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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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Hong GW, Hu H, Park Y, Park HJ, Yi KH. Safe Zones for Facial Fillers: Anatomical Study of SubSMAS Spaces in Asians. Diagnostics (Basel) 2024; 14:1452. [PMID: 39001342 PMCID: PMC11241601 DOI: 10.3390/diagnostics14131452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 07/03/2024] [Accepted: 07/05/2024] [Indexed: 07/16/2024] Open
Abstract
The study "Spaces of the Face for Filler Procedures: Identification of subSMAS Spaces Based on Anatomical Study" explores the anatomy of facial spaces crucial for safe and effective filler injections. By delineating the subSMAS (sub-superficial musculoaponeurotic system) spaces, this research highlights how these virtual compartments, bordered by fat, muscles, fascia, and ligaments, facilitate independent muscle movement and reduce the risk of damaging critical structures. The thicker and more robust skin of East Asians necessitates deeper filler injections, emphasizing the significance of accurately identifying these spaces. A cadaver study with dyed gelatin validated the existence and characteristics of these subSMAS spaces, confirming their safety for filler procedures. Key spaces, such as the subgalea-frontalis, interfascial and temporalis, and prezygomatic spaces, were examined, illustrating safe zones for injections. The findings underscore the importance of anatomical knowledge for enhancing facial aesthetics while minimizing complications. This study serves as a guide for clinicians to perform precise and safe filler injections, providing a foundation for further research on the dynamic interactions of these spaces and long-term outcomes.
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Affiliation(s)
- Gi-Woong Hong
- Sam Skin Plastic Surgery Clinic, Seoul 06577, Republic of Korea
| | - Hyewon Hu
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 FOUR Project, Yonsei University College of Dentistry, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | | | - Hyun Jin Park
- Department of Anatomy, Daegu Catholic University School of Medicine, Daegu 42472, Republic of Korea
| | - Kyu-Ho Yi
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 FOUR Project, Yonsei University College of Dentistry, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
- Maylin Clinic (Apgujeong), Seoul 06005, Republic of Korea
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Kadouch J, Schelke L, Groh O, Sokol V, Velthuis P. Intralesional hyaluronidase injection to relieve non-hyaluronic acid filler-induced vascular adverse events. Int J Dermatol 2024. [PMID: 38955457 DOI: 10.1111/ijd.17355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 06/10/2024] [Accepted: 06/13/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Vascular adverse events (VAEs) occurring during injections of soft-tissue fillers are still considered a challenging issue for both patients and practitioners. Hyaluronidase can dissolve hyaluronic acid (HA)-based soft-tissue fillers during a VAE. For VAEs induced by non-HA fillers, the absence of an "antidote" is regarded as exceptionally challenging. METHODS This multicenter study describes a case series of three VAEs induced by non-HA fillers, for which ultrasound-guided hyaluronidase injections were incorporated into the treatment approach. RESULTS Two cases of calcium hydroxylapatite and one case of poly-L-lactic acid-induced VAEs are described, all of which were resolved without necrosis or scarring using a treatment approach with ultrasound-guided hyaluronidase injections. CONCLUSIONS Unlike the mechanical hypothesis, which assumes filler particles travel antegrade to block arterioles in a large skin area, we hypothesize vasoconstriction as the pivot in VAEs. Filler injection-induced spasms could lead to long-lasting vasoconstriction of the perforator arteries stemming from the central facial arteries. Our results underscore that perforasome vasoconstriction might be the leading cause of the ischemia and subsequent necrosis in VAEs and that relaxation of these perforasomes, rather than dissolving the filler material, resolves the clinical symptoms associated with VAEs.
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Affiliation(s)
- Jonathan Kadouch
- ReSculpt Clinic, Practice for Aesthetic Dermatology, Amsterdam, the Netherlands
| | - Leonie Schelke
- Department of Dermatology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Olivier Groh
- Groh Kliniek, Practice for Aesthetic Medicine, Bloemendaal, the Netherlands
| | - Vicky Sokol
- Aesthetics by Viktorya, Practice for Aesthetic Medicine, Lincolnshire, IL, USA
| | - Peter Velthuis
- Department of Dermatology, Erasmus Medical Centre, Rotterdam, the Netherlands
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Kim SB, Hu H, Bae H, Yi KH. Anatomy of the temporal region to guide filler injections. Surg Radiol Anat 2024; 46:615-624. [PMID: 38480594 DOI: 10.1007/s00276-024-03340-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 03/01/2024] [Indexed: 05/07/2024]
Abstract
Hollow temples are not typically considered aesthetically pleasing, and hollowness worsens with the aging process. When filling this region with fillers, there are several anatomical considerations, with injection techniques varying depending on the layer targeted. Specifically, injections between the superficial temporal fascia and the superficial layer of the deep temporal fascia are performed using a cannula, while periosteal layer injections involve the use of a needle to reach the bone before inserting fillers. Detailed anatomical insights encompass the boundaries of the temporal fossa and cautionary notes regarding blood vessels, supported by specific studies on veins and arteries in the temporal region. Complications, including vessel injuries, are discussed alongside an exploration of various injection techniques. This review provides a comprehensive exploration of anatomical considerations and the specific methodologies employed in temple augmentation with fillers.
