Complications of injectable fillers, part 2: vascular complications

Superselective Arterial Hyaluronidase Thrombolysis is an Effective Treatment for Hyaluronic Acid-Induced Retinal Artery Occlusion: Study in a Rabbit Model

BACKGROUND

There are serious complications associated with hyaluronic acid (HA) facial injections, including vision impairment due to retinal artery ischemia. In this study, we put forth a clinically relevant model of retinal ischemia and reperfusion in rabbit. We used this to verify the efficacy of hyaluronidase intra-artery thrombolysis in the treatment of hyaluronic acid-induced retinal artery occlusion.

METHODS

Retinal artery ischemia was induced by injecting HA into the ophthalmic artery (OA) of adult chinchilla rabbit, and reperfusion was achieved by intra-artery thrombolysis therapy with hyaluronidase following 60 min and 4 h of occlusion. Digital subtraction angiography (DSA) and fundus fluorescein angiography (FFA) were used to evaluate blood flow in the retina. Electroretinogram (ERG), hematoxylin and eosin staining and transmission electron microscope were used to evaluate the structure and function of the retina after ischemia and reperfusion following 60 min and 4 h of occlusion.

RESULTS

DSA and FFA images confirmed occlusion of the ophthalmic and central retinal arteries, as well as reperfusion after hyaluronidase thrombolysis. ERG indicated retinal dysfunction following ischemia, and thrombolysis partially rescued its impairment following 4 h of occlusion. Hematoxylin and eosin staining and TUNEL staining revealed ischemia-induced histological damages in the retina at different time windows, and hyaluronidase thrombolysis partially mitigated these damages.

CONCLUSIONS

We report a method to establish a HA-induced retinal artery occlusion animal model. Hyaluronidase intra-artery thrombolysis was used to recanalize the embolized OA at different time points. Using our method, we achieved retinal reperfusion, and an improvement was observed in the visual function of rabbits after hyaluronidase thrombolysis following 4 h of occlusion. We believe that hyaluronidase intra-artery thrombolysis is an effective method to treat HA-induced retinal artery occlusion in clinic.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Treatment of Cosmetic Lower Eyelid Adverse Events After Injection of Hyaluronic Acid Gel Fillers

Background

Nonsurgical blepharoplasty has been considered as an unmet need particularly for the large potential population of patients who are not interested in or ready for surgery and is generally performed by all providers who offer injectable agents in their practice. Although favorable outcomes can be achieved in most areas of the face, the lower eyelid has shown to be less forgiving and a source of overwhelming unsatisfactory outcomes. Although providers often disclose to their patients that undesirable cosmetic adverse events can be reversed with the injection of hyaluronidase, a larger experience has suggested that this application is not always successful.

Objectives

The author describes an algorithm for the resolution of refractory adverse events using a combination of intraoperative, high-dose, hyaluronidase with lower blepharoplasty.

Methods

From June 2016 to present, 70 consecutive patients, 65 females and 5 males, with ages ranging from 31 to 76 years, presented with unsatisfactory results after they received an injection of a hyaluronic acid (HA) product elsewhere. They were treated with lower blepharoplasty in conjunction with intraoperative "high-dose" transconjunctival hyaluronidase injections.

Results

All patients showed significant but varied improvement after this treatment when, in most situations, in-office, percutaneous injection of hyaluronidase was insufficient.

Conclusions

The combination of intraoperative injection of high-dose hyaluronidase and (upper and/or) lower blepharoplasty can lead to satisfactory outcomes in patients with chronic lower eyelid edema after HA gel injections to the lower eyelid prove ineffective.

Level of Evidence 4

Fillers impacting follicles: the emerging complication of filler-induced alopecia

Filler-induced alopecia is a transient alopecia characterized by localized hair loss and often attributed to vascular compromise following dermal filler injections in facial regions. Although an uncommon phenomenon, the rising incidence of filler-induced alopecia underscores the importance of understanding and managing this condition. We performed an extensive PubMed review of articles reporting filler-induced alopecia and summarizing the implicated filler types, injection areas, hair loss patterns, symptom onset, course progression, treatments, and prognosis. Hyaluronic acid injections were the most implicated in filler-induced alopecia cases, with calcium hydroxylapatite and autologous fat less frequently associated. No cases involved other dermal filler types. Although recovery times varied depending on the treatment, hyaluronidase (HAase) injections rapidly restored near-normal hair density within 3-4 months. Minoxidil and platelet-rich plasma play a more minor role in restoring hair growth but may be used as adjuncts with HAase to facilitate hair growth. Finally, alternative interventions like intralesional triamcinolone, warm compresses, and nitroglycerin warrant exploration, given limited robust clinical data. Our study promotes awareness of filler-induced alopecia's rising incidence and offers practical insights and evidence-based recommendations for effective management. By equipping dermatologists with this knowledge, our aim is to improve patient outcomes and reduce adverse events in filler-based procedures.

Multifocal strokes and vision loss from PDLLA filler injections

BACKGROUND

Poly-D, L-lactic acid (PDLLA) is increasingly used as a commercial dermal filler due to its lasting cosmetic properties. Consequently, PDLLA-related vascular complications are increasingly recognized and described. Herein, we describe the first known occurrence of multifocal strokes from the use of PDLLA as a cosmetic dermal filler, and discuss the mechanisms facilitating PDLLA's entry into the intracranial arterial system.

CASE PRESENTATION

A middle-aged female presented with acute vision loss of both eyes immediately after dermal injections of PDLLA to her nasolabial folds and infraorbital regions. There were no additional neurological deficits. Dilated fundal examination revealed retinal edema bilaterally, with deposition of filler material in the retinal arteries. Magnetic resonance imaging of her brain and orbits demonstrated multifocal strokes (left caudate head, right medial frontal lobe) and ischemia of the left optic nerve. The temporal proximity of the dermal injections to her symptoms, guided by fundal examination and neuroimaging findings, allowed us to attribute her strokes and ischemic optic neuropathy to PDLLA's entry into, and embolism within, the intracranial arterial system. She was treated with hyperbaric oxygen therapy and experience improvement to her right eye's vision, although poor vision persisted in her left eye.

