Complications of Fillers: Overview

Using dermal filler to camouflage forehead osteoma: A case report

OBJECTIVE

To review the technique and outcomes of using dermal filler to camouflage forehead osteoma, providing a minimally invasive alternative to surgical excision.

BACKGROUND

Forehead osteoma, commonly known as a forehead bump or bone spur, can be a cosmetic concern. Surgical excision, while effective, carries risks of scarring and postoperative complications. An innovative approach using dermal filler offers a potential solution.

METHODS

A hyaluronic acid-based filler is injected into the deep subcutaneous plane over the bony prominence using a cannula. The fanning technique ensures even distribution of the filler. The procedure's safety, patient selection, and communication between the injector and patient are emphasized to achieve optimal results.

RESULTS

The technique provides immediate aesthetic improvement with results that can last up to 12 months, depending on the filler used. While generally safe, potential complications include infections, swelling, asymmetry, and lumpiness. Proper technique, patient selection, and good communication between the injector and patient are critical to achieving optimal outcomes.

CONCLUSION

Using dermal filler to camouflage forehead osteoma is a minimally invasive alternative to surgical excision, offering immediate and long-lasting results with minimal downtime and fewer risks. Further studies are needed to refine the technique and optimize outcomes.

Adverse Effects Associated with Dermal Filler Treatments: Part II Vascular Complication

Vascular complications arising from dermal filler treatments pose significant risks, including ischemia, tissue necrosis, and severe outcomes like blindness and pulmonary embolism. This study investigates the mechanisms of vascular complications, categorizing them into extravascular compression and intravascular emboli. Extravascular compression occurs when injected fillers compress adjacent blood vessels, leading to ischemia and potential necrosis, while intravascular emboli result from fillers entering blood vessels, causing blockages. The study emphasizes the importance of anatomical knowledge, careful injection techniques, and early intervention. Management strategies include the use of hyaluronidase to dissolve HA fillers, vasodilators to improve blood circulation, and hyperbaric oxygen therapy. The regions most susceptible to complications align with major arterial pathways, particularly the nasolabial folds and nasal region. The study also highlights the need for meticulous injection techniques, the use of cannulas over needles in high-risk areas, and the aspiration test to detect vessel penetration. Early detection and immediate intervention are crucial to mitigate adverse outcomes. Continuous education and training for practitioners, along with advancements in filler materials and injection methods, are essential for improving the safety of cosmetic procedures. This comprehensive understanding aids in preventing and managing vascular complications, ensuring better patient outcomes. The field of dermal filler treatments is advancing with new techniques and technologies, such as High-Resolution Ultrasound, Infrared Imaging, self-crossing hyaluronic acid filler, biodegradable microspheres, and microinjection.

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 .

Efficacy of Percutaneous Superficial Temporal Arterial Hyaluronidase Injection for Hyaluronic Acid Filler-Induced Necrosis of Frontotemporal Skin and/or the Ipsilateral Scalp With Subsequent Alopecia

BACKGROUND

Necrosis of frontotemporal skin and/or the ipsilateral scalp with subsequent alopecia after hyaluronic acid (HA) filler injection into the temple is rare complications with superficial temporal artery embolization are suspected as the major pathological mechanism. The main treatment currently is intralesional hyaluronidase (HAase) injection, but the effectiveness of percutaneous superficial temporal arterial HAase injection still lacks consensus.

OBJECTIVES

To investigate the effectiveness of superficial temporal arterial HAase injection in dissolving HA filler-induced necrosis of frontotemporal skin and/or the ipsilateral scalp with subsequent alopecia.

METHODS

Five recent clinical cases with necrosis of frontotemporal skin and/or the ipsilateral scalp with subsequent alopecia after HA filler injection into the temple were analyzed retrospectively. The patients underwent HAase injection via superficial temporal artery combined with adjunctive treatments, and the clinical progress was observed.

RESULTS

Significant improvement was observed in terms of necrosis of frontotemporal skin and the ipsilateral scalp after treatment, and the patients were relieved of their clinical symptoms. Alopecia occurred approximately 1 to 2 weeks after HA filler injection, and the well-defined alopecia areas were formed 15 to 20 days after HAase injection. Patients were followed for 3 to 6 months. During follow-up, the skin lesions of all patients were restored to near normal appearance. Hair regrowth was observed 2 to 3 months after HAase treatment, and hair density nearly reached the normal level 3 to 4 months later.

CONCLUSIONS

Percutaneous superficial temporal arterial HAase injection is an effective treatment option for HA filler-induced necrosis of frontotemporal skin and/or the ipsilateral scalp with subsequent alopecia.

LEVEL OF EVIDENCE: 4

Complications following Permanent Filler Injection: A Prospective Cohort Study and Protocol of Management

Permanent filler (PF) substances are increasingly utilized in aesthetic procedures. Concurrently, complications related to fillers have also risen. This study aims to determine the rate of complications secondary to PF injections and develop a therapeutic approach for treating such complications.