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Affiliation(s)
- Soo-Bin Kim
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 FOUR Project, Yonsei University College of Dentistry, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
| | - Hyewon Hu
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 FOUR Project, Yonsei University College of Dentistry, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
| | - Hyungkyu Bae
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 FOUR Project, Yonsei University College of Dentistry, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea.
- Department of Oral Biology, Yonsei University College of Dentistry, Room 601, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea.
| | - Kyu-Ho Yi
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 FOUR Project, Yonsei University College of Dentistry, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea.
- Maylin Clinic (Apgujeong), Seoul, 06005, Korea.
- Department of Oral Biology, Yonsei University College of Dentistry, Room 601, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea.
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5
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Botha VE, Insull EA. Causes and management of sight threatening complications of dermal filler injections: A review. Clin Exp Ophthalmol 2024; 52:365-373. [PMID: 38380782 DOI: 10.1111/ceo.14362] [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: 08/31/2023] [Revised: 12/16/2023] [Accepted: 01/05/2024] [Indexed: 02/22/2024]
Abstract
Injectable dermal fillers continue to increase in popularity in aesthetic medicine. Although rare, vision loss secondary to filler injections is a devastating complication associated with a poor visual prognosis. The mechanism for vision loss is thought to be related to retrograde embolization of the dermal filler from peripheral vessels in the face into the ophthalmic arterial system. Early recognition and prompt management are essential if vision is to be salvaged. The use of retrobulbar hyaluronidase is still contentious, however when administered by a specialist, this treatment gives the best chance at visual recovery and should be considered for all cases.
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Affiliation(s)
- Verona E Botha
- Department of Ophthalmology, Te Whatu Ora Waikato, Hamilton, New Zealand
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Tsai MF, Yu CM, Chen YF, Chung TY, Lin GH, Lee AL, Yang CY, Yu CM, Huang HY, Liu YC, Huang WC, Tung KY, Yao WT. Laser Speckle Contrast Imaging Guides Needling Treatment of Vascular Complications from Dermal Fillers. Aesthetic Plast Surg 2024; 48:1067-1075. [PMID: 37816946 DOI: 10.1007/s00266-023-03629-z] [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: 05/29/2023] [Accepted: 08/07/2023] [Indexed: 10/12/2023]
Abstract
BACKGROUND Although laser Doppler imaging (LDI) accurately delineates a hypoperfused area to help target hyaluronidase treatment, laser speckle contrast imaging (LSCI) is more appropriate for assessing microvascular hemodynamics and has greater reproducibility than LDI. This study investigated the use of LSCI in the evaluation and treatment of six patients who developed vascular complications after facial dermal filler injections. METHODS The areas of vascular occlusion were accurately defined in real time by LSCI and were more precise than visual inspections or photographic evidence for guiding needling and hyaluronidase treatment. RESULTS All patients had achieved satisfactory outcomes as early as Day 2 of treatment and no procedure-related complications were reported after a median follow-up of 9.5 (7-37) days. CONCLUSION LSCI accurately and noninvasively delineated vascular occlusions in real time among patients experiencing complications of facial dermal filler injections. Moreover, LSCI was more accurate than visual and photographic evaluations. Clinicians can use LSCI to reliably follow-up therapeutic outcomes after salvage interventions for vascular occlusions. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Ming-Feng Tsai
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd, Taipei City, 10449, Taiwan
- Department of Medicine, MacKay Medical College, New Taipei, 25245, Taiwan
- Graduate Institute of Medical Science and Technology, Taipei Medical University, Taipei City, 101, Taiwan
| | - Chia-Meng Yu
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd, Taipei City, 10449, Taiwan
- Department of Medicine, MacKay Medical College, New Taipei, 25245, Taiwan
| | - Yu-Fan Chen
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd, Taipei City, 10449, Taiwan
- Department of Medicine, MacKay Medical College, New Taipei, 25245, Taiwan
| | - Tzu-Yi Chung
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd, Taipei City, 10449, Taiwan
| | - Guan-Heng Lin
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd, Taipei City, 10449, Taiwan
| | - An-Li Lee
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd, Taipei City, 10449, Taiwan
- Department of Medicine, MacKay Medical College, New Taipei, 25245, Taiwan
| | - Chin-Yi Yang
- Department of Dermatology, New Taipei Municipal TuCheng Hospital, New Taipei City, 236, Taiwan
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, 333, Taiwan
- Department of Cosmetic Science, Chang Gung University of Science and Technology, Linkuo, Taoyuan, 333, Taiwan
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, 333, Taiwan
| | - Chieh-Ming Yu
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd, Taipei City, 10449, Taiwan
- Department of Medicine, MacKay Medical College, New Taipei, 25245, Taiwan
| | - Hsuan-Yu Huang
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd, Taipei City, 10449, Taiwan
- Department of Medicine, MacKay Medical College, New Taipei, 25245, Taiwan
| | - Ying-Chun Liu
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd, Taipei City, 10449, Taiwan
- Department of Medicine, MacKay Medical College, New Taipei, 25245, Taiwan
| | - Wen-Chen Huang
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd, Taipei City, 10449, Taiwan
- Department of Medicine, MacKay Medical College, New Taipei, 25245, Taiwan
| | - Kwang-Yi Tung
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd, Taipei City, 10449, Taiwan
- Department of Medicine, MacKay Medical College, New Taipei, 25245, Taiwan
| | - Wen-Teng Yao
- Division of Plastic Surgery, Department of Surgery, Mackay Memorial Hospital, No. 92, Sec. 2, Zhongshan N. Rd, Taipei City, 10449, Taiwan.
