Managing Complications of Fillers: Rare and Not-So-Rare

Filler found in bone: Surgical removal of polyacrylamide hydrogel (Amazingel) from the mandible after 24 years: A case report and literature review

Polyacrylamide hydrogel (PAAG) is widely regarded as a safe soft tissue filler and has been extensively utilized for cosmetic enhancements, such as breast and facial augmentation in China from 1997 until its ban in 2006. Common complications associated with its use include inflammation, infection, granulomas, fibrosis, gel migration, and facial and soft tissue deformities. This case report describes a 45-year-old Chinese woman who experienced PAAG migration into her mandible 24 years after facial augmentation, causing irritation of the mandibular alveolar nerve - apparently the first documented instance of this occurrence. Surgical intervention was necessary to remove the migrated gel and associated calcifications. A literature review explored adverse events and management strategies for PAAG complications in cosmetic procedures. While generally considered safe, this report underscores the importance of meticulous injection techniques and careful anatomical site selection to prevent such severe complications.

Biocompatibility Study of Purified and Low-Temperature-Sterilized Injectable Collagen for Soft Tissue Repair: Intramuscular Implantation in Rats

The clinical application of collagen-based biomaterials is expanding rapidly, especially in tissue engineering and cosmetics. While oral supplements and injectable skin boosters are popular for enhancing skin health, clinical evidence supporting their effectiveness remains limited. Injectable products show potential in revitalizing skin, but safety concerns persist due to challenges in sterilization and the risk of biological contamination. Traditional methods of sterilization (heat and irradiation) can denature collagen. This study addresses these issues by introducing a novel technique: the double filtration and low-temperature steam sterilization of a collagen gel. In vitro tests documented the sterility and confirmed that the collagen did not show cytotoxicity, degradation, integrity, and viscosity characteristics changes after the processing and sterilization. The collagen gel induced new collagen expression and the proliferation of human dermal fibroblasts when the cells were cultured with the collagen gel. An in vivo study found no adverse effects in rats or significant lesions at the implantation site over 13 weeks. These results suggest that this novel method to process collagen gels is a safe and effective skin booster. Advanced processing methods are likely to mitigate the safety risks associated with injectable collagen products, though further research is needed to validate their biological effectiveness and clinical benefits.

Efficacy and Safety of Fillers for the Treatment of Nasolabial Folds: A Network meta-Analysis of Randomized Controlled Trials

BACKGROUND

Nasolabial fold formation is increasingly becoming a cause of concern for many people. However, no network meta-analysis has compared the efficacy of different fillers in treating nasolabial folds. This network meta-analysis simultaneously compared the efficacy and safety of various fillers.

METHODS

We included randomized controlled trials (RCTs) that used fillers to treat nasolabial folds. We extracted data of Wrinkle Severity Rating Scale (WSRS), Global Esthetic Improvement Scale (GAIS, investigator) scores, GAIS scores (self-reported) and adverse events.

RESULTS

We included 13 RCTs. WSRS scores at 6 months were higher in patients receiving HA than those receiving poly (L-lactic acid) (mean difference [MD] 0.630, 95% confidence interval [CI] 0.275, 0.985) but significantly lower in patients receiving HA than in those receiving bovine collagen (MD - 0.580, 95% CI - 0.777, - 0.383) and porcine collagen (MD - 0.525, 95% CI - 0.790, - 0.260). Regarding adverse events, HA was significantly less likely to cause nodule formation compared with bovine collagen (RR 0.593, 95% CI 0.438, 0.803).

CONCLUSION

HA is a safe filler for correcting nasolabial folds, and poly (L-lactic acid) showed potential in treating nasolabial folds.

LEVEL OF EVIDENCE I

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

Depth of the subcutaneous tissue in the nose: Application to filler injection

INTRODUCTION

The nasal region plays a pivotal role in both facial esthetics and functionality. The use of volumizing fillers has emerged as a potential means to enhance nasal appearance. Preliminary findings from cadaveric studies have highlighted potential risks associated with deeper needle injection, leading to cartilage damage and lateral migration of filler material. Understanding the subcutaneous tissue depth is crucial to prevent such complications and ensure safe filler placement guided by anatomical knowledge.

METHODS

This study aimed to employ ultrasonographic assessment to precisely measure the depth of soft tissue in the nasal area. Fifty-two participants without prior nasal surgery or filler injections underwent detailed ultrasonographic evaluation, focusing on seven key anatomical points: Glabellar, Sellion, Rhinion, between Rhinion and Pronasal, Pronasal, between Pronasal and Subnasal, and Subnasal.

RESULTS

The ultrasonographic observation revealed varying depths of subcutaneous tissue across these points: Glabellar (4.11 ± 0.79), Sellion (5.21 ± 0.97), Rhinion (2.02 ± 0.74), Rhinion to Pronasal midpoint (6.45 ± 3.1), Pronasal (9.5 ± 2.2), between Pronasal and Subnasal (8.8 ± 0.8), and Subnasal (8.5 ± 0.5).

DISCUSSION

The discussion underscores the significance of understanding subcutaneous tissue depth in guiding needle length and approach angles during filler injections. This knowledge aids in achieving effective filling while ensuring safe placement within the subcutaneous tissue.

The emerging topic of injected cosmetic fillers in the perinasal region of dromedary camels: ultrasonographic and radiographic verification

Background

Dermal cosmetic fillers have been commonly used in camels in the last few years in Gulf countries.

Aim

This study aimed to describe the radiographic as well as sonographic findings of injected cosmetic fillers in Arabian camel perinasal region in beauty shows.