METHODS

This cohort study was conducted by distributing a checklist form among all patients aged 18 years or older who arrived for a new cosmetic consultation between 2015 and 2019. The primary outcome was the occurrence of complications, which are defined as symptoms induced by the PF. The demographics, type of PF, injection site, the time for the complication to occur, and signs and symptoms were recorded and followed up.

RESULTS

In this study, 325 out of 503 (64.61%) patients presented with PF-related complications. About 92.8% were women. All patients with PF-related complications presented with a lump (n = 325, 100%). In regard to the anatomical area of injection, the most common areas were the cheeks (66.6%). The time it took for the complication to occur most commonly ranged from 1-5 years (39.2%, P < 0.001). Complications were significantly higher among patients who received the injection in a nonmedical facility (P < 0.0002). Seventy-seven cases (15.3%, P < 0.0001) underwent PF removal.

CONCLUSIONS

PF-related complications in the body exhibit a wide range of onset and adverse events. The best method to prevent complications caused by permanent filling materials is to avoid them altogether. When it comes to permanent filling agents, we suggest extreme caution.

A Rare Cause of Respiratory Insufficiency in a 30-Year-Old Transgender Woman

CASE PRESENTATION

A 30-year-old transgender woman who was HIV positive presented to the ED with progressive severe dyspnea and hemoptysis that started 1 day earlier. The patient was undergoing antiretroviral therapy with emtricitabine-rilpivirine-tenofovir with good compliance and feminizing hormone therapy with cyproterone acetate. She was otherwise healthy and was not taking any other medications.

Filler Migration to the Orbit

BACKGROUND

Dermal filler injections continue to grow in popularity as a method of facial rejuvenation. This increase in the number of injections performed has resulted in an increasing number of types of filler-related complications.

OBJECTIVES

We report a series of cases where dermal filler injected in the face migrated to the orbit. Treatment methods and possible mechanisms of this newly reported complication are discussed.

METHODS

A retrospective, multicenter analysis was performed on patients with dermal filler migration to the orbit after facial filler injections.

RESULTS

Seven patients (6 females, 1 male; age range, 42-67 years) presented with orbital symptoms after filler injection and were subsequently found to have dermal filler in the orbit. Four out of 7 patients underwent orbitotomy surgery, 1 patient underwent lacrimal surgery, 1 patient had strabismus surgery, and 1 patient was treated with hyalurodinase injections. All patients have remained stable postoperatively.

CONCLUSIONS

Orbital complications secondary to migrated filler may occur long after the initial procedure. Because the site of the complication is distant from the injection site, patients and physicians may not immediately make the connection. Furthermore, this may lead to unnecessary examinations and a delay in diagnosis while looking for standard orbital masses. Dermal fillers should therefore be considered in the differential diagnosis of patients presenting with new-onset orbital masses.

LEVEL OF EVIDENCE: 4

Recommendations for the treatment of tear trough deformity with cross-linked hyaluronic acid filler

Background

Recent years have seen a growing interest in the appearance of the eyes among the concerns expressed by patients in cosmetic clinics. This has led to an increase in the frequency of diagnosis of tear trough deformity, and, as a result, the number of treatments performed by specialized professionals has also risen. Hyaluronic acid filler injection is a rapid, nonsurgical technique that gives good long‐lasting, but not permanent, results. However, to achieve optimal results, the attending physician must have good anatomical knowledge of the area and involvement of the structures in the tear trough, carry out proper clinical assessment of the patient, and use an appropriate injection technique with the right product.

Aims

To support good practice among the professionals who carry out these procedures, this interdisciplinary consensus document describes the relevant issues and recommendations, in order to improve safety standards and to help successfully resolve this aesthetic problem.

Retrospective review of delayed adverse events secondary to treatment with a smooth, cohesive 20-mg/mL hyaluronic acid filler in 4500 patients

BACKGROUND

Recent publications have suggested an increased risk of delayed adverse events (DAEs) with a smooth, cohesive 20-mg/mL hyaluronic acid filler, Juvéderm Voluma (HA-V).

OBJECTIVE

To examine the occurrence of HA-V DAEs and identify patterns and characteristics.

METHODS

Charts from patients who received HA-V between February 1, 2009, and February 28, 2018 from 2 clinics were analyzed.

RESULTS

In 4500 patients who received 9324 treatments with HA-V, 44 DAEs were identified, for a combined incidence of 0.98% per patient, 0.47% per treatment, and 0.23% per syringe. Patients with DAEs received a slightly larger cumulative amount of HA-V than those who did not. Delayed swelling and nodule formation were the most common reactions and occurred a median of 4 months after treatment, with an increase in frequency between October and January. About a third were preceded by an identifiable immunologic stimulus. DAEs were transient and resolved without incident.