- Department of Medicine, MacKay Medical College, New Taipei, 25245, Taiwan.
- Department of Materials Science and Engineering, National Taiwan University, Taipei, 106, Taiwan.
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Guida S, Galadari H. A systematic review of Radiesse/calcium hydroxylapatite and carboxymethylcellulose: evidence and recommendations for treatment of the face. Int J Dermatol 2024; 63:150-160. [PMID: 37897174 DOI: 10.1111/ijd.16888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/14/2023] [Accepted: 10/15/2023] [Indexed: 10/29/2023]
Abstract
Radiesse® is a filler composed of calcium hydroxylapatite microspheres suspended in a carboxymethylcellulose gel (CaHA/CMC). It has robust rheological properties that have been associated with its versatility. CaHA/CMC is employed for both on-label indications of filling wrinkles or lines, volumizing, and contouring of areas as well as off-label indications aiming at biostimulation and skin tightening. However, despite the expanding use of CaHA/CMC, overall evidence and recommendations for treatment are currently lacking. This paper aims to provide an up-to-date overview of CaHA/CMC clinical applications, together with a level of evidence of supporting literature, focusing on the face. Based on the data, CaHA/CMC may be considered a safe and effective treatment option for cheeks, jawline, HIV-related facial lipoatrophy, and nasolabial folds. Treatment of marionette lines, chin, pre-jowl, and corner of the mouth also tends to respond with a high degree of efficacy. Despite the recent trend, guidelines, and safety profile of diluted and hyperdiluted Radiesse® , no randomized controlled trials have been published.
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Affiliation(s)
- Stefania Guida
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Dermatology Clinic, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Hassan Galadari
- College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
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Ding H, Fu Q, Liu B, Xv X, Zhou G, Zheng C, Chen Z, Chen M. Concentrated Growth Factor (CGF): The Newest Platelet Concentrate and Its Application in Nasal Hyaluronic Acid Injection Complications. Aesthetic Plast Surg 2023; 47:1785-1793. [PMID: 36849662 DOI: 10.1007/s00266-023-03289-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 01/30/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND Several cases of wounds caused by vascular compromise after facial cosmetic injection have been reported in recent years. How to promote wound healing, restore facial appearance, and avoid secondary injury in such patients have remained a clinical challenge. Our study was designed to assess the effect of concentrated growth factor (CGF) for repairing nasal wounds after nasal hyaluronic acid injection. METHODS Six women with nasal wounds after hyaluronic acid injection were enrolled from June 2019 to June 2022. The average time of the first CGF treatment from admission was 2-4 days. CGF gel was prepared from each patient's blood by using a Medifuge™ system. After debridement of the wound, the prepared CGF gel was applied on the wound surface, and the wound dressing was fixed to stabilize the CGF gel. The CGF treatment interval was 3-4 days. RESULTS The wound began to heal after the first CGF treatment. After 2-3 CGF treatments, the wound was almost completely healed. There was no deflection of the nasal columella, and nasal ventilation function was good. There was no obvious deformity in the appearance of the nose. After follow-up ranging from 2 months to 1 year, the appearance and function of the nose showed satisfactory recovery. CONCLUSIONS CGF has great potential in promoting wound healing and restoring the appearance after complications from nasal hyaluronic acid injection. The preparation of CGF gel is simple, and the clinical application is convenient and safe. In future, more clinical trials are needed to further prove the efficacy and safety of CGF in the treatment of wounds secondary to cosmetic injection. 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 http://www.springer.com/00266 .
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Affiliation(s)
- Hongfan Ding
- Senior Department of Burns and Plastic Surgery, the Fourth Medical Center, PLA General Hospital, No. 51 Fucheng Road, Haidian District, Beijing, 100038, China
| | - Qiang Fu
- Senior Department of Burns and Plastic Surgery, the Fourth Medical Center, PLA General Hospital, No. 51 Fucheng Road, Haidian District, Beijing, 100038, China
| | - Bing Liu
- Private Practice, Shahekou district, Dalian, Liaoning, China
| | - Xiao Xv
- Senior Department of Burns and Plastic Surgery, the Fourth Medical Center, PLA General Hospital, No. 51 Fucheng Road, Haidian District, Beijing, 100038, China
| | - Guiwen Zhou
- Senior Department of Burns and Plastic Surgery, the Fourth Medical Center, PLA General Hospital, No. 51 Fucheng Road, Haidian District, Beijing, 100038, China
| | - Can Zheng
- Senior Department of Burns and Plastic Surgery, the Fourth Medical Center, PLA General Hospital, No. 51 Fucheng Road, Haidian District, Beijing, 100038, China
| | - Zhaoyang Chen
- Senior Department of Burns and Plastic Surgery, the Fourth Medical Center, PLA General Hospital, No. 51 Fucheng Road, Haidian District, Beijing, 100038, China
| | - Minliang Chen
- Senior Department of Burns and Plastic Surgery, the Fourth Medical Center, PLA General Hospital, No. 51 Fucheng Road, Haidian District, Beijing, 100038, China.