Methods

A total number of (n = 11,626) Arabian camels (Camelus dromedarius) were thoroughly investigated for injection of cosmetic fillers in the perinasal area. The age of the camels was 6 months to 10 years, and their weights were 400-650 kg. In parallel, a control group consisting of 30 age/weight-matched non-injected camels was used. Of the 11,626 examined camels, 25 animals (0.0.002%) were injected with cosmetic fillers in the perinasal region. Of the 25 camels, 19 (76%) were females and 6 (24%) were males. Radiographic examinations were carried out for the 25 injected camel perinasal regions.

Results

Ultrasonographic examination of the injected perinasal regions revealed precise discrimination of the filler material, which appeared hypo-echogenic in 17 camels (68%) and with anechoic spots in the remaining 8 camels (32%). Variable degrees of swelling caused by the injection of moderate and large quantities of fillers were noted by radiographic assessment, the injected cosmetic filler was precisely diagnosed in the perinasal region as grey in color having soft tissue density in obtained radiographs.

Conclusion

In conclusion, radiographic and ultrasonographic examinations are reliable, accurate, and non-invasive diagnostic imaging techniques that can precisely discriminate a filler agent in the soft tissues and determine the situ and size of cutaneous deposits in dromedary camels (C. dromedarius).

Post-Hyaluronic Acid Recurrent Eyelid Edema: Pathophysiologic Mechanisms and a Proposed Treatment Protocol

Background

Hyaluronic acid (HA) filler injections for facial augmentation are commonly administered but can lead to post-hyaluronic acid recurrent eyelid edema (PHAREE). The pathophysiology of this condition has not been fully understood.

Objectives

To report the successful treatment of PHAREE using serial hyaluronidase and fractionated radiofrequency microneedling, with additional carbon dioxide laser skin resurfacing in selected patients.

Methods

Five patients with PHAREE were treated with serial hyaluronidase injections and fractionated radiofrequency microneedling, with 2 patients receiving carbon dioxide laser treatment. The patients were followed up for a minimum of 24 months.

Results

All patients reported a resolution of PHAREE signs/symptoms with no adverse effects or recurrence. One patient demonstrated complete resolution after a single treatment; 4 required a series of treatments.

Conclusions

The proposed treatment protocol may provide advantages over hyaluronidase alone for PHAREE. The impermeable malar septum, vulnerable eyelid lymphatics, and potential immunogenicity of HA fragments likely contribute to PHAREE pathophysiology. Further research on pathophysiologic mechanisms is warranted.

Level of Evidence 4

Is constant needle motion during soft tissue filler injections a safer procedure? A theoretical mathematical model for evaluating patient safety

BACKGROUND

The safety rationale behind the constant needle motion injection technique is based on the assumption that due to the constant needle motion and simultaneous soft tissue filler material administration a smaller amount of product per area may be injected into an artery if an artery within the range of the moving needle is inadvertently entered.

OBJECTIVE

To perform mathematical calculations for determining the probability for causing intra-arterial product administration when constantly moving the needle during facial aesthetic soft tissue filler injections.

METHODS

This study was designed as a theoretical investigation into the probabilities for causing adverse events due to intravascular injection of soft tissue filler material when constantly moving a 27-G needle during facial soft tissue filler administration.

RESULTS

It was revealed that with a higher number of conducted injection passes a greater soft tissue area can be covered by the needle. The odds of encountering an artery within the covered soft tissue volume and the odds of injecting any volume greater than zero into the arterial blood stream increases with the number of performed injection passes. This increase is greatest between 1 and 10 performed injection passes.

CONCLUSION

This model demonstrates that the constant needle motion technique increases the probability of encountering an artery within the treatment area and thus increases the odds for intra-arterial product administration. The constant needle motion technique does not increase safety but rather may increase the odds of causing intra-arterial product administration with the respective adverse consequences for the patient.

Adverse Events Reported From Hyaluronic Acid Dermal Filler Injections to the Facial Region: A Systematic Review and Meta-Analysis

Dermal filler injections are one of the most popular cosmetic procedures in the United States. Of the many options available, hyaluronic acid (HA) dermal fillers like Juvederm or Restylane are often used. Despite their use and popularity, adverse events are known to occur from these procedures. Although most outcomes may be mild and resolve over time, rare instances of severe complications cannot be ignored, as these effects may be irreversible. Healthcare practitioners and patients must be aware of these risks, as these cosmetic procedures can affect the patient's quality of life. The aim of this study was to evaluate the incidence of adverse events (AEs) reported from the use of hyaluronic acid dermal fillers in the facial region. A systemized search of randomized controlled trials was conducted using Cochrane Central, Embase, Medical Literature Analysis and Retrieval System Online (MEDLINE), and the Web of Science databases. After screening for eligibility and conducting a critical appraisal of the articles, 19 studies were retained for the final review. The meta-analysis results included different side effects by facial location, i.e., nasolabial fold (NLF) vs. other (midface, perioral line, and lip region). The midface includes the anteromedial cheek region, the zygomaticomalar region, and the submalar region. The adverse events were swelling, pain, erythema, bruising, lumps and bumps, firmness, tenderness, itching, and skin discoloration. A significant difference was found in the proportion of individuals experiencing swelling, lumps or bumps, and firmness at the nasolabial fold site versus the midface, perioral line, and lip region. There was no significant difference in the proportion of individuals experiencing pain, erythema, bruising, tenderness, itching, or skin discoloration at the nasolabial fold site versus the other sites. The study highlights the prevalence of common AEs that can result from HA dermal fillers like Juvederm or Restylane, thus emphasizing the importance of healthcare professionals explaining the risk and benefits to patients.