LIMITATIONS

The retrospective nature made it difficult to capture time to resolution or remember potential triggers.

CONCLUSION

In this large, long-term, retrospective review, HA-V DAEs occurred at a rate of 0.98% per patient. Although the exact cause has yet to be elucidated, we hypothesize that an increase in fragmentation during the HA-V degradation process may trigger an inflammatory response after an immunologic trigger.

Complications and Litigation Associated With Injectable Facial Fillers: A Cross-Sectional Study

PURPOSE

Soft-tissue injectable fillers are a popular treatment option for patients seeking minimally invasive facial rejuvenation. The use of soft-tissue fillers has increased significantly in the past 10 years. In 2017 alone, clinicians administered nearly 2.7 million soft-tissue fillers, up from 1.3 million in 2007. Although injectable fillers have a relatively high safety profile compared with more invasive rejuvenation procedures, serious adverse events, including intra-arterial injections, necrosis, and visual symptoms such as blindness, have been documented. Complications from injectable fillers have also been a source of litigation, which has been shown to be associated with a perceived lack of informed consent. We sought to document the reported complication rates associated with injectable facial fillers from a national database and to report on the available cases of malpractice litigation.

MATERIALS AND METHODS

The US Food and Drug Administration's Manufacturer and User Facility Device Experience database was used to collect the reported complications from 2013 to 2017 for the following injectable fillers: Artefill, Bellafill, Belotero, Juvederm, Radiesse, Restylane, Sculptra, and Kybella. Complications were organized by filler type, injection location, and complication type. The Thomson Reuters Westlaw Edge database was used to collect the reported jury verdicts and settlements from 2008 to 2017 for injectable facial fillers.

RESULTS

A total of 2813 adverse events were analyzed. The most common locations for complications were the cheek (915 [32.5%]), lips (503 [17.9%]), and nasolabial fold (412 [14.6%]). The commonly reported adverse events were swelling (1,691 [60.1%]), nodule (948 [33.7%]), and pain (636 [22.6%]). Severe complications included intra-arterial injections resulting in necrosis and visual symptoms (eg, blurred vision and blindness). Forehead and dorsal nasal injections were significantly associated with intra-arterial complications resulting in necrosis and visual symptoms (P < .01). Injections with Radiesse were significantly associated with intra-arterial injections resulting in necrosis and visual symptoms (P < .01). A total of 11 malpractice cases were analyzed. The median award in the cases resolved by a verdict in favor of the plaintiff or settlement was $600,000. In 10 of the 11 cases, a lack of informed consent had been alleged.

CONCLUSIONS

The complications associated with injectable facial fillers varied greatly, depending on factors involved with their application. The most common adverse effects were swelling, nodule formation, and pain. Serious complications stemming from intra-arterial injections included necrosis and visual disturbances, including blindness. These complications have been raised in legal cases, in which the lack of informed consent was frequently alleged. The present analysis has documented some of the potential risks involved with injectable facial fillers and demonstrated the need for a thorough informed consent process before their administration.

Long-term outcomes of surgically removed migrated polyalkylimide (bio-alcamid) filler to the periorbital area

Purpose

To report the long-term follow-up results after surgical excision of migrated Bio-Alcamid fillers to the Periorbita area.

Methods

A retrospective case series of all patients who underwent surgical removal of migrated Bio-Alcamid fillers to the Periorbita area with minimal follow-up of 1 year from January 2009 to January 2018 was done.

Results

16 female patients (24–52 y) presented with an upper or lower eyelid swelling 3–7 years following a filler injection in the nasal bridge, temporal or malar area. All patients had surgical excision of a granulomatous mass ranging in size from 1–3.5 cm. The histopathology report revealed a giant cell reaction in all patients. Follow–up periods ranged from 1 to 8 years. One patient developed lid retraction and another had recurrence 3 years later; the remaining had an unremarkable course.

Conclusions

Filler migration is one of the potential complications associated with Bio-Alcamid soft tissue injection. It is important for all physicians to assess nodules/masses/swelling in the facial area to be aware that soft tissue fillers may migrate to a location away from their intended site of injection years after the injection. Patients undergoing surgical excision tend to have favorable overall long-term outcomes in terms of aesthetics and incidence of recurrence.