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9
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Clark NW, Pan DR, Barrett DM. Facial fillers: Relevant anatomy, injection techniques, and complications. World J Otorhinolaryngol Head Neck Surg 2023; 9:227-235. [PMID: 37780674 PMCID: PMC10541169 DOI: 10.1002/wjo2.126] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 06/27/2023] [Accepted: 06/28/2023] [Indexed: 10/03/2023] Open
Abstract
Objective The aim of this review article is to discuss the currently available facial fillers, their differences and indications, relevant anatomy, injection techniques, and avoidance and management of complications. Data Sources Clinical experience and scientific papers. Conclusions Reversal of facial aging via filler injection has been around since the late 1800s with the initial use of detrimental products. Today, many safe and effective products exist and can be tailored to the individual patient's desired effect. With the evolution of both products and injection techniques, the rate of complications with facial filler use is low. Nonetheless, providers offering facial filler injections should have detailed knowledge of facial anatomy, including facial planes and soft tissue compartments. Multiple injection techniques exist. Different techniques should be used, depending on the anatomic target. Providers should also know how to avoid and manage complications.
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Affiliation(s)
- Nicholas W. Clark
- Duke University Department of Head and Neck Surgery and Communication SciencesDurhamNorth CarolinaUSA
| | - Debbie R. Pan
- Duke University Department of Head and Neck Surgery and Communication SciencesDurhamNorth CarolinaUSA
| | - Dane M. Barrett
- Duke University Department of Head and Neck Surgery and Communication SciencesDurhamNorth CarolinaUSA
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10
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A Multimodal Approach to Intra-arterial Occlusion With Calcium Hydroxylapatite. Dermatol Surg 2023; 49:218-220. [PMID: 36728077 DOI: 10.1097/dss.0000000000003667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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11
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Komplikationen bei Behandlung mit injizierbaren Fillern. ÄSTHETISCHE DERMATOLOGIE & KOSMETOLOGIE 2022. [PMCID: PMC9747256 DOI: 10.1007/s12634-022-2244-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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12
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Faria GEDL, Bastos AQ, Vilela CL, Zattar L, Boggio RF. Safety of the inferolateral orbital access for filling the temporal region with the fanning technique. J Cosmet Dermatol 2022; 21:5569-5575. [PMID: 35673959 DOI: 10.1111/jocd.15146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 05/06/2022] [Accepted: 05/31/2022] [Indexed: 12/27/2022]
Abstract
INTRODUCTION The anatomical complexity of the temporal region makes it so treatments with fill-ins are challenging due to high vascular risk. Techniques which provide safer procedures must be encouraged. GOAL Suggest access to the temple through the inferolateral orbital region as a means for safer temporal fill-ins. METHODS The fanning technique was plotted out not only via the conventional access (pretragal) but via the proposed one as well. The superficial temporal artery (STA) was mapped with ultrasound. The angles for each of the five retroinjection vectors were calculated in relation to STA and their mean was extracted. The longitudinality of the vector in regard to the vessel was considered the least safe factor. RESULTS The mean injection angle towards the artery was a 35-degree angle for the conventional access technique and a 73-degree angle for the inferior-lateral orbital access technique (p < 0.05). The more a degree is tangential to the vessel, the higher the chances for inadvertent puncture due to small technical issues. The safety of the procedure through the inferolateral orbital access is corroborated with blind ultrasound imaging done in real-time by radiologists. CONCLUSION The suggested access is shown to be comparably safer from a vascular perspective than the conventional pretragal access.
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Affiliation(s)
| | | | | | - Luciana Zattar
- Instituto Boggio - Medicina, ensino e pesquisa, São Paulo, Brazil
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13
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Jalilian F, Hetz SP, Bostwick J, Boet S. Hyperbaric oxygen therapy for treatment of a late presenting ischaemic complication from hyaluronic acid cosmetic filler injection. BMJ Case Rep 2022; 15:e249190. [PMID: 35798493 PMCID: PMC9263929 DOI: 10.1136/bcr-2022-249190] [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] [Accepted: 06/30/2022] [Indexed: 11/03/2022] Open
Abstract
Vascular compromise and resulting ischaemic injury are known rare complications of cosmetic filler injections. Most hyaluronic acid vascular compromises present early and can be treated effectively by hyaluronidase. Here we present a case of ischaemic wound and mucosal necrosis after cosmetic facial hyaluronic acid injection that appeared within hours of injection but was not diagnosed and treated for 5 days. At day 5, the patient was treated with hyaluronidase injection immediately followed by 14 sessions of daily hyperbaric oxygen therapy (HBOT). Despite the delayed treatment, the patient had essentially complete recovery and the hyperbaric therapy was overall well-tolerated. Our case report suggests that hyaluronidase injection with concurrent daily HBOT sessions may be effective to allow recovery from late-presenting filler ischaemic complication. Furthermore, given the safety profile of HBOT, we suggest a more deliberate approach to this modality as a therapeutic adjunct by cosmetic practitioners when similar complications arise.