CONCLUSION

While PDLLA is generally considered safe, its increasing use as a cosmetic filler renders it crucial for physicians to be cognizant of its vascular complications, especially when early recognition and treatment are essential in mitigating their devastating ramifications.

A rare case of gingival necrosis following an extraoral injection of dermal filler

BACKGROUND

The utilization of dermal fillers for cosmetic procedures has increased dramatically in the past several years, and so is the number of reported adverse events and complications. Most of these reports are centered on extraoral facial structures such as skin, nose, forehead, and eyes. However, as this report illustrates, intraoral complications are also possible and require appropriate management. Our extensive search of the medical and dental literature has failed to yield any such report.

METHODS AND RESULTS

An injection of dermal filler composed of hyaluronic acid for managing a deep nasolabial fold resulting in an arterial occlusion is presented. Patient exhibited facial skin necrosis, with ecchymoses and crusting, extending to the right eye. Transient diplopia and vision changes were also present. Additionally, intraoral necrosis of the palatal mucosa extending from the right central incisor to the molars and approaching the midline was noted. Patient was managed palliatively until complete re-epithelization was noted, with no further loss of periodontal attachment.

CONCLUSION

This case illustrates a rare oral complication of extraoral injection of a dermal filler, and its management. The clinicians should be aware of the potential risks of these cosmetic procedures. Early detection and timely management may prevent lasting damage and discomfort. Additionally, some of these complications may require a well-coordinated multidisciplinary involvement to restore health and functions (plastic surgeon, dermatologist, ophthalmologist, and a periodontist).

KEY POINTS

Why is this case new information? Previous reports of adverse effects linked to dermal fillers were limited to extraoral structures such as the facial skin, nose, forehead, and eye. To the authors' best knowledge, this is the first and only documented case of intraoral necrosis following dermal filler injection What are the keys to successful management of this case? The most important step in managing intra-arterial filler injection and occlusion is the immediate injection of hyaluronidase enzyme to minimize the extent of tissue necrosis. In the case of ocular involvement, immediate referral to an ophthalmologist is required What are the primary limitations to success in this case? Success of managing the adverse effects of vascular occlusion following filler injection depends on several factors, including the anatomical area of occlusion, its extend, along with timely treatment.

Updated Filler Emergency Kit: Next-Generation Emergency Solution

INTRODUCTION

The rising popularity of facial filler injections has corresponded with an increase in reported complications. While a filler emergency kit was previously introduced, advancements in the field have highlighted certain limitations, prompting the development of the updated filler emergency kit (UFEK).

METHODS

The authors conducted literature research up to February 2023, focusing on PubMed and open web searches for articles referred to filler emergent complications: vascular occlusion, blindness and anaphylaxis. Approximately 1200 articles were obtained from PubMed and other sources, and 45 articles were reviewed.

RESULTS

The developed UFEK protocol delineates specific interventions meticulously tailored to address diverse emergent scenarios linked to soft tissue fillers complications. This protocol emphasizes the urgent requirement for timely and personalized interventions.

CONCLUSION

The UFEK offers a standardized, comprehensive and effective approach. This work contributes to the responsible and informed progression of the field of aesthetic medicine, providing more value and safety, both for clinicians and patients. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Complications of Injectables

The field of non-surgical esthetic procedures has witnessed a significant surge in demand in recent years, with neuromodulators, skin treatments, and dermal fillers contributing significantly to the industry's growth. These procedures have become increasingly popular, reflecting the broader acceptance of esthetic enhancements in society. Neuromodulators play a pivotal role in facial rejuvenation, but they require precise knowledge of facial anatomy to optimize results and prevent complications. They include rare hypersensitivity reactions, local injection reactions, and brow and eyelid ptosis. Dermal fillers, both non-permanent and permanent, are widely used to restore volume and improve facial contours. However, they also carry risks, including bruising, temporary edema, and lumps. Permanent fillers present higher complication rates, and their use should be approached with caution. Vascular occlusion is a rare but severe complication associated with dermal fillers. To mitigate these risks, practitioners must have a comprehensive understanding of their compositions and potential complications. Overall, while non-surgical esthetic procedures offer remarkable results with minimal downtime, the importance of training, anatomic knowledge, and effective complication management cannot be overstated in ensuring patient safety and satisfaction in this evolving field of medicine.

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

Background

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

Methods

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

Results

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

Conclusions

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

Percutaneous Intra-arterial Hyaluronidase Injection for Hyaluronic Acid Filler Embolism Threatening Skin Barrier Integrity: Implementation of a Stepwise Treatment Protocol

BACKGROUND

Hyaluronic acid (HA) filler-induced vascular embolism that threatens skin integrity is an urgent situation. There is increasing evidence that percutaneous intra-arterial hyaluronidase injection is an effective therapeutic technique for it. However, until now, there is a lack of a unifying protocol about the technique.

OBJECTIVES

This study aims to provide a conclusion of percutaneous intra-arterial hyaluronidase injection along with adjunctive measures on the treatment of occlusions precipitated by HA-based filler and develop a stepwise treatment protocol.

METHODS

We searched PubMed for peer-reviewed studies, consensus statements, case series, and case reports using a variety of keywords.

RESULTS

High-dose, pulsed hyaluronidase is the mainstay for the treatment of HA filler-induced embolism, but percutaneous intra-arterial hyaluronidase injection is a more effective technique. Until now, hyaluronidase is injected into three arteries percutaneously, including facial artery, supratrochlear artery, and superficial temporal artery. Furthermore, the adjunctive measures that may optimize clearance of an occlusion and/or skin barrier repair such as the use of image guidance and CGF should be considered.

CONCLUSION

Vascular occlusions that threaten skin integrity are an urgent matter which requires accurate diagnosis and effective intervention. Percutaneous intra-arterial hyaluronidase injection along with adjunctive measures performed in a stepwise manner is key to an optimal outcome.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 .

Administration Method and Potential Efficacy of Hyaluronidase for Hyaluronic Acid Filler-Related Vision Loss: A Systematic Review

BACKGROUND

With the global increase in the use of injectable fillers, more cases with serious adverse events such vision loss are being reported. This article aims to review the cases of hyaluronic acid (HA) filler-related vision loss and to discuss the potential efficacy of hyaluronidase (HYASE) treatment via different given methods.