Hyperbaric oxygenation therapy improve recovery in early or late vascular occlusion generates by tissue fillers

INTRODUCTION

Aesthetic medicine is characterized by the efficacy and safety of treatments. Although sometimes adverse events could be occurred, in this case vascular occlusion is the most serious of them. The tissue is deprived of oxygen and there is a possibility of necrosis, so it is necessary to remove the tissue filler and promote oxygenation.

OBJECTIVE

We propose the hyperbaric oxygenation treatment to oxygenate the tissue after vascular occlusion generated by a tissue filler such as Hyaluronic Acid.

RESULTS

We show how hyperbaric oxygenation treatment is an adjuvant therapy after vascular occlusion, improving tissue regeneration and prevent or limit scars or sequelae.

CONCLUSION

Hyperbaric oxygenation treatment is a safe and effective method to treat vascular accident, improving tissue oxygenation in early cases and improving tissue regeneration in cases with necrosis.

Efficacy of injecting hybrid cooperative complexes of hyaluronic acid for the treatment of vulvar lichen sclerosus: A preliminary study

BACKGROUND

Lichen sclerosus is a chronic relapsing inflammatory skin disease, which involves most commonly the anogenital region. The gold standard in treatment is ultra-potent topical steroids (clobetasol propionate): it aims at controlling the symptoms, stopping further scarring and distortion, and reducing the risk of cancer.

OBJECTIVES

The aim of this preliminary study is to evaluate the efficacy of injecting Hybrid Cooperative Complexes of Hyaluronic Acid (HCC) for the treatment of vulvar lichen sclerosus (VLS).

METHODS

Twenty female adult patients (range: 21-78 years), aged over 18, with histopathological diagnosis of lichen sclerosus and good general conditions were enrolled. Patients underwent HCC infiltration every month, for 3 times. Patients were evaluated at baseline (T0) and after one (T1) and six months (T2) after treatment. During every visit, each patient was studied clinically and with videothermography. Itching, burning sensation, pain, and dyspareunia were reported by patients at T0, T1, and T2. The effectiveness of the treatment on patients' quality of life and sexual function was evaluated using the Dermatology Life Quality Index (DLQI) and the Female Sexual Function Index (FSFI) at T0 and at T2.

RESULTS

The results of this preliminary study are very promising, in fact, all patients had a significant reduction in most symptoms after 1 and 6 months of HCC treatment. The reduction of patients with itching (p value ≤ 0.001), pain (p value = 0.031), and burning sensation (p = 0.004) at 6 months is significant. The analysis of DLQI scores revealed a significant improvement in patients' quality of life. At baseline, the average score of DLQI (±SD) was 5.89 ± 3.68 while at follow-up it was 3.42 ± 2.36 (p = 0.002).

CONCLUSIONS

Our preliminary study has demonstrated the validity and tolerability of HCC infiltrations in patients with VLS, and the effectiveness of HCC in reducing symptoms and, thus, to improve sexuality and patient quality of life.

Injection mammoplasty: Normal imaging appearances, complications, and implications for mammographic screening

BACKGROUND

The normal imaging appearances of the common agents used in injection mammoplasty and the challenges of mammography screening will be reviewed.

METHODS

The local database from a tertiary hospital was accessed for imaging cases of injection mammoplasty.

RESULTS

Free silicone is seen as multiple high-density opacities on mammograms. Silicone deposits can often be seen within axillary nodes due to lymphatic migration. Sonographically, a snowstorm appearance is seen when the silicone is diffusely distributed. On MRI, free silicone is hypointense on T1-weighted and hyperintense on T2-weighted images, with no contrast enhancement. Mammograms have a limited role in screening due to the high density of silicone. MRI is often required in these patients.Polyacrylamide gel and hyaluronic acid are seen as multiple collections on mammography. Polyacrylamide gel collections are of the same density as cysts, while hyaluronic acid collections are of higher density but less dense than silicone. On ultrasound, both can appear anechoic or show variable internal echoes. MRI demonstrates fluid signal with hypointense T1-weighted and hyperintense T2-weighted signal. Mammographic screening is possible if the injected material is located predominantly in the retro-glandular space without obscuring the breast parenchyma.On mammograms, autologous fat locules appear as lucent masses. Rim calcification can be seen if fat necrosis had developed. On ultrasound, focal fat collections can demonstrate varying levels of internal echogenicity, depending on the stage of fat necrosis. Mammographic screening is usually possible for patients after autologous fat injection as fat is hypodense compared to breast parenchyma. However, the dystrophic calcification associated with fat necrosis may mimic abnormal breast calcification. In such cases, MRI can be utilized as a problem-solving tool.

CONCLUSION

It is important for the radiologist to recognize the type of injected material on the various imaging modalities and recommend the best modality for screening.

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 .

Ultrasound-assisted management of filler-related complications: Report of a successful treatment of delayed-onset nodules related to polycaprolactone-based filler

A 60-year-old woman underwent polycaprolactone-based filler injection in her midface. Four months later, she developed progressive swelling of midface after a self-limiting viral gastroenteritis. The diagnosis was "delayed-onset immune-mediated nodule formation triggered by a virus." Ultrasonography enabled us to efficiently treat her with a tailored intralesional corticosteroid injection method.

Expert recommendations on the assessment and management of complications due to hyaluronic acid soft tissue filler injections in Asians

BACKGROUND

The use of hyaluronic acid (HA) fillers for medical aesthetic purposes is increasing worldwide. Nonetheless, adverse events do occur because of patient-specific issues, injection technique, or product factors. It would be mandatory to consider cultural and anatomical features of Asians in preventing and managing the complications of HA injections.