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Affiliation(s)
- Farhang Jalilian
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Joanna Bostwick
- University of Ottawa, Ottawa, Ontario, Canada
- Department of Emergency Medicine, Montfort Hospital, Ottawa, Ontario, Canada
| | - Sylvain Boet
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Innovation in Medical Education, University of Ottawa, Ottawa, Ontario, Canada
- Institut du Savoir Montfort, Ottawa, Ontario, Canada
- Francophone Affairs, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Faculty of Education, University of Ottawa, Ottawa, Ontario, Canada
- Kennan Research Centre, Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
- Hyperbaric Medicine Unit, The Ottawa Hospital, Ottawa, Ontario, Canada
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14
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Silveira I, Martinez B. Bilateral Gluteal Augmentation With Hyperdilute Calcium Hydroxylapatite Microspheres Performed Using the Bella Vida Instant Brazilian Butt Lift (BBL)™. Cureus 2022; 14:e26261. [PMID: 35911363 PMCID: PMC9313040 DOI: 10.7759/cureus.26261] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2022] [Indexed: 11/06/2022] Open
Abstract
For decades, aesthetic medical procedures have sought to improve patient appearance, comfort, and self-confidence. In more recent years, a growing interest in body contouring cosmetic procedures has emerged, in large part due to increased transparency in procedures and improved outcomes with minimally invasive procedures. Notably, several biostimulatory fillers have emerged as a suitable treatment modality due to their relatively low cost, low pain, short downtime, high tunability, and sustained biostimulatory effect. One volumizing biostimulatory filler, Radiesse® (Merz Aesthetics, Frankfurt, Germany), consists of calcium hydroxylapatite microspheres suspended in a carboxymethyl cellulose gel. When injected, Radiesse immediately volumizes the injection site and initiates neocollagenesis and neoelastogenesis. One technique, the Bella Vida Instant Brazilian Butt Lift (BBL)™, is a fast, safe, and minimally invasive alternative to surgical gluteal augmentation that accomplishes morphological remodeling, increases volumization, and improves shape and patient satisfaction. This technical report provides the clinical basis, materials, and methods for implementing the Bella Vida Instant BBL™ in aesthetic practices.
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Kern JA, Kollipara R, Hoss E, Boen M, Wu DC, Groff W, Goldman MP. Serious Adverse Events With Injectable Fillers: Retrospective Analysis of 7,659 Patient Outcomes. Dermatol Surg 2022; 48:551-555. [PMID: 35170541 DOI: 10.1097/dss.0000000000003409] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND In total, 2.7 million injectable filler treatments were performed in 2019 in the United States. Although generally considered to be a safe treatment modality, adverse events may occur in rare situations. OBJECTIVE Analyze serious adverse events from injectable filler treatments, including infections, cutaneous necrosis, blindness, or delayed-onset nodule formation, spanning 11 years for 3 board-certified dermatologists and review their incidence, management, and outcomes. MATERIALS AND METHODS A retrospective analysis was performed of injectable filler treatments spanning 11 years at a multipractitioner outpatient clinic. Serious adverse events were identified, and treatment measures were documented. A literature search was performed to determine recent trends and outcomes for comparison. RESULTS Between January 2009 and August 2020, 18,013 mL of injectable filler was administered to 7,659 patients. Of the 18,013 mL administered, 74.1% comprised hyaluronic acid derivatives, 19.19% poly-l-lactic acid, and 6.71% calcium hydroxylapatite. Four serious adverse events were identified. Three events were delayed-onset skin nodule formation. One adverse event was related to vascular compromise and subsequent cutaneous necrosis. After appropriate treatment, all adverse events resolved without significant long-term sequelae. CONCLUSION Serious adverse events associated with injectable fillers, when performed by board-certified dermatologists, are extremely rare and can be successfully managed with appropriate treatment.
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Affiliation(s)
- Jessica A Kern
- University of California, San Diego School of Medicine, San Diego, California
| | | | - Elika Hoss
- Department of Dermatology, Mayo Clinic, Scottsdale, Arizona
| | - Monica Boen
- Cosmetic Laser Dermatology, A West Dermatology Company, San Diego, California
| | - Douglas C Wu
- Cosmetic Laser Dermatology, A West Dermatology Company, San Diego, California
| | - William Groff
- Cosmetic Laser Dermatology, A West Dermatology Company, San Diego, California
| | - Mitchel P Goldman
- Cosmetic Laser Dermatology, A West Dermatology Company, San Diego, California
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16
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Cutaneous Vascular Compromise and Resolution of Skin Barrier Breakdown After Dermal Filler Occlusion-Implementation of Evidence-Based Recommendations Into Real-World Clinical Practice. Dermatol Surg 2022; 48:659-663. [PMID: 35412474 DOI: 10.1097/dss.0000000000003452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Vascular occlusions that threaten skin integrity, although not an emergency like those that threaten a patient's vision, is an urgent situation. Accurately interpreting physical examination findings is paramount. The use of high-dose, pulsed hyaluronidase is the mainstay of therapy; however, adjunctive measures that may optimize clearance of an occlusion and/or skin barrier repair such as the use of image guidance and hyperbaric oxygen should be considered. OBJECTIVE To provide a review of the literature on the treatment of vascular occlusions threatening skin barrier integrity and develop a step-wise treatment guide. MATERIALS AND METHODS The authors searched PubMed for peer-reviewed studies, consensus statements, case series, and case reports using a variety of keywords. RESULTS Twenty-six articles focusing on vascular occlusions threatening the skin barrier were reviewed. The authors collectively agreed on treatments to reverse vascular occlusions and restore the skin barrier. The importance of high-dose, pulsed hyaluronidase was clear. Therapies that lacked evidence such as sodium thiosulfate were also revealed. CONCLUSION Vascular occlusions that threaten skin integrity is an urgent matter which requires accurate interpretation of physical examination findings that will help guide intervention. High-dose, pulsed hyaluronidase along with adjunctive measures performed in a step-wise manner is key to an optimal outcome.