METHODS

A total of 29 articles presenting 144 cases of HA filler-related vision loss were included in this study.

RESULTS

Most cases of HA filler-related vision impairment were reported from China, followed by Korea. The majority of cases were seen in women. The nose, forehead and glabella were the most commonly injection sites. All cases had vision impairment and nearly all cases were unilateral with immediate onset of visual signs and symptoms. Ophthalmic artery occlusion (OAO) and central retinal artery occlusion (CRAO) were the two most commonly involved arterial obstruction patterns featured with a very poor prognosis followed by branch retinal artery occlusion (BRAO), the most favorable involved arterial pattern for a better prognosis. HYASE given subcutaneously and intra-arterially helped with visual recovery to different degrees, while retrobulbar HYASE seemed to be less helpful.

CONCLUSION

Complications after HA-based filler injection are extremely rare but can cause disastrous visual impairment. HYASE given subcutaneously and intra-arterially helped with visual recovery to different extents, and the efficacy might be reinforced when performed together, while retrobulbar HYASE seemed to be less helpful. However, to accurately access the efficacy of HYASE via different administration methods, further randomized controlled trials are needed.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Hyaluronidase for Dermal Filler Complications: Review of Applications and Dosage Recommendations

BACKGROUND

Hyaluronidase (Hyal) can reverse complications of hyaluronic acid (HA) fillers, which has contributed substantially to the popularity of such procedures. Still, there are differing opinions regarding Hyal treatment, including dosage recommendations in filler complication management.

OBJECTIVE

We aimed to address unanswered questions regarding Hyal treatment for HA filler complications, including timing and dosage, skin pretesting, properties of various Hyals and interactions with HA gels, and pitfalls of the treatment.

METHODS

PubMed and Google Scholar databases were searched from inception for articles on Hyal therapy for filler complications. Articles were evaluated regarding their contribution to the field. The extensive literature review includes international leaders' suggestions and expert panels' recommendations.

RESULTS

There are limited controlled data but increasing clinical experience with Hyal treatment. The currently used Hyals provide good results and have an acceptable safety profile. Nonemergent complications such as the Tyndall effect, noninflamed nodules, and allergic or hypersensitivity reactions should be treated with low or moderate Hyal doses. Hyal should be considered with prior or simultaneous oral antibiotic treatment in managing inflammatory nodules. Hyal may be tried for granulomas that have not responded to intralesional steroids. Emergent complications such as vascular occlusion and blindness require immediate, high-dose Hyal treatment. Regarding blindness, the injection technique, retrobulbar versus supraorbital, remains controversial. Ultrasound guidance can increase the efficacy of the above interventions.

CONCLUSIONS

Hyal is essential in aesthetic practice because it can safely treat most HA filler complications. Immediate Hyal treatment is required for emergent complications. Aesthetic practitioners should be versed in using Hyal and effective dosage protocols.

The Needle Versus Cannula Debate in Soft Tissue Augmentation

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

Surgical rhinoplasty after prior hyaluronic acid based nose remodeling

BACKGROUND

Medical rhinoplasty by hyaluronic acid injection (HA) has become nowadays a common practice. The number of patients requesting surgical rhinoplasty and having already undergone one or more injections of HA is increasing. However, the literature lacks publications regarding the management of these patients.

OBJECTIVES

The aim of this study is to discuss the management of patients who have been treated with previous nasal HA injections and who seek surgical rhinoplasty, and elaborate a treatment protocol and algorithm to standardize surgical plans.

METHODS

We are reporting case studies based on our clinical experience. We also reviewed the literature to suggest perioperative management for rhinoplasty with previous HA injections.

RESULTS

Hyaluronidase injection preoperatively allows to carry out an accurate preoperative analysis of the nasal deformities to treat, in order to make an adapted treatment plan. Postoperative course is similar to other rhinoplasty cases without the use of this enzyme.

CONCLUSION

Hyaluronidase should be used in all patients with nasal injections of HA (unless contraindications), who are willing to undergo a surgical rhinoplasty. The operation can be undertaken at one-week interval as soon as the edema subsides and no further treatments are necessary.

Hyaluronic acid filler-induced vascular occlusion-Three case reports and overview of prevention and treatment

BACKGROUND

Vascular occlusion induced by hyaluronic acid injections is rare, but can lead to severe adverse events, including necrosis, blindness, and cerebral infarction.

OBJECTIVE

This study aims to explore methods of reducing the risk of complications such as embolism induced by hyaluronic acid injection, and to study the impact of comprehensive systematic treatment on the prognosis of patients with hyaluronic acid embolism.

METHODS

The clinical data of three female patients with vascular occlusion due to hyaluronic acid injection was analyzed. Their median age was 26 years, with symptoms presenting 1-6 h postinjection. Hospital stays averaged 6 days. Two patients had ptosis, diplopia, and severe pain after injection of eyebrows. The other, who had a nose enhancement, experienced facial skin color changes and intense pain.

RESULTS

Two patients received comprehensive, systematic treatment based on injectable hyaluronidase. One patient self-discharged after receiving injectable hyaluronidase, antispasmodic, and vasodilator treatment on the night of embolism and returned to the hospital 3 days later with worsening embolism symptoms and received symptomatic treatment again. Two patients who received comprehensive, systematic treatment based on injectable hyaluronidase showed significant improvement, while the patient who did not undergo systematic treatment left scars on the face.

CONCLUSION

Vascular occlusion caused by hyaluronic acid facial filling is a severe adverse event, and timely, comprehensive, systematic treatment can effectively improve irreversible damage caused by thrombosis, and even cure it.

Management strategies for vascular complications in hyaluronic acid filler injections: A case series analysis

BACKGROUND

As hyaluronic acid (HA) filler injections have become increasingly popular in the esthetic field, so have their side effects. Vascular complications, which can lead to skin necrosis or permanent scarring, are a particularly dangerous complication and occur when the filler is injected directly into a blood vessel or when an adjacent blood vessel is compressed by the filler material.