Autoimmune/inflammatory syndrome induced by adjuvants-ASIA-related to biomaterials: analysis of 45 cases and comprehensive review of the literature

Systemic autoimmune or granulomatous disorders related to biomaterials of human use have rarely been described. The aim of this study was to report cases of autoimmune/inflammatory syndrome induced by adjuvants (ASIA) related to biomaterial injections and prostheses, mainly silicone, hyaluronic acid, acrylamides and methacrylate compounds in a Spanish patient cohort. This study is a retrospective analysis of clinical, laboratory, histopathological and follow-up data of 45 cases of patients suffering from late-onset, non-infectious inflammatory/autoimmune disorders related to bioimplants. Late onset was defined as 3 months or more post injection. Data were obtained through a further non-systematic but comprehensive review of the literature. Forty-five cases of late-onset adverse reactions related to biomaterial injections or prostheses were reviewed. All cases had systemic complaints that could be categorised as ASIA. In all but four patients, inflammatory features at the implantation site preceded distant or systemic manifestations. Abnormal blood tests were common. Localised inflammatory nodules and panniculitis in 40/45 (88.88%) evolved into a variety of disorders, viz., primary biliary cirrhosis, Sjögren's syndrome, sarcoidosis, human adjuvant disease, vasculitis, inflammatory bowel syndrome and inflammatory polyradiculopathy. Five (11.11%) cases presented primarily with systemic autoimmune disorders. Biomaterials and prostheses can provoke late-onset systemic autoimmune disorders fulfilling ASIA criteria, or present primarily local/regional inflammatory reactions that may eventually evolve into systemic autoimmune and/or granulomatous disorders which fall under ASIA.

Complications of glans penis augmentation

Despite the controversy regarding penile augmentation (PA), glans penis augmentation (GPA) is used in penile reconstructive surgery in selected patients with small glans penis. Since 2003, injectable hyaluronic acid (HA) gel has been used for GPA. The attractiveness of HA gel fillers and interest in this technique have led to the use of other fillers for GPA, particularly irreversible fillers that improve the longevity of HA gels. Conversely, indirect glans augmentation via implantation of dermofat grafts or scaffolds between the corpus spongiosum and the distal tip of the corpus cavernosum is used to overcome poor longevity of the gel and glans surface undulation, which are the primary limitations of GPA using HA gel. Unfortunately, these implants form hard painful lumps over time in most patients and are difficult to remove. Blunt dissection is an invasive procedure that may cause vascular compromise and consequent glans necrosis in a few patients. We present our review regarding the current status of GPA for a more comprehensive understanding of this subject. Additionally, we have discussed a few complicated cases that were referred to us.

Treating the tear trough: A new classification system, a 6-step evaluation procedure, hyaluronic acid injection algorithm, and treatment sequences

INTRODUCTION

The tear trough deformity is commonly requested for correction, most often by filler injections. However, the tear trough remains difficult to treat due to its complex anatomy, a variety of other concurrent deformities, and the high risk of complications.

OBJECTIVES

To create a standardized categorization, evaluation, and treatment protocol for the management of tear troughs with fillers.

METHODS

(1) Patient deformity profiles are determined using three categories of traits: A (Atrophy), B (Bulging), L (Laxity). (2) A 6-step evaluation process (Tilt, Snap, Smile, Squint, Pull, Push) aids in ABL determination. (3) Treatment is simplified into a comprehensive protocol for each category (with 6 major injection points and a variety of injection depths and volumes).

RESULTS

The author has achieved satisfactory results using the presented protocols, with photographic examples.

CONCLUSION

The author proposes a comprehensive categorization system that takes into account both the tear trough and other concurrent deformities. The author also presents 6 tests to aid in categorization, and simple protocols with injection sequences, amounts, and depth.

The host response to naturally-derived extracellular matrix biomaterials

Biomaterials based on natural materials including decellularized tissues and tissue-derived hydrogels are becoming more widely used for clinical applications. Because of their native composition and structure, these biomaterials induce a distinct form of the foreign body response that differs from that of non-native biomaterials. Differences include direct interactions with cells via preserved moieties as well as the ability to undergo remodeling. Moreover, these biomaterials could elicit adaptive immune responses due to the presence of modified native molecules. Therefore, these biomaterials present unique challenges in terms of understanding the progression of the foreign body response. This review covers this response to natural materials including natural polymers, decellularized tissues, cell-derived matrix, tissue derived hydrogels, and biohybrid materials. With the expansion of the fields of regenerative medicine and tissue engineering, the current repertoire of biomaterials has also expanded and requires continuous investigation of the responses they elicit.

An Overview of Vascular Adverse Events Associated With Facial Soft Tissue Fillers: Recognition, Prevention, and Treatment

Minimally invasive facial cosmetic surgery procedures have seen an exponential increase in numbers over the past decade. The most commonly performed procedures are neuromodulator and soft tissue filler procedures. Although soft tissue fillers have a high safety and predictability profile, these procedures recently have been associated with serious and dire adverse events. This article will discuss some of the vascular complications associated with facial soft tissue fillers. Management and prevention of these adverse events also will be discussed.

Perpendicular Strut Injection of Hyaluronic Acid Filler for Deep Wrinkles

Supplemental Digital Content is available in the text.