METHODS

Literature search of studies looking at current evidence and guidelines on the management of complications following HA filler injections in Asian patients was conducted. This was followed by an expert group discussion that was convened to reach consensus recommendations on the best clinical practices.

RESULTS

The expert panel provided specific recommendations focusing on the safe use of soft tissue fillers in Asian patients, including early identification of adverse events and how to prevent and comprehensively manage these outcomes.

CONCLUSIONS

Here, we provide consensus statements of Asian experts in dermatology, plastic surgery, ophthalmology, and aesthetic medicine mainly focusing on AEs with higher risk for Asians and can be used to guide physicians in treating Asian population.

In vitro and in vivo methods to study bacterial colonization of hydrogel dermal fillers

Preclinical in vitro and in vivo methods to study bacterial interactions with dermal fillers and infection pathogenesis are lacking. In this work, first in vitro methods to assess protein biofouling and effective pore size of commercial dermal fillers, including degradable hyaluronic acid (HA)-based fillers and other semi-degradable or permanent fillers (non-HA), were developed. The results were then related to Staphylococcus aureus (S. aureus) adhesion rates in vitro. HA fillers had less protein sorption than non-HA fillers and overall had smaller effective pore sizes. The properties correlated with levels of bacterial adhesion, where the control glass surface had the most rapid increase in bacterial cell adhesion, with a slope of 0.29 cm^-2  min^-1 , three unique non-HA fillers had intermediate adhesion with slopes of 0.11 and 0.06 cm^-2  min^-1 , and three unique HA fillers had the least adhesion with slopes of 0.02, 0.02, and 0.01 cm^-2  min^-1 . S. aureus had greater motility on the HA fillers than on non-HA fillers. Next, a mouse model for dermal filler biofilm and infection was developed. Mice were inoculated with a controlled amount of bioluminescent bacteria (Xen36 S. aureus) and polyacrylamide hydrogels of different stiffness were injected. In vivo bioluminescence was monitored longitudinally for 35 days to ensure that lasting colonization was established. The inoculum was optimized to achieve adequate bioluminescent signal, and bacterial bioburden over time and inter-animal variability in bioburden were determined. These in vitro and in vivo approaches can be used for future studies of antimicrobial interventions for dermal fillers.

The Quality of Online Information on Cosmetic Injectable Fillers: Current Status

Web-based health information plays an increasingly vital role in spreading health information. Many patients interested in aesthetic surgery study the procedure on the Internet. This study aims to evaluate the quality of online health information on injectable fillers using the modified "Ensuring Quality Information for Patients" (EQIP) tool. Nine different search terms, including "fillers," "fuller cheeks," "wrinkle removal," and "antiwrinkle treatment" were identified and queried on Google. Unique links from the first three pages of each search term were identified and evaluated if the contents were in English language and were for general non-medical public use. A total of 172 websites were analyzed, with a median EQIP score of 20. In total 129 websites belonged to aesthetic practitioners, of which 81 were operated by medical doctors. Eighty-three percent of websites disclosed some forms of postoperative complications, most commonly edema (74%) and bruising (73%). Blindness and tissue necrosis were only mentioned by 12 and 10% of the websites, respectively. The current health information available on injectable fillers is of poor quality. While many do provide some information on risks, the majority of websites fail to disclose severe complications and quantifying risks. This poses a barrier against informed decision-making and may lead to unrealistic expectations. Patient satisfaction and expectations may be improved by developing better online education resources on fillers.

99mTc-MDP Bone Scintigraphy and SPECT/CT of Extensive Subcutaneous Calcification in the Setting of Cosmetic-Induced Lipogranulomatosis

ABSTRACT

A 56-year-old woman with history of cosmetic buttock augmentation via mineral oil injection 20+ years ago presented with extensive abdominopelvic skin induration and hypercalcemia. The 99mTc-MDP bone scintigraphy performed for hypercalcemia revealed marked heterogeneous radiotracer activity partially obscuring the skeleton. Subsequent SPECT/CT demonstrated that the radiotracer activity was associated with exclusively subcutaneous calcification, the extent of which far exceeded the originally augmented gluteal regions. After extensive workup including tissue biopsy, the final diagnosis was subcutaneous calcification and hypercalcemia secondary to cosmetic injection-related sclerosing lipogranulomatosis, which is a very rare complication of cosmetic augmentation.

Hyperbaric Oxygen Therapy in Managing Minimally Invasive Aesthetic Procedure Complications: A Report of Three Cases

Introduction

Minimally invasive aesthetic procedures such as filler injections and thread lifts have gained popularity recently. Complications from these aesthetic procedures are difficult to avoid. This increasing public health concern requires a combination of effective therapeutic modalities. Hyperbaric oxygen therapy (HBOT) has generated favorable results in treating a diversity of wounds, inflammation, and infection.

Case Presentations

Three cases with complications arising from aesthetic procedures were described in this report. The patients were all female, with ages ranging from the late-twenties to mid-fifties. Two patients experienced complications from filler injections, one of which progressed to a parotid gland infection due to a placental extract filler while the other was caused by a hyaluronic acid filler. The third patient had notable excoriations and inflammation on both cheeks following a thread lift procedure. Alongside antibiotics and other symptomatic therapies, the patients received multiple, 90-minute HBOT sessions at 2.4 ATA over the course of one to two weeks. The wounds were frequently monitored to evaluate the healing progress.