OBJECTIVE

To assess the clinical prognosis based on post-procedural management and clinical findings of HA filler vascular complications.

METHODS

Herein, we present a case series of vascular complications due to HA filler and evaluate their clinical prognosis based on post-procedural management and clinical findings. Clinical assessments were performed using Doppler ultrasound, thermography, and laboratory tests.

RESULTS

Factors including white blood cell count, the time of treatment initiation, and time of hyaluronidase injection influenced the clinical outcomes. Early recognition and prompt hyaluronidase injection proved crucial in preventing further damage and improving prognosis.

CONCLUSION

This case series highlights the importance of early detection and appropriate management of HA filler complications. Physicians should be aware of the potential risks associated with fillers and promptly address any adverse effects to achieve optimal clinical outcomes. Further studies are warranted to confirm these findings and refine treatment strategies for the HA filler complications.

Arterial Embolism After Facial Fat Grafting: A Systematic Literature Review

BACKGROUND

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Personalization of Minimally-Invasive Aesthetic Procedures with the Use of Ultrasound Compared to Alternative Imaging Modalities

Ultrasonography is a well-tolerated procedure that aids in the targeted esthetic therapies of special cutaneous regions, as well as in the prevention (vascular mapping, identification of previous filler, and others) and management of potential complications (vascular occlusion, external vascular compression, product misplacement or migration, inflammatory reactions, and others). It has lately been promoted as the first-line imaging tool to address injectables. In this article, we aim to review the evolving role of ultrasonography in cosmetic filler procedures, from the fundamental ultrasound characterization of cosmetic fillers to the ultrasound-enhanced detection and management of cosmetic filler complications, including ultrasound's role in hyaluronidase-guided injections for cosmetic filler dissolution. Furthermore, the paper explores the integral role played by ultrasound in enhancing the precision, efficacy, and safety of additional minimally invasive aesthetic techniques such as mesotherapy, radiofrequency, cryolipolysis, and polydioxanone procedures.

Fatal pulmonary embolism following injectable gluteal filler usage: a case report

BACKGROUND

Despite the fact that injectable filler usage in the gluteal region has not been recommended in formal medical institutions, illegal procedures are performed in many clinics and beauty centers across Egypt. This case report illustrates the illegal practice culminating in a fatal complication.

CASE PRESENTATION

A 26-year-old female with no relevant medical history presented to the ER with acute onset shortness of breath. The complaint started 16 h before, with a rapidly progressive course, shortly after undergoing a gluteal filler injection at a center in Cairo. At ER, the patient was severely distressed, yet fully conscious and oriented. She was shocked (BP 70/40 mmHg), tachycardic (130 BPM), and tachypneic (30/min) with normal temperature. She had congested pulsating neck veins with positive Kussmaul sign. Chest auscultation revealed normal vesicular breathing with equal air entry and no adventitious sounds. Her O2 saturation was 60% on room air that improved to 85% on O2 mask. ECG showed sinus tachycardia. Echocardiography showed dilated right side, D-shaped septum with systolic flattening, dilated IVC, mild tricuspid regurgitation and estimated RV systolic pressure 53 mmHg. Her ABG showed compensated metabolic acidosis with elevated lactate level. At the ICU, CVP was 18 mmHg. Saline infusion was continued along with noradrenaline infusion initiation. A provisional diagnosis of high-risk pulmonary embolism was made, though CT pulmonary angiography was not available. Accordingly, thrombolytic therapy was initiated with alteplase (100 mg) over 2 h. Also, a dose of pulse steroids (methylprednisolone 200 mg) was given. Chest X-ray showed bilateral heterogenous opacity and ABG showed deteriorating hypoxia and combined metabolic and respiratory acidosis. The patient was intubated upon deterioration of conscious level and was put on mechanical ventilation. Her ET tube showed frequent blood-tinged secretions. Echocardiography showed more right-side dilatation that was consistent with deterioration of clinical status. Three hours after admission the patient developed cardiac arrest and died 2 h later.

CONCLUSIONS

This case report highlights the dangers associated with injectable filler usage in the gluteal region. Physicians and patients should be aware of the possible complications and how to avoid it.

An Innovative Approach for Nasal Reshaping using Hyaluronic Acid Intradermal Injections

Background

Nasal reshaping using hyaluronic acid (HA) filler has become a widespread technique and injections are usually performed in deep layers. As an alternative, we propose an innovative approach where HA is injected into the dermis, the so called MesoRhinoFiller.

Aims and Objectives

The aim of this study was to describe our injection technique using a smooth, cohesive, and slightly viscous HA filler injected in the dermis.

Materials and Methods

A retrospective review of the author's clinical experience from March 2017 to March 2020 was presented. A total of 280 consecutive patients were treated with HA injections to improve their nasal appearance. The mean volume was 0.5 cc HA filler/treatment.

Results

An average increase of 4.9 ± 3.4° was obtained for the nasofrontal angle, and of 7.0 ± 4.5° for the columella labial angle. Asymmetries in the nasal profile and alar rim were also corrected. All the patients were satisfied with the results and no complications occurred.

Conclusion

Injecting HA fillers in the dermal plane is a versatile approach that provides very satisfactory results. This technique allows one to better correct aesthetical, post-traumatic, and post-surgical defects compared with the usual injection rhinoplasty procedures where the filler is injected deep onto the bone/cartilage in the midline of the nose.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266. .

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Evaluation of facial artery course variations, diameters, and depth by Doppler ultrasonography

BACKGROUND

The facial artery (FA) is the main blood vessel supplying blood to the face. It is essential to understand the anatomy of FA around the nasolabial fold (NLF). This study aimed to provide the detailed anatomy and relative positioning of FA to help avoid unexpected complications in plastic surgery.

METHODS

FA was observed from the inferior border of the mandible to the end of its terminal branch in 66 hemifaces of 33 patients with Doppler ultrasonography. The evaluation parameters were: (1) location, (2) diameter, (3) FA-skin depth, (4) relationship between the NLF and FA, (5) distance between the FA and significant surgical landmarks, and (6) the running layer. The FA course is classified based on the terminal branch.