Although various injection techniques of hyaluronic acid (HA) filler for facial rejuvenation have been developed, correction of deep wrinkles/grooves, such as the nasolabial fold (NLF), with intradermal or subdermal injections remains difficult. We tested the intradermal HA injection method to place multiple HA struts by (1) inserting a small needle perpendicularly to the wrinkle and (2) injecting HA as intradermal struts with the skin fully stretched by the practitioner’s fingers. The results of both NLFs in 10 patients suggest that this technique improves NLFs and maintain the effects more consistently than conventional techniques, although the effects of both methods were almost lost after 6 months. Selective and/or combined application of this technique may enhance the current approach to facial rejuvenation with dermal fillers.

Complications and Management of Polymethylmethacrylate (PMMA) Injections to the Midface

BACKGROUND

Polymethylmethacrylate (PMMA) has been used as an injectable filler to treat hollows and reduce rhytids. PMMA injections have been associated with several side effects, however, the literature is scarce on periorbital complications and their treatments.

OBJECTIVES

The purpose of this study is to report a series of complications after periorbital PMMA injections to the midface and to describe their management.

METHODS

Retrospective chart review, including photography and histopathology when available.

RESULTS

The authors identified 11 cases of complications of PMMA injections to the midface. Patient ages ranged from 36 to 62 years (mean, 47 years; median, 44 years). Two (18%) were males and 9 (82%) were females. Adverse effects began between 2 to 24 months after injection (mean, 7.2 months; median, 6 months). All patients had edema, erythema, and contour irregularity. Seven (64%) patients had nodules, 4 (36%) had yellow, xanthomatous skin changes, and 2 (18%) had eyelid malposition. Histopathology demonstrated a giant cell inflammation in 5 of 6 cases. Corticosteroid injection was tried in 6 cases but was associated with minimal clinical improvement. Surgical debulking of the implanted material was performed in 9 (82%) cases and was effective in improving edema, erythema, and nodularity.

CONCLUSIONS

PMMA injection to the midface may be associated with chronic inflammation, fibrotic nodules, yellowing of the skin, and eyelid malposition. Intralesional corticosteroid injections yielded minimal or no improvement; surgical debulking achieved favorable results. LEVEL OF EVIDENCE 4: Therapeutic.

The Liquid Lift: Looking Natural Without Lumps

Context:

Hyaluronic acid (HA) is the most common filler used to rejuvenate. Today, a three-dimensional approach prevails over previous techniques in which this material was used in specific areas of the face such as the nasolabial fold, the marionette line, and the eye trough giving a strange appearance that does not look natural. Even with a volumizing purpose, the injection of HA can sometimes produce clinically detectable nodules or lumps where the filler is deposited.

Aims:

To develop a new technique of injecting HA that can provide more natural results and avoid the lumpiness and nodular appearance that sometimes occurs with the injection of HA. To detect whether mixing HA with diluted anesthetic agent modifies its behavior.

Settings and Design:

Prospective, case control, single-center study on a private clinic setting.

Materials and Methods:

Eighty six patients were enrolled in this study. All of them had a previous treatment with nondiluted HA using a needle at least a year before. Patients were injected with 8 mL of reticulated HA (RHA) mixed with 6 mL of saline and 2 mL of anesthetic agent. The mixture was administered through a cannula inserted in the face, one at mid-cheek and another at frontal-temporal point of entry. Owing to the lifting effect of this mixture we called this procedure liquid lift (LL). Patients were evaluated 1 month, 6 months, and a year later and asked to compare the LL with previous experiences in terms of natural look, pain, and appearance of nodules.

Statistical Analysis Used:

Student's t-test.

Results:

One month after the treatment, 83 out of 86 patients (96.5%) thought LL produced a more natural look than the previous treatment with the needle. Sixty two (72%) considered LL less painful than the previous treatment and only eight (9.3%) could detect lumps or nodules 1 month after LL was performed compared with 46 (53.5%) that described this problem with previous needle injections. The incidence of bruising was also clearly lower (7% with LL vs 17.4% with traditional needle).

Conclusions:

Injection of diluted HA with saline and anesthetic agents through a cannula all over the face or LL can provide more natural results and less lumps or nodules, and is less painful than traditional treatments involving needle injection of nondiluted HA.

Treatment of Hyaluronic Acid Filler-Induced Impending Necrosis With Hyaluronidase: Consensus Recommendations

Injection-induced necrosis is a rare but dreaded consequence of soft tissue augmentation with filler agents. It usually occurs as a result of injection of filler directly into an artery, but can also result from compression or injury. We provide recommendations on the use of hyaluronidase when vascular compromise is suspected. Consensus recommendations were developed by thorough discussion and debate amongst the authors at a roundtable meeting on Wednesday June 18, 2014 in Las Vegas, NV as well as significant ongoing written and verbal communications amongst the authors in the months prior to journal submission. All authors are experienced tertiary care providers. A prompt diagnosis and immediate treatment with high doses of hyaluronidase (at least 200 U) are critically important. It is not felt necessary to do a skin test in cases of impending necrosis. Some experts recommend dilution with saline to increase dispersion or lidocaine to aid vasodilation. Additional hyaluronidase should be injected if improvement is not seen within 60 minutes. A warm compress also aids vasodilation, and massage has been shown to help. Some experts advocate the use of nitroglycerin paste, although this area is controversial. Introducing an oral aspirin regimen should help prevent further clot formation due to vascular compromise. In our experience, patients who are diagnosed promptly and treated within 24 hours will usually have the best outcomes.

