Permanent Loss of Vision Following Cosmetic Rhinoplastic Surgery

Doppler Ultrasonographic Anatomy of the Midline Nasal Dorsum

BACKGROUND

This study was performed to identify a safe method for filler injection to prevent blood vessel damage, by means of checking the location and depth of the blood vessels on the midline of the nose using Doppler ultrasonographic imaging.

METHODS

Ultrasonographic images of the nasal areas of patients for filler injection rhinoplasty were reviewed. The location and depth of the dorsal nasal arteries and the intercanthal vein in each part on the midline of the nose were checked.

RESULTS

The intercanthal vein was detected in the midline of the radix in 22 patients and the midline of the rhinion region in two patients. There were no patients in whom the intercanthal vein was observed in the midline of the supratip region. The dorsal nasal artery was detected in the rhinion region in six patients and in the supratip region in two patients. There were no patients in whom the dorsal nasal artery was observed in the midline of the radix. The dorsal nasal artery was located within 1.2 mm from the perichondrium or periosteum in three patients in whom it was detected in the rhinion.

CONCLUSIONS

When performing dorsal augmentation, the injection of filler into the preperiosteal layer in the rhinion region should be avoided for the prevention of vascular embolism. During dorsal augmentation in patients with a nasal hump, the filler can be injected into the preperiosteal space in the radix by introducing a needle perpendicular to the periosteum from the skin.

LEVEL OF EVIDENCE V

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.

Ocular complications of soft tissue filler injections: A review of literature

BACKGROUND

Soft tissue filler is commonly used for facial contouring. However, incorrect use can lead to severe ocular complications. Even though filler injections are quite different from fat grafts, they are considered similar procedures. However, to date, there are no proven preventive measures or treatments for blindness secondary to soft tissue filler injections.

OBJECTIVES

This literature review aimed to investigate visual compromise secondary to soft tissue filler injection and discuss the related vascular anatomy, pathophysiology, and prevention of ocular complications of soft tissue filler injections.

METHODS

A literature search until July 2018 was performed for reports on visual compromise after filler injections. We evaluated the previous literature and eliminated cases using fat grafts and unknown fillers.

RESULTS

A total of 50 reports of filler-induced visual compromise were identified. Analysis of these cases showed that the procedure with greatest risk was nasal augmentation, followed by glabellar wrinkle treatment. Within the last 3 years searched, 35% of reported cases involved treatment of the nose. There were no reports of blindness from injections into the temple or chin and relatively few case reports involving forehead injections.

CONCLUSION

The most common injection site associated with blindness in a previous report was the glabella; however, the most common site currently associated with blindness due to filler injections was the nose. Extreme caution is necessary when performing nasal augmentation or glabellar wrinkle correction using soft tissue fillers to avoid the branches of the internal carotid artery.

Does Septorhinoplasty-Related Periorbital Edema Affect Intraocular Pressure and Retina?

BACKGROUND

Open rhinoplasty has been performed for over 50 years. Rhinoplasty procedures have a risk of complications and it is important to follow each step diligently in order to avoid complications. Periorbital edema is the most common complication of septorhinoplasty. As far as we are aware, there are no studies in the available literature examining the impact of the septorhinoplasty on intraocular pressure and the retina.

OBJECTIVES

The aim of this study was to evaluate the effects of septorhinoplasty-related periorbital edema on intraocular pressure and the retina by means of objective tests.

METHODS

Ten patients with phase 4 periorbital edema (5 males and 5 females) who underwent open rhinoplasty with bilateral lateral osteotomies were enrolled in the study. All the patients were examined by an eye specialist for visual acuity, intraocular pressure, retinal nerve fiber layer, and ganglion cell complex pathologies with optical coherence tomography preoperatively and postoperatively on the seventh day.

RESULTS

Preoperative and postoperative best-corrected visual acuity; intraocular pressure; average, superior, and inferior retinal nerve fiber layer thickness; and total, superior, and inferior ganglion cell complex thickness in both eyes for all patients were within normal limits. There was no statistical difference between preoperative and postoperative values (P > .05).

CONCLUSION

We concluded that periorbital edema after septorhinoplasty causes no significant complications affecting intraocular pressure and visual acuity. We believe that when osteotomies and local anesthetic injections are undertaken correctly, periorbital complications do not affect vision.