RESULTS

The most common FA course was Type 1, which had an angular branch as the final branch (59.1%). The most common FA-NLF relationship was that the FA was situated inferior to the NLF (50.0%). The mean FA diameter was 1.56 ± 0.36 mm at the mandibular origin, 1.40 ± 0.37 mm at the cheilion, and 1.32 ± 0.34 mm at the nasal ala. The FA diameter on the right hemiface was thicker than that on the left hemiface (p < 0.05).

CONCLUSION

The FA mainly terminates in the angular branch, running in the medial NLF and in dermis and subcutaneous tissue, with a blood supply advantage in the right hemisphere. We suppose that a deep injection into periosteum around the NLF may be safer than an injection into the superficial musculoaponeurotic system (SMAS) layer.

Complications of fillers in the lips and perioral area: Prevention, assessment, and management focusing on ultrasound guidance

An ever-increasing interest in perioral rejuvenation with dermal fillers reflects the esthetic importance of this region. However, filler injections in the lips and perioral area have been associated with various complications. Such complications are classified according to severity (mild, moderate, severe) or by the time of onset: immediate (within 24 h after injection), early (24 h to 4 weeks post-procedure), and late or delayed (>4 weeks after injection). While most complications are mild and manageable, vascular compromise, infections, and the development of delayed-onset nodules may significantly undermine the ultimate esthetic outcome and cause substantial morbidity. These more serious complications often require more invasive treatment modalities. This article details the prevention and management of such adverse events and discusses safe filler injection principles, including safety recommendations for the lips. Lastly, we highlight the use of ultrasound guidance in complication prevention (vascular mapping, filler identification, location, and extent), assessment (identification of intravascular embolus or external vascular compression by the filler implant), and management (real-time imaging of hyaluronidase or other drug injection in the affected area). Esthetic practitioners should be versed in injection anatomy, and the prevention, recognition, and management of filler complications in the perioral area.

Hyaluronic Acid Filler Injection Guided by Doppler Ultrasound

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

Central retinal artery occlusion following facial injection of hyaluronic acid

A 57-year-old woman with no premorbidities presented with symptoms of sudden painless vision loss in the right eye (RE). Best-corrected visual acuity in the RE was counting fingers to. A relative afferent pupillary defect was observed in the RE. Ocular fundus examination of RE was suggestive of central retinal artery occlusion. Systemic evaluation was normal. The most interesting fact in this case is that a hemorrhagic edema in the right glabellar region was the basis for the diagnostic suspicion. The patient recognized the loss of vision 24 hours after hyaluronic acid injection as a facial rejuvenation treatment.

New Insights into the Communications of the Facial Vein with the Dural Venous Sinuses

Background and Objectives: Anastomoses of the extracranial and intracranial venous system have been described in the literature. The presence of such anastomoses may facilitate a possible spread of infection into the dural venous sinuses. However, the frequency and relevance of such anastomoses is highly debated. The aim of this study was to quantify frequencies of anastomoses between the facial vein and the dural venous sinuses. Materials and Methods: In 32 sides of 16 specimens, latex was injected into the facial vein. Dissection was carried out to follow and described these anastomoses, yielding the presence of latex in the intracranial venous system. Results: In 97% of cases, a dispersal of latex into the cavernous sinus as well as anastomoses was observed. A further dispersal of latex into other dural venous sinuses was found at rates ranging between 34% (transverse sinus)—88% (superior petrosal sinus), respectively. Conclusions: The presence of anastomoses between the extracranial and intracranial venous system in a majority of cases needs to be considered when dealing with pathologies as well as procedures in the facial region.

Case series of tongue necrosis from vascular complications after chin augmentation with hyaluronic acid: Potential pathophysiology and management

BACKGROUND

Even though the chin is considered a safe injection area for facial filler augmentation, tongue necrosis is a rare complication in this area.

OBJECTIVE

Our aim was to present case series of rare complications from chin filler augmentation with possible pathophysiology and management.

METHODS

From our thorough literature search found only one case report of tongue necrosis from chin filler augmentation. We present case series of unilateral tongue necrosis from vascular occlusion following hyaluronic acid injection in the chin, which was successfully treated with a high-dose hyaluronidase injection resulting in complete recovery in all patients.

RESULTS

Variation in vascular anastomosis leads to a possible cause of vascular occlusion. The lingual artery is the primary arterial supply for the tongue, which is an exclusive target for embolism. Two main responsible arteries and branches are the deep lingual and sublingual arteries. The submental artery variation was previously described as the cause of this event. We proposed potential pathophysiology of the occlusion, not only the variation of vasculature but bone. The midline lingual foramen, an anatomical bone variation on the surface of the midline inferior jaw, was found to be another possible cause. This foramen contains a branch of the submental and sublingual artery, which includes the perforating artery, median perforating artery, or both. Filler injection with a sharp needle on the bone can potentially increase the risk of this vascular incident. A high dose of hyaluronidase administered with multiplane injections was accomplished with complete recovery.

CONCLUSIONS

Tongue necrosis from vascular complications after hyaluronic acid filler injection can occur. Not only vessels but bone variation pathology were possible causes.

Potential Effects of Repetitive Panfacial Filler Injections on Facelift Surgery and Surgical Outcomes: Survey Results of the Members of The Aesthetic Society

Background

Facial soft-tissue filler injections are being performed in the United States with increasing popularity.f.

Objectives

This study aimed to characterize the observations of The Aesthetic Society members regarding the potential impact of repetitive panfacial fillers on the outcomes of subsequent facelift surgery.

Methods

A survey containing closed and open-ended questions was sent to The Aesthetic Society members through email.

Results

The response rate was 3.7%. The majority of the respondents (80.8%) believed that less than 60% of their facelift patients had previous repetitive panfacial filler injections. One half (51.9%) reported that a history of panfacial filler injections increased the difficulty of performing facelifts. A large subset (39.7%) of respondents believed that a history of panfacial fillers increased postoperative complication rates, while the remaining either disagreed (28.9%) or were unsure (31.4%). The most common complications following the facelift surgery included undesirable palpability or visibility of filler (32.7%), compromised flap vascularity (15.4%), and decreased longevity of the lifting effect (9.6%).