Glans Penis Augmentation Using Hyaluronic Acid Gel as an Injectable Filler

Glans penis augmentation (GPA) has received little attention from experts despite the existence of a subset of patients who may be dissatisfied with a small glans or poor tumescence of the glans during erection. Recently, GPA using an injectable filler or implantation of a graft or filler has been developed. Despite a demanding injection technique and inevitable uneven undulation of the glandular surface, GPA using injectable hyaluronic acid (HA) gel is a novel and useful therapy and an effective and safe procedure for soft tissue enhancement. For long-term presence of implants, timed supplementation can be used similar to that for fascial plasty. In complications such as mucosal necrosis of the glans penis, most cases occur from the use of non-HA gel or an unpurified form and misunderstanding of the management protocol for immediate side effects. Currently, GPA using injectable HA gel is not recommended in the International Society for Sexual Medicine guideline due to possible sensory loss. In a 5-year long-term follow-up of GPA by subcutaneous injection of HA gel, the residual volume of implants decreased by 15% of the maximal glandular circumference, but was still effective for alleviating the hypersensitivity of the glans penis in premature ejaculation patients. For efficacy in premature ejaculation, selection of appropriate candidates is the most important factor for success. GPA does not harm erectile function and is less invasive and irreversible compared to dorsal neurectomy. To refine the procedure, more interest and well-designed studies are required for the establishment of the procedure.

Hyaluronic Acid Filler in HIV-Associated Facial Lipoatrophy: Evaluation of Tissue Distribution and Morphology with MRI

OBJECTIVE

This prospective observational study evaluated magnetic resonance imaging (MRI) findings of hyaluronic acid (HA) injections used for the correction of HIV-associated facial lipoatrophy.

METHODS

Ten consecutive males underwent subdermal HA injection (mean 1.3 ± 0.6 ml per side) and MRI examinations prior to and then 1, 6 and 12 months after injection. Two radiologists blinded to the clinical data assessed morphologic and quantitative changes.

RESULTS

MRI revealed HA deposition in the subdermal and deep fat compartments. A significant HA volume increase was observed 1 month after injection (mean increase 331%, p < 0.0001) as compared to the injected amount. No volume reduction occurred at 12 months (p = 0.9961). The measured bound water content did not change (p > 0.9991), whereas skin thickness and tissue vascularization increased during the first 6 months (p = 0.01).

CONCLUSION

Our data show that the cosmetic results of HA injections are caused by water binding in the deep facial fat and by a transient increase in vascularization and skin thickness.

Anatomic and mechanical considerations in restoring volume of the face with use of hyaluronic acid fillers with a novel layered technique

CONTEXT

Facial fillers have revolutionized the field of cosmetic facial rejuvenation as it has become the prime sought - after rejuvenation procedure offering youthful, 3-dimensional look with minimal invasiveness. Fillers are expensive and need to be redone periodically hence a sound understanding of structural basis on which they are laid is important in reducing the quantity of filler required in each sitting as well as increasing the longevity of results.

AIM

The aim of the following study is to analyse a novel method of facial filling "The pillars pyramids and tie beams (PPT)" technique and its advantages over the conventional methods.

SUBJECTS AND METHODS

A novel technique of injecting the facial fillers was employed on 67 patients visiting our clinic. These patients were followed-up for a period of 3 years.

RESULTS

We observed that the amount of filler material required in initial sitting remains the same, however the frequency of touch up visits is decreased and so is the amount of filler material required for follow-up injections.

CONCLUSION

Facial contour remodelling is being revolutionised by the new filler materials for volume augmentation and no uniform consensus has been reached on the techniques currently used in clinical practice. We advocate this novel PPT technique of facial filling in facial rejuvenation to restore a youthful look as a primary goal.

Clinical data on injectable tissue fillers: a review

Treatment with injectable tissue fillers for aesthetic purposes is increasingly popular. In parallel with this success, questions related to the safety of these treatments and the products involved are being raised more prominently. To gain insight in the safety aspects of injectable tissue fillers, we performed a literature review to collect studies reporting clinical data of injectable tissue fillers. We found several case reports where serious complications after more than three years are described. However, there are only a limited number of well-defined prospective clinical studies available with follow-up periods longer than three years. Furthermore, causes of complications, that is, treatment or product related, are often not specified in literature. Considering the intended functional period of fillers in combination with the known occurrence of long-term complications, there is a need for well-defined prospective clinical studies. In order to be able to discriminate between product failure (a product safety issue) or application methodology (a physician expertise or training issue), better identification of observed complications and whether they are product or treatment related, is needed. For the safe use of the fillers it is important that treatment with injectable tissue fillers is performed by a trained physician, who knows the product specifications and its applications.