Hyaluronic Acid Filler Emergency Kit

Widespread use of facial filler has led to a rise in reports of associated complications. The aim of this kit is to encompass all needed items to treat the patient and to be organized and prepared to provide correct treatment in urgent situations. A search was performed to gather information on the treatment of complications that occur after injection of soft tissue fillers. The search included reports published in English up to June 2018. We focused on reports of complications arising from emergent/urgent situations following the use of hyaluronic acid injectables; these included filler embolization resulting in impending skin necrosis, blindness or partial loss of vision, and anaphylaxis. We collated treatment of emergent complications from our search of published articles. There were 2 described protocols for filler complications in the literature. One protocol, the “old” protocol, was based on a low dose of hyaluronidase with longer intervals of injections and ancillary treatment. This protocol did not show good results in comparison with the “new” protocol, which was needed to improve these results. The new protocol demonstrated that a high dose of hyaluronidase had better efficacy; this protocol involves hourly injections with no ancillary treatment required except for aspirin. We propose a filler emergency kit (FEK) to deal with complications of hyaluronic acid fillers according to the new protocol to manage the stresses caused by these situations. Every physician needs to be prepared for any potential complication; therefore, there is a need to have a FEK as a crash kit in the clinic to avoid distressing the physician and the patient.

Topography of the dorsal nasal artery and its clinical implications for augmentation of the dorsum of the nose

BACKGROUND

Injections of filler into the nose for dorsum augmentation have a higher risk of complications due to the complicated blood supply and anastomotic channels in this area.

OBJECTIVES

The aim of this study was to determine the anatomical features and location of the dorsal nasal artery (DNA), and to provide clinical anatomical information to reduce side effects and severe complications in the perinasal area.

METHODS

Using the 31 cadaveric noses in Asians, dissections and histologic examinations were performed to identify the location and depth of the vascular structures including DNA.

RESULTS

Dorsal nasal artery ran downward at 20.3 ± 3.5 mm from the intercanthal line and the communicating branch that connected the bilateral DNAs was located 8.5 ± 3.5 mm inferior to the intercanthal line. The DNA was located at 4.4 ± 3.2 mm, 4.6 ± 4.4 mm, and 5.2 ± 4.4 mm lateral to the midline of the nose on the intercanthal, quadrisected, and bisected lines, respectively. At the level of nasal bone, DNA was located superficial to the muscular layer and it runs inferolaterally on dorsum on nose. It was running more deeply and located beneath the fibromuscular layer at the cartilaginous portion of the dorsum of nose.

CONCLUSIONS

Injection into deep fatty layer may reduce the risk of arterial injury and the consequent complications. However, in a hooked nose, the tip of the needle traveling along the deep layer approaches the superficial layer due to the convexity of the hump as it passes over it, which can increase the probability of damaging the DNA.

Optimizing outcomes with polymethylmethacrylate fillers

INTRODUCTION

The ideal filler should be long-lasting, biocompatible, chemically inert, soft and easy to use, and have a long history of safety. This review focuses on the evolution and development of the PMMA-collagen gel, Bellafill, and the 10 years of postmarketing experience of Bellafill since it received premarket approval (PMA) from the FDA as Artefill in 2006. Artefill was rebranded to Bellafill in 2015.

METHODS

The authors conducted a literature search on PubMed for key articles describing the steps in which Arteplast, a PMMA filler developed in 1989, led to the development of Bellafill, the only PMMA filler approved by the US FDA for the treatment of nasolabial folds and acne scar correction. The factors governing efficacy and safety were also evaluated for the major PMMA fillers available in the world.

RESULTS

The process of manufacturing and purifying PMMA has played a major role in minimizing adverse events for Bellafill. Postmarketing surveillance data for the 2007-2016 period show that for more than 530 000 Bellafill syringes distributed worldwide, 11 confirmed granulomas (excluding clinical trial data) (0.002% of syringes sold) have been reported. Data on other PMMA fillers are limited and inconsistent. The authors suggest that adverse events are often attributable to lack of proficiency in treatment technique and other factors.

CONCLUSION

Bellafill has demonstrated an excellent safety and effectiveness profile in multiple clinical studies, customer feedback, and 10 years of postmarketing surveillance experience. Adverse events occur with all fillers for a variety of reasons. In addition to quality of the product, injector skill and technique are critical to ensuring good clinical outcomes.