Discussion

Complications from facial rejuvenation procedures can be disastrous. They expose the patient to the risk of developing vascular occlusions and skin infections that require prompt and effective treatment. Multiple treatment options (eg, frequently massaging the affected area, warm compresses, aspirin, and antibiotics) have been used to treat these complications. HBOT serves a valuable purpose in restoring adequate tissue perfusion in cases of filler-induced vascular occlusion and infection. Moreover, HBOT assists in restoring tissue injury and reducing inflammation following thread lift procedures.

Conclusion

HBOT has proven helpful as a treatment adjunct toward counteracting the effects of minimally invasive aesthetic procedures in several cosmetic-related cases.

Puzzle Facelift: A non-surgical, whole treatment for facial modelling and rejuvenation

The assessment of correct anatomy of face and the evaluation of the dynamic interplay between anatomy and function, in order to get an overall improvement, is a leading topic in aesthetic surgery and has increased its impact in the recent years. A non-surgical impact technique reduces both post-treatment discomfort and the overall cost. Obtaining the simultaneous correction in forehead, nose, lips and chin means obtaining an overall improvement in face view. Likewise, the high predictability of the procedure and the absence of alloplastic implant, bone re-absorption and scars have to be considered in non-surgical aesthetic medicine. In conclusion, a single-session of profile correction using HA filler should be proposed to patient, every time the aesthetic practitioner sees a coexistence of forehead, nose lips and chin defects.

Botox and dermal fillers in orthodontics – A review

Botulinum toxin and derma fillers have made their way into dentistry in recent years for both cosmetic and medicinal purposes. They are here to stay, and with more and more intraoral applications, they are quickly becoming a standard element of dental treatment. They offer the most important, minimally invasive procedures at a cheap cost and with little to no downtime. Botox and derma fillers are used together for rejuvenation and esthetic operations nowadays. The mechanism of action and numerous uses of Botox and derma fillers in the maxillofacial areas, as well as their future implications in dentistry are discussed in this article.

A New Approach for Lip Filler Injection Using an Inverted Mercedes Benz Sign

Lip fillers have a great impact on the facial aesthetic industry, where several techniques have been proposed for lip beautification in terms of both the results and delivering a safe injection procedure. The study aimed to report a personal experience with a new lip filler technique, via inserting a microcannula through three entry points, resembling an inverted Mercedes Benz sign. Ten female patients between 22 and 29 years of age had a lip filler treatment with a cross-linked hyaluronic acid injected using a microcannula through two entry points at both Glogau-Klein points of the upper lip and one entry point at the midline of the lower lip. The filler product was deposited in both retrograde and aliquots fashion in the superficial muscular plane. All patients reported a high degree of satisfaction with the results of the procedure, with slight swelling and bruising transiently present in some of the patients. Unlike the conventional cannula technique, this new technique offers artistry in accentuating the cupid’s bow and redrawing the lips.

A Safe and Effective Lip Augmentation Method: The Step-by-Step Φ (Phi) Technique

The shape and fullness of the lips are essential in facial aesthetics. We describe a safe injection technique of hyaluronic acid (HA), based on the well-known golden number Φ (phi), for lip augmentation.

Quantitative magnetic resonance imaging: differentiating soft tissue implants and fillers used in cosmetic and reconstructive surgery

OBJECTIVE

To evaluate the value of synthetic magnetic resonance imaging (MRI) and T2 mapping in distinguishing between different types of fillers in soft tissues.

MATERIALS AND METHODS

Ex vivo fillers of buttock soft tissues (silicone, collagen, and different types of hyaluronic acid) were scanned using a synthetic MRI sequence at 1.5 and 3 T and an optimized T2 mapping sequence to measure the T2 relaxation times of the fillers ex vivo. Three patients addressed to assess complications with buttock fillers underwent MRI with the standard morphological sequences and an additional synthetic MRI sequence; T2 mapping was not performed for the patients. Two patients had silicone fillers, whereas the exact filler composition for the third patient was unknown.

RESULTS

Measurements of T1 and T2 relaxation times of ex vivo fillers at 1.5 and 3 T using synthetic MRI showed that the silicone, collagen, and hyaluronic acid had distinct relaxation time characteristics. In vivo, the synthetic MRI correctly identified silicone in the two patients with known silicone fillers, showing low T1 and T2 values, whereas in the third patient with an unknown filler type, the synthetic MRI suggested a collagen filler, with intermediate relaxation time values.

CONCLUSION

Quantitative sequences have the potential to differentiate between filler types in a noninvasive fashion.

Collagen-Based Materials Modified by Phenolic Acids-A Review

Collagen-based biomaterials constitute one of the most widely studied types of materials for biomedical applications. Low thermal and mechanical parameters are the main disadvantages of such structures. Moreover, they present low stability in the case of degradation by collagenase. To improve the properties of collagen-based materials, different types of cross-linkers have been researched. In recent years, phenolic acids have been studied as collagen modifiers. Mainly, tannic acid has been tested for collagen modification as it interacts with a polymeric chain by strong hydrogen bonds. When compared to pure collagen, such complexes show both antimicrobial activity and improved physicochemical properties. Less research reporting on other phenolic acids has been published. This review is a summary of the present knowledge about phenolic acids (e.g., tannic, ferulic, gallic, and caffeic acid) application as collagen cross-linkers. The studies concerning collagen-based materials with phenolic acids are summarized and discussed.

Non surgical facial reshaping using MD Codes

BACKGROUND

Both age-related and congenital volume deficiencies may be addressed through the injection of hyaluronic acid (HA) fillers. Deep injection provides structural support, more superficial fat-tissue injection mediates contouring, and superficial intradermal use of HA filler and/or onabotulinumtoxinA may be used for refinement.

AIMS

To evaluate the clinical efficacy, patient satisfaction, and safety of the MD Codes approach as a proposed standardized methodology for full-face rejuvenation.