Current status of surgery in dermatology

An article titled "Current issues in dermatologic office-based surgery" was published in the JAAD in October 1999 (volume 41, issue 4, pp. 624-634). The article was developed by the Joint American Academy of Dermatology/American Society for Dermatologic Surgery Liaison Committee. A number of subjects were addressed in the article including surgical training program requirements for dermatology residents and selected advances in dermatologic surgery that had been pioneered by dermatologists. The article concluded with sections on credentialing, privileging, and accreditation of office-based surgical facilities. Much has changed since 1999, including more stringent requirements for surgical training during dermatology residency, and the establishment of 57 accredited Procedural Dermatology Fellowship Training Programs. All of these changes have been overseen and approved by the Residency Review Committee for Dermatology and the Accreditation Committee for Graduate Medical Education. The fertile academic environment of academic training programs with interaction between established dermatologic surgeons and fellows, as well as the inquisitive nature of many of our colleagues, has led to the numerous major advances in dermatologic surgery, which are described herein.

Polymethylmethacrylate dermal fillers: evaluation of the systemic toxicity in rats

This study evaluated local and systemic reactions after an intravascular injection of polymethylmethacrylate (PMMA) at two concentrations in a murine model. Thirty rats were divided equally into three groups: 2% PMMA, 30% PMMA, and a control group (normal saline only injection). The filler was injected into the ranine vein. The rats were sedated at 7 and 90 days and a clinical evaluation performed. After euthanasia, the right lung, liver, and right kidney were removed, weighed, and microscopically analyzed. The submandibular lymph nodes and tongue were removed and examined microscopically. Serum was subjected to liver and kidney function tests. No groups showed clinical alterations. Microspheres were not observed at any distant organ. Two samples from the 2% PMMA group showed a local inflammatory response at day 7 and another two samples from the 30% PMMA group at day 90. The group injected with 30% PMMA presented higher levels of alanine aminotransferase (P = 0.047) after 90 days when compared with the other groups. The data obtained in this study demonstrate that intravascular injections of PMMA fillers show potential health risks such as chronic inflammation at the implantation site.

Complications of injectable fillers, part I

Dermal filling has rapidly become one of the most common procedures performed by clinicians worldwide. The vast majority of treatments are successful and patient satisfaction is high. However, complications, both mild and severe, have been reported and result from injection of many different types of dermal fillers. In this Continuing Medical Education review article, the author describes common technical errors, the signs and symptoms of both common and rare complications, and management of sequelae in clear, easily adaptable treatment algorithms.

Complications of facial fillers: resource implications for NHS hospitals

Facial rejuvenation seeks to reverse the negative sequelae of multiple factors but most importantly of genetic predisposition, sun damage and smoking. With the advent of the so-called 'non-surgical' techniques, and perhaps fuelled by these austere times, volumetric facial augmentation using dermal fillers has soared in popularity among both patients and practitioners. However, legislation has yet to keep pace with the change in clinical practices leaving patients poorly informed and with no protection against unscrupulous suppliers and unregulated practitioners. When things go wrong, patients often turn to the National Health Service (NHS) to rectify both the acute and chronic sequelae resulting in potentially difficult ethical and resource implications. Here, we report one of an increasing number of cases presenting to our NHS craniofacial service with acute filler-related complications.

Autoimmune/inflammatory syndrome (ASIA) induced by biomaterials injection other than silicone medical grade

BACKGROUND

Systemic autoimmune/granulomatous adverse reactions related to biomaterials other than silicone have rarely been reported.

AIM

The aim of this paper is to communicate the cases of autoimmune/inflammatory syndrome induced by adjuvants (ASIA) in a study of Spanish patients suffering from inflammatory disorders related to biomaterial injections other than silicone, principally hyaluronic acid, acrylamides or methacrylate compounds.

METHODS

The authors performed a retrospective analysis of the clinical, laboratory, histopathology and follow-up of a cohort of 250 cases of patients suffering from inflammatory/autoimmune disorders related to bioimplant injections.

RESULTS

Of these 250 cases, patients with adverse reactions related to silicone injections (n = 65) were excluded. Of the remaining 185, 15 cases (8%) had systemic or distant and multiple complaints that could be categorized as ASIA. In all but four patients, inflammatory features at the implantation site preceded distant or systemic manifestations. Abnormal blood tests were common. Eleven cases (73.3%) with inflammatory localized nodules and panniculitis evolved into a variety of disorders, namely, primary biliary cirrhosis, Sjögren's syndrome, sarcoidosis, human adjuvant disease and inflammatory polyradiculopathy. Four cases presented primarily with systemic autoimmune disorders.