Dermal filler-associated malar edema: Treatment of a persistent adverse effect

A 72-year-old Caucasian female presented for evaluation of bilateral lower eyelid "fluid filled" bags that had been present and slowly worsening for 7 years. She reported a history of lower eyelid blepharoplasty in her 40s, as well as hyaluronic acid tear trough fillers 8 years prior to presentation. Her malar edema completely resolved following injection of hyaluronidase. To our knowledge, this is the longest reported interval for presentation and treatment of hyaluronic acid associated malar edema.

Unintentional Complications After Uneventful Rhinoplasty Operations: Case Reports and a Review of the Literature

INTRODUCTION

No surgical procedure is free of complications; however, some of these complications are unintentional. Plastic surgeons may be unfamiliar with certain complications after rhinoplasty operations. In this study, we aimed to present four unintentional complications that have occurred in our patients and review the literature related to these complications.

MATERIALS AND METHODS

In this study, we conducted a review of 1400 patients who were operated on from 2007 to 2015. The medical recordings of all patients were investigated. Four patients with unintentional complications after rhinoplasty operations are presented and the related literature was reviewed.

CASES

Cases 1 and 2: These patients included a 26-year-old woman and a 30-year-old man who developed herpes simplex virus (HSV) infections after a primary septorhinoplasty. Case 3: This was a 25-year-old woman who developed periorbital emphysema after a primary rhinoplasty operation. Case 4: This was a 22-year-old woman who developed a second-degree burn on the nasal dorsum. All patients healed without sequel or scars.

DISCUSSION

Many unexpected complications have been reported in the literature. Some of these complications include bleeding disorders, allergic reactions, dermatitis, visual loss, gastric bleeding, benign paroxysmal positional vertigo, false aneurysm after rhinoplasty, pneumocephalus, Tapia's syndrome, cavernous sinus syndrome, and skin reactions to prolene.

CONCLUSION

Meticulous patient histories, consistent surgical routines, careful radiologic examinations, and frequent patient visits can help surgeons control these types of complications.

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.

Avoiding and Treating Blindness From Fillers: A Review of the World Literature

BACKGROUND

As the popularity of soft tissue fillers increases, so do the reports of adverse events. The most serious complications are vascular in nature and include blindness.

OBJECTIVE

To review the cases of blindness after filler injection, to highlight key aspects of the vascular anatomy, and to discuss prevention and management strategies.

METHODS

A literature review was performed to identify all the cases of vision changes from filler in the world literature.

RESULTS

Ninety-eight cases of vision changes from filler were identified. The sites that were high risk for complications were the glabella (38.8%), nasal region (25.5%), nasolabial fold (13.3%), and forehead (12.2%). Autologous fat (47.9%) was the most common filler type to cause this complication, followed by hyaluronic acid (23.5%). The most common symptoms were immediate vision loss and pain. Most cases of vision loss did not recover. Central nervous system complications were seen in 23.5% of the cases. No treatments were found to be consistently successful in treating blindness.

CONCLUSION

Although the risk of blindness from fillers is rare, it is critical for injecting physicians to have a firm knowledge of the vascular anatomy and to understand key prevention and management strategies.

Complications following injection of soft-tissue fillers

BACKGROUND

Soft-tissue filler injection is a very common procedure in the United States. Although the safety profile is favorable, adverse events (AE) can occur, ranging from mild to severe in intensity.

OBJECTIVES

The authors performed a literature search to identify the facial sites most prone to severe complications. They review the course of these complications and discuss preventive measures.

METHODS

The National Library of Medicine, the Cochrane Library, and Ovid MEDLINE were searched, and relevant articles (published through August 2012) were retrieved based on prespecified inclusion criteria. The complications reviewed were limited to "severe" events, such as soft-tissue necrosis, filler embolization, visual impairment, and anaphylaxis. The filler materials included were those approved by the US Food and Drug Administration at the time of this study.

RESULTS

Forty-one articles, representing 61 patients with severe complications, were identified. Data collected from these case reports included filler type, injection site, complication site, symptom interval, symptom of complication, time to therapy, modality of treatment, and outcome. The most common injection site for necrosis was the nose (33.3%), followed by the nasolabial fold (31.2%). Blindness was most often associated with injection of the glabella (50%). An estimated incidence of 0.0001% for developing a severe complication was calculated by reviewing society-based filler data and case reports within same time period.

CONCLUSIONS

Although soft-tissue fillers are a popular choice for minimally invasive rejuvenation of the face, physicians should be aware of the serious potential adverse effects, recognize their presentations, and have appropriate treatments readily available.

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.