Conclusions

This study identified a potential association with repetitive panfacial filler injections and outcomes following facelift surgery, although the exact effect on postoperative outcomes remains unclear. Large prospectively designed studies are needed to capture objective data comparing facelift patients with a history of repetitive panfacial fillers with those facelift patients who have never had injectables. Given the results of The Aesthetic Society members' survey, the authors encourage careful history-taking to elicit an accurate filler injection record including complications after filler injections, as well as engaging patients in a thorough preoperative discussion regarding the potential of panfacial fillers on the facelift procedure and postoperative outcomes.

Level of Evidence 5

Early warm compress treatment can promote recanalization of vascular embolisms and reduce tissue necrosis after polymethyl methacrylate injection

Injection of fillers for soft tissue augmentation can lead to a variety of complications, among which vascular occlusion caused by intravascular injection of filler will induce severe or permanent damage. The treatment strategies for intravascular embolization caused by injection include warm compress application, but the exact beneficial effects of this therapy have not been confirmed. The purpose of this study is to construct an intravascular injection embolism model and observe the effectiveness of warm and cold compress through a randomized, controlled trial. Thirty rabbit's sixty ears were randomly divided into warm compress group, cold compress group, and control group. Polymethyl methacrylate (PMMA) was slowly injected into the central ear artery (CEA) to cause vascular embolism. Warm compress and cold compress treatment were performed respectively. The vascular recanalization and other related indexes were observed at 30 min, 1 day, and 7 days after injection, and the tissue necrosis was analyzed at 7 days. In the early stage of vascular embolization, warm compress can immediately promote vascular dilatation, blood circulation and partial blood flow recovery. One day after intravascular injection, warm compress can reduce intravascular embolization and reduce the incidence of tissue necrosis. At 7 days after intravascular injection, the vessels in the cold compress and control groups were still embolized while the percentage of recanalization in the warm compress group was 47.4% (P < 0.000). Early-stage warm compress after intravascular PMMA injection is conducive to recanalization of vascular embolization and reducing tissue necrosis.

Efficacy and safety of hyaluronic acid filler on the treatment of horizontal neck lines

BACKGROUND

Injection of hyaluronic acid fillers (HA) fillers for horizontal neck line correction and rejuvenation has gained popularity in recent years despite conflicting reports on its efficacy and safety. Most published reports are retrospective studies that commonly use the sharp needle technique. In this prospective study, we therefore aimed to determine the efficacy and safety of an HA filler (Belotero Balance®, Merz Aesthetics) on the treatment of horizontal neck lines by blunt cannula injection technique.

MATERIALS AND METHODS

Thirty subjects were enrolled and treated with HA filler injections on the neck region using a blunt cannula injection technique into the deep dermis. Standardized photographic documentation was done at baseline, immediately after injection, and at 2-week, 1-, 3-, and 6-month follow-up after treatment. The rejuvenation effect was graded by the patients themselves and two blinded dermatologists using comparative photographs. Side effects were likewise recorded at each follow-up visit.

RESULTS

All 30 subjects completed treatment and attended every follow-up visit. The study participants comprised both females and males aged 20-69 years with mild, moderate, and severe neck lines based on the Horizontal Neck Wrinkle Severity Scale (HNWS) (Plast Reconstr Surg Glob Open, 2019, 7, 2366). All patients received approximately 3 ml of HA fillers for the entire treatment area. Both patient and physician ratings revealed peak benefits at 1-month post-treatment, with a significant decline at 3 months, which was sustained until 6 months after the procedure. Only one patient developed bruising related to the treatment, which resolved spontaneously without any additional medication.

CONCLUSION

The study demonstrated efficacy in improving the appearance of horizontal neck lines after one session of HA filler injection. The results showed peak improvement at 1 month, but with sustained rejuvenation effects up to 6 months after injection.

Use of the high-dose pulsed hyaluronidase protocol in the management of impending skin necrosis associated with hyaluronic acid fillers: a systematic review

Impending skin necrosis resulting from inadvertent intravascular injection of hyaluronic acid (HA) fillers can lead to tissue loss and significant scarring. In recent years, management trends have shifted from multimodal approaches to the sole use of high doses of hyaluronidase. The aim of this systematic review was to evaluate the effectiveness of the high-dose pulsed hyaluronidase management protocol in preventing skin necrosis and possible subsequent scarring. An online search of the bibliographic databases PubMed and Embase yielded 3039 articles. A total of 72 studies reporting 186 cases were found to be eligible for inclusion. The selection and evaluation process was done according to the PRISMA criteria. Included studies were assessed using the JBI and STROBE critical appraisal tools. The analysis of treatment outcomes was done according to the timing of treatment initiation and the type of intervention used. This review found that an immediate intervention using the high-dose pulsed hyaluronidase management protocol provided predictable and satisfactory outcomes. Initiating the protocol within 24 h of filler injection halted the progression of necrosis and prevented permanent sequelae. The conclusions are limited by the lack of a high level of evidence, since the only available sources of data are case reports and case series.

Ophthalmic Complications Following Facial Autologous Fat Graft Injection: A Systematic Review and Meta-Analysis

INTRODUCTION

With the recent increase in interest in using autologous fat (AF) filler injections to enhance aesthetic facial appearance, there is a noticeable increase in the complications such as vascular compromise and blindness. This systematic review and meta-analysis aimed to understand the symptomatology of ophthalmic complications related to AF facial injections for cosmetic purposes, their underlying causes, management options, and the final clinical outcomes.

METHODS

This review was conducted according to the International Prospective Register of Systematic Reviews (PROSPERO) guidelines. In November 2021, we performed a systematic review of available literature using the following electronic databases: Cochrane, MEDLINE, and EMBASE. Our search was limited to the published studies between 2000 and 2021.

RESULTS

A total of 1052 publications and 34 articles published were included. Twenty case reports, two case series, one prospective cohort study, and eleven retrospective studies were evaluated. The forehead was the most common single injection site (n = 196, 55.36%). The most common initial symptom was periorbital swelling (92.7%). The pooled prevalence of ophthalmic artery occlusion was 50.4% out of all AF injection-related complications. Regarding the management, most patients were managed conservatively (n = 278, 51.38%). Complete improvement was observed among 423 patients (80.57%).