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Distal Internal Maxillary Artery Occlusion with Palatal Necrosis following Cheek Injection with Calcium Hydroxylapatite. Plast Reconstr Surg Glob Open 2022; 10:e4164. [PMID: 35265444 PMCID: PMC8901201 DOI: 10.1097/gox.0000000000004164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 01/10/2022] [Indexed: 12/02/2022]
Abstract
Accidental intravascular injection of cosmetic fillers resulting in dermal infarction represents one of the most feared complications in aesthetic medicine. Despite the infrequency of these injuries, the rapid rise in filler use has caused a sudden increase in the incidence of filler-induced skin necrosis. Because the complex vascular anatomy of the face subserves a wide range of cutaneous and mucosal tissues, it has been surmised that occult injuries affecting the oronasal cavities could occur as a result of accidental intravascular injection of dermal fillers. We report an instance of ischemic skin injury of the infraorbital territory of the face with hemi-palatal mucosal necrosis secondary to vascular occlusion with calcium hydroxylapatite.
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Oley MH, Oley MC, Mawu FO, Aling DMR, Faruk M. Hyperbaric Oxygen Therapy in Managing Minimally Invasive Aesthetic Procedure Complications: A Report of Three Cases. Clin Cosmet Investig Dermatol 2022; 15:63-68. [PMID: 35058700 PMCID: PMC8765711 DOI: 10.2147/ccid.s344408] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 12/24/2021] [Indexed: 12/25/2022]
Abstract
Introduction Minimally invasive aesthetic procedures such as filler injections and thread lifts have gained popularity recently. Complications from these aesthetic procedures are difficult to avoid. This increasing public health concern requires a combination of effective therapeutic modalities. Hyperbaric oxygen therapy (HBOT) has generated favorable results in treating a diversity of wounds, inflammation, and infection. Case Presentations Three cases with complications arising from aesthetic procedures were described in this report. The patients were all female, with ages ranging from the late-twenties to mid-fifties. Two patients experienced complications from filler injections, one of which progressed to a parotid gland infection due to a placental extract filler while the other was caused by a hyaluronic acid filler. The third patient had notable excoriations and inflammation on both cheeks following a thread lift procedure. Alongside antibiotics and other symptomatic therapies, the patients received multiple, 90-minute HBOT sessions at 2.4 ATA over the course of one to two weeks. The wounds were frequently monitored to evaluate the healing progress. Discussion Complications from facial rejuvenation procedures can be disastrous. They expose the patient to the risk of developing vascular occlusions and skin infections that require prompt and effective treatment. Multiple treatment options (eg, frequently massaging the affected area, warm compresses, aspirin, and antibiotics) have been used to treat these complications. HBOT serves a valuable purpose in restoring adequate tissue perfusion in cases of filler-induced vascular occlusion and infection. Moreover, HBOT assists in restoring tissue injury and reducing inflammation following thread lift procedures. Conclusion HBOT has proven helpful as a treatment adjunct toward counteracting the effects of minimally invasive aesthetic procedures in several cosmetic-related cases.