CONCLUSIONS

Infrequently, biomaterials other than silicone can provoke local inflammatory adverse reactions that may evolve into systemic autoimmune and/or granulomatous disorders. Whether or not these biomaterials act as an adjuvant, they could be included in the ASIA category.

Sharp-needle intradermal fat grafting (SNIF)

BACKGROUND

Reversing the effects of facial aging is best accomplished with a combination of techniques. Minimizing the appearance of fine wrinkles is an essential part of treatment, which can involve resurfacing, intradermal filler injections, or a combination of the two. The quest for the ideal filler material is ongoing, but intradermal fat injections can serve as an inexpensive and safe alternative to classic intradermal fillers.

OBJECTIVES

The aim of this study was to evaluate the feasibility, validity, and safety of the sharp-needle intradermal fat grafting (SNIF) technique.

METHODS

The records of 250 consecutive patients treated over a 3-year period with the authors' SNIF technique were reviewed to evaluate the SNIF technique and its results, including complications.

RESULTS

Results were evaluated by clinical examination and patient photographs. Good improvement was achieved with SNIF, with results lasting more than 1 year, which exceeds the expected duration for resorbable dermal fillers (typically 3 to 6 months). No major complications occurred; the most common minor complications were bruising and swelling.

CONCLUSIONS

SNIF is a safe and effective alternative to classic resorbable dermal fillers for patients who can accept the minor discomfort involved in extracting fat from the donor site. The harvesting and injection techniques should be performed with precision to achieve favorable results and avoid complications.

Fillers: contraindications, side effects and precautions

Fillers are generally considered safe. However side effects may happen and hence a practicing dermatologist need to be aware of such side effects, contraindicatons and precaution to be adopted while using fillers.

Complications related to Artecoll injections for soft tissue augmentation of the hand: 3 case reports

Rejuvenation of the aging hand has gained recent popularity. I report on 3 cases with complications related to the use of Artecoll (a permanent filler composed of polymethylmethacrylate) in soft tissue augmentation of the hand. All 3 patients had late-onset granuloma reactions, and the acute attacks were successfully treated with local injections of triamcinolone. However, recurrent reactions and hypopigmentation at the injection sites were noted.

Expanded median forehead flap and abbé flap for nasal and upper lip reconstruction after complications of polymethylmethacrylate

Despite the benefits from the minimally invasive technique, complications may occur, raising doubts about the safety of polymethylmethacrylate as an injectable filler material. The authors report their treatment of a patient from another institution with necrosis involving full-thickness nasal skin and upper lip after injection of polymethylmethacrylate in the nasolabial folds and nose for augmentation. An expanded median forehead flap was used to reconstruct the nose, and an Abbé flap was used for the upper lip. The flaps and the skin expander allowed reconstruction with correct texture, color, and dimensions, producing a good aesthetic and functional outcome.

The effects of penile girth enhancement using injectable hyaluronic acid gel, a filler

INTRODUCTION

Despites the debates on penile girth enhancement (PGE), demands for enhancement are increasing. Recently, various fillers have been widely used for soft tissue augmentation with proven efficacy and safety.

AIMS

To identify the feasibility and efficacy of PGE by injection of filler.

METHODS

Fifty patients with subjective small penis who visited Korea University Guro outpatient clinic were enrolled and prospectively followed. Restylane Sub-Q (Q-med, Upssala, Sweden) was injected into the fascial layer of penile body via 21G cannula with "Back & Forth Technique" and homogenized with a roller.

MAIN OUTCOME MEASURES

From April 2006 to February 2008, 50 patients were enrolled and 41 patients were followed until 18 months after PGE. Changes in penile girth at midshaft were measured by tapeline at 1 and 18 months. Patient's visual estimation of residual volume (Gr 0-4), patient's satisfaction (Gr 0-4), and any adverse reactions were also evaluated.

RESULTS

Mean injected volume was 20.56 cc (18-22). Compared with basal girth of 7.48 ± 0.35 cm, maximal circumference was significantly increased to 11.41 ± 0.34 cm at 1 month (P < 0.0001) and maintained as 11.26 ± 0.33 cm until 18 months. In patient's visual estimation, two patients complained the decrease as Gr 3 with focal depression at 1 month. At 18 months, all patients answered as Gr 4 without asymmetry. Patient's and partner's satisfaction score was 3.71 ± 0.46 and 3.65 ± 0.48 at 1 month and 3.34 ± 0.53 and 3.38 ± 0.49 at 18 months. There were no inflammatory signs or serious adverse reactions in all cases.

CONCLUSIONS

Considering the property of material, methods, and follow-up results of 18 months, PGE using filler is a very effective and safe technique for penile augmentation.