocular volume augmentation. Although they have an excellent safety profile, filler-related issues such as visibility/palpability, contour abnormalities, malar edema, and blue-gray dyschromia can occur. Recognition and management of filler-related issues are critical prior to subsequent procedures. The clinical course of patients who had periocular HA filler-related issues and subsequently underwent lower eyelid blepharoplasty is described. METHODS HA filler was dissolved with hyaluronidase (15-30 U/cm2) treatment. Visible lower eyelid fat prolapse after filler removal was corrected with transconjunctival blepharoplasty with fat repositioning and skin resurfacing. Complications and outcome were assessed and recorded. RESULTS Twenty-three patients (46 eyelids) were treated. All presented with contour abnormalities, 19 with contour abnormalities and malar edema, and seven with blue-gray dyschromia. In 15 patients, one session of hyaluronidase completely dissolved the filler, and in eight patients, two sessions were required. Of these eight patients, edema resolved after the second hyaluronidase injection in four; in the remaining four, mild edema persisted despite absence of visible/palpable filler. Postblepharoplasty, 19 patients had an acceptable outcome with no complications (82.6%). Four patients had prolonged edema postoperatively; three had a resolution by 6 months. In 23 patients who had skin resurfacing procedures, there was no incidence of postinflammatory hyperpigmentation. CONCLUSIONS HA filler-related issues need to be identified and managed prior to further intervention. Hyaluronidase treatment effectively dissolves the filler, but mild malar edema can persist. Outcomes are acceptable after subsequent blepharoplasty, but adequate patient counseling is necessary about expectations and limitations. 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)
- Christopher I Zoumalan
- Keck School of Medicine, University of Southern California, 9401 Wilshire Blvd, Suite 1105, Beverly Hills, CA, 90212, USA.
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Nasolacrimal Duct Obstruction Following Hyaluronic Acid Rejuvenation of the Tear Trough. Ophthalmic Plast Reconstr Surg 2018; 35:e14-e15. [PMID: 30407998 DOI: 10.1097/iop.0000000000001278] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although generally safe, hyaluronic acid rejuvenation of periorbital tissue has been reported to cause minor and major adverse events. The authors document a case of nasolacrimal duct obstruction due to hyaluronic acid rejuvenation of the tear trough. Nasolacrimal duct obstruction immediately resolved following irrigation of hyaluronidase into the affected lacrimal system. To the authors' knowledge, this is the first reported case of nasolacrimal duct obstruction due to filler injection.
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Park KY, Kwon HJ, Youn CS, Seo SJ, Kim MN. Treatments of Infra-Orbital Dark Circles by Various Etiologies. Ann Dermatol 2018; 30:522-528. [PMID: 33911473 PMCID: PMC7992473 DOI: 10.5021/ad.2018.30.5.522] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 04/02/2018] [Accepted: 04/09/2018] [Indexed: 11/16/2022] Open
Abstract
Dark circles refer to visible darkness of the infra-orbital areas. Dark circles are a cosmetic concern for many individuals, although not a medical concern. Moreover, clear definitions and possible causes of dark circles have not been elucidated. This study reviews the possible causes and treatment options for dark circles based on a review of the medical literature and the authors' clinical experience. Potential factors that contribute to dark circles include excessive pigmentation, shadowing due to tear troughs and infra-orbital fat herniation, shadowing due to infraorbital laxity and wrinkles, and thin, translucent skin overlying the orbicularis oculi muscle. Given the different possible causes for dark circles, therapeutic modalities must be individualized for each patient. Because various factors cause dark circles, it is useful to identify the underlying causes in order to select the appropriate treatment.
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Affiliation(s)
- Kui Young Park
- Department of Dermatology, Chung-Ang University College of Medicine, Seoul, Korea
| | - Hyun Jung Kwon
- Department of Dermatology, Chung-Ang University College of Medicine, Seoul, Korea
| | | | - Seong Jun Seo
- Department of Dermatology, Chung-Ang University College of Medicine, Seoul, Korea
| | - Myeong Nam Kim
- Department of Dermatology, Chung-Ang University College of Medicine, Seoul, Korea
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