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Affiliation(s)
- Mendy Hatibie Oley
- Plastic Reconstructive and Aesthetic Surgery Division, Department of Surgery, Faculty of Medicine, Sam Ratulangi University, Manado, Indonesia.,Plastic Reconstructive and Aesthetic Surgery Division, Department of Surgery, R. D. Kandou Hospital, Manado, Indonesia.,Hyperbaric Centre, Siloam Hospital, Manado, Indonesia
| | - Maximillian Christian Oley
- Hyperbaric Centre, Siloam Hospital, Manado, Indonesia.,Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Sam Ratulangi University, Manado, Indonesia.,Division of Neurosurgery, Department of Surgery, R. D. Kandou Hospital, Manado, Indonesia
| | - Ferra Olivia Mawu
- Department of Dermatology and Venereology, Faculty of Medicine, Sam Ratulangi University, Manado, Indonesia
| | | | - Muhammad Faruk
- Department of Surgery, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia
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Pavicic T. Commentary on: Skin Tightening With Hyperdilute CaHA: Dilution Practices and Practical Guidance for Clinical Practice. Aesthet Surg J 2022; 42:NP38-NP40. [PMID: 34487518 DOI: 10.1093/asj/sjab331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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20
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Williams MN, Burgess C. Management of Calcium Hydroxyapatite Vascular Occlusion in a Hemophiliac With HIV-Associated Facial Lipoatrophy. Dermatol Surg 2021; 47:1173-1174. [PMID: 33675297 DOI: 10.1097/dss.0000000000002991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Monica N Williams
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Cheryl Burgess
- Center for Dermatology and Dermatologic Surgery, Washington, District of Columbia
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Heydenrych I, De Boulle K, Kapoor KM, Bertossi D. The 10-Point Plan 2021: Updated Concepts for Improved Procedural Safety During Facial Filler Treatments. Clin Cosmet Investig Dermatol 2021; 14:779-814. [PMID: 34276222 PMCID: PMC8279269 DOI: 10.2147/ccid.s315711] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/19/2021] [Indexed: 12/24/2022]
Abstract
Dermal filler treatments require constant reassessment for improving and safeguarding the rapidly evolving aesthetic field. Suboptimal injection technique, patient selection and product knowledge have touted a concerning increase in filler complications, with new challenges such as the COVID-19 pandemic leading to new paradigms in the understanding, prevention, diagnosis and treatment of complications. The updated 10-point plan has been developed to curtail complications through consideration of causative factors, categorized as patient, product, and procedure-related. Patient-related factors include a preprocedural consultation with careful elucidation of skin conditions (acne, rosacea, dermatitis), systemic disease (allergies, autoimmune disease, underlying bacterial and viral disease (herpes simplex virus, COVID-19 infection), medications (antineoplastic drugs, recreational drugs) and previous cosmetic procedures (including fillers and energy-based devices). Patient assessment should include standardized photography and also evaluate the role of social media, ethnicity, gender, generational, and LGBTQ+ needs. Specified informed consent for both adverse events and their treatment is essential due to the increase in vascular complications, including the risk of blindness. Product-related factors include the powerful advantage of reversibility when using hyaluronic acid (HA) products. Product characteristics such as molecular weight and filler degradation should be understood. Product layering over late or minimally degradable fillers is still inadvisable due to the initial filler being teased into reactivity. Procedural factors such as consistent photographic documentation, procedural planning, aseptic non-touch technique (ANTT), knowledge of topographical anatomy and angiosomes, and technical dexterity including pinch anatomy and needle skills are of pivotal importance. The final section is dedicated to algorithms and checklists for managing and treating complications such as allergic hypersensitivity reactions, vascular events, infection, edema and late-onset adverse events (LOAEs). The updated 10-point plan is a methodical strategy aimed at further minimising the risk of dermal filler complications.
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Affiliation(s)
- Izolda Heydenrych
- Cape Town Cosmetic Dermatology Centre, Century City, Cape Town, South Africa
| | | | | | - Dario Bertossi
- Maxillofacial Department, University of Verona, Verona, Italy
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22
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Graivier M. Commentary on: Intraarterial Degradation of Calcium Hydroxylapatite Using Sodium Thiosulfate-An In Vitro and Cadaveric Study. Aesthet Surg J 2021; 41:NP237-NP238. [PMID: 33629717 DOI: 10.1093/asj/sjab020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Searle T, Al-Niaimi F, Ali FR. Saline in dermatologic surgery. J Cosmet Dermatol 2021; 20:1346-1347. [PMID: 33569876 DOI: 10.1111/jocd.13996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 02/09/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Tamara Searle
- University of Birmingham Medical School, Birmingham, UK
| | - Firas Al-Niaimi
- Department of Dermatology, Aalborg University Hospital, Aalborg, Denmark
| | - Faisal R Ali
- Dermatological Surgery & Laser Unit, Guy's Hospital Cancer Centre, St John's Institute of Dermatology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Danysz W, Nowag B, Hengl T, Kreymerman P, Furne C, Madeuf E, Höennscheidt C, Mraz Robinson D. Can Sodium Thiosulfate Act as a Reversal Agent for Calcium Hydroxylapatite Filler? Results of a Preclinical Study. Clin Cosmet Investig Dermatol 2020; 13:1059-1073. [PMID: 33408497 PMCID: PMC7781022 DOI: 10.2147/ccid.s271760] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 11/24/2020] [Indexed: 12/22/2022]
Abstract
Introduction Calcium hydroxylapatite microspheres suspended in a gel carrier of sodium carboxymethylcellulose (CaHA; Radiesse®) has demonstrated safe and effective restoration of facial volume in clinical trials, as well as collagen biostimulation leading to skin quality improvement. The potential with CaHA, as with any filler, to produce overcorrection and subsequent complications has led to the search for a reversal agent. Sodium thiosulfate (STS) was proposed based on experience with it as a chelating agent to treat calciphylaxis. Previous pilot studies with small sample sizes have suggested its efficacy in the reduction of CaHA volume and nodule formation. The present study focuses on the verification of this effect using various readout methods in preclinical experiments. Methods We use both in vitro (co-incubation of STS with CaHA) and in vivo (injections in farm pig) methods with readout techniques such as 3D camera analysis, micro-computed tomography ex vivo (µCT), computed tomography in vivo (CT), histopathology and scanning electron microscopy. Results We did not obtain any indications of CaHA degradation by STS, either in vitro or in vivo. 3D-camera analysis also did not show any decreasing effect of STS on CaHA. However, histology, µCT ex vivo, and CT in vivo indicated a decrease of Radiesse amount/volume after STS treatment, which could be attributed to dispersion effect. It should be noted that necrosis and haemorrhages were observed after STS treatment. Discussion Results suggest no indication of CaHA microspheres degradation with STS and that the STS mechanism of action on CaHA is consistent with a dispersion effect. Observed necrosis is a further obstacle in the use of STS.