CONCLUSION

Autologous facial fat injection is a minimally invasive procedure with a favorable safety profile in cosmetic applications. However, the common use of these injections in aesthetic surgery has resulted in a concomitant increase in devastating consequences, such as blindness. Therefore, a firm understanding of the potential complications of such interventions is essential.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

NOT SO "HAPPY BUMP": A complication due to hyaluronic acid

INTRODUCTION

The use of hyaluronic acid (HA) as a dermal filler is considered safe. However, as new brands come to the market, reports of adverse events are becoming more and more common.

OBJECTIVE

To describe a particular type of adverse effect that, unlike the erythematous, indurated, and painful nodules described in the literature as "angry red bumps," is characterized by noninflammatory, stony-like nodules that appear in sites previously treated with HA.

METHODS

The report of four patients who presented this complication, and the occurrence of two HA syringes from the same batch that had hardened the product inside at the time of filling.

CONCLUSION

The authors propose the nomenclature "happy bump" to group adverse reactions to HA that translate into noninflammatory nodules, with a stony consistency, appearing up to 4 weeks (recent) or after one month (late) in sites previously treated with AH.

The role of hyaluronic acid in polidocanol foam: An in vitro study

Objective

To study the role of hyaluronic acid (HA) in polidocanol (POL) foam.

Methods

The dose-dependent effect of HA-POL on cultured human umbilical vein endothelial cells (HUVECs) as well as foam stability was evaluated by measuring optical density (OD) values and foam half-life time (FHT), respectively. An in vitro model was utilized for estimating the foam blood-displacement capacity by adopting maximum displacement distance (MDD) and displacement time. A comparison of foam viscosity was also carried out.

Results

The OD values of HUVECs treated with HA first increased and then decreased with the growing dosage of HA while cells treated with HA-POL died. Both FHT and displacement time were prolonged statistically with a gradually enhanced foam viscosity. As to MDD, there were no significant differences.

Conclusions

HA was found to promote HUVECs proliferation slightly, but this was almost negligible when compared to the cell-killing capacity of 1% POL. The viscosity of POL foam was enhanced by HA indicating its positive correlation with both stability and displacement capacity of POL foam.

Soft Tissue Dermal Filler-Associated Necrosis and Impending Necrosis: A Systematic Review of the Literature

BACKGROUND

Cosmetic soft tissue fillers are a popular minimally invasive procedure. Necrosis is a rare yet devastating complication of soft tissue fillers. To date, the relationship between soft tissue fillers and necrosis has not been fully described.

OBJECTIVE

To systematically compile published cases of soft tissue fillers resulting in necrosis and collect data regarding the injection, treatment, and outcome.

METHODS AND MATERIALS

Using PRISMA protocol, a comprehensive search for soft tissue filler necrosis was performed using no time constraints, resulting in 97 articles encompassing 192 cases of soft tissue filler necrosis containing individual-level data.

RESULTS

Of the cases analyzed, 66.1% had progressed to necrosis, whereas 33.9% of patients had impending necrosis. Necrosis most commonly resulted from injection of the nasolabial fold (32.4%, n = 88). The filler material most commonly used was hyaluronic acid (71.9%, n = 138). Hyaluronidase was used most frequently as an initial treatment agent (19.1%, n = 88). Forty-three patients (22.4%) with necrosis had a prior minor procedure or surgery.

CONCLUSION

This systematic review is an extensive overview of necrosis as a complication of soft tissue fillers. It serves as a reference tool for any clinician who injects soft tissue fillers and any provider who encounters soft tissue filler necrosis.

Filler-induced non-thrombotic pulmonary embolism after genital aesthetic injection

Genital aesthetic procedures have increased in popularity among women and men. Many clinicians tried to expand the application of fill injection by using it for genital aesthetic injection. However, this procedure is not so safe as imagined and may lead to a fatal complication of pulmonary embolism. This article summarizes the clinical manifestations and proposed mechanism of the filler-induced non-thrombotic pulmonary embolism (FINTPE) cases. A literature review was performed with the search keywords including "genital aesthetic injection, vaginal injection, vaginoplasty, vaginal tightening, penile augmentation, penis injection, hyaluronic acid, fat grafting, pulmonary embolism, alveolar hemorrhage, hypoxemia, and dyspnea." Among the 14 cases from 11 articles enrolled, 12 patients were female, and two were male. Eight patients received silicone injection, followed by two received fat grafting and hyaluronic acid injection, respectively. All the female patients had one single injection site, including 11 cases for the vaginal wall and one for G-spot, while all the male patients received injections into the penis and scrotum. The main symptoms were dyspnea and chest pain. Almost 60% of FINTPE patients presented respiratory disorders within 12 hours post-operation. Treatment includes oxygen therapy, corticosteroids, and anticoagulation. Five patients improved with an average of 14.6-day treatment, and seven died due to organ failures. Genital aesthetic filler injections are experimental procedures without being strictly reviewed or approved. As a severe complication following these procedures, FINTPE requires cautious performance, careful prevention, timely identification, and treatment to decrease its incidence and mortality.

Unravelling the Complex Anatomy of the Tear Trough and Lower Eyelid Folds: A Review of Cadaveric Studies in the Literature

The lower eyelid tear trough deformity is a common cosmetic concern which is the result of multiple anatomic changes in the lower eyelid, usually resulting from age. A sound understanding of the underlying anatomy is vital to inform surgeons about the ideal treatment options for rejuvenation of this region and to minimize the risk of complications. Cadaveric studies provide unique insight into underlying anatomic changes. Here we review the relevant published cadaveric studies relating to the tear trough deformity and its treatment.