METHODS

This was a retrospective, single-center study of 250 consecutive adult patients undergoing full-face rejuvenation with HA fillers (Vycross) and onabotulinumtoxinA based on the MD Codes approach.

RESULTS

The mean age was 39.4 ± 11.6 years, and 80.4% were female. All patients were treated with HA filler in the midface; 89.6% were also treated in the upper face, and 63.2% in the lower face. The mean number of syringes used was 14 ± 4 (range 4-25), with more syringes typically required in older versus younger patients. All patients received onabotulinumtoxinA treatment. Mean FACE-Q Appearance-Related Psychosocial Distress score decreased from 54.3 ± 9.3 pretreatment to 36.1 ± 8.9 at 3 months post-treatment (P < .05). The most common complications were bruising (35.2%), transient soft-tissue edema (14.0%), and prolonged periorbital edema (3.6%).

CONCLUSIONS

Full-face rejuvenation based on the MD Codes approach provides significant esthetic improvements, with no major safety issues observed.

Global Approaches to the Prevention and Management of Delayed-onset Adverse Reactions with Hyaluronic Acid-based Fillers

BACKGROUND

Delayed-onset adverse reactions to hyaluronic acid (HA) fillers are uncommon but have received increased attention, particularly with regard to late-onset nodules. Globally, there is a need for comprehensive prevention and management strategies.

METHODS

Experts with clinical practices in diverse regions of the world and extensive experience in managing complications related to HA fillers convened to propose and evaluate approaches to prevent delayed-onset adverse reactions after HA filler administration and manage late-onset nodules.

RESULTS

The expert panel agreed to define delayed-onset adverse reactions as those presenting more than 4 weeks posttreatment, with swelling, induration, and nodulation being the most common clinical signs. The panel recommended 5 general key approaches for the prevention of delayed-onset reactions (patient selection, anatomic location of injection/product selection, aseptic technique, injection procedure/filler, and posttreatment care). Strategies recommended for managing late-onset nodules included oral antibiotics, oral steroids, nonsteroidal anti-inflammatory drugs if needed, hyaluronidase for noninflammatory nodules (recognizing the limitations and regional availability of this treatment), intralesional antibiotics, intralesional immunosuppressive drugs such as steroids and fluorouracil, and surgical excision as a last resort. The panel noted that late-onset nodules may vary in both clinical presentation and etiology, making them challenging to address or prevent, and stressed individualized treatment based on clinical presentation. Regional differences in aseptic protocols, antibiotic selection, and steroid formulations were described.

CONCLUSION

Insights from global experts on approaches to prevent and manage delayed-onset adverse reactions following HA filler administration, including late-onset nodules, support clinicians worldwide in optimizing patient outcomes and safety.

Dermal fillers do not induce upregulation of NLRP3 inflammasomes or expression of inflammatory cytokines in granulomas

BACKGROUND

Filling materials have increasingly been used in aesthetics over the last decades. Understanding the pathophysiology of granuloma formation as a very relevant unwanted side effect of filler application may be essential to help avoid these adverse events.

AIMS

Our aim was to investigate the role of the inflammasome in the formation of filler granuloma, as a central column of the innate immune response.

METHODS

RPMI 1640 medium was used for growth of THP-1 cells and the induction of THP-1 macrophages. Sonication was applied in order to crush the acrylic particles of the filler. ELISA was the method of analysis for the specific cytokines. Biopsy specimens of filler granuloma were analyzed by various immunohistochemical methods. GraphPad Prism 5 software was used for the statistical data analysis.

RESULTS

Neither was the sensor NALP3 overexpressed, nor could an elevated expression of cleaved IL-1β, IL-18, or IFN-γ be detected. Furthermore, no increased expression of IL-8 or IL-1β was detectable in vitro.

CONCLUSION

No increased inflammasome activation could be observed; however, filler granulomas were infiltrated with granulocytes and macrophages. Therefore, we speculate that an unspecific immune response might be the key player in the formation of filler granuloma.

Non-infectious granulomatous dermatoses

Granulomatous dermatoses comprise a wide range of etiologically and clinically distinct skin diseases that share a common histology characterized by the accumulation of histiocytes include macrophages. While the pathogenesis of these disorders is not fully understood, the underlying mechanism is thought to involve a reaction pattern caused by an immunogenic stimulus. Antigen-presenting cells and the effect of various cytokines play a key role. Our understanding of granulomatous reaction patterns has been advanced by insights drawn from observations of such reactions in patients on immunomodulatory therapy and in individuals with genetic immunodeficiency. Traditionally, a distinction is made between infectious and non-infectious granulomatous dermatoses. The present CME article addresses granulomatous skin diseases for which there is no evidence of a causative infectious agent. Common representatives include granuloma annulare, necrobiosis lipoidica and cutaneous sarcoidosis. Granulomatous dermatoses may be part of the clinical spectrum of various systemic disorders or may be associated therewith. Some neoplastic disorders may mimic granulomatous dermatoses histologically. Given the pathogenetic diversity involved, the clinical presentation, too, is quite varied. Overall, however, each disorder is characterized by typical clinical features. The diagnosis always requires thorough clinicopathologic correlation. Treatment is preferably based on the underlying pathogenesis and frequently involves anti-inflammatory agents. In most cases, however, there is insufficient study data. The dermal nature of these disorders frequently poses a therapeutic challenge, especially with respect to topical treatment.