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Affiliation(s)
| | - Bartosch Nowag
- R&D, Merz Pharmaceuticals GmbH, Frankfurt am Main, Germany
| | - Thomas Hengl
- R&D, Merz Pharmaceuticals GmbH, Frankfurt am Main, Germany
| | | | | | - Elise Madeuf
- Preclinical Studies, Voxcan, Marcy L´Etoile, France
| | | | - Deanne Mraz Robinson
- Modern Dermatology of Connecticut, Westport, CT, USA.,Yale-New Haven Hospital, New Haven, CT, USA
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van Loghem J, Funt D, Pavicic T, Goldie K, Yutskovskaya Y, Fabi S, Siebenga P, Thuis J, Hkeik J, Kadouch J, Prager W, Azib N, Casabona G, Dayan S, Bay Aguilera S, Snozzi P, Saeed P. Managing intravascular complications following treatment with calcium hydroxylapatite: An expert consensus. J Cosmet Dermatol 2020; 19:2845-2858. [PMID: 32185876 PMCID: PMC7687073 DOI: 10.1111/jocd.13353] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 02/17/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Inadvertent intra-arterial injection of dermal fillers including calcium hydroxylapatite (CaHA) can result in serious adverse events including soft tissue necrosis, permanent scarring, visual impairment, and blindness. When intra-arterial injection occurs, immediate action is required for optimal outcomes, but the infrequency of this event means that many physicians may never have experienced this scenario. The aim of this document is to provide evidence-based and expert opinion recommendations for the recognition and management of vascular compromise following inadvertent injection of CaHA. METHODS An international group of experts with experience in injection of CaHA and management of vascular complications was convened to develop a consensus on the optimal management of vascular compromise following intra-arterial CaHA injection. The consensus members were asked to provide preventative advice for the avoidance of intravascular injection and to produce a treatment protocol for acute and delayed presentation. To ensure all relevant treatment options were included, the recommendations were supplemented with a PubMed search of the literature. RESULTS For prevention of intra-arterial CaHA injection, consensus members outlined the importance of a thorough knowledge of facial vascular anatomy and patient history, as well as highlighting potential risk zones and optimal injection techniques. Individual sections document how to recognize the symptoms of vascular occlusion leading to vision loss and tissue necrosis as well as detailed treatment protocols for the management of these events. For impending tissue necrosis, recommendations are provided for early and delayed presentations with treatment protocols for acute and follow-up treatment. A separate section details the treatment options for open and closed wounds. CONCLUSIONS All physicians should be prepared for the eventuality of intra-arterial injection of a dermal filler, despite its rarity. These consensus recommendations combine advice from aesthetic experts with the latest reports from the published literature to provide an up-to-date office-based protocol for the prevention and treatment of complications arising from intra-arterial CaHA injection.
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Affiliation(s)
- Jani van Loghem
- Falck ClinicAesthetic Medicine CentreAmsterdamThe Netherlands
| | - David Funt
- Mount Sinai School of MedicineNew YorkNYUSA
- Mount Sinai School of MedicineGarden CityNYUSA
- Mount Sinai School of MedicineWoodmereNYUSA
| | - Tatjana Pavicic
- Private Practice for Dermatology and AestheticsMunichGermany
| | | | - Yana Yutskovskaya
- Dermatovenerology and Cosmetology DepartmentPacific State MedicalUniversity of HealthMoscowRussia
| | - Sabrina Fabi
- Department of DermatologyUniversity of CaliforniaSan DiegoCAUSA
| | - Pieter Siebenga
- Falck ClinicAesthetic Medicine CentreAmsterdamThe Netherlands
| | - Job Thuis
- Falck ClinicAesthetic Medicine CentreAmsterdamThe Netherlands
| | | | - Jonathan Kadouch
- ReSculpt ClinicPractice for Aesthetic DermatologyAmsterdamThe Netherlands
| | - Welf Prager
- Prager & Partner Dermatologische PraxisHamburgGermany
| | | | | | - Steve Dayan
- Division of Facial Plastic and Reconstructive SurgeryDepartment of OtolaryngologyUniversity of Illinois at ChicagoChicagoILUSA
| | - Shino Bay Aguilera
- Department of DermatologyNova Southeastern University College of Osteopathic MedicineFort LauderdaleFLUSA
| | | | - Peerooz Saeed
- Falck ClinicAesthetic Medicine CentreAmsterdamThe Netherlands
- Departments of Ophthalmology and EndocrinologyOrbital CenterAcademic Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
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