Ultrasound Imaging of Facial Vascular Neural Structures and Relevance to Aesthetic Injections: A Pictorial Essay

The facial and submental regions are supplied by complicated neurovascular networks; therefore, facial aesthetic injections may be associated with serious adverse events such as skin necrosis and blindness. Pre-injection localization of neurovascular structures using high-resolution ultrasound can theoretically prevent unexpected complications. Therefore, a systematic protocol that focuses on these facial neurovascular structures is warranted. In this pictorial essay, we discuss the sonoanatomy of facial and submental neurovascular structures and its relevance to aesthetic injections. Moreover, we have highlighted the mechanisms underlying potential neurovascular injuries during aesthetic injections.

Sudden vision loss and neurological deficits after facial hyaluronic acid filler injection

BACKGROUND

The ongoing expansion of the cosmetic armamentarium of facial rejuvenation fails to uncover the inherent risks of cosmetic interventions. Informed consent to all risks of cosmetic filler injections and potential sequelae, including ocular and neurological complications, should be carefully ensured. We present two cases of complications following facial hyaluronic acid filler injections.

CASE PRESENTATIONS

Case 1: A 43-year-old woman presented with monocular vision loss of the left eye, associated ptosis, ophthalmoplegia, periocular pain and nausea, cutaneous changes of the glabella region and forehead, and sensory impairment in the left maxillary branch dermatome (V2) after receiving a hyaluronic acid (HA) filler injection into the left glabellar area. On ophthalmological examination, an ophthalmic artery occlusion (OAO) was diagnosed upon identification of a "cherry-red spot". Magnetic resonance imaging (MRI) revealed a left ischemic optic neuropathy. Supportive therapy and hyaluronidase injections were initiated. A follow-up MRI of the head performed two months after presentation corresponded to stable MRI findings. The patient had irreversible and complete vision loss of the left eye, however, the ptosis resolved. Case 2: A 29-year-old woman was admitted to hospital a few hours after a rhinoplasty and cheek augmentation with hyaluronic acid, presenting with acute monocular vision loss in the right eye, retrobulbar pain, fatigue and vomiting. In addition, the patient presented a harbinger of impending skin necrosis and a complete oculomotor nerve palsy on the right side, choroidal ischemia and vision impairment. Supportive treatment and hyaluronidase injections into the ischemic tissue were initiated. A small scar at the tip of the nose, vision impairment and an irregular pupillary margin on the right side persisted at follow-up.

CONCLUSION

These two case reports and the literature review emphasize the pathophysiological mechanisms leading to potentially devastating complications. In order to reduce the risk of vision loss secondary to cosmetic filler injections, practitioners should possess a thorough knowledge of anatomy and preventive strategies.

Hyperbaric oxygen therapy for treatment of a late presenting ischaemic complication from hyaluronic acid cosmetic filler injection

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.

An Italian Online Survey Regarding the Use of Hyaluronidase in Previously Hyaluronic Acid-Injected Noses Looking for Surgical Rhinoplasty

Background

Nonsurgical nasal reshaping (nSNR) with hyaluronic acid (HA) filler is a well-established procedure performed to ameliorate nasal appearance and is considered a valid alternative to surgical rhinoplasty in selected patients.

Objectives

The aim of our study is to evaluate the decision-making process and management of patients undergoing rhinoplasty, with previous HA filler injection, and evaluate if consensus could be achieved to recommend guidelines.

Methods

Between April and May 2021, an online survey was sent to 402 Italian surgeons of different specialties. The survey collected information regarding the types of treatment of patients who have previously undergone nSNR, who should undergo surgical rhinoplasty. For those surgeons using hyaluronidase, an additional information was collected.

Results

In a range of time of 2 months (April and May 2021), a total of 72 surgeons replied and completed the survey: out of the 402 questionnaires sent, the response rate was approximately 18%. The majority of respondents (61.5%) replied to inject hyaluronidase (HYAL) in patients who had to undergo a rhinoplasty but reported previous nSNR. Of the surgeons who use HYAL, 70% performed rhinoplasty after a waiting time of 3 to 4 weeks.

Conclusions

Either direct surgical approach or hyaluronidase injection first seems to be a viable options. The use of HYAL before surgery is the choice with the broadest consensus in our survey. However, a larger case-control study with long follow-ups is necessary to understand if in patient seeking surgical rhinoplasty who already received nSNR, the injection of hyaluronidase before surgery is mandatory, recommended, or not.

Vasculature of the Nasal Cartilage Region Related to Filler Injection

BACKGROUND

A filler injection in the nose can be essential but is also dangerous, especially in the nasal cartilage region. To safely and accurately perform a filler injection, surgeons must have detailed knowledge of nasal anatomy.

OBJECTIVES

Associated the vessel branches and the characteristics of different nasal regions to provide suggestions for more suitable injection sites.

METHODS

Fifty specimens underwent computed tomography (CT) after contrast infusion. Qualified specimens were selected for 3D CT reconstruction. Dissection was performed to confirm the accuracy of the CT data.

RESULTS

The branches of arteries with large diameters, the dorsal nasal artery (DNA) and the lateral nasal artery (LNA) were distributed within the superficial musculoaponeurotic system layer. The DNA was seen in only 58% of specimens. The artery crossed the midline over the upper lateral cartilage in 16% of specimens. The LNA was a constant branch that traversed the nasal tip. The LNA crossed the midline to the contralateral side in 18% of patients. We divided the nasal cartilage dorsum into two regions for easy handling: the supratip region (STR) and the nasal tip region (NTR). The branches distributed in the STR mostly originated from the DNA (81.6%, 40/49), while those in the NTR mostly originated from the LNA.

CONCLUSIONS

The vasculature of the nasal cartilage region observed in this study is similar to that observed in previous studies. However, we found that the STR was an advantageous area for filler injection. At the same time, we provided suggestions for more suitable injection methods.

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 .

Case Report: Peri-oral Vascular Compromise Due to Calcium Hydroxyapatite

The increasing popularity of nonsurgical cosmetic treatments with the use of hyaluronic acid and calcium hydroxyapatite shows how effective and versatile these treatments can be. However, this is very likely to increase the number of complications that occur. Treatment protocols exist for vascular complications due to injections with hyaluronic acids. However, protocols for such events due to injections with calcium hydroxylapatite are less defined. The author suggests an exemplified protocol for the basis of managing such life-changing complications of impending necrosis after injections with calcium hydroxyapatite.