Persistent collection of antibiotic ointment masquerading as a lipoma arising at a surgical site

Antibiotic ointments are often used to treat or prevent infections in surgical wounds. However, due to a dearth of reports on adverse effects, the complications of the use of such ointments, especially possible long-term effects, are largely unknown. We experienced a unique case of a cystic lesion that developed after surgical site infection treated with gentamicin ointment in a 62-year-old man who underwent subtotal glossectomy for tongue cancer. The antibiotic ointment that was applied following abscess drainage remained there, replacing the abscess cavity and forming an oval mass. The lesion was found incidentally on follow-up MR examination to monitor cancer recurrence. On both T1- and T2-weighted images, it showed high-intensity reflecting oily base material, constituting the ointment, which appeared to be a fat-containing tumor such as a lipoma that had arisen at the surgical site. Echo-guided drainage extracted the ointment, which was seemingly unaltered from the time it was applied 11 months before. We describe the clinical course and imaging findings to acknowledge this potential adverse effect associated with topical antibiotic treatment for surgical site infection.

A Cross-sectional Analysis of Adverse Events and Litigation for Injectable Fillers

Importance

Injectable fillers are increasing in popularity as a noninvasive option to address concerns related to facial aging and volume loss. To our knowledge, there have been no large-scale analyses of adverse events and associated litigation related to filler injections.

Objectives

To determine risks of injectable fillers and analyze factors raised in litigation related to injectable fillers.

Design, Setting, and Participants

In this cross-sectional review, the US Food and Drug Administration's (FDA) manufacturer and user facility device experience (MAUDE) database was evaluated for complications from the use of the following fillers: Juvederm, Restylane, Belotero, Sculptra, Radiesse, Artefill, Bellafill, and Juvederm Voluma from 2014 to 2016. The Westlaw Next database was used to identify jury verdicts.

Main Outcomes and Measures

Complications were organized by type of filler used, location of injection, and severity. Intra-arterial injections without sequelae and those resulting in blindness or necrosis were considered severe complications. Factors raised during the litigation process were also analyzed.

Results

Of 1748 adverse events analyzed, most cases stemmed from cheek (751 [43.0%]) or lip (524 [30.0%]) injection. Commonly reported adverse events reported included swelling (755 [43.2%]) and infection (725 [41.5%]). Among FDA-reported complications, blindness was significantly associated with dorsal nasal injections (P < .001). Vascular compromise with and without sequela of dermal necrosis and blindness were significantly associated with Radiesse injections P < .001. Of the 9 malpractice cases identified, two-thirds involved allegations of inadequate informed consent, and the median award in cases resolved with payment was $262 000.

Conclusions and Relevance

Although specific complication profiles vary by material and injection site, common adverse events associated with injectable fillers include swelling and infection. More serious events include vascular compromise, resulting in necrosis and blindness; these events are also raised in cases involving litigation. This analysis illustrates the importance of outlining these risks in a comprehensive preoperative informed consent process.

Level of Evidence

NA.

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.

Ocular and cerebral infarction from periocular filler injection

A 20-year-old woman presented with loss of vision in her right eye and a "black nose" after receiving hyaluronic acid filler injections in her right glabella 1 month prior. Her vision was no light perception, and external examination revealed resolving skin necrosis at the nasal tip. A dilated fundus exam showed a fibrotic membrane emanating from a pale optic nerve and a diffusely atrophic retina with sclerotic vessels. An MRI demonstrated scattered right-sided parietal lobe infarcts. These findings were consistent with inadvertent cannulation of the supraorbital artery, followed by injection of filler into the internal carotid circulation. The product traveled in a retrograde fashion, occluding the right ophthalmic artery, right dorsal nasal artery, and arterial segments to the Circle of Willis. This case highlights the importance of understanding the complex vascular architecture of the periorbita and the mechanism by which such occlusions occur.

Self Injection of Topical Skin Preparation by Patient Seeking Facial Volume Enhancement: A Case Report

A 25-year-old man seeking increased prominence of the cheeks self-injected a topical skin preparation containing hyaluronic acid into his malar soft tissues. Labeling and marketing of the product, which highlighted the hyaluronic acid as one of the ingredients, might have contributed to his misunderstanding of the intended use for the product. Additionally, a popular medical-based talk show and numerous videos online contributed to the errant belief that self-administration was a viable option. Complications from the injection of nonpharmaceutical substances of this type and implications for treatment in clinical practice are discussed.

Soft-tissue Filler-associated Blindness: A Systematic Review of Case Reports and Case Series

BACKGROUND

With the increase in the use of soft-tissue fillers worldwide, there has been a rise in the serious adverse events such as vascular compromise and blindness. This article aims to review the role of fillers in causing blindness and the association between hyaluronic acid (HA) filler and blindness.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were used to report this review.

RESULTS

A total of 190 cases of blindness due to soft-tissue fillers were identified, of which 90 (47%) cases were attributed to autologous fat alone, and 53 (28%) cases were caused by HA. The rest of the cases were attributed to collagen, calcium hydroxylapatite, and other fillers.

CONCLUSIONS

Autologous fat was the most common filler associated with blindness despite HA fillers being the most commonly used across the globe. However, the blindness caused by other soft-tissue fillers like collagen and calcium hydroxylapatite was represented. It was also evident through the review that the treatment of HA-related blindness was likely to have better outcomes compared with other fillers due to hyaluronidase use.

Another face of dermal fillers

Potential complications related to dermal fillers depend on the type of the fillers and the site of their application. The classification of dermal filler complications can be divided into early and late, and into minor and major events. According to their mechanism, they can be divided into non-ischaemic and ischaemic complications. The aim of this study is to present possible complications related to dermal fillers, to explain their aetiology and to propose preventive management and treatment. Non-ischaemic complications can be technique-dependent and include the reactions at the site of the injection, contour irregularities, and inflammatory and infectious reactions. They are usually resolved as a matter of course after 2-7 days. Arterial or venous occlusion leads to ischemia, with subsequent necrosis of the skin and/or vision loss.

The Successful Mechanical Lipectomy Treatment of Cerebral Fat Embolism following Autologous Fat Injection

Autologous fat injection is becoming a more and more widely accepted procedure in plastic surgery nowadays. Concomitantly, there are many complications. The most serious one is arterial fat embolism, for which there is only poor prognosis and no effective treatment. Here, we report the first case of successful treatment of cerebral fat embolization with the help of mechanical lipectomy. Our patient was found unconscious with left-sided hemiparesis after a facial fat injection surgery 4 hours before. Cerebral artery computed tomography angiography indicated it was multiple fat embolism. Then Solitaire stent (4 × 20 mm) and Solumbra (continuously negative pressure attraction) were utilized for the mechanical extraction of fat emboli. The patient recovered from left-side hemiparesis to muscle strength of Medical Research Council scale grade 4, and National Institutes of Health Stroke Scale score was 0 after 3 months visit. In the cerebral infarction after fat transplantation, mechanical lipectomy can be a novel and significant treatment.

Simplifying Injectables for Volumetric Rejuvenation of Face

Volumetric rejuvenation with fillers is a minimally invasive technique used for facial volume restoration. Volume restoration demands adequate knowledge of fat pads and vascularity of the face and the understanding of the depletion patterns. Volumetric restoration with injectable has witnessed a paradigm shift in the last decade with a global rejuvenation, acquiring a predominant emphasis over focal wrinkle filling to restore the depletion pattern of facial fat layers. The techniques used to achieve optimal restoration of facial volume revolve around zonal lifting and tenting, and the impact of treatment on one zone of the surrounding zones is crucial. A face mapping performed for filler technique has thus evolved, with many experts advocating varied techniques from global restoration to point lifts at key areas, to improve the outcome of filler injections, albeit safely, thus simplifying the process. A systematic approach to various techniques and the point lifts in various zones pertaining to the face structure in the Indian skin are highlighted in this article.

Treatment of a traumatic atrophic depressed scar with hyaluronic acid fillers: a case report

BACKGROUND

Hyaluronic acid filler has been documented in the treatment of atrophic depressed acne scars relatively frequently in the literature but rarely in chronic depressed traumatic atrophic facial scars.

METHODS

This case report discusses the use of hyaluronic acid fillers in the correction of a post-traumatic facial atrophic scar on the right cheek.

RESULTS

The right cheek scar was substantially corrected with one session of two different hyaluronic acids injected in a deep and superficial plane.

CONCLUSION

Relatively accurate, simple and effective correction of this atrophic traumatic scar may suggest that fillers are a suitable alternative to surgery for such scars.

Lipogranuloma after facial cosmetic procedures

OBJECTIVE

Lipogranuloma is a rare inflammatory reactive process in the dermis and subcutis. We present a summary of the 6 cases of lipogranuloma after facial cosmetic procedures.

STUDY DESIGN

We performed a retrospective review including patient demographic data, clinical symptoms, appearance on computed tomography, treatment, pathology results, and history of facial cosmetic procedures.

RESULTS

In most cases, the nodules were painless and showed no significant growth. Computed tomography revealed ill-defined swellings in the buccal fat pad with heterogeneous density. Histopathological examinations revealed numerous variable-sized empty microcysts surrounded by abundant lymphocytes and foamy macrophages, the characteristic features of lipogranuloma. On further questioning, all of the patients revealed that they had undergone some form of facial cosmetic procedure in the preceding months to years. Among the 6 cases, facial autologous fat injection may have been the main cause of lipogranuloma.

CONCLUSION

Lipogranulomas can develop months to years after facial cosmetic procedures distant from the injection sites. A thorough understanding of the patient's medical history and the clinical and histopathologic characteristics of lipogranuloma are necessary to make a definite diagnosis and allow appropriate treatment.

Labia Majora Augmentation with Hyaluronic Acid Filler: Technique and Results

BACKGROUND

External female genitalia lose elasticity and volume with age. In the literature several techniques address the redundancy of the labia minora, but only few reports describe the augmentation of labia majora with fat grafting. At present, no studies describe the augmentation of the labia majora with hyaluronic acid.

OBJECTIVES

This study aims to present our technique of infiltration of hyaluronic acid filler, analyzing effectiveness, patient satisfaction, and complications.

METHODS

We retrospectively analyzed 54 patients affected by hypotrophy of the labia majora; they were treated with hyaluronic acid filler between November 2010 and December 2014. The Global Aesthetic Improvement Scale (GAIS) filled out by the doctor and the patients was used to evaluate the results 12 months after the infiltration. Complications were recorded.

RESULTS

A total of 31 patients affected by mild to moderate labia majora hypotrophy were treated with 19 mg/mL HA filler; 23 patients affected by severe labia majora hypotrophy were treated with 21 mg/mL HA filler. Among the first group of patients, one underwent a second infiltration 6 months later with 19 mg/mL HA filler (maximum 1 mL). A significant improvement (P < .0001) in GAIS score was observed, both in the scores provided by the patients and by the doctor. A greater relative improvement was observed in patients affected by severe hypotrophy. No complications were recorded.

CONCLUSIONS

Hyaluronic acid infiltration of the labia majora is able to provide a significant rejuvenation with a simple outpatient procedure. We achieved significant improvements with one infiltration in all cases. The treatment is repeatable, has virtually no complications and it is reversible.

LEVEL OF EVIDENCE

4 Therapeutic.